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This is a 40-item sample questions with rationales in preparation for the 2014 Philippine Nurse Licensure

Exam

1. A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration

record. The nurse should notify the health care provider if the client received which medication during the

preceding 24 hours?

A) digoxin (Lanoxin)

B) diltiazam (Cardizem)

C) nitroglycerine ointment

D) metoprolol (Toprol XL)

The correct answer is A: digoxin (Lanoxin) Digoxin increases ventricular irritability and increases the risk of

ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability

2. Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the

health care provider examine first?

A) An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago."

B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy

C) A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past week

D) A teenager with a history of falling off a bicycle and did not hit the handle bars

The correct answer is A: An elderly client who stated that "My awful pain in my right side suddenly stopped about

3 hours ago." This client has the highest risk for hypovolemic and septic shock since the appendix has most likely

ruptured as based on the history of the pain suddenly stopping over three hours ago. Being elderly there, is less

reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also.

However, given that they fall in younger age groups, they would more likely be able to tolerate an inbalance in

circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often

on the left, resulting in a ruptured spleen.

3. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be

conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if

they wish. This affirms the ethical principle of

A) Anonymity

B) Beneficence

C) Justice

D) Autonomy

The correct answer is D: Autonomy Individuals must be free to make independent decisions about participation in

research without coercion from others.

4. Which statement made by a nurse about the goal of total quality management or continuous quality

improvement in a health care setting is correct?

A) “It is to observe reactive service and product problem solving."

B) Improvement of the processes in a proactive, preventive mode is paramount.

C) A chart audits to finds common errors in practice and outcomes associated with goals.

D) A flow chart to organize daily tasks is critical to the initial stages.

The correct answer is B: Improvement of the processes in a proactive, preventive mode is paramount. Total

quality management and continuous quality improvement have a major goal of identifying ways to do the right

thing at the right time in the right way by proactive problem-solving.

5. A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is

receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate

intervention?

A) Decreased blood pressure and respirations.

B) Flushing and headache.

C) Restlessness and palpitations.

D) Increased heart rate and blood pressure.

The correct answer is C: Restlessness and palpitations. Side effects of Aminophylline include restlessness and

palpitations

6. When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included?

A) Tachycardia blurred vision, hypotension, anorexia

B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods

C) Diarrhea, dry mouth, weight loss, reduced libido

D) Photosensitivity, seizures, edema, hyperglycemia

The correct answer is C: Diarrhea, dry mouth, weight loss, reduced libido Commonly reported side effects for

fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido

7. The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for

agastostomy tube placement, the priority is to

A) Auscultate the abdomen while instilling 10 cc of air into the tube

B) Place the end of the tube in water to check for air bubbles

C) Retract the tube several inches to check for resistance

D) Measure the length of tubing from nose to epigastrium

The correct answer is A: Auscultate the abdomen while instilling 10 cc of air into the tube If a swoosh of air is

heard over the abdominal cavity while instilling air into the gastric tube, this indicates that it is accurately placed

in the stomach. The feeding can begin after assessing the client for bowel sounds

8.Which of these questions is priority when assessing a client with hypertension?

A) "What over-the-counter medications do you take?"

B) "Describe your usual exercise and activity patterns."

C) "Tell me about your usual diet."

D) "Describe your family's cardiovascular history."

The correct answer is A: "What over-the-counter medications do you take?" Over-the-counter medications,

especially those that contain cold preparations can increase the blood pressure to the point of hypertension.

9. The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is

anappropriate finger food?

A) Hot dog pieces

B) Sliced bananas

C) Whole grapes

D) Popcorn

The correct answer is B: Sliced bananas Finger foods should be bite-size pieces of soft food such as bananas. Hot

dogs

and grapes can accidentally be swallowed whole and can occlude the airway. Popcorn is too difficult to chew at

this age and can irritate the airway if swallowed

10 client is ordered warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in

the nurse’s discharge instruction?

A) Maintain a consistent intake of green leafy foods

B) Report any nose or gum bleeds

C) Take Tylenol for minor pains

D) Use a soft toothbrush

The correct answer is B: Report any nose or gum bleeds The client should notify the health care provider if blood

is noted in their stools or urine, or any other signs of bleeding occ

11. The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments

requires an immediate response from the nurse?

A) Decreased breath sounds in right lower lobe

B) Aspiration of a residual of 100cc of formula

C) Decrease in bowel sounds

D) Urine output of 250 cc in past 8 hours

The correct answer is A: Decreased breath sounds in right lower lobe

The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees during

feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours

if continuous feeding

12. The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in

communicating with the parents is

A) Discuss the need for genetic counseling

B) Inform them that combined therapy is seldom effective

C) Prepare for the child's permanent disfigurement

D) Suggest that total blindness may follow surgery

The correct answer is A: Discussing the need for genetic counseling The hereditary aspects of this disease are

well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for

future offspring

Question Number 13 of 40

The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula

following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5. Which of

the following would the nurse anticipate?

A) Additional potassium will be given IV

B) Blood for coagulation studies will be drawn

C) Total parenteral nutrition (TPN) will be started

D) Serum lipase levels will be evaluated

The correct answer is C: Total parenteral nutrition (TPN) will be started The client is not absorbing nutrients

adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0.)

TPN will maintain a positive nitrogen balance in the client who is unable to digest and absorb nutrients

adequately.


The nurse is teaching about nonsteroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the

side effects, the nurse should emphasize which of the following actions?

A) Reporting joint stiffness in the morning

B) Taking the medication 1 hour before or 2 hours after meals

C) Using alcohol in moderation unless driving

D) Continuing to take aspirin for short term relief

The correct answer is B: Taking the medication 1 hour before or 2 hours after meals Taking the medication 1 hour

before or 2 hours after meals will result in a more rapid effect.


Which approach is a priority for the nurse who works with clients from many different cultures?

A) Speak at least 2 other languages of clients in the neighborhood

B) Learn about the cultures of clients who are most often encountered

C) Have a list of persons for referral when interaction with these clients occur

D) Recognize personal attitudes about cultural differences and real or expected biases

The correct answer is D: Recognize personal attitudes about cultural differences and real or expected biases The

nurse must discover personal attitudes, prejudices and biases specific to different cultures. Sensitivity to these

will affect interactions with clients and families across cultures.


A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “I refuse

both radiation and chemotherapy because they are 'hot.'” The next action for the nurse to take is to

A) Document the situation in the notes

B) Report the situation to the health care provider

C) Talk with the client's family about the situation

D) Ask the client to talk about the concerns about the "hot" treatments

The correct answer is D: Ask the client to talk about the concerns about the "hot" treatments The "hot-cold"

system is found among Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. Most foods, beverages,

herbs, and medicines are categorized as hot or cold, which are symbolic designations and do not necessarily

indicate temperature or spiciness. Care and treatment regimens can be negotiated with clients within this

framework.


During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results

indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?

A) Rotation of injection sites

B) Insulin mixing and preparation

C) Daily blood sugar monitoring

D) Regular high protein diet

The correct answer is C: Daily blood sugar monitoring Normal hemoglobin A1C (glycosylated hemoglobin) level is

7 to 9%. Elevation indicates elevated glucose levels over time.


The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing

the report?

A) The client with asthma who is now ready for discharge

B) The client with a peptic ulcer who has been vomiting all night

C) The client with chronic renal failure returning from dialysis

D) The client with pancreatitis who was admitted yesterday

The correct answer is B: The client with a peptic ulcer who has been vomiting all night A perforated peptic ulcer

could cause nausea, vomiting and abdominal distention, and may be a life threatening situation. The client should

be assessed immediately and findings reported to the health care provider


To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are

usually added to drug therapy?

A) Anti-inflammatory agent

B) High doses of B complex vitamins

C) Aminoglycoside antibiotic

D) Two anti-tuberculosis drugs

The correct answer is D: Two anti-tuberculosis drugs Resistance of the tubercle bacilli often occurs to a single

antimicrobial agent. Therefore, therapy with multiple drugs over a long period of time helps to ensure eradication

of the organism.


While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the

radial pulse can be accurately assessed at about what age?

A) 1 year of age

B) 2 years of age

C) 3 years of age

D) 4 years of age

The correct answer is B: 2 years of age A child should be at least 2 years of age to use the radial pulse to assess

heart rate.


Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?

A) An adolescent taking medications for acne

B) An elderly client living in a retirement center taking prednisone

C) A young adult at home taking a prescribed aminoglycoside

D) A hospitalized middle aged client receiving clindamycin

The correct answer is D: A hospitalized middle aged client receiving clindamycin Hospitalized patients, especially

those receiving antibiotic therapy, are primary targets for C. difficile. Of patients receiving antibiotics, 5-38%

experience antibiotic-associated diarrhea; C. difficile causes 15 to 20% of the cases. Several antibiotic agents have

been associated with C. difficile. Broad-spectrum agents, such as clindamycin, ampicillin, amoxicillin, and

cephalosporins, are the most frequent sources of C. difficile. Also, C. difficile infection has been caused by the

administration of agents containing beta-lactamase inhibitors (ie, clavulanic acid, sulbactam, tazobactam) and

intravenous agents that achieve substantial colonic intraluminal concentrations (ie, ceftriaxone, nafcillin,

oxacillin). Fluoroquinolones, aminoglycosides, vancomycin, and trimethoprim are seldom associated with C.

difficile infection or pseudomembranous colitis.


The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should

the nurse do first?

A) Explain that the procedure will help him to get well

B) Show a cartoon character with a blood pressure cuff

C) Explain that the blood pressure checks the heart pump

D) Permit handling the equipment before putting the cuff in place

The correct answer is D: Permit handling the equipment before putting the cuff in place The best way to gain the

toddler''s cooperation is to encourage handling the equipment. Detailed explanations are not helpful.


The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is

A) A firm touch to the trapezius muscle or arm

B) Pinching any body part

C) Sternal rub

D) Gentle pressure on eye orbit

The correct answer is D: Gentle pressure on eye orbit This is an acceptable stimuli only after progressing from

lighter to stimuli to more obnoxious.


The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse

recognizes that, as a result of the radiation therapy, the client is most likely to experience

A) High fever

B) Nausea

C) Face and neck edema

D) Night sweats

The correct answer is B: Nausea Because the client with Hodgkin''s disease is usually healthy when therapy

begins, the nausea is especially troubling


A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these

mediations would the nurse anticipate the health care provider ordering?

A) Oral Coumadin therapy

B) Heparin 5000 units subcutaneously b.i.d.

C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value

D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value

The correct answer is D: Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value

Several studies have been conducted in pregnant women where oral anticoagulation agents are contraindicated.

Warfarin (Coumadin) is known to cross the placenta and is therefore reported to be teratogenic.


A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds

the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?

A) The newborn needs additional assessments

B) The mother should breast feed more often

C) A change to formula is indicated

D) The loss is within normal limits

The correct answer is D: The loss is within normal limits A newborn is expected to lose 5-10% of the birth weight

in the first few days because of changes in elimination and feeding.


A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes

dislodged from the site. Which action by the nurse should take priority?

A) Check that the catheter tip is intact

B) Apply a pressure dressing to the site

C) Monitor respiratory status

D) Assess for mental status changes

The correct answer is B: Apply a pressure dressing to the site The client is at risk of bleeding or the development

of an air embolus if the catheter exit site is not covered immediately


A client with a panic disorder has a new prescription for Xanax (Alpazolam). In teaching the client about the

drug's actions and side effects, which of the following should the nurse emphasize?

A) Short-term relief can be expected

B) The medication acts as a stimulant

C) Dosage will be increased as tolerated

D) Initial side effects often continue

The correct answer is A: Short-term relief can be expected Xanax is a short-acting benzodiazepine useful in

controlling panic symptoms quickly.


A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half

hour after admission, the nurse notes several physical changes. Which changes would require the nurse's

immediate attention?

A) Increased restlessness

B) Tachycardia

C) Tracheal deviation

D) Tachypnea

The correct answer is C: Tracheal deviation The deviated trachea is a sign that a mediastinal shift has occurred.

This is a medical emergency.


A client being discharged from the cardiac step-down unit following a myocardial infarction ( MI), is given a

prescription for a beta-blocking drug. A nursing student asks the charge nurse why this drug would be used by a

client who is not hypertensive. What is an appropriate response by the charge nurse?

A) "Most people develop hypertension following an MI."

B) "A beta-Blocker will prevent orthostatic hypotension."

C) "This drug will decrease the workload on his heart."

D) "Beta-blockers increase the strength of heart contractions."

The correct answer is C: "This drug will decrease the workload on his heart." One action of beta-blockers is to

decrease systemic vascular resistance by dilating arterioles. This is useful for the client with coronary artery

disease, and will reduce the risk of another MI or sudden death


A client has gastroesophageal reflux. Which recommendation made by the nurse would be most helpful to the

client?

A) Avoid liquids unless a thickening agent is used

B) Sit upright for at least 1 hour after eating

C) Maintain a diet of soft foods and cooked vegetables

D) Avoid eating 2 hours before going to sleep

The correct answer is D: Avoid eating2 hours before going to sleep Eating before sleeping enhances the

regurgitation of stomach contents which have increased acidity into the esophagus. Maintaining an upright

posture should be for about 2 hours after eating to allow for the stomach emptying. The options A and C are

interventions for clients with swallowing difficulties


As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The

serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?

A) Give oral glucose water

B) Notify the pediatrician

C) Repeat the test in 2 hours

D) Check the pulse oximetry reading

The correct answer is C: Repeat the test in two hours This blood sugar is within the normal range for a full-term

newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3

mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and

>300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood

sugars will be drawn.


An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the

nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps,

rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving

immunizations to this child?

A) Live vaccines are withheld in children with renal chronic illness

B) The MMR vaccine should be given now, prior to the transplant

C) An inactivated form of the vaccine can be given at any time

D) The risk of vaccine side effects precludes giving the vaccine

The correct answer is B: The MMR vaccine should be given now, prior to the transplant MMR is a live virus

vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the

administration of the live vaccine at that time would be contraindicated because of the compromised immune

system.


A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction,

is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be

A) Order an EKG

B) Administer morphine sulphate

C) Start an IV

D) Measure vital signs

The correct answer is B: Administer pain medication as ordered Decreasing the clients pain is the most important

priority at this time. As long as pain is present there is danger in extending the infarcted area. Morphine will

decrease the oxygen demands of the heart and act as a mild diuretic as well.


The clinic nurse is counseling a substance-abusing post partum client on the risks of continued cocaine use. In

order to provide continuity of care, which nursing diagnosis is a priority ?

A) Social isolation

B) Ineffective coping

C) Altered parenting

D) Sexual dysfunction

The correct answer is C: Altered parenting The cocaine abusing mother puts her newborn and other children at

risk for neglect and abuse. Continuing to use drugs has the potential to impact parenting behaviors. Social service

referrals are indicated


The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent

would be important in determining the etiology of the seizure?

A) "He has been taking long naps for a week."

B) "He has had an ear infection for the past 2 days."

C) "He has been eating more red meat lately."

D) "He seems to be going to the bathroom more frequently."

The correct answer is B: "He has had an ear infection for the past 2 days." Contributing factors to seizures in

children include those such as age (more common in first 2 years), infections (late infancy and early childhood),

fatigue, not eating properly and excessive fluid intake or fluid retention


Which of the following drugs should the nurse anticipate administering to a client before they are to receive

electroconvulsive therapy?

A) Benzodiazephines

B) Chlorpromazine (Thorazine)

C) Succinylcholine (Anectine)

D) Thiopental sodium (Pentothal Sodium)

The correct answer is C: Succinylcholine (Anectine) Succinylcholine is given intravenously to promote skeletal

relaxation


A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client

should be instructed to immediatley report which of these?

A) Double vision and visual halos

B) Extremity tingling and numbness

C) Confusion and lightheadedness

D) Sensitivity of sunlight

The correct answer is B: Extremity tingling and numbness Peripheral neuropathy is the most common side effect

of INH and should be reported to the health care provider; it can be reversed.


The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?

A) Encourage child to engage in activities in the playroom

B) Promote independence in activities of daily living

C) Talk with the child and allow him to express his opinions

D) Provide frequent reassurance and cuddling

The correct answer is A: Encourage child to engage in activities in the playroom According to Erikson, the school

age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage

them to carry out tasks and activities in their room or in the playroom


During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the

nurse?

A) The client's self-report is the most important consideration

B) Cultural sensitivity is fundamental to pain management

C) Clients have the right to have their pain relieved

D) Nurses should not prejudge a client's pain using their own values

The correct answer is A: The client''s self-report is the most important consideration Pain is a complex

phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other

statements are correct but not the priority.

FUNDAMENTALS OF NURSING QUESTIONS WITH RATIONALES 1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be…

a. Maintain the patient on strict bed rest at all timesb. Maintain the patient in an orthopneic position as neededc. Administer oxygen by Venturi mask at 24%, as neededd. Allow a 1 hour rest period between activities2.The nurse observes that Mr. Adams begins to have increased difficulty

breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:

a. Tachypneab. Eupncac. Orthopnead. Hyperventilation

3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:

a. Instructing the patient about this diagnostic testb. Writing the order for this testc. Giving the patient breakfastd. All of the above4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the

foods allowed on a 500-mg low sodium diet. These include:a. A ham and Swiss cheese sandwich on whole wheat breadb. Mashed potatoes and broiled chickenc. A tossed salad with oil and vinegar and olivesd. Chicken bouillon5. The physician orders a maintenance dose of 5,000 units of subcutaneous

heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.

b. Reporting an APTT above 45 seconds to the physicianc. Assessing the patient for signs and symptoms of frank and occult

bleedingd. All of the above6. The four main concepts common to nursing that appear in each of the

current conceptual models are:a. Person, nursing, environment, medicineb. Person, health, nursing, support systemsc. Person, health, psychology, nursingd. Person, environment, health, nursing7. In Maslow’s hierarchy of physiologic needs, the human need of greatest

priority is:a. Loveb. Eliminationc. Nutritiond. Oxygen8. The family of an accident victim who has been declared brain-dead seems

amenable to organ donation. What should the nurse do?a. Discourage them from making a decision until their grief has easedb. Listen to their concerns and answer their questions honestlyc. Encourage them to sign the consent form right awayd. Tell them the body will not be available for a wake or funeral9. A new head nurse on a unit is distressed about the poor staffing on the 11

p.m. to 7 a.m. shift. What should she do?a. Complain to her fellow nursesb. Wait until she knows more about the unitc. Discuss the problem with her supervisord. Inform the staff that they must volunteer to rotate

10. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?

a. Continuity of patient care promotes efficient, cost-effective nursing careb. Autonomy and authority for planning are best delegated to a nurse who

knows the patient wellc. Accountability is clearest when one nurse is responsible for the overall

plan and its implementation.d. The holistic approach provides for a therapeutic relationship, continuity,

and efficient nursing care.11. If nurse administers an injection to a patient who refuses that injection,

she has committed:a. Assault and batteryb. Negligencec. Malpracticed. None of the above12. If patient asks the nurse her opinion about a particular physicians and

the nurse replies that the physician is incompetent, the nurse could be held liable for:

a. Slanderb. Libelc. Assaultd. Respondent superior13. A registered nurse reaches to answer the telephone on a busy pediatric

unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with:

a. Defamationb. Assaultc. Batteryd. Malpractice14. Which of the following is an example of nursing malpractice?a. The nurse administers penicillin to a patient with a documented history

of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.

b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.

c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.

d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.

15. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

a. Decreased blood pressure and heart rate and shallow respirationsb. Quiet crying

c. Immobility, diaphoresis, and avoidance of deep breathing or coughingd. Changing position every 2 hours16. A patient is admitted to the hospital with complaints of nausea, vomiting,

diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?

a. Complete blood countb. Guaiac testc. Vital signsd. Abdominal girth17. The correct sequence for assessing the abdomen is:a. Tympanic percussion, measurement of abdominal girth, and inspectionb. Assessment for distention, tenderness, and discoloration around the

umbilicus.c. Percussions, palpation, and auscultationd. Auscultation, percussion, and palpation18. High-pitched gurgles head over the right lower quadrant are:a. A sign of increased bowel motilityb. A sign of decreased bowel motilityc. Normal bowel soundsd. A sign of abdominal cramping19. A patient about to undergo abdominal inspection is best placed in which

of the following positions?a. Proneb. Trendelenburgc. Supined. Side-lying20. For a rectal examination, the patient can be directed to assume which of

the following positions?a. Genupecterolb. Simsc. Horizontal recumbentd. All of the above21. During a Romberg test, the nurse asks the patient to assume which

position?a. Sittingb. Standingc. Genupectorald. Trendelenburg22. If a patient’s blood pressure is 150/96, his pulse pressure is:a. 54b. 96c. 150d. 24623. A patient is kept off food and fluids for 10 hours before surgery. His oral

temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:

a. Infectionb. Hypothermiac. Anxietyd. Dehydration24. Which of the following parameters should be checked when assessing

respirations?a. Rateb. Rhythmc. Symmetryd. All of the above25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6

F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?

a. Respiratory rate onlyb. Temperature onlyc. Pulse rate and temperatured. Temperature and respiratory rate26. All of the following can cause tachycardia except:a. Feverb. Exercisec. Sympathetic nervous system stimulationd. Parasympathetic nervous system stimulation27. Palpating the midclavicular line is the correct technique for assessinga. Baseline vital signsb. Systolic blood pressurec. Respiratory rated. Apical pulse28. The absence of which pulse may not be a significant finding when a

patient is admitted to the hospital?a. Apicalb. Radialc. Pedald. Femoral29. Which of the following patients is at greatest risk for developing

pressure ulcers?a. An alert, chronic arthritic patient treated with steroids and aspirinb. An 88-year old incontinent patient with gastric cancer who is confined to

his bed at homec. An apathetic 63-year old COPD patient receiving nasal oxygen via

cannulad. A confused 78-year old patient with congestive heart failure (CHF) who

requires assistance to get out of bed.30. The physician orders the administration of high-humidity oxygen by face

mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the

following nursing interventions has the greatest potential for improving this situation?

a. Encourage the patient to increase her fluid intake to 200 ml every 2 hours

b. Place a humidifier in the patient’s room.c. Continue administering oxygen by high humidity face maskd. Perform chest physiotheraphy on a regular schedule31. The most common deficiency seen in alcoholics is:a. Thiamineb. Riboflavinc. Pyridoxined. Pantothenic acid32. Which of the following statement is incorrect about a patient with

dysphagia?a. The patient will find pureed or soft foods, such as custards, easier to

swallow than waterb. Fowler’s or semi Fowler’s position reduces the risk of aspiration during

swallowingc. The patient should always feed himselfd. The nurse should perform oral hygiene before assisting with feeding.33. To assess the kidney function of a patient with an indwelling urinary

(Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is:

a. Less than 30 ml/hourb. 64 ml in 2 hoursc. 90 ml in 3 hoursd. 125 ml in 4 hours34. Certain substances increase the amount of urine produced. These

include:a. Caffeine-containing drinks, such as coffee and cola.b. Beetsc. Urinary analgesicsd. Kaolin with pectin (Kaopectate)35. A male patient who had surgery 2 days ago for head and neck cancer is

about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?

a. Encourage the patient to walk in the hall aloneb. Discourage the patient from walking in the hall for a few more daysc. Accompany the patient for his walk.d. Consuit a physical therapist before allowing the patient to ambulate36. A patient has exacerbation of chronic obstructive pulmonary disease

(COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be:

a. Ineffective airway clearance related to thick, tenacious secretions.

b. Ineffective airway clearance related to dry, hacking cough.c. Ineffective individual coping to COPD.d. Pain related to immobilization of affected leg.37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best

response would be:a. “Don’t worry. It’s only temporary”b. “Why are you crying? I didn’t get to the bad news yet”c. “Your hair is really pretty”d. “I know this will be difficult for you, but your hair will grow back after

the completion of chemotheraphy”38. An additional Vitamin C is required during all of the following periods

except:a. Infancyb. Young adulthoodc. Childhoodd. Pregnancy39. A prescribed amount of oxygen s needed for a patient with COPD to

prevent:a. Cardiac arrest related to increased partial pressure of carbon dioxide in

arterial blood (PaCO2)b. Circulatory overload due to hypervolemiac. Respiratory excitementd. Inhibition of the respiratory hypoxic stimulus40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which

of the following is the most significant symptom of his disorder?a. Lethargyb. Increased pulse rate and blood pressurec. Muscle weaknessd. Muscle irritability41. Which of the following nursing interventions promotes patient safety?a. Asses the patient’s ability to ambulate and transfer from a bed to a chairb. Demonstrate the signal system to the patientc. Check to see that the patient is wearing his identification bandd. All of the above42. Studies have shown that about 40% of patients fall out of bed despite the

use of side rails; this has led to which of the following conclusions?a. Side rails are ineffectiveb. Side rails should not be usedc. Side rails are a deterrent that prevent a patient from falling out of bed.d. Side rails are a reminder to a patient not to get out of bed43. Examples of patients suffering from impaired awareness include all of

the following except:a. A semiconscious or over fatigued patientb. A disoriented or confused patientc. A patient who cannot care for himself at homed. A patient demonstrating symptoms of drugs or alcohol withdrawal

44. The most common injury among elderly persons is:a. Atheroscleotic changes in the blood vesselsb. Increased incidence of gallbladder diseasec. Urinary Tract Infectiond. Hip fracture45. The most common psychogenic disorder among elderly person is:a. Depressionb. Sleep disturbances (such as bizarre dreams)c. Inability to concentrated. Decreased appetite46. Which of the following vascular system changes results from aging?a. Increased peripheral resistance of the blood vesselsb. Decreased blood flowc. Increased work load of the left ventricled. All of the above47. Which of the following is the most common cause of dementia among

elderly persons?a. Parkinson’s diseaseb. Multiple sclerosisc. Amyotrophic lateral sclerosis (Lou Gerhig’s disease)d. Alzheimer’s disease48. The nurse’s most important legal responsibility after a patient’s death in

a hospital is:a. Obtaining a consent of an autopsyb. Notifying the coroner or medical examinerc. Labeling the corpse appropriatelyd. Ensuring that the attending physician issues the death certification49. Before rigor mortis occurs, the nurse is responsible for:a. Providing a complete bath and dressing changeb. Placing one pillow under the body’s head and shouldersc. Removing the body’s clothing and wrapping the body in a shroudd. Allowing the body to relax normally50. When a patient in the terminal stages of lung cancer begins to exhibit

loss of consciousness, a major nursing priority is to:a. Protect the patient from injuryb. Insert an airwayc. Elevate the head of the bedd. Withdraw all pain medications

ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PRACTICE QUESTIONS

1. B. When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia.

2. C. Orthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without effort.

3. C. A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test.

4. B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet.

5. D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation.

6. D. The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs.

7. D. Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs.

8. B. The brain-dead patient’s family needs support and reassurance in making a decision about organ donation. Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. However, the family’s concerns must be addressed before members are asked to sign a consent form. The body of an organ donor is available for burial.

9. C. Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem

threatens patient safety. In this case, the supervisor is the resource person to approach.

10. D. Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps.

11. A. Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act that a nurse performs on the patient against his will is considered assault and battery.

12. A. Oral communication that injures an individual’s reputation is considered slander. Written communication that does the same is considered libel.

13. D. Malpractice is defined as injurious or unprofessional actions that harm another. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale.

14. A. The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or heating pad to a patient without a physician’s order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice.

15. C. An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display emotion, such as crying.

16. B. To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Changes in vital signs may be cause by factors other than blood loss. Abdominal girth is unrelated to blood loss.

17. D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. Tympanic percussion, measurement of abdominal girth, and inspection are

methods of assessing the abdomen. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis.

18. C. Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.

19. C. The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen. In the prone position, the patient lies on his abdomen with his face turned to the side. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. In the lateral position, the patient lies on his side.

20. D. All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward.

21. B. During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sides—first with eyes open, then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding.

22. A. The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case, 54.

23. D. A slightly elevated temperature in the immediate preoperative or post operative period may result from the lack of fluids before surgery rather than from infection. Anxiety will not cause an elevated temperature. Hypothermia is an abnormally low body temperature.

24. D. The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations.

25. D. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body temperature, as measured on an oral thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal.

26. D. Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Fever, exercise, and sympathetic stimulation all increase the heart rate.

27. D. The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. Base line

vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration.

28. C. Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated.

29. B. Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Age is also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk.

30. A. Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. High- humidity air and chest physiotherapy help liquefy and mobilize secretions.

31. A. Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition.

32. C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Feeding himself is a long-range expected outcome. Soft foods, Fowler’s or semi-Fowler’s position, and oral hygiene before eating should be part of the feeding regimen.

33. A. A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake.

34. A. Fluids containing caffeine have a diuretic effect. Beets and urinary analgesics, such as pyridium, can color urine red. Kaopectate is an anti diarrheal medication.

35. C. A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Accompanying him will offer moral support, enabling him to face the rest of the world. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. Waiting to consult a physical therapist is unnecessary.

36. A. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Ineffective individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture.

37. D. “I know this will be difficult” acknowledges the problem and suggests a resolution to it. “Don’t worry..” offers some relief but doesn’t recognize the patient’s feelings. “..I didn’t get to the bad news yet” would be inappropriate at any time. “Your hair is really pretty” offers no consolation or alternatives to the patient.

38. B. Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress.

39. D. Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Circulatory overload and respiratory excitement have no relevance to the question.

40. C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems.

41. D. Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patient’s ability to carry out these functions safely. Demonstrating the signal system and providing an opportunity for a return demonstration ensures that the patient knows how to operate the equipment and encourages him to call for assistance when needed. Checking the patient’s identification band verifies the patient’s identity and prevents identification mistakes in drug administration.

42. D. Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. The other answers are incorrect interpretations of the statistical data.

43. C. A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility.

44. D. Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. The other answers are diseases that can occur in the elderly from physiologic changes.

45. A. Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors

46. D. Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. These changes, in turn, increase the work load of the left ventricle.

47. D. Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer’s type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Parkinson’s disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Multiple sclerosis, a progressive, degenerative disease involving demyelination of the nerve fibers, usually begins in young adulthood and is marked by periods of remission and exacerbation. Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the neurons, eventually results in atrophy of all the muscles; including those necessary for respiration.

48. C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patient’s death; however, she is not legally responsible for performing these functions. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it.

49. B. The nurse must place a pillow under the decreased person’s head and shoulders to prevent blood from settling in the face and discoloring it. She is required to bathe only soiled areas of the body since the mortician will wash the entire body. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth.

50. A. Ensuring the patient’s safety is the most essential action at this time. The other nursing actions may be necessary but are not a major priority.

MATERNAL AND CHILD HEALTH NURSING PRACTICE QUESTIONS WITH RATIONALE

1. When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?

1. Sperm count2. Sperm motility3. Sperm maturity4. Semen volume2. A couple who wants to conceive but has been unsuccessful during the last

2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, “We know several friends in our age group and all of them have their own child already, Why can’t we have one?”. Which of the following would be the most pertinent nursing diagnosis for this couple?

1. Fear related to the unknown2. Pain related to numerous procedures.3. Ineffective family coping related to infertility.4. Self-esteem disturbance related to infertility.

3. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?

1. Dysuria2. Frequency3. Incontinence4. Burning4. Heartburn and flatulence, common in the second trimester, are most

likely the result of which of the following?1. Increased plasma HCG levels2. Decreased intestinal motility3. Decreased gastric acidity4. Elevated estrogen levels5. On which of the following areas would the nurse expect to observe

chloasma?1. Breast, areola, and nipples2. Chest, neck, arms, and legs3. Abdomen, breast, and thighs4. Cheeks, forehead, and nose6. A pregnant client states that she “waddles” when she walks. The nurse’s

explanation is based on which of the following as the cause?1. The large size of the newborn2. Pressure on the pelvic muscles3. Relaxation of the pelvic joints4. Excessive weight gain7. Which of the following represents the average amount of weight gained

during pregnancy?1. 12 to 22 lb2. 15 to 25 lb3. 24 to 30 lb4. 25 to 40 lb8. When talking with a pregnant client who is experiencing aching swollen,

leg veins, the nurse would explain that this is most probably the result of which of the following?

1. Thrombophlebitis2. Pregnancy-induced hypertension3. Pressure on blood vessels from the enlarging uterus4. The force of gravity pulling down on the uterus9. Cervical softening and uterine souffle are classified as which of the

following?1. Diagnostic signs2. Presumptive signs3. Probable signs4. Positive signs10.Which of the following would the nurse identify as a presumptive sign of

pregnancy?1. Hegar sign

2. Nausea and vomiting3. Skin pigmentation changes4. Positive serum pregnancy test11.Which of the following common emotional reactions to pregnancy would

the nurse expect to occur during the first trimester?1. Introversion, egocentrism, narcissism2. Awkwardness, clumsiness, and unattractiveness3. Anxiety, passivity, extroversion4. Ambivalence, fear, fantasies12. During which of the following would the focus of classes be mainly on

physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?

1. Prepregnant period2. First trimester3. Second trimester4. Third trimester13.Which of the following would be disadvantage of breast feeding?1. Involution occurs more rapidly2. The incidence of allergies increases due to maternal antibodies3. The father may resent the infant’s demands on the mother’s body4. There is a greater chance for error during preparation14.Which of the following would cause a false-positive result on a pregnancy

test?1. The test was performed less than 10 days after an abortion2. The test was performed too early or too late in the pregnancy3. The urine sample was stored too long at room temperature4. A spontaneous abortion or a missed abortion is impending15. FHR can be auscultated with a fetoscope as early as which of the

following?1. 5 weeks gestation2. 10 weeks gestation3. 15 weeks gestation4. 20 weeks gestation16. A client LMP began July 5. Her EDD should be which of the following?1. January 22. March 283. April 124. October 1217.Which of the following fundal heights indicates less than 12 weeks’

gestation when the date of the LMP is unknown?1. Uterus in the pelvis2. Uterus at the xiphoid3. Uterus in the abdomen4. Uterus at the umbilicus18.Which of the following danger signs should be reported promptly during

the antepartum period?

1. Constipation2. Breast tenderness3. Nasal stuffiness4. Leaking amniotic fluid19.Which of the following prenatal laboratory test values would the nurse

consider as significant?1. Hematocrit 33.5%2. Rubella titer less than 1:83. White blood cells 8,000/mm34. One hour glucose challenge test 110 g/dL20.Which of the following characteristics of contractions would the nurse

expect to find in a client experiencing true labor?1. Occurring at irregular intervals2. Starting mainly in the abdomen3. Gradually increasing intervals4. Increasing intensity with walking21. During which of the following stages of labor would the nurse assess

“crowning”?1. First stage2. Second stage3. Third stage4. Fourth stage22. Barbiturates are usually not given for pain relief during active labor for

which of the following reasons?1. The neonatal effects include hypotonia, hypothermia, generalized

drowsiness, and reluctance to feed for the first few days.2. These drugs readily cross the placental barrier, causing depressive

effects in the newborn 2 to 3 hours after intramuscular injection.3. They rapidly transfer across the placenta, and lack of an antagonist

make them generally inappropriate during labor.4. Adverse reactions may include maternal hypotension, allergic or toxic

reaction or partial or total respiratory failure23.Which of the following nursing interventions would the nurse perform

during the third stage of labor?1. Obtain a urine specimen and other laboratory tests.2. Assess uterine contractions every 30 minutes.3. Coach for effective client pushing4. Promote parent-newborn interaction.24.Which of the following actions demonstrates the nurse’s understanding

about the newborn’s thermoregulatory ability?1. Placing the newborn under a radiant warmer.2. Suctioning with a bulb syringe3. Obtaining an Apgar score4. Inspecting the newborn’s umbilical cord25. Immediately before expulsion, which of the following cardinal movements

occur?

1. Descent2. Flexion3. Extension4. External rotation26. Before birth, which of the following structures connects the right and left

auricles of the heart?1. Umbilical vein2. Foramen ovale3. Ductus arteriosus4. Ductus venosus27.Which of the following when present in the urine may cause a reddish

stain on the diaper of a newborn?1. Mucus2. Uric acid crystals3. Bilirubin4. Excess iron28.When assessing the newborn’s heart rate, which of the following ranges

would be considered normal if the newborn were sleeping?1. 80 beats per minute2. 100 beats per minute3. 120 beats per minute4. 140 beats per minute29.Which of the following is true regarding the fontanels of the newborn?1. The anterior is triangular shaped; the posterior is diamond shaped.2. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.3. The anterior is large in size when compared to the posterior fontanel.4. The anterior is bulging; the posterior appears sunken.30.Which of the following groups of newborn reflexes below are present at

birth and remain unchanged through adulthood?1. Blink, cough, rooting, and gag2. Blink, cough, sneeze, gag3. Rooting, sneeze, swallowing, and cough4. Stepping, blink, cough, and sneeze31.Which of the following describes the Babinski reflex?1. The newborn’s toes will hyperextend and fan apart from dorsiflexion of

the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.

2. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.

3. The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched.

4. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface

32.Which of the following statements best describes hyperemesis gravidarum?

1. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.

2. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.

3. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients

4. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding

33.Which of the following would the nurse identify as a classic sign of PIH?1. Edema of the feet and ankles2. Edema of the hands and face3. Weight gain of 1 lb/week4. Early morning headache34. In which of the following types of spontaneous abortions would the nurse

assess dark brown vaginal discharge and a negative pregnancy tests?1. Threatened2. Imminent3. Missed4. Incomplete35.Which of the following factors would the nurse suspect as predisposing a

client to placenta previa?1. Multiple gestation2. Uterine anomalies3. Abdominal trauma4. Renal or vascular disease36.Which of the following would the nurse assess in a client experiencing

abruptio placenta?1. Bright red, painless vaginal bleeding2. Concealed or external dark red bleeding3. Palpable fetal outline4. Soft and nontender abdomen37.Which of the following is described as premature separation of a normally

implanted placenta during the second half of pregnancy, usually with severe hemorrhage?

1. Placenta previa2. Ectopic pregnancy3. Incompetent cervix4. Abruptio placentae38.Which of the following may happen if the uterus becomes overstimulated

by oxytocin during the induction of labor?1. Weak contraction prolonged to more than 70 seconds2. Tetanic contractions prolonged to more than 90 seconds3. Increased pain with bright red vaginal bleeding4. Increased restlessness and anxiety39.When preparing a client for cesarean delivery, which of the following key

concepts should be considered when implementing nursing care?

1. Instruct the mother’s support person to remain in the family lounge until after the delivery

2. Arrange for a staff member of the anesthesia department to explain what to expect postoperatively

3. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth

4. Explain the surgery, expected outcome, and kind of anesthetics40.Which of the following best describes preterm labor?1. Labor that begins after 20 weeks gestation and before 37 weeks

gestation2. Labor that begins after 15 weeks gestation and before 37 weeks



gestation41.When PROM occurs, which of the following provides evidence of the

nurse’s understanding of the client’s immediate needs?1. The chorion and amnion rupture 4 hours before the onset of labor.2. PROM removes the fetus most effective defense against infection3. Nursing care is based on fetal viability and gestational age.4. PROM is associated with malpresentation and possibly incompetent

cervix42.Which of the following factors is the underlying cause of dystocia?1. Nurtional2. Mechanical3. Environmental4. Medical43.When uterine rupture occurs, which of the following would be the

priority?1. Limiting hypovolemic shock2. Obtaining blood specimens3. Instituting complete bed rest4. Inserting a urinary catheter44.Which of the following is the nurse’s initial action when umbilical cord

prolapse occurs?1. Begin monitoring maternal vital signs and FHR2. Place the client in a knee-chest position in bed3. Notify the physician and prepare the client for delivery4. Apply a sterile warm saline dressing to the exposed cord45.Which of the following amounts of blood loss following birth marks the

criterion for describing postpartum hemorrhage?1. More than 200 ml2. More than 300 ml3. More than 400 ml4. More than 500 ml

46.Which of the following is the primary predisposing factor related to mastitis?

1. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts

2. Endemic infection occurring randomly and localizing in the periglandular connective tissue

3. Temporary urinary retention due to decreased perception of the urge to avoid

4. Breast injury caused by overdistention, stasis, and cracking of the nipples

47.Which of the following best describes thrombophlebitis?1. Inflammation and clot formation that result when blood components

combine to form an aggregate body2. Inflammation and blood clots that eventually become lodged within the

pulmonary blood vessels3. Inflammation and blood clots that eventually become lodged within the

femoral vein4. Inflammation of the vascular endothelium with clot formation on the

vessel wall48.Which of the following assessment findings would the nurse expect if the

client develops DVT?1. Midcalf pain, tenderness and redness along the vein2. Chills, fever, malaise, occurring 2 weeks after delivery3. Muscle pain the presence of Homans sign, and swelling in the affected

limb4. Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery49.Which of the following are the most commonly assessed findings in

cystitis?1. Frequency, urgency, dehydration, nausea, chills, and flank pain2. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic

pain3. Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever4. High fever, chills, flank pain nausea, vomiting, dysuria, and frequency50.Which of the following best reflects the frequency of reported postpartum

“blues”?1. Between 10% and 40% of all new mothers report some form of

postpartum blues2. Between 30% and 50% of all new mothers report some form of



postpartum blues51. For the client who is using oral contraceptives, the nurse informs the

client about the need to take the pill at the same time each day to accomplish which of the following?

1. Decrease the incidence of nausea2. Maintain hormonal levels3. Reduce side effects4. Prevent drug interactions52.When teaching a client about contraception. Which of the following would

the nurse include as the most effective method for preventing sexually transmitted infections?

1. Spermicides2. Diaphragm3. Condoms4. Vasectomy53.When preparing a woman who is 2 days postpartum for discharge,

recommendations for which of the following contraceptive methods would be avoided?

1. Diaphragm2. Female condom3. Oral contraceptives4. Rhythm method54. For which of the following clients would the nurse expect that an

intrauterine device would not be recommended?1. Woman over age 352. Nulliparous woman3. Promiscuous young adult4. Postpartum client55. A client in her third trimester tells the nurse, “I’m constipated all the

time!” Which of the following should the nurse recommend?1. Daily enemas2. Laxatives3. Increased fiber intake4. Decreased fluid intake56.Which of the following would the nurse use as the basis for the teaching

plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy?

1. 10 pounds per trimester2. 1 pound per week for 40 weeks3. ½ pound per week for 40 weeks4. A total gain of 25 to 30 pounds57. The client tells the nurse that her last menstrual period started on

January 14 and ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of the following?

1. September 272. October 213. November 74. December 2758.When taking an obstetrical history on a pregnant client who states, “I had

a son born at 38 weeks gestation, a daughter born at 30 weeks gestation

and I lost a baby at about 8 weeks,” the nurse should record her obstetrical history as which of the following?

1. G2 T2 P0 A0 L22. G3 T1 P1 A0 L23. G3 T2 P0 A0 L24. G4 T2 P1 A1 L259.When preparing to listen to the fetal heart rate at 12 weeks’ gestation,

the nurse would use which of the following?1. Stethoscope placed midline at the umbilicus2. Doppler placed midline at the suprapubic region3. Fetoscope placed midway between the umbilicus and the xiphoid

process4. External electronic fetal monitor placed at the umbilicus60.When developing a plan of care for a client newly diagnosed with

gestational diabetes, which of the following instructions would be the priority?

1. Dietary intake2. Medication3. Exercise4. Glucose monitoring61. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of

the following would be the priority when assessing the client?1. Glucosuria2. Depression3. Hand/face edema4. Dietary intake62. A client 12 weeks’ pregnant come to the emergency department with

abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation. The nurse would document these findings as which of the following?

1. Threatened abortion2. Imminent abortion3. Complete abortion4. Missed abortion63.Which of the following would be the priority nursing diagnosis for a client

with an ectopic pregnancy?1. Risk for infection2. Pain3. Knowledge Deficit4. Anticipatory Grieving64. Before assessing the postpartum client’s uterus for firmness and position

in relation to the umbilicus and midline, which of the following should the nurse do first?

1. Assess the vital signs2. Administer analgesia3. Ambulate her in the hall

4. Assist her to urinate65.Which of the following should the nurse do when a primipara who is

lactating tells the nurse that she has sore nipples?1. Tell her to breast feed more frequently2. Administer a narcotic before breast feeding3. Encourage her to wear a nursing brassiere4. Use soap and water to clean the nipples66. The nurse assesses the vital signs of a client, 4 hours’ postpartum that are

as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first?

1. Report the temperature to the physician2. Recheck the blood pressure with another cuff3. Assess the uterus for firmness and position4. Determine the amount of lochia67. The nurse assesses the postpartum vaginal discharge (lochia) on four

clients. Which of the following assessments would warrant notification of the physician?

1. A dark red discharge on a 2-day postpartum client2. A pink to brownish discharge on a client who is 5 days postpartum3. Almost colorless to creamy discharge on a client 2 weeks after delivery4. A bright red discharge 5 days after delivery68. A postpartum client has a temperature of 101.4ºF, with a uterus that is

tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

1. Lochia2. Breasts3. Incision4. Urine69.Which of the following is the priority focus of nursing practice with the

current early postpartum discharge?1. Promoting comfort and restoration of health2. Exploring the emotional status of the family3. Facilitating safe and effective self-and newborn care4. Teaching about the importance of family planning70.Which of the following actions would be least effective in maintaining a

neutral thermal environment for the newborn?1. Placing infant under radiant warmer after bathing2. Covering the scale with a warmed blanket prior to weighing3. Placing crib close to nursery window for family viewing4. Covering the infant’s head with a knit stockinette71. A newborn who has an asymmetrical Moro reflex response should be

further assessed for which of the following?1. Talipes equinovarus2. Fractured clavicle3. Congenital hypothyroidism4. Increased intracranial pressure

72. During the first 4 hours after a male circumcision, assessing for which of the following is the priority?

1. Infection2. Hemorrhage3. Discomfort4. Dehydration73. The mother asks the nurse. “What’s wrong with my son’s breasts? Why

are they so enlarged?” Whish of the following would be the best response by the nurse?

1. “The breast tissue is inflamed from the trauma experienced with birth”2. “A decrease in material hormones present before birth causes

enlargement,”3. “You should discuss this with your doctor. It could be a malignancy”4. “The tissue has hypertrophied while the baby was in the uterus”74. Immediately after birth the nurse notes the following on a male newborn:

respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do?

1. Call the assessment data to the physician’s attention2. Start oxygen per nasal cannula at 2 L/min.3. Suction the infant’s mouth and nares4. Recognize this as normal first period of reactivity75. The nurse hears a mother telling a friend on the telephone about

umbilical cord care. Which of the following statements by the mother indicates effective teaching?

1. “Daily soap and water cleansing is best”2. ‘Alcohol helps it dry and kills germs”3. “An antibiotic ointment applied daily prevents infection”4. “He can have a tub bath each day”76. A newborn weighing 3000 grams and feeding every 4 hours needs 120

calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional needs?

1. 2 ounces2. 3 ounces3. 4 ounces4. 6 ounces77. The postterm neonate with meconium-stained amniotic fluid needs care

designed to especially monitor for which of the following?1. Respiratory problems2. Gastrointestinal problems3. Integumentary problems4. Elimination problems78.When measuring a client’s fundal height, which of the following

techniques denotes the correct method of measurement used by the nurse?

1. From the xiphoid process to the umbilicus2. From the symphysis pubis to the xiphoid process3. From the symphysis pubis to the fundus4. From the fundus to the umbilicus79. A client with severe preeclampsia is admitted with of BP 160/110,

proteinuria, and severe pitting edema. Which of the following would be most important to include in the client’s plan of care?

1. Daily weights2. Seizure precautions3. Right lateral positioning4. Stress reduction80. A postpartum primipara asks the nurse, “When can we have sexual

intercourse again?” Which of the following would be the nurse’s best response?

1. “Anytime you both want to.”2. “As soon as choose a contraceptive method.”3. “When the discharge has stopped and the incision is healed.”4. “After your 6 weeks examination.”81.When preparing to administer the vitamin K injection to a neonate, the

nurse would select which of the following sites as appropriate for the injection?

1. Deltoid muscle2. Anterior femoris muscle3. Vastus lateralis muscle4. Gluteus maximus muscle82.When performing a pelvic examination, the nurse observes a red swollen

area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following?

1. Clitoris2. Parotid gland3. Skene’s gland4. Bartholin’s gland83. To differentiate as a female, the hormonal stimulation of the embryo that

must occur involves which of the following?1. Increase in maternal estrogen secretion2. Decrease in maternal androgen secretion3. Secretion of androgen by the fetal gonad4. Secretion of estrogen by the fetal gonad84. A client at 8 weeks’ gestation calls complaining of slight nausea in the

morning hours. Which of the following client interventions should the nurse question?

1. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water2. Eating a few low-sodium crackers before getting out of bed3. Avoiding the intake of liquids in the morning hours4. Eating six small meals a day instead of thee large meals

85. The nurse documents positive ballottement in the client’s prenatal record. The nurse understands that this indicates which of the following?

1. Palpable contractions on the abdomen2. Passive movement of the unengaged fetus3. Fetal kicking felt by the client4. Enlargement and softening of the uterus86. During a pelvic exam the nurse notes a purple-blue tinge of the cervix.

The nurse documents this as which of the following?1. Braxton-Hicks sign2. Chadwick’s sign3. Goodell’s sign4. McDonald’s sign87. During a prenatal class, the nurse explains the rationale for breathing

techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following?

1. Eliminate pain and give the expectant parents something to do2. Reduce the risk of fetal distress by increasing uteroplacental perfusion3. Facilitate relaxation, possibly reducing the perception of pain4. Eliminate pain so that less analgesia and anesthesia are needed88. After 4 hours of active labor, the nurse notes that the contractions of a

primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

1. Obtaining an order to begin IV oxytocin infusion2. Administering a light sedative to allow the patient to rest for several

hour3. Preparing for a cesarean section for failure to progress4. Increasing the encouragement to the patient when pushing begins89. A multigravida at 38 weeks’ gestation is admitted with painless, bright

red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?

1. Maternal vital sign2. Fetal heart rate3. Contraction monitoring4. Cervical dilation90.Which of the following would be the nurse’s most appropriate response to

a client who asks why she must have a cesarean delivery if she has a complete placenta previa?

1. “You will have to ask your physician when he returns.”2. “You need a cesarean to prevent hemorrhage.”3. “The placenta is covering most of your cervix.”4. “The placenta is covering the opening of the uterus and blocking your

baby.”91. The nurse understands that the fetal head is in which of the following

positions with a face presentation?1. Completely flexed

2. Completely extended3. Partially extended4. Partially flexed92.With a fetus in the left-anterior breech presentation, the nurse would

expect the fetal heart rate would be most audible in which of the following areas?

1. Above the maternal umbilicus and to the right of midline2. In the lower-left maternal abdominal quadrant3. In the lower-right maternal abdominal quadrant4. Above the maternal umbilicus and to the left of midline93. The amniotic fluid of a client has a greenish tint. The nurse interprets this

to be the result of which of the following?1. Lanugo2. Hydramnio3. Meconium4. Vernix94. A patient is in labor and has just been told she has a breech presentation.

The nurse should be particularly alert for which of the following?1. Quickening2. Ophthalmia neonatorum3. Pica4. Prolapsed umbilical cord95.When describing dizygotic twins to a couple, on which of the following

would the nurse base the explanation?1. Two ova fertilized by separate sperm2. Sharing of a common placenta3. Each ova with the same genotype4. Sharing of a common chorion96.Which of the following refers to the single cell that reproduces itself after

conception?1. Chromosome2. Blastocyst3. Zygote4. Trophoblast97. In the late 1950s, consumers and health care professionals began

challenging the routine use of analgesics and anesthetics during childbirth. Which of the following was an outgrowth of this concept?

1. Labor, delivery, recovery, postpartum (LDRP)2. Nurse-midwifery3. Clinical nurse specialist4. Prepared childbirth98. A client has a midpelvic contracture from a previous pelvic injury due to a

motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth?

1. Symphysis pubis

2. Sacral promontory3. Ischial spines4. Pubic arch99.When teaching a group of adolescents about variations in the length of

the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in which of the following phases?

1. Menstrual phase2. Proliferative phase3. Secretory phase4. Ischemic phase100. When teaching a group of adolescents about male hormone

production, which of the following would the nurse include as being produced by the Leydig cells?

1. Follicle-stimulating hormone2. Testosterone3. Leuteinizing hormone

Gonadotropin releasing hormone101. While performing physical assessment of a 12 month-old, the nurse

notes that the infant’s anterior fontanelle is still slightly open. Which of the following is the nurse’s most appropriate action?

1. Notify the physician immediately because there is a problem.2. Perform an intensive neurologic examination.3. Perform an intensive developmental examination.4. Do nothing because this is a normal finding for the age.102. When teaching a mother about introducing solid foods to her child,

which of the following indicates the earliest age at which this should be done?

1. 1 month2. 2 months3. 3 months4. 4 months103. The infant of a substance-abusing mother is at risk for developing a

sense of which of the following?1. Mistrust2. Shame3. Guilt4. Inferiority104. Which of the following toys should the nurse recommend for a 5-

month-old?1. A big red balloon2. A teddy bear with button eyes3. A push-pull wooden truck4. A colorful busy box105. The mother of a 2-month-old is concerned that she may be spoiling

her baby by picking her up when she cries. Which of the following would be the nurse’s best response?

1. “ Let her cry for a while before picking her up, so you don’t spoil her”2. “Babies need to be held and cuddled; you won’t spoil her this way”3. “Crying at this age means the baby is hungry; give her a bottle”4. “If you leave her alone she will learn how to cry herself to sleep”106. When assessing an 18-month-old, the nurse notes a characteristic

protruding abdomen. Which of the following would explain the rationale for this finding?

1. Increased food intake owing to age2. Underdeveloped abdominal muscles3. Bowlegged posture4. Linear growth curve107. If parents keep a toddler dependent in areas where he is capable of

using skills, the toddle will develop a sense of which of the following?1. Mistrust2. Shame3. Guilt4. Inferiority108. Which of the following is an appropriate toy for an 18-month-old?1. Multiple-piece puzzle2. Miniature cars3. Finger paints4. Comic book109. When teaching parents about the child’s readiness for toilet

training, which of the following signs should the nurse instruct them to watch for in the toddler?

1. Demonstrates dryness for 4 hours2. Demonstrates ability to sit and walk3. Has a new sibling for stimulation4. Verbalizes desire to go to the bathroom110. When teaching parents about typical toddler eating patterns, which

of the following should be included?1. Food “jags”2. Preference to eat alone3. Consistent table manners4. Increase in appetite111. Which of the following suggestions should the nurse offer the

parents of a 4-year-old boy who resists going to bed at night?1. “Allow him to fall asleep in your room, then move him to his own bed.”2. “Tell him that you will lock him in his room if he gets out of bed one

more time.”3. “Encourage active play at bedtime to tire him out so he will fall asleep

faster.”4. “Read him a story and allow him to play quietly in his bed until he falls

asleep.”112. When providing therapeutic play, which of the following toys would

best promote imaginative play in a 4-year-old?

1. Large blocks2. Dress-up clothes3. Wooden puzzle4. Big wheels113. Which of the following activities, when voiced by the parents

following a teaching session about the characteristics of school-age cognitive development would indicate the need for additional teaching?

1. Collecting baseball cards and marbles2. Ordering dolls according to size3. Considering simple problem-solving options4. Developing plans for the future114. A hospitalized schoolager states: “I’m not afraid of this place, I’m

not afraid of anything.” This statement is most likely an example of which of the following?

1. Regression2. Repression3. Reaction formation4. Rationalization115. After teaching a group of parents about accident prevention for

schoolagers, which of the following statements by the group would indicate the need for more teaching?

1. “Schoolagers are more active and adventurous than are younger children.”

2. “Schoolagers are more susceptible to home hazards than are younger children.”

3. “Schoolagers are unable to understand potential dangers around them.”4. “Schoolargers are less subject to parental control than are younger

children.”116. Which of the following skills is the most significant one learned

during the schoolage period?1. Collecting2. Ordering3. Reading4. Sorting117. A child age 7 was unable to receive the measles, mumps, and

rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine?

1. In a month from now2. In a year from now3. At age 104. At age 13118. The adolescent’s inability to develop a sense of who he is and what

he can become results in a sense of which of the following?1. Shame2. Guilt3. Inferiority

4. Role diffusion119. Which of the following would be most appropriate for a nurse to use

when describing menarche to a 13-year-old?1. A female’s first menstruation or menstrual “periods”2. The first year of menstruation or “period”3. The entire menstrual cycle or from one “period” to another4. The onset of uterine maturation or peak growth120. A 14-year-old boy has acne and according to his parents, dominates

the bathroom by using the mirror all the time. Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents?

1. “This is probably the only concern he has about his body. So don’t worry about it or the time he spends on it.”

2. “Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming.”

3. “A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes?”

4. “You appear to be keeping your face well washed. Would you feel comfortable discussing your cleansing method?”

121. Which of the following should the nurse suspect when noting that a 3-year-old is engaging in explicit sexual behavior during doll play?

1. The child is exhibiting normal pre-school curiosity2. The child is acting out personal experiences3. The child does not know how to play with dolls4. The child is probably developmentally delayed.122. Which of the following statements by the parents of a child with

school phobia would indicate the need for further teaching?1. “We’ll keep him at home until phobia subsides.”2. “We’ll work with his teachers and counselors at school.”3. “We’ll try to encourage him to talk about his problem.”4. “We’ll discuss possible solutions with him and his counselor.”123. When developing a teaching plan for a group of high school

students about teenage pregnancy, the nurse would keep in mind which of the following?

1. The incidence of teenage pregnancies is increasing.2. Most teenage pregnancies are planned.3. Denial of the pregnancy is common early on.4. The risk for complications during pregnancy is rare.124. When assessing a child with a cleft palate, the nurse is aware that

the child is at risk for more frequent episodes of otitis media due to which of the following?

1. Lowered resistance from malnutrition2. Ineffective functioning of the Eustachian tubes3. Plugging of the Eustachian tubes with food particles4. Associated congenital defects of the middle ear.

125. While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected?

1. A strong Moro reflex2. A strong parachute reflex3. Rolling from front to back4. Lifting of head and chest when prone126. By the end of which of the following would the nurse most

commonly expect a child’s birth weight to triple?1. 4 months2. 7 months3. 9 months4. 12 months127. Which of the following best describes parallel play between two

toddlers?1. Sharing crayons to color separate pictures2. Playing a board game with a nurse3. Sitting near each other while playing with separate dolls4. Sharing their dolls with two different nurses128. Which of the following would the nurse identify as the initial priority

for a child with acute lymphocytic leukemia?1. Instituting infection control precautions2. Encouraging adequate intake of iron-rich foods3. Assisting with coping with chronic illness4. Administering medications via IM injections129. Which of the following information, when voiced by the mother,

would indicate to the nurse that she understands home care instructions following the administration of a diphtheria, tetanus, and pertussis injection?

1. Measures to reduce fever2. Need for dietary restrictions3. Reasons for subsequent rash4. Measures to control subsequent diarrhea130. Which of the following actions by a community health nurse is most

appropriate when noting multiple bruises and burns on the posterior trunk of an 18-month-old child during a home visit?

1. Report the child’s condition to Protective Services immediately.2. Schedule a follow-up visit to check for more bruises.3. Notify the child’s physician immediately.4. Don nothing because this is a normal finding in a toddler.131. Which of the following is being used when the mother of a

hospitalized child calls the student nurse and states, “You idiot, you have no idea how to care for my sick child”?

1. Displacement2. Projection3. Repression4. Psychosis

132. Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?

1. Susceptibility to respiratory infection2. Bleeding tendencies3. Frequent vomiting and diarrhea4. Seizure disorder133. Which of the following would the nurse do first for a 3-year-old boy

who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is learning forward and drooling?

1. Auscultate his lungs and place him in a mist tent.2. Have him lie down and rest after encouraging fluids.3. Examine his throat and perform a throat culture4. Notify the physician immediately and prepare for intubation.134. Which of the following would the nurse need to keep in mind as a

predisposing factor when formulating a teaching plan for child with a urinary tract infection?

1. A shorter urethra in females2. Frequent emptying of the bladder3. Increased fluid intake4. Ingestion of acidic juices135. Which of the following should the nurse do first for a 15-year-old

boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome?

1. Medicate him with acetaminophen.2. Notify the physician immediately3. Release the traction4. Monitor him every 5 minutes136. At which of the following ages would the nurse expect to administer

the varicella zoster vaccine to child?1. At birth2. 2 months3. 6 months4. 12 months137. When discussing normal infant growth and development with

parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old?

1. Push-pull toys2. Rattle3. Large blocks4. Mobile138. Which of the following aspects of psychosocial development is

necessary for the nurse to keep in mind when providing care for the preschool child?

1. The child can use complex reasoning to think out situations.2. Fear of body mutilation is a common preschool fear

3. The child engages in competitive types of play4. Immediate gratification is necessary to develop initiative.139. Which of the following is characteristic of a preschooler with mid

mental retardation?1. Slow to feed self2. Lack of speech3. Marked motor delays4. Gait disability140. Which of the following assessment findings would lead the nurse to

suspect Down syndrome in an infant?1. Small tongue2. Transverse palmar crease3. Large nose4. Restricted joint movement141. While assessing a newborn with cleft lip, the nurse would be alert

that which of the following will most likely be compromised?1. Sucking ability2. Respiratory status3. Locomotion4. GI function142. When providing postoperative care for the child with a cleft palate,

the nurse should position the child in which of the following positions?1. Supine2. Prone3. In an infant seat4. On the side143. While assessing a child with pyloric stenosis, the nurse is likely to

note which of the following?1. Regurgitation2. Steatorrhea3. Projectile vomiting4. “Currant jelly” stools144. Which of the following nursing diagnoses would be inappropriate

for the infant with gastroesophageal reflux (GER)?1. Fluid volume deficit2. Risk for aspiration3. Altered nutrition: less than body requirements4. Altered oral mucous membranes145. Which of the following parameters would the nurse monitor to

evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)?

1. Vomiting2. Stools3. Uterine4. Weight

146. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?

1. Rice2. Milk3. Wheat4. Chicken147. Which of the following would the nurse expect to assess in a child

with celiac disease having a celiac crisis secondary to an upper respiratory infection?

1. Respiratory distress2. Lethargy3. Watery diarrhea4. Weight gain148. Which of the following should the nurse do first after noting that a

child with Hirschsprung disease has a fever and watery explosive diarrhea?

1. Notify the physician immediately2. Administer antidiarrheal medications3. Monitor child ever 30 minutes4. Nothing, this is characteristic of Hirschsprung disease149. A newborn’s failure to pass meconium within the first 24 hours after

birth may indicate which of the following?1. Hirschsprung disease2. Celiac disease3. Intussusception4. Abdominal wall defect150. When assessing a child for possible intussusception, which of the

following would be least likely to provide valuable information?1. Stool inspection2. Pain pattern3. Family history4. Abdominal palpation

ANSWER AND RATIONALE1. B . Although all of the factors listed are important, sperm motility is the

most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.

2. D . Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.

3. B . Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.

4. C . During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.

5. D . Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.

6. C . During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain has no effect on gait.

7. C . The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.

8. C . Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.

9. C. Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac.

Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.

10.B. Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

11.D. During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.

12.B . First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

13. C . With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife’s time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation is required for breast feeding.

14. A . A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false-negative results.

15.D . The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.

16. C. To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.

17. A. When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the

symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks.

18.D . Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred vision, rapid weight gain, and elevated blood pressure. Constipation, breast tenderness, and nasal stuffiness are common discomforts associated with pregnancy.

19.B . A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.

20.D . With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of true labor contractions gradually shortens.

21.B . Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.

22. C . Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist makes them generally inappropriate during active labor. Neonatal side effects of barbiturates include central nervous system depression, prolonged drowsiness, delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. Narcotic analgesic readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. Regional anesthesia is associated with adverse reactions such as maternal hypotension, allergic or toxic reaction, or partial or total respiratory failure.

23.D . During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor.

24. A. The newborn’s ability to regulate body temperature is poor. Therefore, placing the newborn under a radiant warmer aids in maintaining his or

her body temperature. Suctioning with a bulb syringe helps maintain a patent airway. Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life. Inspecting the umbilical cord aids in detecting cord anomalies.

25.D. Immediately before expulsion or birth of the rest of the body, the cardinal movement of external rotation occurs. Descent flexion, internal rotation, extension, and restitution (in this order) occur before external rotation.

26.B. The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. The umbilical vein, ductus arteriosus, and ductus venosus are obliterated at birth.

27.B. Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper. Mucus would not produce a stain. Bilirubin and iron are from hepatic adaptation.

28.B . The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.

29. C . The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increased intracranial pressure, or sunken, which may indicate dehydration.

30.B . Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year.

31. A . With the babinski reflex, the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.

32.B . The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis, which, if it continues, can deplete the nutrients transported to the fetus. Diarrhea does not occur with hyperemesis.

33.B. Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman experience foot and ankle edema. A weight gain of 2 lb

or more per week indicates a problem. Early morning headache is not a classic sign of PIH.

34. C. In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An incomplete abortion presents with bleeding, cramping, and cervical dilation. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.

35. A. Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae.

36.B. A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa.

37.D. Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage. Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.

38.B. Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture. Weak contractions would not occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with hyperstimulation.

39. C. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. Allowing the mother’s support person to remain with her as much as possible is an important concept, although doing so depends on many variables. Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility. The nurse is responsible for reinforcing the explanations about the surgery, expected outcome, and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome and the

anesthesiology staff is responsible for explanations about the type of anesthesia to be used.

40. A. Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.

41.B. PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client’s most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of PROM.

42.B. Dystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus (passenger), uterus (powers), pelvis (passage), or psyche. Nutritional, environment, and medical factors may contribute to the mechanical factors that cause dystocia.

43. A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for surgery. Obtaining blood specimens, instituting complete bed rest, and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture.

44.B. The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.

45.D. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage.

46.D. With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary predisposing factor. Epidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.

47.D. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral thrombophlebitis.

48. C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis.

49.B. Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapubic pain. Dehydration, hypertension, and chills are not typically associated with cystitis. High fever chills, flank pain, nausea, vomiting, dysuria, and frequency are associated with pvelonephritis.

50. C. According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.

51.B . Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. Therefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented. The estrogen content of the oral site contraceptive may cause the nausea, regardless of when the pill is taken. Side effects and drug interactions may occur with oral contraceptives regardless of the time the pill is taken.

52. C . Condoms, when used correctly and consistently, are the most effective contraceptive method or barrier against bacterial and viral sexually transmitted infections. Although spermicides kill sperm, they do not provide reliable protection against the spread of sexually transmitted infections, especially intracellular organisms such as HIV. Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations, which could place the client at risk for infection transmission. Male sterilization eliminates spermatozoa from the ejaculate, but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections.

53. A . The diaphragm must be fitted individually to ensure effectiveness. Because of the changes to the reproductive structures during pregnancy and following delivery, the diaphragm must be refitted, usually at the 6 weeks’ examination following childbirth or after a weight loss of 15 lbs or more. In addition, for maximum effectiveness, spermicidal jelly should be placed in the dome and around the rim. However, spermicidal jelly should not be inserted into the vagina until involution is completed at approximately 6 weeks. Use of a female condom protects the reproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. Oral contraceptives may be started within the first postpartum week to ensure suppression of ovulation. For the couple who has determined the female’s fertile period, using the rhythm method, avoidance of intercourse during this period, is safe and effective.

54. C . An IUD may increase the risk of pelvic inflammatory disease, especially in women with more than one sexual partner, because of the increased risk of sexually transmitted infections. An UID should not be used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities. Age is not a factor in determining the risks associated with IUD use. Most IUD users are over the age of 30. Although there is a slightly higher risk for infertility in women who have never been pregnant, the IUD is an acceptable option as long as the risk-benefit ratio is discussed. IUDs may be inserted immediately after delivery, but this is not recommended because of the increased risk and rate of expulsion at this time.

55. C . During the third trimester, the enlarging uterus places pressure on the intestines. This coupled with the effect of hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). Increasing fiber in the diet will help fecal matter pass more quickly through the intestinal tract, thus decreasing the amount of water that is absorbed. As a result, stool is softer and easier to pass. Enemas could precipitate preterm labor and/or electrolyte loss and should be avoided. Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. Use for more than 1 week can also lead to laxative dependency. Liquid in the diet helps provide a semisolid, soft consistency to the stool. Eight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation.

56.D . To ensure adequate fetal growth and development during the 40 weeks of a pregnancy, a total weight gain 25 to 30 pounds is recommended: 1.5 pounds in the first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by 40 weeks. The pregnant woman should gain less weight in the first and second trimester than in the third. During the first trimester, the client should only gain 1.5 pounds in the first 10 weeks, not 1 pound per week. A weight gain of ½ pound per week would be 20 pounds for the total pregnancy, less than the recommended amount.

57.B . To calculate the EDD by Nagele’s rule, add 7 days to the first day of the last menstrual period and count back 3 months, changing the year appropriately. To obtain a date of September 27, 7 days have been added to the last day of the LMP (rather than the first day of the LMP), plus 4 months (instead of 3 months) were counted back. To obtain the date of November 7, 7 days have been subtracted (instead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January. To obtain the date of December 27, 7 days were added to the last day of the LMP (rather than the first day of the LMP) and December indicates counting back only 1 month (instead of 3 months) from January.

58.D. The client has been pregnant four times, including current pregnancy (G). Birth at 38 weeks’ gestation is considered full term (T), while birth form 20 weeks to 38 weeks is considered preterm (P). A spontaneous abortion occurred at 8 weeks (A). She has two living children (L).

59.B. At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. The fetal heart rate at this age is not audible with a stethoscope. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity, not midway between the umbilicus and the xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. Although the external electronic fetal monitor would project the FHR, the uterus has not risen to the umbilicus at 12 weeks.

60. A. Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and should always be the priority. Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. Exercise, is important for all pregnant women and especially for diabetic women, because it burns up glucose, thus decreasing blood sugar. However, dietary intake, not exercise, is the priority. All pregnant women with diabetes should have periodic monitoring of serum glucose. However, those with gestational diabetes generally do not need daily glucose monitoring. The standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2 weeks.

61. C. After 20 weeks’ gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria. Although urine is checked for glucose at each clinic visit, this is not the priority. Depression may cause either anorexia or excessive food intake, leading to excessive weight gain or loss. This is not, however, the priority consideration at this time. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary consideration for this client at this time.

62.B. Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. Thus, the nurse would document an imminent abortion. In a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. The symptoms may subside or progress to abortion. In a complete abortion all the products of conception are expelled. A missed abortion is early fetal intrauterine death without expulsion of the products of conception.

63.B. For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus, pain is the priority. Although the potential for infection is always present, the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. The client may have a limited

knowledge of the pathology and treatment of the condition and will most likely experience grieving, but this is not the priority at this time.

64.D. Before uterine assessment is performed, it is essential that the woman empty her bladder. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. Uterine assessment should not cause acute pain that requires administration of analgesia. Ambulating the client is an essential component of postpartum care, but is not necessary prior to assessment of the uterus.

65. A. Feeding more frequently, about every 2 hours, will decrease the infant’s frantic, vigorous sucking from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct latching-on for feeding. Narcotics administered prior to breast feeding are passed through the breast milk to the infant, causing excessive sleepiness. Nipple soreness is not severe enough to warrant narcotic analgesia. All postpartum clients, especially lactating mothers, should wear a supportive brassiere with wide cotton straps. This does not, however, prevent or reduce nipple soreness. Soaps are drying to the skin of the nipples and should not be used on the breasts of lactating mothers. Dry nipple skin predisposes to cracks and fissures, which can become sore and painful.

66.D. A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage.

67.D. Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the lochia is typically pink to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epithelial cells, erythrocyes, leukocytes and decidua. Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms. Lochia alba is an almost colorless to yellowish discharge

occurring from 10 days to 3 weeks after delivery and containing leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

68. A. The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection. All the client’s data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 101ºF, may be present with breast engorgement. Symptoms of mastitis include influenza-like manifestations. Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution would not be affected. The client data do not include dysuria, frequency, or urgency, symptoms of urinary tract infections, which would necessitate assessing the client’s urine.

69. C. Because of early postpartum discharge and limited time for teaching, the nurse’s priority is to facilitate the safe and effective care of the client and newborn. Although promoting comfort and restoration of health, exploring the family’s emotional status, and teaching about family planning are important in postpartum/newborn nursing care, they are not the priority focus in the limited time presented by early post-partum discharge.

70. C. Heat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows. Thus placing the newborn’s crib close to the viewing window would be least effective. Body heat is lost through evaporation during bathing. Placing the infant under the radiant warmer after bathing will assist the infant to be rewarmed. Covering the scale with a warmed blanket prior to weighing prevents heat loss through conduction. A knit cap prevents heat loss from the head a large head, a large body surface area of the newborn’s body.

71.B. A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction. In talipes equinovarus (clubfoot) the foot is turned medially, and in plantar flexion, with the heel elevated. The feet are not involved with the Moro reflex. Hypothyroiddism has no effect on the primitive reflexes. Absence of the Moror reflex is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure.

72.B. Hemorrhage is a potential risk following any surgical procedure. Although the infant has been given vitamin K to facilitate clotting, the prophylactic dose is often not sufficient to prevent bleeding. Although infection is a possibility, signs will not appear within 4 hours after the surgical procedure. The primary discomfort of circumcision occurs during the surgical procedure, not afterward. Although feedings are withheld prior to the circumcision, the chances of dehydration are minimal.

73.B. The presence of excessive estrogen and progesterone in the maternal-fetal blood followed by prompt withdrawal at birth precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth.

The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. Newborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. Breast tissue does not hypertrophy in the fetus or newborns.

74.D. The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. The infant’s assessment data reflect normal adaptation. Thus, the physician does not need to be notified and oxygen is not needed. The data do not indicate the presence of choking, gagging or coughing, which are signs of excessive secretions. Suctioning is not necessary.

75.B. Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. The cord should be kept dry until it falls off and the stump has healed. Antibiotic ointment should only be used to treat an infection, not as a prophylaxis. Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed.

76.B. To determine the amount of formula needed, do the following mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. Based on the calculation. 2, 4 or 6 ounces are incorrect.

77. A. Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. The infant is not at increased risk for gastrointestinal problems. Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating. The postterm meconium-stained infant is not at additional risk for bowel or urinary problems.

78. C . The nurse should use a nonelastic, flexible, paper measuring tape, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement).

79.B. Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Because of edema, daily weight is important but not the priority. Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.

80. C. Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. Choice of a contraceptive method is important, but not the specific criteria for safe resumption of sexual activity. Culturally, the 6-weeks’ examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier.

81. C . The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication. The deltoid muscle of a newborn is not large enough for a newborn IM injection. Injections into this muscle in a small child might cause damage to the radial nerve. The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. Because of the proximity of the sciatic nerve, the gluteus maximus muscle should not be until the child has been walking 2 years.

82.D . Bartholin’s glands are the glands on either side of the vaginal orifice. The clitoris is female erectile tissue found in the perineal area above the urethra. The parotid glands are open into the mouth. Skene’s glands open into the posterior wall of the female urinary meatus.

83.D . The fetal gonad must secrete estrogen for the embryo to differentiate as a female. An increase in maternal estrogen secretion does not effect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy. Maternal androgen secretion remains the same as before pregnancy and does not effect differentiation. Secretion of androgen by the fetal gonad would produce a male fetus.

84. A . Using bicarbonate would increase the amount of sodium ingested, which can cause complications. Eating low-sodium crackers would be appropriate. Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. Eating six small meals a day would keep the stomach full, which often decrease nausea.

85.B . Ballottement indicates passive movement of the unengaged fetus. Ballottement is not a contraction. Fetal kicking felt by the client represents quickening. Enlargement and softening of the uterus is known as Piskacek’s sign.

86.B . Chadwick’s sign refers to the purple-blue tinge of the cervix. Braxton Hicks contractions are painless contractions beginning around the 4th month. Goodell’s sign indicates softening of the cervix. Flexibility of the uterus against the cervix is known as McDonald’s sign.

87. C . Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation. Breathing techniques do not eliminate pain, but they can reduce it. Positioning, not breathing, increases uteroplacental perfusion.

88. A . The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to

contact more forcefully in an attempt to dilate the cervix. Administering light sedative would be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this time. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. It is too early to anticipate client pushing with contractions.

89.D . The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. Assessing maternal vital signs can help determine maternal physiologic status. Fetal heart rate is important to assess fetal well-being and should be done. Monitoring the contractions will help evaluate the progress of labor.

90.D . A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. Telling the client to ask the physician is a poor response and would increase the patient’s anxiety. Although a cesarean would help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur. With a complete previa, the placenta is covering all the cervix, not just most of it.

91.B . With a face presentation, the head is completely extended. With a vertex presentation, the head is completely or partially flexed. With a brow (forehead) presentation, the head would be partially extended.

92.D . With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.

93. C. The greenish tint is due to the presence of meconium. Lanugo is the soft, downy hair on the shoulders and back of the fetus. Hydramnios represents excessive amniotic fluid. Vernix is the white, cheesy substance covering the fetus.

94.D. In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical cord is common. Quickening is the woman’s first perception of fetal movement. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood substances.

95. A. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. Monozygotic (identical) twins involve a common placenta, same genotype, and common chorion.

96. C. The zygote is the single cell that reproduces itself after conception. The chromosome is the material that makes up the cell and is gained from each parent. Blastocyst and trophoblast are later terms for the embryo after zygote.

97.D. Prepared childbirth was the direct result of the 1950’s challenging of the routine use of analgesic and anesthetics during childbirth. The LDRP was a much later concept and was not a direct result of the challenging of

routine use of analgesics and anesthetics during childbirth. Roles for nurse midwives and clinical nurse specialists did not develop from this challenge.

98. C. The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. The symphysis pubis, sacral promontory, and pubic arch are not part of the mid-pelvis.

99.B. Variations in the length of the menstrual cycle are due to variations in the proliferative phase. The menstrual, secretory and ischemic phases do not contribute to this variation.

100. B . Testosterone is produced by the Leyding cells in the seminiferous tubules. Follicle-stimulating hormone and leuteinzing hormone are released by the anterior pituitary gland. The hypothalamus is responsible for releasing gonadotropin-releasing hormone.

101. D. The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying he physician or performing additional examinations are inappropriate.

102. D. Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate.

103. A. According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. Schoolagers develop a sense of inferiority when they do not develop a sense of industry.

104. D. A busy box facilitates the fine motor development that occurs between 4 and 6 months. Balloons are contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old is too young to use a push-pull toy.

105. B. Infants need to have their security needs met by being held and cuddled. At 2 months of age, they are unable to make the connection between crying and attention. This association does not occur until late infancy or early toddlerhood. Letting the infant cry for a time before picking up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young age. Infants cry for many reasons. Assuming that the child s hungry may cause overfeeding problems such as obesity.

106. B. Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. During toddlerhood, food intake decreases, not increases. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. Toddler growth patterns occur in a steplike, not linear pattern.

107. B. According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Infants develop mistrust when their needs are not consistently gratified. Preschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met.

108. C. Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints would be an appropriate toy choice. Multiple-piece toys, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart.

109. D. The child must be able to sate the need to go to the bathroom to initiate toilet training. Usually, a child needs to be dry for only 2 hours, not 4 hours. The child also must be able to sit, walk, and squat. A new sibling would most likely hinder toilet training.

110. A. Toddlers become picky eaters, experiencing food jags and eating large amounts one day and very little the next. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time. Toddlers typically enjoy socialization and limiting others at meal time. Toddlers prefer to feed themselves and thus are too young to have table manners. A toddler’s appetite and need for calories, protein, and fluid decrease due to the dramatic slowing of growth rate.

111. D. Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child’s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

112. B. Dress-up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich fantasy play. Building blocks and wooden puzzles are appropriate for encouraging fine motor development. Big wheels and tricycles encourage gross motor development.

113. D. The school-aged child is in the stage of concrete operations, marked by inductive reasoning, logical operations, and reversible concrete thought. The ability to consider the future requires formal thought operations, which are not developed until adolescence. Collecting

baseball cards and marbles, ordering dolls by size, and simple problem-solving options are examples of the concrete operational thinking of the schoolager.

114. C. Reaction formation is the schoolager’s typical defensive response when hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors. Regression is seen in toddlers and preshcoolers when they retreat or return to an earlier level of development. Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness. Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors.

115. C. The schoolager’s cognitive level is sufficiently developed to enable good understanding of and adherence to rules. Thus, schoolagers should be able to understand the potential dangers around them. With growth comes greater freedom and children become more adventurous and daring. The school-aged child is also still prone to accidents and home hazards, especially because of increased motor abilities and independence. Plus the home hazards differ from other age groups. These hazards, which are potentially lethal but tempting, may include firearms, alcohol, and medications. School-age children begin to internalize their own controls and need less outside direction. Plus the child is away from home more often. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities.

116. C. The most significant skill learned during the school-age period is reading. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. Collective, ordering, and sorting, although important, are not most significant skills learned.

117. C. Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. Immunization for diphtheria and tetanus is required at age 13.

118. D. According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. School-age children develop a sense of inferiority when they do not develop a sense of industry.

119. A. Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. Uterine growth and broadening of the pelvic girdle occurs before menarche.

120. A. Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time her spends on it shuts off further investigation and is likely to make the adolescent and his

parents feel defensive. The statement about peer acceptance and time spent in front of the mirror for the development of self image provides information about the adolescent’s needs to the parents and may help to gain trust with the adolescent. Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings. Discussing the cleansing method shows interest and concern for the adolescent and also can help to identify any patient-teaching needs for the adolescent regarding cleansing.

121. B. Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. If a child does so, the child has been exposed to such behavior, and sexual abuse should be suspected. Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. Whether or nor the child knows how to play with dolls is irrelevant.

122. A. The parents need more teaching if they state that they will keep the child home until the phobia subsides. Doing so reinforces the child’s feelings of worthlessness and dependency. The child should attend school even during resolution of the problem. Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions. Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions.

123. C. The adolescent who becomes pregnant typically denies the pregnancy early on. Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care. The incidence of adolescent pregnancy has declined since 1991, yet morbidity remains high. Most teenage pregnancies are unplanned and occur out of wedlock. The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants, high neonatal mortality, iron deficiency anemia, prolonged labor, and fetopelvic disproportion as well as numerous psychological crises.

124. B. Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media. Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques. Food particles do not pass through the cleft and into the Eustachian tubes. There is no association between cleft palate and congenial ear deformities.

125. D. A 3-month-old infant should be able to lift the head and chest when prone. The Moro reflex typically diminishes or subsides by 3 months. The parachute reflex appears at 9 months. Rolling from front to back usually is accomplished at about 5 months.

126. D. A child’s birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months.

127. C. Toddlers engaging in parallel play will play near each other, but not with each other. Thus, when two toddlers sit near each other but play with separate dolls, they are exhibiting parallel play. Sharing crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all examples of cooperative play.

128. A. Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. Iron-rich foods help with anemia, but dietary iron is not an initial intervention. The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion. Injections should be discouraged, owing to increased risk from bleeding due to thrombocytopenia.

129. A. The pertusis component may result in fever and the tetanus component may result in injection soreness. Therefore, the mother’s verbalization of information about measures to reduce fever indicates understanding. No dietary restrictions are necessary after this injection is given. A subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine, not the diphtheria, pertussis, and tetanus vaccine. Diarrhea is not associated with this vaccine.

130. A. Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm. Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data. Although the nurse should notify the physician, the goal is to initiate measures to protect the child’s safety. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility. Multiple bruises and burns are not normal toddler injuries.

131. B. The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another. Displacement is the transfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut. Repression is the submerging of painful ideas into the unconscious. Psychosis is a state of being out of touch with reality.

132. A. Children with congenital heart disease are more prone to respiratory infections. Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

133. D. The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening

emergency. Having the child lie down would cause additional distress and may result in respiratory arrest. Throat examination may result in laryngospasm that could be fatal.

134. A. In females, the urethra is shorter than in males. This decreases the distance for organisms to travel, thereby increasing the chance of the child developing a urinary tract infection. Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress. Increased fluid intake enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections. The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development.

135. B. Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation. Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia. The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate. In this situation, specific action not continued monitoring is indicated.

136. D. The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.

137. C. Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of making hand-to-hand transfers, large blocks would be the most appropriate toy selection. Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment. Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. Mobiles pose a danger to older infants because of possible strangulation.

138. B. During the preschool period, the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences. The preschool child uses simple, not complex, reasoning, engages in associative, not competitive, play (interactive and cooperative play with sharing), and is able to tolerate longer periods of delayed gratification.

139. A. Mild mental retardation refers to development disability involving an IQ 50 to 70. Typically, the child is not noted as being retarded, but exhibits slowness in performing tasks, such as self-feeding, walking, and taking. Little or no speech, marked motor delays, and gait disabilities would be seen in more severe forms mental retardation.

140. B. Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high-arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness.

141. A. Because of the defect, the child will be unable to from the mouth adequately around nipple, thereby requiring special devices to allow for feeding and sucking gratification. Respiratory status may be compromised if the child is fed improperly or during postoperative period, Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip.

142. B. Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. If the child is placed in the supine position, he or she may aspirate. Using an infant seat does not facilitate drainage. Side-lying does not facilitate drainage as well as the prone position.

143. C. Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly with GER. Steatorrhea occurs in malabsorption disorders such as celiac disease. “Currant jelly” stools are characteristic of intussusception.

144. D. GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses.

145. A. Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings. No relationship exists between feedings and characteristics of stools and uterine. If feedings are ineffective, this should be noted before there is any change in the child’s weight.

146. C. Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoided. Rice, milk, and chicken do not contain gluten and need not be avoided.

147. C. Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea. Respiratory distress is unlikely in a routine upper respiratory infection. Irritability, rather than lethargy, is more likely. Because of the fluid loss associated with the severe watery diarrhea, the child’s weight is more likely to be decreased.

148. A. For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately. Generally, because of the

intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. Hirschsprung disease typically presents with chronic constipation.

149. A. Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

150. C. Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

250-ITEM NOVEMBER 2014 NURSE LICENSURE EXAM (NLE) PRACTICE TEST

The test will cover the following topics:

Blood Disorders

http://3.bp.blogspot.com/-Q8J5xQzXcLc/U8JTF4NXxvI/AAAAAAAAALU/L3ynAnZ3PFw/s1600/TEST.jpg

Endocrine Disorders

Cardiovascular Disorders

Neurolgical Disorders

Pregnacy, Labor and Delivery

Burns

Psychological Disorders

Immobility

Digestive Disorders

Wounds

1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

A.Body temperature of 99°F or lessB. Toes moved in active range of motionC. Sensation reported when soles of feet are touchedD.Capillary refill of < 3 seconds2. A 30-year-old male from Haiti is brought to the emergency department in

sickle cell crisis. What is the best position for this client?A.Side-lying with knees flexedB. Knee-chestC. High Fowler's with knees flexedD.Semi-Fowler's with legs extended on the bed3. A 25-year-old male is admitted in sickle cell crisis. Which of the following

interventions would be of highest priority for this client?A.Taking hourly blood pressures with mechanical cuffB. Encouraging fluid intake of at least 200mL per hourC. Position in high Fowler's with knee gatch raisedD.Administering Tylenol as ordered4. Which of the following foods would the nurse encourage the client in

sickle cell crisis to eat?A.PeachesB. Cottage cheeseC. PopsicleD.Lima beans5. A newly admitted client has sickle cell crisis. The nurse is planning care

based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.

A.Adjust the room temperatureB. Give a bolus of IV fluidsC. Start O2

D.Administer meperidine (Demerol) 75mg IV push

6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

A.Roast beef, gelatin salad, green beans, and peach pieB. Chicken salad sandwich, coleslaw, French fries, ice creamC. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pieD.Pork chop, creamed potatoes, corn, and coconut cake7. Clients with sickle cell anemia are taught to avoid activities that cause

hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

A.A family vacation in the Rocky MountainsB. Chaperoning the local boys club on a snow-skiing tripC. Traveling by airplane for business tripsD.A bus trip to the Museum of Natural History8. The nurse is conducting an admission assessment of a client with vitamin

B12 deficiency. Which of the following would the nurse include in the physical assessment?

A.Palpate the spleenB. Take the blood pressureC. Examine the feet for petechiaeD.Examine the tongue9. An African American female comes to the outpatient clinic. The physician

suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?

A.Conjunctiva of the eyeB. Soles of the feetC. Roof of the mouthD.Shins10. The nurse is conducting a physical assessment on a client with anemia.

Which of the following clinical manifestations would be most indicative of the anemia?

A.BP 146/88B. Respirations 28 shallowC. Weight gain of 10 pounds in 6 monthsD.Pink complexion

11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

A."I will drink 500mL of fluid or less each day."B. "I will wear support hose when I am up."C. "I will use an electric razor for shaving."D."I will eat foods low in iron."12. A 33-year-old male is being evaluated for possible acute leukemia. Which

of the following would the nurse inquire about as a part of the assessment?A.The client collects stamps as a hobby.B. The client recently lost his job as a postal worker.

C. The client had radiation for treatment of Hodgkin's disease as a teenager.D.The client's brother had leukemia as a child.13. An African American client is admitted with acute leukemia. The nurse is

assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

A.The abdomenB. The thoraxC. The earlobesD.The soles of the feet14. A client with acute leukemia is admitted to the oncology unit. Which of the

following would be most important for the nurse to inquire?A."Have you noticed a change in sleeping habits recently?"B. "Have you had a respiratory infection in the last 6 months?"C. "Have you lost weight recently?"D."Have you noticed changes in your alertness?"15. Which of the following would be the priority nursing diagnosis for the adult

client with acute leukemia?A.Oral mucous membrane, altered related to chemotherapyB. Risk for injury related to thrombocytopeniaC. Fatigue related to the disease processD.Interrupted family processes related to life-threatening illness of a family

member16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local

university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

A.Sexual dysfunction related to radiation therapyB. Anticipatory grieving related to terminal illnessC. Tissue integrity related to prolonged bed restD.Fatigue related to chemotherapy17. A client has autoimmune thrombocytopenic purpura. To determine the

client's response to treatment, the nurse would monitor:A.Platelet countB. White blood cell countC. Potassium levelsD.Partial prothrombin time (PTT)18. The home health nurse is visiting a client with autoimmune

thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:

A.Bleeding precautionsB. Prevention of fallsC. Oxygen therapyD.Conservation of energy19. A client with a pituitary tumor has had a transphenoidal hyposphectomy.

Which of the following interventions would be appropriate for this client?A.Place the client in Trendelenburg position for postural drainage

B. Encourage coughing and deep breathing every 2 hoursC. Elevate the head of the bed 30°D.Encourage the Valsalva maneuver for bowel movements20. The client with a history of diabetes insipidus is admitted with polyuria,

polydipsia, and mental confusion. The priority intervention for this client is:A.Measure the urinary outputB. Check the vital signsC. Encourage increased fluid intakeD.Weigh the client21. A client with hemophilia has a nosebleed. Which nursing action is most

appropriate to control the bleeding?A.Place the client in a sitting position with the head hyperextendedB. Pack the nares tightly with gauze to apply pressure to the source of

bleedingC. Pinch the soft lower part of the nose for a minimum of 5 minutesD.Apply ice packs to the forehead and back of the neck22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent

complications, the most important measurement in the immediate post-operative period for the nurse to take is:

A.Blood pressureB. TemperatureC. OutputD.Specific gravity23. A client with Addison's disease has been admitted with a history of nausea

and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

A.Glucometer readings as orderedB. Intake/output measurementsC. Sodium and potassium levels monitoredD.Daily weights24. A client had a total thyroidectomy yesterday. The client is complaining of

tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

A.Obtain a crash cartB. Check the calcium levelC. Assess the dressing for drainageD.Assess the blood pressure for hypertension25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52,

there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

A.Impaired physical mobility related to decreased enduranceB. Hypothermia r/t decreased metabolic rateC. Disturbed thought processes r/t interstitial edemaD.Decreased cardiac output r/t bradycardia

26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

A.Report muscle weakness to the physician.B. Allow six months for the drug to take effect.C. Take the medication with fruit juice.D.Ask the doctor to perform a complete blood count before starting the

medication.27. The client is admitted to the hospital with hypertensive crises. Diazoxide

(Hyperstat) is ordered. During administration, the nurse should:A.Utilize an infusion pumpB. Check the blood glucose levelC. Place the client in Trendelenburg positionD.Cover the solution with foil28. The 6-month-old client with a ventral septal defect is receiving Digitalis for

regulation of his heart rate. Which finding should be reported to the doctor?A.Blood pressure of 126/80B. Blood glucose of 110mg/dLC. Heart rate of 60bpmD.Respiratory rate of 30 per minute29. The client admitted with angina is given a prescription for nitroglycerine.

The client should be instructed to:A.Replenish his supply every 3 monthsB. Take one every 15 minutes if pain occursC. Leave the medication in the brown bottleD.Crush the medication and take with water30. The client is instructed regarding foods that are low in fat and cholesterol.

Which diet selection is lowest in saturated fats?A.Macaroni and cheeseB. Shrimp with riceC. Turkey breastD.Spaghetti31. The client is admitted with left-sided congestive heart failure. In assessing

the client for edema, the nurse should check the:A.FeetB. NeckC. HandsD.Sacrum32. The nurse is checking the client's central venous pressure. The nurse

should place the zero of the manometer at the:A.Phlebostatic axisB. PMIC. Erb's pointD.Tail of Spence

33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

A.Question the orderB. Administer the medicationsC. Administer separatelyD.Contact the pharmacy34. The best method of evaluating the amount of peripheral edema is:A.Weighing the client dailyB. Measuring the extremityC. Measuring the intake and outputD.Checking for pitting35. A client with vaginal cancer is being treated with a radioactive vaginal

implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

A.Overnight stays by family members is against hospital policy.B. There is no need for him to stay because staffing is adequate.C. His wife will rest much better knowing that he is at home.D.Visitation is limited to 30 minutes when the implant is in place.36. The nurse is caring for a client hospitalized with a facial stroke. Which diet

selection would be suited to the client?A.Roast beef sandwich, potato chips, pickle spear, iced teaB. Split pea soup, mashed potatoes, pudding, milkC. Tomato soup, cheese toast, Jello, coffeeD.Hamburger, baked beans, fruit cup, iced tea37. The physician has prescribed Novalog insulin for a client with diabetes

mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

A."I will make sure I eat breakfast within 10 minutes of taking my insulin."B. "I will need to carry candy or some form of sugar with me all the time."C. "I will eat a snack around three o'clock each afternoon."D."I can save my dessert from supper for a bedtime snack."38. The nurse is teaching basic infant care to a group of first-time parents. The

nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:

A.New parents need time to learn how to hold the baby.B. The umbilical cord needs time to separate.C. Newborn skin is easily traumatized by washing.D.The chance of chilling the baby outweighs the benefits of bathing.39. A client with leukemia is receiving Trimetrexate. After reviewing the

client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

A.Treat iron-deficiency anemia caused by chemotherapeutic agentsB. Create a synergistic effect that shortens treatment timeC. Increase the number of circulating neutrophils

D.Reverse drug toxicity and prevent tissue damage40. A 4-month-old is brought to the well-baby clinic for immunization. In

addition to the DPT and polio vaccines, the baby should receive:A.Hib titerB. Mumps vaccineC. Hepatitis B vaccineD.MMR41. The physician has prescribed Nexium (esomeprazole) for a client with

erosive gastritis. The nurse should administer the medication:A.30 minutes before mealsB. With each mealC. In a single dose at bedtimeD.30 minutes after meals42. A client on the psychiatric unit is in an uncontrolled rage and is

threatening other clients and staff. What is the most appropriate action for the nurse to take?

A.Call security for assistance and prepare to sedate the client.B. Tell the client to calm down and ask him if he would like to play cards.C. Tell the client that if he continues his behavior he will be punished.D.Leave the client alone until he calms down.43. When the nurse checks the fundus of a client on the first postpartum day,

she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

A.Check the client for bladder distentionB. Assess the blood pressure for hypotensionC. Determine whether an oxytocic drug was givenD.Check for the expulsion of small clots44. A client is admitted to the hospital with a temperature of 99.8°F,

complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:

A.PneumoniaB. Reaction to antiviral medicationC. TuberculosisD.Superinfection due to low CD4 count45. The client is seen in the clinic for treatment of migraine headaches. The

drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?

A.DiabetesB. Prinzmetal's anginaC. CancerD.Cluster headaches46. The client with suspected meningitis is admitted to the unit. The doctor is

performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:

A.Pain on flexion of the hip and knee

B. Nuchal rigidity on flexion of the neckC. Pain when the head is turned to the left sideD.Dizziness when changing positions47. The client with Alzheimer's disease is being assisted with activities of daily

living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

A.AgnosiaB. ApraxiaC. AnomiaD.Aphasia48. The client with dementia is experiencing confusion late in the afternoon

and before bedtime. The nurse is aware that the client is experiencing what is known as:

A.Chronic fatigue syndromeB. Normal agingC. SundowningD.Delusions49. The client with confusion says to the nurse, "I haven't had anything to eat

all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

A."You know you had breakfast 30 minutes ago."B. "I am so sorry that they didn't get you breakfast. I'll report it to the charge

nurse."C. "I'll get you some juice and toast. Would you like something else?"D."You will have to wait a while; lunch will be here in a little while."50. The doctor has prescribed Exelon (rivastigmine) for the client with

Alzheimer's disease. Which side effect is most often associated with this drug?

A.Urinary incontinenceB. HeadachesC. ConfusionD.Nausea51. A client is admitted to the labor and delivery unit in active labor. During

examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

A.Document the findingB. Report the finding to the doctorC. Prepare the client for a C-sectionD.Continue primary care as prescribed52. A client with a diagnosis of HPV is at risk for which of the following?A.Hodgkin's lymphomaB. Cervical cancerC. Multiple myelomaD.Ovarian cancer

53. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

A.SyphilisB. HerpesC. GonorrheaD.Condylomata54. A client visiting a family planning clinic is suspected of having an STI. The

best diagnostic test for treponema pallidum is:A.Venereal Disease Research Lab (VDRL)B. Rapid plasma reagin (RPR)C. Florescent treponemal antibody (FTA)D.Thayer-Martin culture (TMC)55. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP

syndrome. Which laboratory finding is associated with HELLP syndrome?A.Elevated blood glucoseB. Elevated platelet countC. Elevated creatinine clearanceD.Elevated hepatic enzymes56. The nurse is assessing the deep tendon reflexes of a client with

preeclampsia. Which method is used to elicit the biceps reflex?A.The nurse places her thumb on the muscle inset in the antecubital space and

taps the thumb briskly with the reflex hammer.B. The nurse loosely suspends the client's arm in an open hand while tapping

the back of the client's elbow.C. The nurse instructs the client to dangle her legs as the nurse strikes the

area below the patella with the blunt side of the reflex hammer.D.The nurse instructs the client to place her arms loosely at her side as the

nurse strikes the muscle insert just above the wrist.57. A primigravida with diabetes is admitted to the labor and delivery unit at

34 weeks gestation. Which doctor's order should the nurse question?A.Magnesium sulfate 4gm (25%) IVB. Brethine 10mcg IVC. Stadol 1mg IV push every 4 hours as needed prn for painD.Ancef 2gm IVPB every 6 hours58. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks

gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:

A.The infant is at low risk for congenital anomalies.B. The infant is at high risk for intrauterine growth retardation.C. The infant is at high risk for respiratory distress syndrome.D.The infant is at high risk for birth trauma.59. Which observation in the newborn of a diabetic mother would require

immediate nursing intervention?

A.CryingB. WakefulnessC. JitterinessD.Yawning60. The nurse caring for a client receiving intravenous magnesium sulfate

must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

A.Decreased urinary outputB. HypersomnolenceC. Absence of knee jerk reflexD.Decreased respiratory rate61. The client has elected to have epidural anesthesia to relieve labor pain. If

the client experiences hypotension, the nurse would:A.Place her in Trendelenburg positionB. Decrease the rate of IV infusionC. Administer oxygen per nasal cannulaD.Increase the rate of the IV infusion62. A client has cancer of the pancreas. The nurse should be most concerned

about which nursing diagnosis?A.Alteration in nutritionB. Alteration in bowel eliminationC. Alteration in skin integrityD.Ineffective individual coping63. The nurse is caring for a client with ascites. Which is the best method to

use for determining early ascites?A.Inspection of the abdomen for enlargementB. Bimanual palpation for hepatomegalyC. Daily measurement of abdominal girthD.Assessment for a fluid wave64. The client arrives in the emergency department after a motor vehicle

accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

A.Alteration in cerebral tissue perfusionB. Fluid volume deficitC. Ineffective airway clearanceD.Alteration in sensory perception65. The home health nurse is visiting an 18-year-old with osteogenesis

imperfecta. Which information obtained on the visit would cause the most concern? The client:

A.Likes to play footballB. Drinks several carbonated drinks per dayC. Has two sisters with sickle cell tractD.Is taking acetaminophen to control pain

66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

A.Allow the client to keep the fruitB. Place the fruit next to the bed for easy access by the clientC. Offer to wash the fruit for the clientD.Tell the family members to take the fruit home67. The nurse is caring for the client following a laryngectomy when suddenly

the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:

A.Place the client in Trendelenburg positionB. Increase the infusion of Dextrose in normal salineC. Administer atropine intravenouslyD.Move the emergency cart to the bedside68. The client admitted 2 days earlier with a lung resection accidentally pulls

out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

A.Order a chest x-rayB. Reinsert the tubeC. Cover the insertion site with a Vaseline gauzeD.Call the doctor69. A client being treated with sodium warfarin has a Protime of 120 seconds.

Which intervention would be most important to include in the nursing care plan?

A.Assess for signs of abnormal bleedingB. Anticipate an increase in the Coumadin dosageC. Instruct the client regarding the drug therapyD.Increase the frequency of neurological assessments70. Which selection would provide the most calcium for the client who is 4

months pregnant?A.A granola barB. A bran muffinC. A cup of yogurtD.A glass of fruit juice71. The client with preeclampsia is admitted to the unit with an order for

magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?

A.The nurse places a sign over the bed not to check blood pressure in the right arm.

B. The nurse places a padded tongue blade at the bedside.C. The nurse inserts a Foley catheter.D.The nurse darkens the room.72. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The

physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child's mother tells the nurse that she does

not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?

A.Ask the mother to leave while the blood transfusion is in progressB. Encourage the mother to reconsiderC. Explain the consequences without treatmentD.Notify the physician of the mother's refusal73. A client is admitted to the unit 2 hours after an explosion causes burns to

the face. The nurse would be most concerned with the client developing which of the following?

A.HypovolemiaB. Laryngeal edemaC. HypernatremiaD.Hyperkalemia74. The nurse is evaluating nutritional outcomes for an elderly client with

bulimia. Which data best indicates that the plan of care is effective?A.The client selects a balanced diet from the menu.B. The client's hemoglobin and hematocrit improve.C. The client's tissue turgor improves.D.The client gains weight.75. The client is admitted following repair of a fractured tibia and cast

application. Which nursing assessment should be reported to the doctor?A.Pain beneath the castB. Warm toesC. Pedal pulses weak and rapidD.Paresthesia of the toes76. The client is having an arteriogram. During the procedure, the client tells

the nurse, "I'm feeing really hot." Which response would be best?A."You are having an allergic reaction. I will get an order for Benadryl."B. "That feeling of warmth is normal when the dye is injected."C. "That feeling of warmth indicates that the clots in the coronary vessels are

dissolving."D."I will tell your doctor and let him explain to you the reason for the hot

feeling that you are experiencing."77. The nurse is observing several healthcare workers providing care. Which

action by the healthcare worker indicates a need for further teaching?A.The nursing assistant wears gloves while giving the client a bath.B. The nurse wears goggles while drawing blood from the client.C. The doctor washes his hands before examining the client.D.The nurse wears gloves to take the client's vital signs.78. The client is having electroconvulsive therapy for treatment of severe

depression. Which of the following indicates that the client's ECT has been effective?

A.The client loses consciousness.B. The client vomits.C. The client's ECG indicates tachycardia.D.The client has a grand mal seizure.

79. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

A.Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep

B. Scrape the skin with a piece of cardboard and bring it to the clinicC. Obtain a stool specimen in the afternoonD.Bring a hair sample to the clinic for evaluation80. The nurse is teaching the mother regarding treatment for enterobiasis.

Which instruction should be given regarding the medication?A.Treatment is not recommended for children less than 10 years of age.B. The entire family should be treated.C. Medication therapy will continue for 1 year.D.Intravenous antibiotic therapy will be ordered.81. The registered nurse is making assignments for the day. Which client

should be assigned to the pregnant nurse?A.The client receiving linear accelerator radiation therapy for lung cancerB. The client with a radium implant for cervical cancerC. The client who has just been administered soluble brachytherapy for

thyroid cancerD.The client who returned from placement of iridium seeds for prostate cancer82. The nurse is planning room assignments for the day. Which client should

be assigned to a private room if only one is available?A.The client with Cushing's diseaseB. The client with diabetesC. The client with acromegalyD.The client with myxedema83. The nurse caring for a client in the neonatal intensive care unit

administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:

A.NegligenceB. TortC. AssaultD.Malpractice84. Which assignment should not be performed by the licensed practical

nurse?A.Inserting a Foley catheterB. Discontinuing a nasogastric tubeC. Obtaining a sputum specimenD.Starting a blood transfusion85. The client returns to the unit from surgery with a blood pressure of 90/50,

pulse 132, and respirations 30. Which action by the nurse should receive priority?

A.Continuing to monitor the vital signsB. Contacting the physician

C. Asking the client how he feelsD.Asking the LPN to continue the post-op care86. Which nurse should be assigned to care for the postpartal client with

preeclampsia?A.The RN with 2 weeks of experience in postpartumB. The RN with 3 years of experience in labor and deliveryC. The RN with 10 years of experience in surgeryD.The RN with 1 year of experience in the neonatal intensive care unit87. Which information should be reported to the state Board of Nursing?A.The facility fails to provide literature in both Spanish and English.B. The narcotic count has been incorrect on the unit for the past 3 days.C. The client fails to receive an itemized account of his bills and services

received during his hospital stay.D.The nursing assistant assigned to the client with hepatitis fails to feed the

client and give the bath.88. The nurse is suspected of charting medication administration that he did

not give. After talking to the nurse, the charge nurse should:A.Call the Board of NursingB. File a formal reprimandC. Terminate the nurseD.Charge the nurse with a tort89. The home health nurse is planning for the day's visits. Which client should

be seen first?A.The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tubeB. The 5-month-old discharged 1 week ago with pneumonia who is being

treated with amoxicillin liquid suspensionC. The 50-year-old with MRSA being treated with Vancomycin via a PICC lineD.The 30-year-old with an exacerbation of multiple sclerosis being treated with

cortisone via a centrally placed venous catheter90. The emergency room is flooded with clients injured in a tornado. Which

clients can be assigned to share a room in the emergency department during the disaster?

A.A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis

B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury

D.The client who arrives with a large puncture wound to the abdomen and the client with chest pain

91. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?

A.The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.

B. The child should be allowed to instill his own eyedrops.

C. The mother should be allowed to instill the eyedrops.D.If the eye is clear from any redness or edema, the eyedrops should be held.92. The nurse is discussing meal planning with the mother of a 2-year-old

toddler. Which of the following statements, if made by the mother, would require a need for further instruction?

A."It is okay to give my child white grape juice for breakfast."B. "My child can have a grilled cheese sandwich for lunch."C. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."D."For a snack, my child can have ice cream."93. A 2-year-old toddler is admitted to the hospital. Which of the following

nursing interventions would you expect?A.Ask the parent/guardian to leave the room when assessments are being

performed.B. Ask the parent/guardian to take the child's favorite blanket home because

anything from the outside should not be brought into the hospital.C. Ask the parent/guardian to room-in with the child.D.If the child is screaming, tell him this is inappropriate behavior.94. Which instruction should be given to the client who is fitted for a behind-

the-ear hearing aid?A.Remove the mold and clean every week.B. Store the hearing aid in a warm place.C. Clean the lint from the hearing aid with a toothpick.D.Change the batteries weekly.95. A priority nursing diagnosis for a child being admitted from surgery

following a tonsillectomy is:A.Body image disturbanceB. Impaired verbal communicationC. Risk for aspirationD.Pain96. A client with bacterial pneumonia is admitted to the pediatric unit. What

would the nurse expect the admitting assessment to reveal?A.High feverB. Nonproductive coughC. RhinitisD.Vomiting and diarrhea97. The nurse is caring for a client admitted with epiglottis. Because of the

possibility of complete obstruction of the airway, which of the following should the nurse have available?

A.Intravenous access suppliesB. A tracheostomy setC. Intravenous fluid administration pumpD.Supplemental oxygen98. A 25-year-old client with Grave's disease is admitted to the unit. What

would the nurse expect the admitting assessment to reveal?

A.BradycardiaB. Decreased appetiteC. ExophthalmosD.Weight gain99. The nurse is providing dietary instructions to the mother of an 8-year-old

child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?

A.Ham sandwich on whole-wheat toastB. Spaghetti and meatballsC. Hamburger with ketchupD.Cheese omelet100. The nurse is caring for an 80-year-old with chronic bronchitis. Upon

the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

A.Notify the physicianB. Recheck the O2 saturation level in 15 minutesC. Apply oxygen by maskD.Assess the child's pulse101. A gravida III para 0 is admitted to the labor and delivery unit. The

doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?

A.Fetal heart tones 160bpmB. A moderate amount of straw-colored fluidC. A small amount of greenish fluidD.A small segment of the umbilical cord102. The client is admitted to the unit. A vaginal exam reveals that she is

2cm dilated. Which of the following statements would the nurse expect her to make?

A."We have a name picked out for the baby."B. "I need to push when I have a contraction."C. "I can't concentrate if anyone is touching me."D."When can I get my epidural?"103. The client is having fetal heart rates of 90–110bpm during the

contractions. The first action the nurse should take is:A.Reposition the monitorB. Turn the client to her left sideC. Ask the client to ambulateD.Prepare the client for delivery104. In evaluating the effectiveness of IV Pitocin for a client with

secondary dystocia, the nurse should expect:A.A painless deliveryB. Cervical effacementC. Infrequent contractionsD.Progressive cervical dilation

105. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

A.Anticipate the need for a Caesarean sectionB. Apply the fetal heart monitorC. Place the client in Genu Pectoral positionD.Perform an ultrasound exam106. A vaginal exam reveals that the cervix is 4cm dilated, with intact

membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:

A.The cervix is closed.B. The membranes are still intact.C. The fetal heart tones are within normal limits.D.The contractions are intense enough for insertion of an internal monitor.107. The following are all nursing diagnoses appropriate for a gravida 1

para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?

A.Impaired gas exchange related to hyperventilationB. Alteration in placental perfusion related to maternal positionC. Impaired physical mobility related to fetal-monitoring equipmentD.Potential fluid volume deficit related to decreased fluid intake108. As the client reaches 8cm dilation, the nurse notes late decelerations

on the fetal monitor. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?

A.The baby is asleep.B. The umbilical cord is compressed.C. There is a vagal response.D.There is uteroplacental insufficiency.109. The nurse notes variable decelerations on the fetal monitor strip. The

most appropriate initial action would be to:A.Notify her doctorB. Start an IVC. Reposition the clientD.Readjust the monitor110. Which of the following is a characteristic of a reassuring fetal heart

rate pattern?A.A fetal heart rate of 170–180bpmB. A baseline variability of 25–35bpmC. Ominous periodic changesD.Acceleration of FHR with fetal movements111. The rationale for inserting a French catheter every hour for the client

with epidural anesthesia is:A.The bladder fills more rapidly because of the medication used for the

epidural.B. Her level of consciousness is such that she is in a trancelike state.C. The sensation of the bladder filling is diminished or lost.D.She is embarrassed to ask for the bedpan that frequently.

112. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

A.Estrogen levels are low.B. Lutenizing hormone is high.C. The endometrial lining is thin.D.The progesterone level is low.113. A client tells the nurse that she plans to use the rhythm method of

birth control. The nurse is aware that the success of the rhythm method depends on the:

A.Age of the clientB. Frequency of intercourseC. Regularity of the mensesD.Range of the client's temperature114. A client with diabetes asks the nurse for advice regarding methods of

birth control. Which method of birth control is most suitable for the client with diabetes?

A.Intrauterine deviceB. Oral contraceptivesC. DiaphragmD.Contraceptive sponge115. The doctor suspects that the client has an ectopic pregnancy. Which

symptom is consistent with a diagnosis of ectopic pregnancy?A.Painless vaginal bleedingB. Abdominal crampingC. Throbbing pain in the upper quadrantD.Sudden, stabbing pain in the lower quadrant116. The nurse is teaching a pregnant client about nutritional needs during

pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

A.Hamburger pattie, green beans, French fries, and iced teaB. Roast beef sandwich, potato chips, baked beans, and colaC. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced teaD.Fish sandwich, gelatin with fruit, and coffee117. The client with hyperemesis gravidarum is at risk for developing:A.Respiratory alkalosis without dehydrationB. Metabolic acidosis with dehydrationC. Respiratory acidosis without dehydrationD.Metabolic alkalosis with dehydration118. A client tells the doctor that she is about 20 weeks pregnant. The

most definitive sign of pregnancy is:A.Elevated human chorionic gonadatropinB. The presence of fetal heart tonesC. Uterine enlargementD.Breast enlargement and tenderness

119. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

A.Hypoglycemic, small for gestational ageB. Hyperglycemic, large for gestational ageC. Hypoglycemic, large for gestational ageD.Hyperglycemic, small for gestational age120. Which of the following instructions should be included in the nurse's

teaching regarding oral contraceptives?A.Weight gain should be reported to the physician.B. An alternate method of birth control is needed when taking antibiotics.C. If the client misses one or more pills, two pills should be taken per day for 1

week.D.Changes in the menstrual flow should be reported to the physician.121. The nurse is discussing breastfeeding with a postpartum client.

Breastfeeding is contraindicated in the postpartum client with:A.DiabetesB. Positive HIVC. HypertensionD.Thyroid disease122. A client is admitted to the labor and delivery unit complaining of

vaginal bleeding with very little discomfort. The nurse's first action should be to:

A.Assess the fetal heart tonesB. Check for cervical dilationC. Check for firmness of the uterusD.Obtain a detailed history123. A client telephones the emergency room stating that she thinks that

she is in labor. The nurse should tell the client that labor has probably begun when:

A.Her contractions are 2 minutes apart.B. She has back pain and a bloody discharge.C. She experiences abdominal pain and frequent urination.D.Her contractions are 5 minutes apart.124. The nurse is teaching a group of prenatal clients about the effects of

cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

A.Low birth weightB. Large for gestational ageC. Preterm birth, but appropriate size for gestationD.Growth retardation in weight and length125. The physician has ordered an injection of RhoGam for the postpartum

client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:

A.Within 72 hours of deliveryB. Within 1 week of deliveryC. Within 2 weeks of delivery

D.Within 1 month of delivery126. After the physician performs an amniotomy, the nurse's first action

should be to assess the:A.Degree of cervical dilationB. Fetal heart tonesC. Client's vital signsD.Client's level of discomfort127. A client is admitted to the labor and delivery unit. The nurse performs

a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?

A.ActiveB. LatentC. TransitionD.Early128. A newborn with narcotic abstinence syndrome is admitted to the

nursery. Nursing care of the newborn should include:A.Teaching the mother to provide tactile stimulationB. Wrapping the newborn snugly in a blanketC. Placing the newborn in the infant seatD.Initiating an early infant-stimulation program129. A client elects to have epidural anesthesia to relieve the discomfort of

labor. Following the initiation of epidural anesthesia, the nurse should give priority to:

A.Checking for cervical dilationB. Placing the client in a supine positionC. Checking the client's blood pressureD.Obtaining a fetal heart rate130. The nurse is aware that the best way to prevent post- operative

wound infection in the surgical client is to:A.Administer a prescribed antibioticB. Wash her hands for 2 minutes before careC. Wear a mask when providing careD.Ask the client to cover her mouth when she coughs131. The elderly client is admitted to the emergency room. Which symptom

is the client with a fractured hip most likely to exhibit?A.PainB. DisalignmentC. Cool extremityD.Absence of pedal pulses132. The nurse knows that a 60-year-old female client's susceptibility to

osteoporosis is most likely related to:A.Lack of exerciseB. Hormonal disturbancesC. Lack of calciumD.Genetic predisposition

133. A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction. Which finding by the nurse indicates that the traction is working properly?

A.The infant no longer complains of pain.B. The buttocks are 15° off the bed.C. The legs are suspended in the traction.D.The pins are secured within the pulley.134. A client with a fractured hip has been placed in Buck's traction.

Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:

A.Utilizes a Steinman pinB. Requires that both legs be securedC. Utilizes Kirschner wiresD.Is used primarily to heal the fractured hips135. The client is admitted for an open reduction internal fixation of a

fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

A.Serum collection (Davol) drainB. Client's painC. Nutritional statusD.Immobilizer136. Which statement made by the family member caring for the client

with a percutaneous gastrostomy tube indicates understanding of the nurse's teaching?

A."I must flush the tube with water after feedings and clamp the tube."B. "I must check placement four times per day."C. "I will report to the doctor any signs of indigestion."D."If my father is unable to swallow, I will discontinue the feeding and call the

clinic."137. The nurse is assessing the client with a total knee replacement 2

hours post-operative. Which information requires notification of the doctor?A.Bleeding on the dressing is 3cm in diameter.B. The client has a temperature of 6°F.C. The client's hematocrit is 26%.D.The urinary output has been 60 during the last 2 hours.138. The nurse is caring for the client with a 5-year-old diagnosis of

plumbism. Which information in the health history is most likely related to the development of plumbism?

A.The client has traveled out of the country in the last 6 months.B. The client's parents are skilled stained-glass artists.C. The client lives in a house built in 1D.The client has several brothers and sisters.139. A client with a total hip replacement requires special equipment.

Which equipment would assist the client with a total hip replacement with activities of daily living?

A.High-seat commode

B. ReclinerC. TENS unitD.Abduction pillow140. An elderly client with an abdominal surgery is admitted to the unit

following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:

A.Administer oxygen via nasal cannulaB. Have narcan (naloxane) availableC. Prepare to administer blood productsD.Prepare to do cardioresuscitation141. Which roommate would be most suitable for the 6-year-old male with

a fractured femur in Russell's traction?A.16-year-old female with scoliosisB. 12-year-old male with a fractured femurC. 10-year-old male with sarcomaD.6-year-old male with osteomylitis142. A client with osteoarthritis has a prescription for Celebrex

(celecoxib). Which instruction should be included in the discharge teaching?A.Take the medication with milk.B. Report chest pain.C. Remain upright after taking for 30 minutes.D.Allow 6 weeks for optimal effects.143. A client with a fractured tibia has a plaster-of-Paris cast applied to

immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:

A.Handles the cast with the fingertipsB. Petals the castC. Dries the cast with a hair dryerD.Allows 24 hours before bearing weight144. The teenager with a fiberglass cast asks the nurse if it will be okay to

allow his friends to autograph his cast. Which response would be best?A."It will be alright for your friends to autograph the cast."B. "Because the cast is made of plaster, autographing can weaken the cast."C. "If they don't use chalk to autograph, it is okay."D."Autographing or writing on the cast in any form will harm the cast."145. The nurse is assigned to care for the client with a Steinmen pin.

During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?

A.Assisting the LPN with opening sterile packages and peroxideB. Telling the LPN that clean gloves are allowedC. Telling the LPN that the registered nurse should perform pin careD.Asking the LPN to clean the weights and pulleys with peroxide146. A child with scoliosis has a spica cast applied. Which action specific to

the spica cast should be taken?A.Check the bowel soundsB. Assess the blood pressure

C. Offer pain medicationD.Check for swelling147. The client with a cervical fracture is placed in traction. Which type of

traction will be utilized at the time of discharge?A.Russell's tractionB. Buck's tractionC. Halo tractionD.Crutchfield tong traction148. A client with a total knee replacement has a CPM (continuous passive

motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?

A."Use of the CPM will permit the client to ambulate during the therapy."B. "The CPM machine controls should be positioned distal to the site."C. "If the client complains of pain during the therapy, I will turn off the

machine and call the doctor."D."Use of the CPM machine will alleviate the need for physical therapy after

the client is discharged."149. A client with a fractured hip is being taught correct use of the walker.

The nurse is aware that the correct use of the walker is achieved if the:A.Palms rest lightly on the handlesB. Elbows are flexed 0°C. Client walks to the front of the walkerD.Client carries the walker150. When assessing a laboring client, the nurse finds a prolapsed cord.

The nurse should:A.Attempt to replace the cordB. Place the client on her left sideC. Elevate the client's hipsD.Cover the cord with a dry, sterile gauze151. The nurse is caring for a 30-year-old male admitted with a stab

wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

A.The tube will allow for equalization of the lung expansion.B. Chest tubes serve as a method of draining blood and serous fluid and assist

in reinflating the lungs.C. Chest tubes relieve pain associated with a collapsed lung.D.Chest tubes assist with cardiac function by stabilizing lung expansion.152. A client who delivered this morning tells the nurse that she plans to

breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:

A.Mother's educational levelB. Infant's birth weightC. Size of the mother's breastD.Mother's desire to breastfeed153. The nurse is monitoring the progress of a client in labor. Which

finding should be reported to the physician immediately?

A.The presence of scant bloody dischargeB. Frequent urinationC. The presence of green-tinged amniotic fluidD.Moderate uterine contractions154. The nurse is measuring the duration of the client's contractions.

Which statement is true regarding the measurement of the duration of contractions?

A.Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.

B. Duration is measured by timing from the end of one contraction to the beginning of the next contraction.

C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.

D.Duration is measured by timing from the peak of one contraction to the end of the same contraction.

155. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:

A.Maternal hypoglycemiaB. Fetal bradycardiaC. Maternal hyperreflexiaD.Fetal movement156. A client with diabetes visits the prenatal clinic at 28 weeks gestation.

Which statement is true regarding insulin needs during pregnancy?A.Insulin requirements moderate as the pregnancy progresses.B. A decreased need for insulin occurs during the second trimester.C. Elevations in human chorionic gonadotrophin decrease the need for insulin.D.Fetal development depends on adequate insulin regulation.157. A client in the prenatal clinic is assessed to have a blood pressure of

180/96. The nurse should give priority to:A.Providing a calm environmentB. Obtaining a diet historyC. Administering an analgesicD.Assessing fetal heart tones158. A primigravida, age 42, is 6 weeks pregnant. Based on the client's

age, her infant is at risk for:A.Down syndromeB. Respiratory distress syndromeC. Turner's syndromeD.Pathological jaundice159. A client with a missed abortion at 29 weeks gestation is admitted to

the hospital. The client will most likely be treated with:A.Magnesium sulfateB. Calcium gluconateC. Dinoprostone (Prostin E.)D.Bromocrystine (Pardel)

160. A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:

A.Continue the infusion of magnesium sulfate while monitoring the client's blood pressure

B. Stop the infusion of magnesium sulfate and contact the physicianC. Slow the infusion rate and turn the client on her left sideD.Administer calcium gluconate IV push and continue to monitor the blood

pressure161. Which statement made by the nurse describes the inheritance pattern

of autosomal recessive disorders?A.An affected newborn has unaffected parents.B. An affected newborn has one affected parent.C. Affected parents have a one in four chance of passing on the defective gene.D.Affected parents have unaffected children who are carriers.162. A pregnant client, age 32, asks the nurse why her doctor has

recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

A.Because it is a state lawB. To detect cardiovascular defectsC. Because of her ageD.To detect neurological defects163. A client with hypothyroidism asks the nurse if she will still need to

take thyroid medication during the pregnancy. The nurse's response is based on the knowledge that:

A.There is no need to take thyroid medication because the fetus's thyroid produces a thyroid-stimulating hormone.

B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.

C. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.

D.Fetal growth is arrested if thyroid medication is continued during pregnancy.

164. The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:

A.An apical pulse of 100B. An absence of tonusC. Cyanosis of the feet and handsD.Jaundice of the skin and sclera165. A client with sickle cell anemia is admitted to the labor and delivery

unit during the first phase of labor. The nurse should anticipate the client's need for:

A.Supplemental oxygenB. Fluid restrictionC. Blood transfusion

D.Delivery by Caesarean section166. A client with diabetes has an order for ultrasonography. Preparation

for an ultrasound includes:A.Increasing fluid intakeB. Limiting ambulationC. Administering an enemaD.Withholding food for 8 hours167. An infant who weighs 8 pounds at birth would be expected to weigh

how many pounds at 1 year?A.14 poundsB. 16 poundsC. 18 poundsD.24 pounds168. A pregnant client with a history of alcohol addiction is scheduled for a

nonstress test. The nonstress test:A.Determines the lung maturity of the fetusB. Measures the activity of the fetusC. Shows the effect of contractions on the fetal heart rateD.Measures the neurological well-being of the fetus169. A full-term male has hypospadias. Which statement describes

hypospadias?A.The urethral opening is absent.B. The urethra opens on the dorsal side of the penis.C. The penis is shorter than usual.D.The urethra opens on the ventral side of the penis.170. A gravida III para II is admitted to the labor unit. Vaginal exam

reveals that the client's cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

A.Alteration in coping related to painB. Potential for injury related to precipitate deliveryC. Alteration in elimination related to anesthesiaD.Potential for fluid volume deficit related to NPO status171. The client with varicella will most likely have an order for which

category of medication?A.AntibioticsB. AntipyreticsC. AntiviralsD.Anticoagulants172. A client is admitted complaining of chest pain. Which of the following

drug orders should the nurse question?A.NitroglycerinB. AmpicillinC. PropranololD.Verapamil173. Which of the following instructions should be included in the teaching

for the client with rheumatoid arthritis?

A.Avoid exercise because it fatigues the joints.B. Take prescribed anti-inflammatory medications with meals.C. Alternate hot and cold packs to affected joints.D.Avoid weight-bearing activity.174. A client with acute pancreatitis is experiencing severe abdominal

pain. Which of the following orders should be questioned by the nurse?A.Meperidine 100mg IM q 4 hours PRN painB. Mylanta 30 ccs q 4 hours via NGC. Cimetadine 300mg PO q.i.d.D.Morphine 8mg IM q 4 hours PRN pain175. The client is admitted to the chemical dependence unit with an order

for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:

A.Hallucinogenic drugs create both stimulant and depressant effects.B. Hallucinogenic drugs induce a state of altered perception.C. Hallucinogenic drugs produce severe respiratory depression.D.Hallucinogenic drugs induce rapid physical dependence.176. A client with a history of abusing barbiturates abruptly stops taking

the medication. The nurse should give priority to assessing the client for:A.Depression and suicidal ideationB. Tachycardia and diarrheaC. Muscle cramping and abdominal painD.Tachycardia and euphoric mood177. During the assessment of a laboring client, the nurse notes that the

FHT are loudest in the upper-right quadrant. The infant is most likely in which position?

A.Right breech presentationB. Right occipital anterior presentationC. Left sacral anterior presentationD.Left occipital transverse presentation178. The primary physiological alteration in the development of asthma is:A.Bronchiolar inflammation and dyspneaB. Hypersecretion of abnormally viscous mucusC. Infectious processes causing mucosal edemaD.Spasm of bronchiolar smooth muscle179. A client with mania is unable to finish her dinner. To help her

maintain sufficient nourishment, the nurse should:A.Serve high-calorie foods she can carry with herB. Encourage her appetite by sending out for her favorite foodsC. Serve her small, attractively arranged portionsD.Allow her in the unit kitchen for extra food whenever she pleases180. To maintain Bryant's traction, the nurse must make certain that the

child's:A.Hips are resting on the bed, with the legs suspended at a right angle to the

bed

B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed

C. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed

D.Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

181. Which action by the nurse indicates understanding of herpes zoster?A.The nurse covers the lesions with a sterile dressing.B. The nurse wears gloves when providing care.C. The nurse administers a prescribed antibiotic.D.The nurse administers oxygen.182. The client has an order for a trough to be drawn on the client

receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:

A.15 minutes after the infusionB. 30 minutes before the infusionC. 1 hour after the infusionD.2 hours after the infusion183. The client using a diaphragm should be instructed to:A.Refrain from keeping the diaphragm in longer than 4 hoursB. Keep the diaphragm in a cool locationC. Have the diaphragm resized if she gains 5 poundsD.Have the diaphragm resized if she has any surgery184. The nurse is providing postpartum teaching for a mother planning to

breastfeed her infant. Which of the client's statements indicates the need for additional teaching?

A."I'm wearing a support bra."B. "I'm expressing milk from my breast."C. "I'm drinking four glasses of fluid during a 24-hour period."D."While I'm in the shower, I'll allow the water to run over my breasts."185. Damage to the VII cranial nerve results in:A.Facial painB. Absence of ability to smellC. Absence of eye movementD.Tinnitus186. A client is receiving Pyridium (phenazopyridine hydrochloride) for a

urinary tract infection. The client should be taught that the medication may:A.Cause diarrheaB. Change the color of her urineC. Cause mental confusionD.Cause changes in taste187. Which of the following tests should be performed before beginning a

prescription of Accutane?A.Check the calcium levelB. Perform a pregnancy testC. Monitor apical pulse

D.Obtain a creatinine level188. A client with AIDS is taking Zovirax (acyclovir). Which nursing

intervention is most critical during the administration of acyclovir?A.Limit the client's activityB. Encourage a high-carbohydrate dietC. Utilize an incentive spirometer to improve respiratory functionD.Encourage fluids189. A client is admitted for an MRI. The nurse should question the client

regarding:A.PregnancyB. A titanium hip replacementC. Allergies to antibioticsD.Inability to move his feet190. The nurse is caring for the client receiving Amphotericin B. Which of

the following indicates that the client has experienced toxicity to this drug?A.Changes in visionB. NauseaC. Urinary frequencyD.Changes in skin color191. The nurse should visit which of the following clients first?A.The client with diabetes with a blood glucose of 95mg/dLB. The client with hypertension being maintained on LisinoprilC. The client with chest pain and a history of anginaD.The client with Raynaud's disease192. A client with cystic fibrosis is taking pancreatic enzymes. The nurse

should administer this medication:A.Once per day in the morningB. Three times per day with mealsC. Once per day at bedtimeD.Four times per day193. Cataracts result in opacity of the crystalline lens. Which of the

following best explains the functions of the lens?A.The lens controls stimulation of the retina.B. The lens orchestrates eye movement.C. The lens focuses light rays on the retina.D.The lens magnifies small objects.194. A client who has glaucoma is to have miotic eyedrops instilled in both

eyes. The nurse knows that the purpose of the medication is to:A.Anesthetize the corneaB. Dilate the pupilsC. Constrict the pupilsD.Paralyze the muscles of accommodation195. A client with a severe corneal ulcer has an order for Gentamycin gtt.

q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?

A.Allow 5 minutes between the two medications.

B. The medications may be used together.C. The medications should be separated by a cycloplegic drug.D.The medications should not be used in the same client.196. The client with color blindness will most likely have problems

distinguishing which of the following colors?A.OrangeB. VioletC. RedD.White197. The client with a pacemaker should be taught to:A.Report ankle edemaB. Check his blood pressure dailyC. Refrain from using a microwave ovenD.Monitor his pulse rate198. The client with enuresis is being taught regarding bladder retraining.

The nurse should advise the client to refrain from drinking after:A.1900B. 1200C. 1000D.0700199. Which of the following diet instructions should be given to the client

with recurring urinary tract infections?A.Increase intake of meats.B. Avoid citrus fruits.C. Perform pericare with hydrogen peroxide.D.Drink a glass of cranberry juice every day.200. The physician has prescribed NPH insulin for a client with diabetes

mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

A."I will make sure I eat breakfast within 2 hours of taking my insulin."B. "I will need to carry candy or some form of sugar with me all the time."C. "I will eat a snack around three o'clock each afternoon."D."I can save my dessert from supper for a bedtime snack."201. A client with pneumacystis carini pneumonia is receiving

trimetrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:

A.Treat anemia.B. Create a synergistic effect.C. Increase the number of white blood cells.D.Reverse drug toxicity.202. A client tells the nurse that she is allergic to eggs, dogs, rabbits, and

chicken feathers. Which order should the nurse question?A.TB skin testB. Rubella vaccineC. ELISA testD.Chest x-ray

203. The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:

A.30 minutes before mealsB. With each mealC. In a single dose at bedtimeD.60 minutes after meals204. A temporary colostomy is performed on the client with colon cancer.

The nurse is aware that the proximal end of a double barrel colostomy:A.Is the opening on the client's left sideB. Is the opening on the distal end on the client's left sideC. Is the opening on the client's right sideD.Is the opening on the distal right side205. While assessing the postpartal client, the nurse notes that the fundus

is displaced to the right. Based on this finding, the nurse should:A.Ask the client to voidB. Assess the blood pressure for hypotensionC. Administer oxytocinD.Check for vaginal bleeding206. The physician has ordered an MRI for a client with an orthopedic

ailment. An MRI should not be done if the client has:A.The need for oxygen therapyB. A history of claustrophobiaC. A permanent pacemakerD.Sensory deafness207. A 6-month-old client is placed on strict bed rest following a hernia

repair. Which toy is best suited to the client?A.Colorful crib mobileB. Hand-held electronic gamesC. Cars in a plastic containerD.30-piece jigsaw puzzle208. The nurse is preparing to discharge a client with a long history of

polio. The nurse should tell the client that:A.Taking a hot bath will decrease stiffness and spasticity.B. A schedule of strenuous exercise will improve muscle strength.C. Rest periods should be scheduled throughout the day.D.Visual disturbances can be corrected with prescription glasses.209. A client on the postpartum unit has a proctoepisiotomy. The nurse

should anticipate administering which medication?A.Dulcolax suppositoryB. Docusate sodium (Colace)C. Methyergonovine maleate (Methergine)D.Bromocriptine sulfate (Parlodel)210. A client with pancreatic cancer has an infusion of TPN (Total

Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:

A.Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.

B. Total Parenteral Nutrition cannot be managed with oral hypoglycemics.C. Total Parenteral Nutrition is a high-glucose solution that often elevates the

blood glucose levels.D.Total Parenteral Nutrition leads to further pancreatic disease.211. An adolescent primigravida who is 10 weeks pregnant attends the

antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:

A.The client's knowledge of the signs of preterm laborB. The client's feelings about the pregnancyC. Whether the client was using a method of birth controlD.The client's thought about future children212. An obstetric client is admitted with dehydration. Which IV fluid would

be most appropriate for the client?A..45 normal salineB. Dextrose 1% in waterC. Lactated Ringer'sD.Dextrose 5% in .45 normal saline213. The physician has ordered a thyroid scan to confirm the diagnosis.

Before the procedure, the nurse should:A.Assess the client for allergiesB. Bolus the client with IV fluidC. Tell the client he will be asleepD.Insert a urinary catheter214. The physician has ordered an injection of RhoGam for a client with

blood type A negative. The nurse understands that RhoGam is given to:A.Provide immunity against Rh isoenzymesB. Prevent the formation of Rh antibodiesC. Eliminate circulating Rh antibodiesD.Convert the Rh factor from negative to positive215. The nurse is caring for a client admitted to the emergency room after

a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

A.Application of a short inclusive spica castB. Stabilization with a plaster-of-Paris castC. Surgery with Kirschner wire implantationD.A gauze dressing only216. A client with bladder cancer is being treated with iridium seed

implants. The nurse's discharge teaching should include telling the client to:A.Strain his urineB. Increase his fluid intakeC. Report urinary frequencyD.Avoid prolonged sitting

217. Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?

A.AntiviralsB. AntibioticsC. ImmunosuppressantsD.Analgesics218. The nurse is preparing a client for cataract surgery. The nurse is

aware that the procedure will use:A.Mydriatics to facilitate removalB. Miotic medications such as TimopticC. A laser to smooth and reshape the lensD.Silicone oil injections into the eyeball219. A client with Alzheimer's disease is awaiting placement in a skilled

nursing facility. Which long-term plans would be most therapeutic for the client?

A.Placing mirrors in several locations in the homeB. Placing a picture of herself in her bedroomC. Placing simple signs to indicate the location of the bedroom, bathroom, and

so onD.Alternating healthcare workers to prevent boredom220. A client with an abdominal cholecystectomy returns from surgery

with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

A.Prevent the need for dressing changesB. Reduce edema at the incisionC. Provide for wound drainageD.Keep the common bile duct open221. The nurse is performing an initial assessment of a newborn Caucasian

male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

A.Mongolian spotsB. Scrotal rugaeC. Head lagD.Vernix caseosa222. The nurse is caring for a client admitted with multiple trauma.

Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

A.HematuriaB. Muscle spasmsC. DizzinessD.Nausea223. A client is brought to the emergency room by the police. He is

combative and yells, "I have to get out of here. They are trying to kill me." Which assessment is most likely correct in relation to this statement?

A.The client is experiencing an auditory hallucination.

B. The client is having a delusion of grandeur.C. The client is experiencing paranoid delusions.D.The client is intoxicated.224. The nurse is preparing to suction the client with a tracheotomy. The

nurse notes a previously used bottle of normal saline on the client's bedside table. There is no label to indicate the date or time of initial use. The nurse should:

A.Lip the bottle and use a pack of sterile 4x4 for the dressingB. Obtain a new bottle and label it with the date and time of first useC. Ask the ward secretary when the solution was requestedD.Label the existing bottle with the current date and time225. An infant's Apgar score is 9 at 5 minutes. The nurse is aware that the

most likely cause for the deduction of one point is:A.The baby is cold.B. The baby is experiencing bradycardia.C. The baby's hands and feet are blue.D.The baby is lethargic.226. The primary reason for rapid continuous rewarming of the area

affected by frostbite is to:A.Lessen the amount of cellular damageB. Prevent the formation of blistersC. Promote movementD.Prevent pain and discomfort227. A client recently started on hemodialysis wants to know how the

dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:

A.Passing water through a dialyzing membraneB. Eliminating plasma proteins from the bloodC. Lowering the pH by removing nonvolatile acidsD.Filtering waste through a dialyzing membrane228. During a home visit, a client with AIDS tells the nurse that he has

been exposed to measles. Which action by the nurse is most appropriate?A.Administer an antibioticB. Contact the physician for an order for immune globulinC. Administer an antiviralD.Tell the client that he should remain in isolation for 2 weeks229. A client hospitalized with MRSA (methicillin-resistant staph aureus) is

placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

A.The client should be placed in a room with negative pressure.B. Infection requires close contact; therefore, the door may remain open.C. Transmission is highly likely, so the client should wear a mask at all times.D.Infection requires skin-to-skin contact and is prevented by hand washing,

gloves, and a gown.

230. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

A."The pain will go away in a few days."B. "The pain is due to peripheral nervous system interruptions. I will get you

some pain medication."C. "The pain is psychological because your foot is no longer there."D."The pain and itching are due to the infection you had before the surgery."231. A client with cancer of the pancreas has undergone a Whipple

procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:

A.Head of the pancreasB. Proximal third section of the small intestinesC. Stomach and duodenumD.Esophagus and jejunum232. The physician has ordered a minimal-bacteria diet for a client with

neutropenia. The client should be taught to avoid eating:A.FruitsB. SaltC. PepperD.Ketchup233. A client is discharged home with a prescription for Coumadin (sodium

warfarin). The client should be instructed to:A.Have a Protime done monthlyB. Eat more fruits and vegetablesC. Drink more liquidsD.Avoid crowds234. The nurse is assisting the physician with removal of a central venous

catheter. To facilitate removal, the nurse should instruct the client to:A.Perform the Valsalva maneuver as the catheter is advancedB. Turn his head to the left side and hyperextend the neckC. Take slow, deep breaths as the catheter is removedD.Turn his head to the right while maintaining a sniffing position235. A client has an order for streptokinase. Before administering the

medication, the nurse should assess the client for:A.Allergies to pineapples and bananasB. A history of streptococcal infectionsC. Prior therapy with phenytoinD.A history of alcohol abuse236. The nurse is providing discharge teaching for the client with

leukemia. The client should be told to avoid:A.Using oil- or cream-based soapsB. Flossing between the teethC. The intake of saltD.Using an electric razor

237. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

A.Apply the new tie before removing the old one.B. Have a helper present.C. Hold the tracheotomy with the nondominant hand while removing the old

tie.D.Ask the doctor to suture the tracheostomy in place.238. The nurse is monitoring a client following a lung resection. The hourly

output from the chest tube was 300mL. The nurse should give priority to:A.Turning the client to the left sideB. Milking the tube to ensure patencyC. Slowing the intravenous infusionD.Notifying the physician239. The infant is admitted to the unit with tetrology of falot. The nurse

would anticipate an order for which medication?A.DigoxinB. EpinephrineC. AminophylineD.Atropine240. The nurse is educating the lady's club in self-breast exam. The nurse

is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

241. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

A.Tire easilyB. Grow normallyC. Need more caloriesD.Be more susceptible to viral infections242. The nurse is monitoring a client with a history of stillborn infants. The

nurse is aware that a nonstress test can be ordered for this client to:A.Determine lung maturityB. Measure the fetal activity

C. Show the effect of contractions on fetal heart rateD.Measure the well-being of the fetus243. The nurse is evaluating the client who was admitted 8 hours ago for

induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

A.Instruct the client to pushB. Perform a vaginal examC. Turn off the Pitocin infusionD.Place the client in a semi-Fowler's position244. The nurse notes the following on the ECG monitor. The nurse would

evaluate the cardiac arrhythmia as:

A.Atrial flutterB. A sinus rhythmC. Ventricular tachycardiaD.Atrial fibrillation245. A client with clotting disorder has an order to continue Lovenox

(enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

A.Be injected into the deltoid muscleB. Be injected into the abdomenC. Aspirate after the injectionD.Clear the air from the syringe before injections

246. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

A.Administer the medications together in one syringeB. Administer the medication separatelyC. Administer the Valium, wait 5 minutes, and then inject the PhenerganD.Question the order because they cannot be given at the same time247. A client with frequent urinary tract infections asks the nurse how she

can prevent the reoccurrence. The nurse should teach the client to:A.Douche after intercourseB. Void every 3 hoursC. Obtain a urinalysis monthlyD.Wipe from back to front after voiding248. Which task should be assigned to the nursing assistant?A.Placing the client in seclusionB. Emptying the Foley catheter of the preeclamptic clientC. Feeding the client with dementiaD.Ambulating the client with a fractured hip249. The client has recently returned from having a thyroidectomy. The

nurse should keep which of the following at the bedside?A.A tracheotomy setB. A padded tongue bladeC. An endotracheal tubeD.An airway250. The physician has ordered a histoplasmosis test for the elderly client.

The nurse is aware that histoplasmosis is transmitted to humans by:A.CatsB. DogsC. TurtlesD.Birds

Answers and Rationales for Comprehensive Examination Part 2

1. Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.

2. Answer D is correct. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.

3. Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

4. Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.

5. Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.

6. Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.

7. Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.

8. Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the

physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect.

9. Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.

10. Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.

11. Answer A is correct. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

12. Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

13. Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment.

14. Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

15. Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

16. Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.

17. Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct

answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.

18. Answer A is correct. The normal platelet count is 120,000–400,000. Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.

19. Answer C is correct. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

20. Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.

21. Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.

22. Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

23. Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

24. Answer B is correct. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.

25. Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.

26. Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of

rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

27. Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

28. Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect.

29. Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.

30. Answer C is correct. Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

31. Answer B is correct. The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.

32. Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.

33. Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.

34. Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.

35. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.

36. Answer B is correct. The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.

37. Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.

38. Answer B is correct. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.

39. Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.

40. Answer A is correct. The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.

41. Answer B is correct. Proton pump inhibitors such as Nexium and Protonix should be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals, so answer A is incorrect. Tagamet can be taken in a single dose at bedtime, making answer C incorrect. Answer D does not treat the problem adequately and, therefore, is incorrect.

42. Answer A is correct. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer C is incorrect because telling the client that if he continues he will be punished is a threat

and may further anger him. Answer D is incorrect because if the client is left alone he might harm himself.

43. Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage.

44. Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem.

45. Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.

46. Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.

47. Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect.

48. Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect.

49. Answer C is correct. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.

50. Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect.

51. Answer B is correct. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to

document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.

52. Answer B is correct. The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.

53. Answer B is correct. A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Condylomata lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.

54. Answer C is correct. Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis, so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea, so answer D is incorrect.

55. Answer D is correct. The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer C is incorrect.

56. Answer A is correct. Answer B elicits the triceps reflex, so it is incorrect. Answer C elicits the patella reflex, making it incorrect. Answer D elicits the radial nerve, so it is incorrect.

57. Answer B is correct. Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so they are incorrect.

58. Answer C is correct. When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer D is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, making answer B incorrect.

59. Answer C is correct. Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers A, B, and D are incorrect.

60. Answer B is correct. The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers A, C, and D are incorrect.

61. Answer D is correct. If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the

anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B, the IV rate should be increased, not decreased. In answer C, the oxygen should be applied by mask, not cannula.

62. Answer A is correct. Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus, answers B, C, and D are incorrect.

63. Answer C is correct. Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus, answer D is incorrect.

64. Answer B is correct. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect.

65. Answer A is correct. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Answers B, C, and D are not factors for concern.

66. Answer D is correct. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions.

67. Answer B is correct. In clients who have not had surgery to the face or neck, the answer would be answer A; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time.

68. Answer C is correct. If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers A, B, and D are not the first action to be taken.

69. Answer A is correct. The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B, C, and D may be needed at a later time but are not the most important actions to take first.

70. Answer C is correct. The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.

71. Answer C is correct. The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary, so answers A, B, and D are incorrect.

72. Answer D is correct. If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, so answers B and C are incorrect.

73. Answer B is correct. The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, as well as hyponatremia and hypokalemia in C and D, but these answers are not of primary concern so are incorrect.

74. Answer D is correct. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat, so answer A is incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, answer B is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so answer C is incorrect.

75. Answer D is correct. At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, Answers A, B, and C are incorrect.

76. Answer B is correct. It is normal for the client to have a warm sensation when dye is injected. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.

77. Answer D is correct. It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The healthcare workers in answers A, B, and C indicate knowledge of infection control by their actions.

78. Answer D is correct. During ECT, the client will have a grand mal seize. This indicates completion of the electroconvulsive therapy. Answers A, B, and C do not indicate that the ECT has been effective, so are incorrect.

79. Answer A is correct. Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrap the skin, collect a stool specimen, or bring a sample of hair, so answers B, C, and D are incorrect.

80. Answer B is correct. Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.

81. Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The clients in answers B, C, and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks.

82. Answer A is correct. The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema and poses no risk to others or himself.

83. Answer D is correct. The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Answers A, B, and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.

84. Answer D is correct. The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen; therefore, answers A, B, and C are incorrect.

85. Answer B is correct. The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition, making answer A incorrect. Asking the client how he feels in answer C will only provide subjective data, and the nurse in answer D is not the best nurse to assign because this client is unstable.

86. Answer B is correct. The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit, and the nurses in answers C and D have no experience with the postpartum client.

87. Answer B is correct. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.

88. Answer B is correct. The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore, Answers A, C, and D are incorrect.

89. Answer D is correct. The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A, B, and C are more stable and can be seen later.

90. Answer B is correct. The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A, C, and D need to be placed in separate rooms due to the serious natures of their injuries.

91. Answer A is correct. Before instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration, making answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect.

92. Answer C is correct. Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A, B, and C are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.

93. Answer C is correct. The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore, answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities.

94. Answer B is correct. The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide, making answer C incorrect. Changing the batteries weekly, as in answer D, is not necessary.

95. Answer C is correct. Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers B and D might be appropriate for this child, answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy.

96. Answer A is correct. If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive

cough, not a nonproductive cough, making answer B incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so answers C and D are incorrect.

97. Answer B is correct. For a child with epiglottis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies, fluid, and oxygen will not treat an obstruction; therefore, answers A, C, and D are incorrect.

98. Answer C is correct. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss; therefore, answers A, B, and D are incorrect.

99. Answer D is correct. The child with celiac disease should be on a gluten-free diet. Answers A, B, and C all contain gluten, while answer D gives the only choice of foods that does not contain gluten.

100. Answer C is correct. Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.

101. Answer B is correct. An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium, so answers A and C are incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord, so answer D is incorrect and would need to be reported immediately.

102. Answer D is correct. Dilation of 2cm marks the end of the latent phase of labor. Answer A is a vague answer, answer B indicates the end of the first stage of labor, and answer C indicates the transition phase.

103. Answer B is correct. The normal fetal heart rate is 120–160bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time.

104. Answer D is correct. The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making answer A incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is opposite the action of Pitocin.

105. Answer B is correct. Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genu Pectoral position (knee-chest), so answers A and C are incorrect. Answer D is incorrect because there is no need for an ultrasound based on the finding.

106. Answer B is correct. The nurse decides to apply an external monitor because the membranes are intact. Answers A, C, and D are incorrect. The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.

107. Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase. Answers B and C are not correct in relation to the stem.

108. Answer D is correct. This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer A has no relation to the readings, so it’s incorrect; answer B results in a variable deceleration; and answer C is indicative of an early deceleration.

109. Answer C is correct. The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Answer A might be necessary but not before turning the client to her side. Answer B is not necessary at this time. Answer D is incorrect because there is no data to indicate that the monitor has been applied incorrectly.

110. Answer D is correct. Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor.

111. Answer C is correct. Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A, B, and D are incorrect for the stem.

112. Answer B is correct. Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.

113. Answer C is correct. The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature; therefore, answers A, B, and D are incorrect.

114. Answer C is correct. The best method of birth control for the client with diabetes is the diaphragm. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided, oral contraceptives tend to elevate blood glucose levels, and contraceptive sponges are not good at preventing pregnancy. Therefore, answers A, B, and D are incorrect.

115. Answer D is correct. The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy, making answers A, B, and C incorrect.

116. Answer C is correct. All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium. Answer A is lacking in fruits and milk. Answer B contains the potato chips, which contain a large amount of sodium. Answer C contains meat, fruit, potato salad, and yogurt, which has about 360mg of calcium. Answer D is not the best diet because it lacks vegetables and milk products.

117. Answer B is correct. The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Answers A and C are incorrect because they are respiratory dehydration. Answer D is incorrect because the client will not be in alkalosis with persistent vomiting.

118. Answer B is correct. The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A, C, and D are subjective and might be related to other medical conditions. Answers A and C may be related to a hydatidiform mole, and answer D is often present before menses or with the use of oral contraceptives.

119. Answer C is correct. The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Answer A is incorrect because the infant will not be small for gestational age. Answer B is incorrect because the infant will not be hyperglycemic. Answer D is incorrect because the infant will be large, not small, and will be hypoglycemic, not hyperglycemic.

120. Answer B is correct. When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

121. Answer B is correct. Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A, C, and D—those with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed.

122. Answer A is correct. The symptoms of painless vaginal bleeding are consistent with placenta previa. Answers B, C, and D are incorrect. Cervical check for dilation is contraindicated because this can increase the bleeding.

Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. A detailed history can be done later.

123. Answer D is correct. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge, so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection.

124. Answer A is correct. Infants of mothers who smoke are often low in birth weight. Infants who are large for gestational age are associated with diabetic mothers, so answer B is incorrect. Preterm births are associated with smoking, but not with appropriate size for gestation, making answer C incorrect. Growth retardation is associated with smoking, but this does not affect the infant length; therefore, answer D is incorrect.

125. Answer A is correct. To provide protection against antibody production, RhoGam should be given within 72 hours. The answers in B, C, and D are too late to provide antibody protection. RhoGam can also be given during pregnancy.

126. Answer B is correct. When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort, making answers A, C, and D incorrect.

127. Answer A is correct. The active phase of labor occurs when the client is dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in dilation, so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation, making answer C incorrect.

128. Answer B is correct. The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time, so answers A and D are incorrect. Placing the infant in an infant seat in answer C is incorrect because this will also cause movement that can increase muscle irritability.

129. Answer C is correct. Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client can be checked for cervical dilation later after she is stable. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Fetal heart tones should be assessed after the blood pressure is checked. Therefore, answers A, B, and D are incorrect.

130. Answer B is correct. The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection,

not prevent infections, making answer A incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore, answers C and D are incorrect.

131. Answer B is correct. The client with a hip fracture will most likely have disalignment. Answers A, C, and D are incorrect because all fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.

132. Answer B is correct. After menopause, women lack hormones necessary to absorb and utilize calcium. Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes, so answers A and C are incorrect. Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis, so answer D is incorrect.

133. Answer B is correct. The infant’s hips should be off the bed approximately 15° in Bryant’s traction. Answer A is incorrect because this does not indicate that the traction is working correctly, nor does C. Answer D is incorrect because Bryant’s traction is a skin traction, not a skeletal traction.

134. Answer A is correct. Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Answer B is incorrect because only the affected leg is in traction. Kirschner wires are used to stabilize small bones such as fingers and toes, as in answer C. Answer D is incorrect because this type of traction is not used for fractured hips.

135. Answer A is correct. Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. The client’s pain should be assessed, but this is not life-threatening. When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used; thus, answers B, C, and D are incorrect.

136. Answer A is correct. The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers B and C are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer D is incorrect.

137. Answer C is correct. The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is also not

uncommon and no need for concern; therefore answers A, B, and D are incorrect.

138. Answer B is correct. Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Answer A is incorrect because simply traveling out of the country does not increase the risk. In answer C, the house was built after the lead was removed with the paint. Answer D is unrelated to the stem.

139. Answer A is correct. The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but not daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management and an abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis; therefore, answers B, C, and D are incorrect.

140. Answer B is correct. Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardioresuscitation, so answers A, C, and D are incorrect.

141. Answer B is correct. The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed, the 6-year-old with osteomylitis is infected, and the client in answer A is too old and is female; therefore, answers A, C, and D are incorrect.

142. Answer B is correct. Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect, so answers A, C, and D are incorrect.

143. Answer D is correct. A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. The cast should be handled with the palms, not the fingertips, so answer A is incorrect. Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast, making answer B incorrect. The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying; thus, answer C is incorrect.

144. Answer A is correct. There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers B, C, and D are incorrect.

145. Answer A is correct. The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required; therefore, answers B, C, and D are incorrect.

146. Answer A is correct. A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic illeus. Checking the blood pressure is a treatment for any client, offering pain medication is not called for, and checking for swelling isn’t specific to the stem, so answers B, C, and D are incorrect.

147. Answer C is correct. Halo traction will be ordered for the client with a cervical fracture. Russell’s traction is used for bones of the lower extremities, as is Buck’s traction. Cruchfield tongs are used while in the hospital and the client is immobile; therefore, answers A, B, and D are incorrect.

148. Answer B is correct. The controller for the continuous passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. The client is in the bed during CPM therapy, so answer A is incorrect. Answer C is incorrect because clients will experience pain with the treatment. Use of the CPM does not alleviate the need for physical therapy, as suggested in answer D.

149. Answer A is correct. The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Answer B is incorrect because 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. The client should walk to the middle of the walker, not to the front of the walker, making answer C incorrect. The client should be taught not to carry the walker because this would not provide stability; thus, answer D is incorrect.

150. Answer C is correct. The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze.

151. Answer B is correct. Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answers A and C are incorrect. Answer D is true, but this is not the primary rationale for performing chest tube insertion.

152. Answer D is correct. Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size

of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect.

153. Answer C is correct. Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, making answers A, B, and D incorrect.

154. Answer C is correct. Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end, as stated in D.

155. Answer B is correct. The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are incorrect.

156. Answer D is correct. Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them; therefore, answers A, B, and C are incorrect.

157. Answer A is correct. A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Obtaining a diet history should be done later, and administering an analgesic is not indicated because there is no data in the stem to indicate pain. Therefore, answers B and C are incorrect. Assessing the fetal heart tones is important, but this is not the highest priority in this situation as stated in answer D.

158. Answer A is correct. The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. Answers B, C, and D are incorrect because the client is not at higher risk for respiratory distress syndrome or pathological jaundice, and Turner’s syndrome is a genetic disorder.

159. Answer C is correct. The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, answers A, B, and D are incorrect. Pardel was used at one time to dry breast milk.

160. Answer A is correct. The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Answers B, C, and D are incorrect. There is no need to stop the infusion at this time or slow the rate. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity.

161. Answer C is correct. Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Answer A is incorrect because, to have an affected newborn, the parents must be carriers. Answer B is incorrect because both parents must be carriers. Answer D is incorrect because the parents might have affected children.

162. Answer D is correct. Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer A. It does not indicate cardiovascular defects, and the mother’s age has no bearing on the need for the test, so answers B and C are incorrect.

163. Answer B is correct. During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer D is incorrect.

164. Answer C is correct. Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120–160, and the baby should have muscle tone, making answers A and B incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is incorrect.

165. Answer A is correct. Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, answers B, C, and D are incorrect.

166. Answer A is correct. Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for 8 hours. Therefore, answers B, C, and D are incorrect.

167. Answer D is correct. By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C are incorrect because they are too low.

168. Answer B is correct. A nonstress test is done to evaluate periodic movement of the fetus. It is not done to evaluate lung maturity as in answer A. An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus, so answers C and D are incorrect.

169. Answer B is correct. Hypospadia is a condition in which there is an opening on the dorsal side of the penis. Answer A is incorrect because hypospadia does not concern the urethral opening. Answer C is incorrect because the size of the penis is not affected. Answer D is incorrect because the opening is on the dorsal side, not the ventral side.

170. Answer A is correct. Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury

related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers C and D incorrect.

171. Answer C is correct. Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants as stated in answers A and D. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer B is incorrect.

172. Answer B is correct. Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil. There is no indication for an antibiotic such as Ampicillin, so answers A, C, and D are incorrect.

173. Answer B is correct. Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Answers A, C, and D are incorrect. Clients with rheumatoid arthritis should exercise, but not to the point of pain. Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Weight-bearing activities such as walking are useful but is not the best answer for the stem.

174. Answer D is correct. Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. Meperidine, Mylanta, and Cimetadine are ordered for pancreatitis, making answers A, B, and C incorrect.

175. Answer B is correct. Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answers A, C, and D are incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. However, they do produce psychological dependence rather than physical dependence.

176. Answer B is correct. Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Answer A is incorrect even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates, but euphoria is not.

177. Answer A is correct. If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occipital anterior presentation, the FHTs will be located in the right lower quadrant, so answer B is incorrect. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen, so answer C is incorrect. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occipital transverse position, making answer D incorrect.

178. Answer D is correct. Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect

because the primary physiological alteration is not inflammation. Answer B is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer C is incorrect because infection is not primary to asthma.

179. Answer A is correct. The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed, so answer D is incorrect.

180. Answer B is correct. Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips and legs should not be flat on the bed.

181. Answer B is correct. Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles; therefore, answers A, C, and D are incorrect.

182. Answer B is correct. A trough level should be drawn 30 minutes before the third or fourth dose. The times in answers A, C, and D are incorrect times to draw blood levels.

183. Answer B is correct. The client using a diaphragm should keep the diaphragm in a cool location. Answers A, C, and D are incorrect. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.

184. Answer C is correct. Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed, so answer A is incorrect. Expressing milk from the breast will stimulate milk production, making answer B incorrect. Allowing the water to run over the breast will also facilitate "letdown," when the milk begins to be produced; thus, answer D is incorrect.

185. Answer A is correct. The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell; therefore, answers B, C, and D are incorrect.

186. Answer B is correct. Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste; therefore, answers A, C,

and D are incorrect. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.

187. Answer B is correct. Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary; therefore, answers A, C, and D are incorrect.

188. Answer D is correct. Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir; therefore, answers A, B, and C are incorrect.

189. Answer A is correct. Clients who are pregnant should not have an MRI because radioactive isotopes are used. However, clients with a titanium hip replacement can have an MRI, so answer B is incorrect. No antibiotics are used with this test and the client should remain still only when instructed, so answers C and D are not specific to this test.

190. Answer D is correct. Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency. Thus, answers A, B, and C are incorrect.

191. Answer C is correct. The client with chest pain should be seen first because this could indicate a myocardial infarction. The client in answer A has a blood glucose within normal limits. The client in answer B is maintained on blood pressure medication. The client in answer D is in no distress.

192. Answer B is correct. Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Answers A, C, and D are incorrect methods of administering pancreatic enzymes.

193. Answer C is correct. The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina, assist with eye movement, or magnify small objects, so answers A, B, and D are incorrect.

194. Answer C is correct. Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye, making answers A, B, and D incorrect.

195. Answer A is correct. When using eyedrops, allow 5 minutes between the two medications; therefore, answer B is incorrect. These medications can be used by the same client but it is not necessary to use a cyclopegic with these medications, making answers C and D incorrect.

196. Answer B is correct. Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in answers A, C, and D are less commonly affected.

197. Answer D is correct. The client with a pacemaker should be taught to count and record his pulse rate. Answers A, B, and C are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating.

198. Answer A is correct. Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1 The times in answers B, C, and D are too early in the day.

199. Answer D is correct. Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so answer A is incorrect. The client does not have to avoid citrus fruits and pericare should be done, but hydrogen peroxide is drying, so answers B and C are incorrect.

200. Answer C is correct. NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack.

201. Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect.

202. Answer B is correct. The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect.

203. Answer B is correct. Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers A and D are incorrect.

204. Answer C is correct. The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side.

205. Answer A is correct. If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B.

Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding.

206. Answer C is correct. Clients with an internal defibrillator or a pacemaker should not have an MRI because it can cause dysrhythmias in the client with a pacemaker. If the client has a need for oxygen, is claustrophobic, or is deaf, he can have an MRI, but provisions such as extension tubes for the oxygen, sedatives, or a signal system should be made to accommodate these problems. Therefore, answers A, B, and D are incorrect.

207. Answer C is correct. A 6-month-old is too old for the colorful mobile. He is too young to play with the electronic game or the 30-piece jigsaw puzzle. The best toy for this age is the cars in a plastic container, so answers A, B, and D are incorrect.

208. Answer C is correct. The client with polio has muscle weakness. Periods of rest throughout the day will conserve the client’s energy. A hot bath can cause burns; however, a warm bath would be helpful, so answer A is incorrect. Strenuous exercises are not advisable, making answer B incorrect. Visual disturbances are directly associated with polio and cannot be corrected with glasses; therefore, answer D is incorrect.

209. Answer B is correct. The client with a protoepisiotomy will need stool softeners such as docusate sodium. Suppositories are given only with an order from the doctor, Methergine is a drug used to contract the uterus, and Parlodel is an anti-Parkinsonian drug; therefore, answers A, C, and D are incorrect.

210. Answer C is correct. Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answers A, B, and D are incorrect. TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral Nutrition will not lead to further pancreatic disease.

211. Answer B is correct. The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. It is too early to discuss preterm labor, too late to discuss whether she was using a method of birth control, and after the client delivers, a discussion of future children should be instituted. Thus, answers A, C, and D are incorrect.

212. Answer A is correct. The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringer’s contains more electrolytes than the client’s serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers B, C, and D are incorrect.

213. Answer A is correct. A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid,

will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.

214. Answer B is correct. RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers A, C, and D are incorrect.

215. Answer B is correct. A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer, so answers A, C, and D are incorrect.

216. Answer A is correct. Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.

217. Answer C is correct. Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers A, B, and D are incorrect.

218. Answer A is correct. Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers B, C, and D are incorrect.

219. Answer C is correct. Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers A, B, and D are incorrect.

220. Answer C is correct. A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep the common bile duct open.

221. Answer C is correct. The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa, the cheesy appearing covering found on most full-term infants. Therefore, answers A, B, and D are incorrect.

222. Answer A is correct. Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. It is not unusual for the client to complain of muscles spasms with multiple fractures, so answer B is incorrect. Dizziness can be associated with blood

loss and is nonspecific, making answer C incorrect. Nausea, as stated in answer D, is also common in the client with multiple traumas.

223. Answer C is correct. The client’s statement "They are trying to kill me" indicates paranoid delusions. There is no data to indicate that the client is hearing voices or is intoxicated, so answers A and D are incorrect. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, making answer B incorrect.

224. Answer B is correct. Because the nurse is unaware of when the bottle was opened or whether the saline is sterile, it is safest to obtain a new bottle. Answers A, C, and D are not safe practices.

225. Answer C is correct. Infants with an Apgar of 9 at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. It is not related to the infant being cold, experiencing bradycardia, or being lethargic; thus, answers A, B, and D are incorrect.

226. Answer A is correct. Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity; therefore, answers B, C, and D are incorrect.

227. Answer D is correct. Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH, so answers A, B, and C are incorrect.

228. Answer B is correct. The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation, so answers A, C, and D are incorrect.

229. Answer D is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer C is incorrect.

230. Answer B is correct. Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Answer A is incorrect because phantom limb pain can last several months or indefinitely. Answer C is incorrect because it is not psychological. It is also not due to infections, as stated in answer D.

231. Answer A is correct. During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach

is not removed, as in answer C, and in answer D, the esophagus is not removed.

232. Answer C is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.

233. Answer A is correct. Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting, so answer B is incorrect. Drinking more liquids and avoiding crowds is not necessary, so answers C and D are incorrect.

234. Answer A is correct. The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Answers B, C, and D will not facilitate removal.

235. Answer B is correct. Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, answers A, C, and D are incorrect.

236. Answer B is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect.

237. Answer A is correct. The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.

238. Answer D is correct. The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer A does nothing to help the client. Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not correct; thus, answers B and C are incorrect.

239. Answer A is correct. The infant with tetrology of falot has five heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client; therefore, answers B, C, and D are incorrect.

240. The correct answer is marked by an X in the diagram. The Tail of Spence is located in the upper outer quadrant of the breast.

241. Answer A is correct. The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more

susceptible to viral infections than other children. Therefore, answers B, C, and D are incorrect.

242. Answer B is correct. A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, making answers A, C, and D incorrect.

243. Answer C is correct. The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore, answers B and D are incorrect.

244. Answer C is correct. The graph indicates ventricular tachycardia. The answers in A, B, and D are not noted on the ECG strip.

245. Answer B is correct. Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore, answers A, C, and D are incorrect.

246. Answer B is correct. Valium is not given in the same syringe with other medications, so answer A is incorrect. These medications can be given to the same client, so answer D is incorrect. In answer C, it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.

247. Answer B is correct. Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary, making answers A and C incorrect. The client should practice wiping from front to back after voiding and bowel movements, so answer D is incorrect.

248. Answer C is correct. Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion, so answer A is incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable, making answer B incorrect. A nurse or physical therapist should ambulate the client with a fractured hip, so answer D is incorrect.

249. Answer A is correct. The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer B is incorrect. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D are incorrect.

250. Answer D is correct. Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles. Therefore, answers A, B, and C are incorrect.

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