QB 10

1. A patient receives pentamidine isethionate (Pentam). Which of the following observations

of the patient BEST indicates to the nurse that the drug is effective?

Increased T-cell count.

Increased deep tendon reflexes.
Decreased bleeding and bruising.
Decreased crackles and dyspnea.

Strategy: Think about each answer.

(1.) shows improvement in patient’s overall condition, but not particularly related to
pentamidine; pentamidine is antiprotozoal, not antiretroviral medication; it is the
antiretrovirals that can increase T-cell count in HIV infection

(2.) has nothing to do with deep tendon reflexes

(3.) pentamidine can cause leukemia and thrombocytopenia as adverse effects

(4.) CORRECT—pentamidine is an antiprotozoal agent used to prevent and/or treat

Pneumocystis jiroveci pneumonia, a common opportunistic infection in AIDS patients;
manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and
crackles are heard in the lungs

2. The nurse provides care to a client with suspected cholelithiasis. Which information in the
client's health history indicates a risk for this disease process? (Select all that apply.)

African American ethnicity.

Body mass index of 21.

Given birth to 3 children.

Being 50 years of age.

Fasting for religious reasons.

1) A Native American or U.S. Southwestern Hispanic ethnicity places a client at risk for
cholelithiasis, not African American ethnicity.

2) Obesity increases the risk for cholelithiasis, but a BMI of 21 is within normal range.

3) CORRECT – Multiparous clients at higher risk of developing cholelithiasis.

4) CORRECT – Risk increases with age, with the highest incidence occurring after age 40.

5) CORRECT – Fasting decreases gallbladder movement, and bile can become overly
concentrated with cholesterol, causing stones to form.

3. The nurse reviews the importance of receiving an annual influenza vaccination with a
client. Which client statement indicates to the nurse that the client
requires furtherinstruction?

"I will get the shot since I am 69 years old."

"I had bronchitis twice last year, so I will get the shot."
"I volunteer at a preschool, so I will get the shot."
"I live with two large dogs, so I will get the shot."

1) The annual influenza vaccination is recommended for people over 65 years of age.

2) The annual influenza vaccination is recommended for people with chronic respiratory or
cardiovascular disease.

3) The annual influenza vaccination is recommended for people who come in contact with
young children.

4) CORRECT – The client is not at risk for getting influenza from a dog. Therefore, this
client statement indicates the need for further education.

4. The nurse provides care to a male client. The health care provider (HCP) prescribes IV
infusion of 1000 mL 0.9% sodium chloride (NaCl) over 8 hours. Which assessment finding
causes the nurse to hold administration of the IV fluid and clarify the HCP's
prescription? (Select all that apply.)

Blood urea nitrogen (BUN) is 18 mg/dL.

Hematocrit is 38%.

Urine output is 2200 mL/day.

Urine specific gravity is 1.008.

Serum sodium (Na+) is 139 mEq/L.

1) Normal BUN is 10 to 20 mg/dL. The client's BUN is within normal limits.

2) CORRECT – Normal hematocrit is 42 to 52% (men) and 35 to 47% (women). In the

absence of bleeding, decreased hematocrit may indicate fluid volume excess. Further
evaluation is needed prior to administering additional fluid.
3) CORRECT – Normal adult urine output is 800 to 2000 mL/day. Excessive urine
production may indicate fluid volume overload. Administration of additional fluid should be
questioned.

4) CORRECT – Normal urine specific gravity is 1.010 to 1.030. A decrease in urine specific
gravity is reflective of dilute urine and may indicate excess fluid volume is present.
Administration of additional fluid should be questioned.

5) Normal serum sodium is 135 to 145 mEq/L. The client's sodium is within normal limits.

5. The nurse provides care for clients in the intensive care unit (ICU). A client diagnosed
with a head trauma needs to be admitted. There are no empty beds. Which client does the
nurse anticipate may be transferred to the step-down neurological unit?

A client diagnosed with bacterial meningitis and Glasgow Coma Scale of 7.

A client 1 day postoperative after a transsphenoidal craniotomy with a possible
cerebrospinal leak.
A client diagnosed with a stroke 4 days ago with confusion.
A client with a head injury and is having seizures.

1) A Glasgow Coma Scale of 7 indicates a comatose state. The client is unstable and cannot
be transferred.

2) The client is at risk of ICP and is unstable.

3) CORRECT— The risk of a second stroke is reduced, and the focus is on rehabilitation.
This client can be transferred.

4) A client with a head injury who is experiencing seizures is unstable and should not be
transferred.

6. The client reports chronic constipation to the nurse. The nurse in the health care clinic
should advise the client to take which action?

Reduce intake of highly seasoned foods and fats.

Drink 1,000 ml of fluids daily.
Increase intake of cereals, fresh fruits, and vegetables.
Ask the health care provider to prescribe Dulcolax 5 mg enteric-coated tablets daily.

Strategy: All answers are implementations. Determine the outcome of each answer choice.
Is it desired?

(1) unnecessary, no effect on constipation

(2) normal intake 1,500–2,000 ml, reduced intake causes constipation

(3) correct—bulk-forming foods help with constipation

(4) passing the buck, laxatives are a last resort

7. The physician on the medical unit writes orders for heat application for four patients. The
nurse should question which of the following orders?

Warm sterile saline compresses for a patient with phlebitis from an IV.
Aquathermia pad for a patient with low back pain.
Heat lamp for a patient with a diabetic foot ulcer.
Sitz bath for a patient after incision and drainage of an anorectal abscess.

Strategy: Determine the outcome of each answer. Is it desired?

(1.) appropriate order; the warmth and moisture will dilate the vein and encourage
circulation

(2.) appropriate order; electronic device comprised of a waterproof pad that has water
circulating through it; the moist heat it provides decreases muscle tension and muscle
spasms and decreases inflammation in various musculoskeletal conditions

(3.) CORRECT—diabetics often have impaired peripheral circulation and sensation; foot
ulcers can be especially dangerous because they can lead to gangrene and amputation; not
only might the diabetic not be able to feel problems with the feet, but if heat were applied
they might well not be able to detect if the heat were too high; burns and further tissue
destruction could occur

(4.) appropriate order; the vasodilation that occurs increases blood flow and therefore
oxygen and nutrients to the area, and helps with waste product removal; it decreases
inflammation

8. The physician on the medical unit writes orders for heat application for four patients.
The nurse should question which of the following orders?

Warm sterile saline compresses for a patient with phlebitis from an IV.
Aquathermia pad for a patient with low back pain.
Heat lamp for a patient with a diabetic foot ulcer.
Sitz bath for a patient after incision and drainage of an anorectal abscess.
 Strategy: Determine the outcome of each answer. Is it desired?

(1.) appropriate order; the warmth and moisture will dilate the vein and encourage
circulation

(2.) appropriate order; electronic device comprised of a waterproof pad that has water
circulating through it; the moist heat it provides decreases muscle tension and muscle
spasms and decreases inflammation in various musculoskeletal conditions

(3.) CORRECT—diabetics often have impaired peripheral circulation and sensation; foot
ulcers can be especially dangerous because they can lead to gangrene and amputation;
not only might the diabetic not be able to feel problems with the feet, but if heat were
applied they might well not be able to detect if the heat were too high; burns and
further tissue destruction could occur

(4.) appropriate order; the vasodilation that occurs increases blood flow and therefore
oxygen and nutrients to the area, and helps with waste product removal; it decreases
inflammation

9. The nurse provides care to a client with the following assessment data: nonproductive
cough, fever, lung crackles, headache, and myalgia. Which nursing diagnosis
is appropriate? (Select all that apply.)

Pain, acute.

Risk for aspiration.

Impaired gas exchange.

Ineffective breathing pattern.

Risk for infection.

1) CORRECT — This is an appropriate diagnosis related to inflammation in the lungs and

muscle pain.

2) This is not an appropriate diagnosis related to these symptoms.

3) CORRECT — This is an appropriate diagnosis related to the fluid buildup in alveoli.

4) CORRECT — This is an appropriate diagnosis related to the inflammation and pain.

5) This is not an appropriate nursing diagnosis as the client has an infection already
present.
10. A client in a domestic violence shelter asks the nurse to explain why the client continues
to be beaten. Which response is the best for the nurse to make?

"Can you remember what you said or did just before being hit?"
"Let's focus on getting your face and ribs healed first."
"We can help you when you're ready; you do not deserve to be abused."
"Only the person who is beating you can tell us what causes the violence."

1) Asking a yes/no question is non-therapeutic and this one implies that the client did
something to cause the abuse.

2) Focusing on physical healing is a closed statement and is non-therapeutic. Emotional

healing should not be delayed if the client indicates a willingness to participate.

3) CORRECT— Saying that help is available when the client is ready is a reflective
statement that is therapeutic. This statement also provides information because it offers
support and a path to help, coupled with reinforcement that the client does not deserve to
be abused.

4) Saying that the person doing the beating knows the reason places the focus on the
abuser and not the client. This gives power to the abuser to place blame on the victim, and
it implies the victim is to blame.

11. During a routine prenatal visit, the nurse assesses a client at 38 weeks’ gestation. The
nurse auscultates the fetal heart rate (FHR) and notes that the fetal position is left occiput
anterior (LOA). Identify the point of maximum intensity of the fetal heart tone.

Strategy: Identify the mother’s left side.

LOA indicates vertex is the presenting part with fetal occiput on the mother’s left side
toward the front of her pelvis; because infant is vertex, FHT heard below the umbilicus.
12. The triage nurse at a busy urgent care center prioritizes clients for evaluation. The nurse
determines that which of the following clients should be seen FIRST?

A woman at 6 weeks’ gestation who complains of left lower quadrant abdominal pain
and vaginal spotting.
A toddler whose parents report nausea and vomiting for 2 hours and a fever of 102.8°F
(39.0°C).
A patient diagnosed with renal disease who missed his dialysis appointment the day
before and who complains of swelling in his feet and ankles.
A toddler who has a forehead laceration from a fall and who is smiling and playful.

Strategy: Determine the most unstable client.

1) CORRECT— symptoms of ectopic pregnancy, which may result in death if allowed to

progress

2) though at risk for dehydration, short duration of the child’s symptoms indicate a potential
and not actual risk at this time; nurse likely to obtain an order for an antipyretic while the
patient waits for evaluation

3) likely requires dialysis; ectopic pregnancy is an actual risk

4) level of consciousness is appropriate

13. The nurse performs a physical assessment on a client diagnosed with bulimia nervosa.
Which finding warrants an immediate referral to the health care provider?

Bilateral parotid gland enlargement.

A hoarse voice that is barely audible.
Grey to black eroded teeth with foul odor.
Multiple papulopustular skin eruptions.

1) Bilateral parotid gland enlargement is a hallmark sign of chronic vomiting as the glands
become clogged with foreign matter. This is not a priority.

2) CORRECT – The client with a hoarse voice is at high risk for tracheoesophageal fistula
from esophageal tear secondary to forceful vomiting. Laryngitis is a danger sign.

3) Eroded teeth is a sign of chronic vomiting as gastric acid erodes teeth. The client needs
an eventual dental referral.

4) Skin eruptions indicate acne vulgaris related to binge eating and poor personal care.
14. A client is prescribed intravenous penicillin G potassium 1.2 million units per day in
divided doses every 6 hours. The medication vial contains 300,000 units/mL. Which amount
of the medication in mL will the nurse provide to the client for a single dose? (Record your
answer rounding to the nearest whole number.)

Your Response:
Correct Response:1
mL

15. The nurse provides care to a client who is receiving enteral feedings via a nasogastric
tube. Immediately after administering a tube feeding, the nurse ensures the client remains
in which position?

Right lateral decubitus for 60 minutes.

High-Fowler's for 30 minutes.
Left lateral decubitus for 30 minutes.
Semi-Fowler's for 60 minutes.

1) The recommended position following a tube feeding is semi-Fowler's, in which the head
of the bed is elevated 30–45 degrees. The right lateral decubitus (right side down) position
does not protect the client from regurgitation and aspiration of stomach contents.

2) In the high-Fowler's position, the head of the bed is elevated 60–90 degrees, which may
not be comfortable for the client. Rather than the high-Fowler's position, the semi-Fowler's
position is recommended for 30–60 minutes following administration of an enteral feeding.
In the semi-Fowler's position, the head of the bed is elevated 30–45 degrees.
3) The recommended position following a tube feeding is semi-Fowler's, in which the head
of the bed is elevated 30–45 degrees. The left lateral decubitus (left side down) position
does not protect the client from regurgitation and aspiration of stomach contents.

4) CORRECT— In the semi-Fowler's position, the head of the bed is elevated between 30–
45 degrees. Elevation of the head of the bed 30–45 degrees for 30–60 minutes allows
gravity to help prevent reflux and subsequent aspiration of gastric contents.

16. The client is brought to the emergency department with a blood glucose level of 32
mg/dL (1.8 mmol/L). The client received an ampule of 1 mg glucagon intramuscular (IM) 10
minutes prior to arrival. While assessing the client, the nurse instructs the nursing assistive
personnel (NAP) to perform which action?

Recheck the client’s blood glucose in 30 minutes.

Obtain one-half cup of orange juice.
Give the client a high-protein nutritional beverage.
Obtain an electrocardiogram on the client.

1) The client is unstable. The nurse will recheck the blood glucose in 15 minutes. The nurse
will not delegate the task of checking blood glucose on an unstable client.

2) CORRECT — If the client is able to take oral fluids, a high-carbohydrate beverage should
be given. The nurse will delegate the task of obtaining the beverage to the NAP, although
the nurse will give the juice to the client and monitor the client during intake.

3) This is not an appropriate beverage. The nurse will not delegate oral fluid administration
to the NAP as the client is unstable. The nurse will give a high-carbohydrate fluid to the
client and monitor the client during intake.

4) This action is not warranted.

17. The nurse performs a physical assessment of the precordium on an adult male. Identify
where the nurse should place the stethoscope to auscultate the tricuspid area.
Strategy: Locate landmarks.

Located in the fifth intercostal space at the lower left of the sternal border; auscultate for
S1.

18. The oncology nurse is floated to the medical-surgical unit. The medical-surgical unit
charge nurse assigns which client to the oncology nurse? (Select all that apply.)

Client who is receiving total parenteral nutrition (TPN) following gastrectomy 48 hours
ago.
Client who will be discharged to home today following total hip replacement 72 hours
ago.
Client who requires administration of pain medication after undergoing bariatric
surgery 6 hours ago.
Client admitted yesterday who is newly diagnosed with atrial fibrillation.
Client who requires QID dressing changes for treatment of a MSRA-positive stage IV
pressure ulcer.
Client admitted 3 days ago who is prescribed IV antibiotics for treatment of
pneumonia.

1) CORRECT – Based on the available client data, no unexpected assessment findings are
present and there is no apparent deterioration of the client's condition. The TPN
administration requires application of the RN's fundamental knowledge and skills.

2) The client being discharged will require specialized teaching related to postoperative
care, hip precautions, equipment, and referrals. The client's care is best assigned to a nurse
who is familiar with the specialized plan of care.

3) The client underwent a surgical procedure within the past 24 hours and, as such, is at
high risk for complications. The client's care is best assigned to a nurse who is familiar with
postoperative complications relevant to the procedure.

4) The client with a newly-diagnosed cardiac abnormality is at high risk for instability and
will require close monitoring for complications. The client's care is best assigned to a nurse
who is familiar with the specialized plan of care.

5) CORRECT – Based on the available client data, no unexpected assessment findings are
present and there is no apparent deterioration of the client's condition. Dressing changes
and implementation of MRSA precautions require application of the RN's fundamental
knowledge and skills.

6) CORRECT – Based on the available client data, no unexpected assessment findings are
present and there is no apparent deterioration of the client's condition. Administration of IV
antibiotics requires application of the RN's fundamental knowledge and skills.
19. The nurse on the medical/surgical floor receives four new admissions. Which of the
following clients should be placed in a private room?

A client diagnosed with Lyme disease.

A client diagnosed with pneumonia caused by S. aureus .
A client diagnosed with meningococcal meningitis.
A client diagnosed with toxic shock syndrome.

Strategy: Determine the outcome of each answer. Is it desired?

1) requires standard precautions

2) requires standard precautions

3) CORRECT— requires droplet precautions until 24 hours after initiation of effective

therapy

4) requires standard precautions

20. The nurse on the medical/surgical floor receives four new admissions. Which of the
following clients should be placed in a private room?

A client diagnosed with Lyme disease.

A client diagnosed with pneumonia caused by S. aureus .
A client diagnosed with meningococcal meningitis.
A client diagnosed with toxic shock syndrome.

Strategy: Determine the outcome of each answer. Is it desired?

1) requires standard precautions

2) requires standard precautions

3) CORRECT— requires droplet precautions until 24 hours after initiation of effective

therapy

4) requires standard precautions

21. The nurse follows up a community education session by asking clients to describe ways
to reduce their cancer risk. Which client statement requires clarification by the
nurse? (Select all that apply.)
 "I will limit my exposure to second-hand smoke."

"I will walk for 30 minutes, at least 5 days a week."

"I should stop eating meat."

"I will lose 20 pounds."

"I should not go outside on very sunny days."

"I will avoid being around persons consuming alcohol."

1) It is correct to quit smoking and reduce exposure to second-hand smoke to reduce

cancer risk.

2) It is accurate that regular exercise can reduce cancer risk, especially the risk of colorectal
and breast cancers.

3) CORRECT – The nurse should clarify that it is not necessary to give up all meat. If the
client desires to omit meat, the nurse may inform the client of ways to meet dietary
requirements without meat.

4) CORRECT – The nurse should clarify that persons should strive for a normal weight.
Each client will have different weight loss or maintenance goals, depending on age, gender,
height, and weight.

5) CORRECT – the nurse should clarify that clients may spend a moderate amount of time
in the sun, as long as they use sunscreen and wear a protective hat and clothing.

6) CORRECT – The nurse should clarify that clients should limit alcohol intake, but being
around persons who drink is not a risk factor for cancer.

22. The nurse working on an organ transplant unit provides discharge teaching for a client
taking cyclosporine. Which client statements indicate correct understanding of the
instructions? Select all that apply.

"This medication will help my body fight infection."

"I will need to take this medication for the rest of my life."

"I will check my pulse every morning before taking this medication."

"My health care provider will be checking my blood work at my regular visits."

"It is important to take this medication at the same time every day."
"Before having any dental work, I should be sure to stop this medication for at least 3
days."
Strategy: "correct understanding" indicates the nurse is looking for correct information
about the medication.

1) the nurse should clarify that cyclosporine is an anti-rejection medication, not an anti-
infective agent

2) CORRECT— in most cases, anti-rejection therapy is lifelong

3) a significant adverse effect of cyclosporine is hypertension, but there is no need for the
client to check his/her pulse

4) CORRECT— due to nephrotoxicity, blood work will be monitored during therapy

5) CORRECT— taking at the same time helps to maintain therapeutic blood levels and
decreases risk of nephrotoxicity

6) although all health care providers should be notified that the client is taking cyclosporine,
the medication should not be stopped

23. The nurse provides care to a client receiving thrombolytic therapy for a blood clot in the
left calf. Which assessment finding indicates that treatment is effective? (Select all that
apply.)

Dorsal pedal pulses +1 bilaterally.

Numbness and tingling present in the left foot.

Left foot slightly pink.

Capillary refill 4 seconds.

Client reports feeling pinprick on left great toe.

1) CORRECT – The presence of +1 dorsal pedal pulses bilaterally indicates adequate blood
flow to both legs and feet. Treatment is being effective.

2) Numbness and tingling in the left foot indicates impaired neurovascular status, which
indicates that treatment is not effective.

3) CORRECT – The left foot color being slightly pink indicates an adequate blood flow past
the clot to the left foot. Treatment is being effective.

4) A capillary refill of 4 seconds indicates impaired vascular status and treatment is not
effective. Capillary refill should be less than 3 seconds.

5) CORRECT – The client being able to feel a pinprick on the left great toe indicates
circulation is present. Treatment is being effective.
24. The nurse cares for a toddler diagnosed with pneumonia caused by Haemophilus
influenzae, type b. The nurse should follow which of the following transmission-based
precautions?

Standard precautions.
Airborne precautions.
Droplet precautions.
Contact precautions.

Strategy: Think about each answer.

1) barrier precautions used for all clients to prevent nosocomial infections

2) used with pathogens transmitted by airborne route

3) CORRECT— used with pathogens transmitted by infectious droplets; droplet precautions

indicated for Haemophilus influenzae, type b pneumonia in infants and children

4) contact precautions required for all client care activities that require physical skin-to-skin
contact or those that require contact with contaminated inanimate objects in the client’s
environment

25. The nurse evaluates a client diagnosed with myxedema. The nurse determines that
treatment is effective if which of the following is observed?

The client wears multiple layers of clothing.

The client discusses the family’s finances with his wife.
The client becomes short of breath after climbing the stairs.
The client takes his medication every day.

Strategy: “Treatment is effective” indicates an improvement in the client’s condition.

1) indicates client still feeling excessively cold, which indicates hypothyroidism

2) CORRECT— hypothyroidism causes slowed mental functioning; improved thought

processes indicate improvement

3) indicates hypothyroidism

4) vital that client takes medication as prescribed, but does not indicate that client’s
condition is improving
26. The nurse talks with a child who has been sexually abused by a family member. The
child asks the nurse, "If I tell you something, will you tell anyone my secret?" Which
response by the nurse to the client is appropriate?

"I will not tell anyone your secret."

"I will not tell your mom and dad."
"I'll call the nursing supervisor as a witness."
"I cannot keep this information a secret."

1) Lying and withholding information is detrimental to the client and to the nurse-client
relationship.

2) The nurse cannot promise that the parents will not be informed of this information.

3) The nursing supervisor does not have a role in this scenario. The nurse must establish
the relationship with this child.

4) CORRECT – The nurse cannot keep secret information vital to the safety of the child or
others. The nurse is honest with the child.

27. The nurse cares for a client scheduled for electroconvulsive therapy. The nurse observes
that the client is anxious. Which of the following actions by the nurse is MOST appropriate?

Offer the client a cup of coffee.

Encourage the client to listen to relaxation tapes.
Administer lorazepam (Ativan) 1 mg IM.
Remain with the client to discuss fears.

Strategy: “MOST appropriate” indicates discrimination may be required to answer the

question.

1) client is NPO; coffee is a stimulant that might escalate anxiety

2) nurse should remain with client

3) might be used if level of anxiety is severe; more important for client to develop coping
strategies

4) CORRECT— will convey acceptance of client; allowing client to discuss fears may
decrease anxiety

28. The nurse supervises the nursing assistive personnel (NAP) caring for the client
diagnosed with a C7-C8 cervical spinal cord injury. Which action by the NAP requires
an immediate intervention by the nurse?
 The NAP elevates the head of the bed 30 degrees when assisting with meals.
The NAP firmly massages the client's lower back and buttocks with lotion.
The NAP instructs the client to shift weight every 15 minutes when sitting.
The NAP positions the client in a 30-degree lateral turn position in bed.

1) The head of bed can be elevated up to 30 degrees. This will avoid the shearing force and
damage due to tissues rubbing together. Elevating the head of bed higher than 30 degrees
increases the client's risk for sacral pressure injury.

2) CORRECT — Providing a firm massage can damage tissue, increasing the risk for skin
breakdown. This client is already at risk for skin breakdown due to immobility. This
action requires immediate intervention by the nurse.

3) Shifting weight is recommended to decrease pressure on the capillaries. The client does
have some arm movement and can shift weight.

4) Placing the client in a 30-degree lateral turn position is the recommended position when
the client is in bed; this reduces pressure on pressure points.

29. The nurse on the medical unit administered an incorrect dose of IV medication to a
client. The nurse should record which of the following statements on the incident report?

“Due to illegible physician order, gentamycin (Garamycin) 9 mg given IV at 0200

instead of 7 mg IV.”
“At 0200, gentamycin (Garamycin) 9 mg administered IV. Gentamycin (Garamycin) 7
mg IV ordered.”
“At 0200, client received 2 mg more of gentamycin (Garamycin) than was ordered.”
“Gentamycin (Garamycin) 9 mg IV was given at 0200. Physician’s order to decrease
dose was not transcribed by previous shift.”

Strategy: Think about each answer

1) incident report is an accurate and comprehensive report on any unexpected or unplanned

occurrence that affects or could potentially affect a client, family member, or staff; do not
explain the cause or blame any staff member

2) CORRECT— describe what happened in concise, objective terms

3) draws a conclusion

4) do not assign blame or explain the cause

30. The nurse cares for a client diagnosed with a cerebrovascular accident (CVA). When
creating a teaching plan, which of the following actions by the nurse is MOST important?
 Ask the client to discuss his perception of his health status.
Identify the client’s strengths and weaknesses.
Encourage the client to discuss his concerns with a client who has rehabilitated after a
CVA.
Offer the client a written plan of therapy.

Strategy: “MOST important” indicates discrimination is required to answer the question.

1) CORRECT— for teaching to be successful, the nurse should assess client’s perception
about his health problem

2) appropriate, but more important to determine client’s perceptions

3) assess before implementing

4) assess before implementing

31. The nurse cares for a client receiving 1,800 ml of IV fluid over a 12-hour period. The
physician orders that the amount of fluid lost in gastric drainage every 2 hours be replaced
during the next 2 hours. Between 8 AM and 10 AM, the nurse measures 250 cc of gastric
fluid. How many milliliters of fluid should the nurse administer the client between 10 AM and
12 noon? Type the correct answer into the blank.

Your Response:
Correct Response:550

Strategy: Do the math.

Correct answer: 550

32. The nurse counsels a client diagnosed with a seizure disorder. The client has just won a
national beauty pageant and will be frequently traveling during the next year. It is MOST
important for the nurse to include which of the following instructions?

“Travel with a person experienced in handling health problems.”

“Place your medication in a carry-on bag.”
“Ask for hotel rooms on the first floor.”
“Avoid flashing lights.”
Strategy: “MOST important” indicates discrimination is required to answer the question.

1) constant supervision not required for health management; client should carry medical
alert bracelet or card

2) CORRECT— take medication as prescribed to keep drug levels constant to prevent

seizures; should carry medication because luggage can get lost

3) should avoid exercise in excessive heat; room location not a priority

4) priority is carrying anti-seizure medication

33. The nurse provides care to a client with a tracheostomy who is receiving oxygen. Which
action is considered negligence by the nurse?

Wears goggles when changing the tracheostomy dressing.

Applies cream on the feet and legs after a bath.
Sprinkles powder on the chest after a bath.
Places a pre-cut gauze dressing around the tracheostomy.

1) Wearing goggles when changing the tracheostomy dressing is appropriate because it

reduces the risk of transmission of microorganisms to the nurse.

2) Applying cream to the legs and feet after a bath is an appropriate action because it helps
to prevent dry skin.

3) CORRECT— Powder should not be used on a client with a tracheostomy because it could
occlude or irritate the airway.

4) Placing a pre-cut gauze dressing around the tracheostomy is an appropriate procedure.

The nurse should not cut the gauze because it could leave fibers that may irritate or occlude
the airway.

34. The nurse cares for clients on an oncology floor. After receiving a report, which client
should the nurse assess first?

The client diagnosed with breast cancer with extensive bone metastasis and who is
irritable and confused.
The client who reports nausea and vomiting 6 hours after receiving chemotherapy.
The client diagnosed with lung cancer and who reports fatigue and mild shortness of
breath with ambulation.
The client with a white blood count of 1,600/mm3 and who reports burning with
urination.
 Strategy: Determine the most unstable client.

1) CORRECT— hypercalcemia (more than 10.2 mg/dL) (more than 2.6 mmol/L) may occur
as a result of bone destruction by the tumors; elevated levels affect mental status and can
negatively affect multiple organ systems

2) symptoms management important; electrolyte imbalance takes precedence

3) because the symptoms occur with activity, the client requires teaching related to the
disease process and symptom management; however, electrolyte imbalance takes
precedence

4) requires evaluation of possible urinary tract infection because of low white count; an
electrolyte imbalance takes precedence

35. The nursing faculty teaches the nursing student the tasks required to insert an
indwelling urinary catheter for a client. Place the tasks in the correct order, beginning
with the first task. All options must be used.

Your Response

INCORRECT

Correct Answer

 Perform hand hygiene.

 Position and drape client.
 Apply sterile gloves.
 Cleanse urinary meatus.
 Insert catheter using sterile technique.
 Fill balloon with sterile water.

Strategy: Determine the outcome of each answer. Is it desired?

1) hand hygiene reduces microorganism transfer; required before handling materials

2) assist client into position, use sterile drape provided without breaking sterile technique

3) sterile gloves will keep sterile items sterile

4) urinary meatus cleansed with antiseptic solution to decrease microorganisms on meatus

5) catheter must remain sterile to prevent introduction of microorganisms into urinary
system

6) balloon must be filled for catheter to remain in place

36. The nurse provides care for the client in the post-anesthesia care unit (PACU). Which
assessment finding requires the nurse to contact the health care provider (HCP)?(Select all
that apply.)

The client experiences coarse, crowing respirations.

The client's respiratory rate is 10 breaths/min.

The client is disoriented and has oliguria.

The client is restless and shouting.

The client's core temperature is 94.8ºF (34.89ºC).

The client's blood pressure is 110/69 mm Hg.

1) CORRECT— Coarse, crowing respirations require the nurse to contact the HCP. Stridor
indicates laryngospasm, which is an emergent airway complication.

2) CORRECT— A respiratory rate of 10 breaths/min requires the nurse to contact the

HCP. Hypoventilation related to anesthesia and opioids indicates an oxygenation
complication.

3) CORRECT— Disorientation with oliguria requires the nurse to contact the HCP. Oliguria is
a sign of hypoperfusion and indicates a circulation complication. Disorientation deepens the
nurse's concern about this client.

4) CORRECT— Restlessness and shouting require the nurse to contact the HCP. The
emergence of restlessness may be neurological or a sign of an impending and emergent
oxygenation or perfusion issue.

5) CORRECT— A core temperature below normal requires the nurse to contact the
HCP. Hypothermia can increase risks and increases oxygen consumption.

6) This is a normal blood pressure and not a cause for concern.

37. The nurse in the same-day surgery prepares a preschool-age client for discharge after a
tonsillectomy. It is most important to give the parent which instruction?

Observe for frequent swallowing.

Place the child in a high-Fowler position.
Increase the child’s fluid intake.
Look for white patches on the throat.
1) CORRECT – Assessment is first. The most obvious early sign of bleeding is frequent
swallowing. The parent observes the child when awake and asleep. Other signs are
increased pulse, pallor, and vomiting bright red blood.

2) The child can sit up once awake. The head of the bed should be elevated, but sitting
straight up is not required.

3) Restrict fluids until there are no signs of hemorrhage and then offer clear liquids,
avoiding fluids with red or brown color. After this, the client should be encouraged to drink
well.

4) The child is at risk for infection. The parent is taught to watch for fever, increased pain,
and foul breath.

38. The nurse positions an unconscious client. In which location will the nurse place a
trochanter roll?

Iliac crest to the knee.

Lateral aspect of the hip to the midthigh.
Midthigh to the ankle.
Medial aspect of the hip to the midcalf.

1) Placing the roll from the iliac crest to the knee is too low. The trochanter roll functions as
a mechanical wedge under the greater trochanter, prevents external rotation of the hip
joint, and prevents the femur from rolling.

2) CORRECT— The roll should be placed at the lateral aspect of the hip to the midthigh.
The hip joint lies between these points. The hip tends to rotate externally when the client is
positioned supine. If the hip is in correct alignment, the patella faces upward.

3) Placing the roll from the midthigh to the ankle is too low. This location will not prevent
hip rotation.

4) Placing the roll at the medial aspect of the hip to the midcalf is too low and will not
prevent hip rotation. The roll should be placed laterally and not medially.

39. The nurse on the cardiac unit notes that a patient recovering from a myocardial
infarction appears worried and irritable. When asked about his thoughts, the patient replies,
"I’m worried about my business. You know, I own a restaurant and I’m not there. I’m used
to working 6 days a week, at least 12 hours a day. I’m worried about how things are going
there now, and I’m worried about whether I will be able to handle the stress once I’m back
there." Which of the following responses by the nurse is BEST?
 Give him a list of complementary therapies related to relaxation and say, "Pretend this
is a menu. Which of these would you like to order for yourself?"
"You might find it interesting to attend the cardiac cooking class the dietitian gives
before you are discharged."
"Who is supposed to be taking care of the restaurant while you are here in the
hospital?"
Hand the patient the TV control and say, "Sometimes when I have a lot on my mind, I
watch a movie. It makes me feel better."

Strategy: "BEST" indicates that discrimination is required to answer the question.

(1.) CORRECT—patient needs to learn to relax, both to prevent and to cope with stressors
of the job and avoid further physiologic damage; relaxation strategies also part of cardiac
rehabilitation program; providing a list of possible complementary therapies gives the
patient choices

(2.) valid idea; relates to patient’s professional life, but does not address expressed
concerns

(3.) assessment to elicit factual information related to one of the patient’s current concerns,
but by itself does not offer coping options; also, does not respond to emotional tone and is
rather closed-ended

(4.) distraction can be a valid stress management technique at times; however, this
response does not respond directly enough to the content and tone of patient’s concerns

40. The nurse administers carbamazepine (Tegretol) to a client for trigeminal neuralgia (tic
douloureux). The nurse knows that the therapeutic effect of this medication is to

relieve accompanying depression.

reduce the possibility of grand mal seizures.
relieve the agonizing pain.
provide sedation effects.

Strategy: Think about each answer.

1) may occur as a result of the diminished pain, but is not the primary purpose of giving
Tegretol

2) grand mal seizures are not associated with tic douloureux

3) CORRECT— agonizing pain of tic douloureux may result in severe depression and
suicide; Tegretol inhibits nerve impulses and reduces the pain of the condition
4) may occur as a result of the diminished pain, but is not the primary purpose of giving
Tegretol

41. The home care nurse makes an initial visit for an elderly client diagnosed with heart
failure, hypertension, and osteoarthritis. The nurse asks the client if she is experiencing any
pain caused by the arthritis. The client admits to being in pain. Which of the following
actions should the nurse take NEXT?

“What has worked to relieve your pain in the past?”

“What have you taken today to relieve the pain?”
“Does it help to take a warm bath?”
“Does your physician know you are experiencing pain?”

Strategy: “NEXT” indicates priority.

1) priority is to determine what patient is doing now to relieve the pain

2) CORRECT— if client is in pain, priority is to determine what client is doing now to relieve
the pain

3) yes/no question; when assessing, nurse should ask broad, open-ended questions

4) yes/no question; nurse should complete assessment of client’s pain

42. The nurse instructs a client on the use of antibiotic eye drops as treatment after
cataract surgery. Which client statement indicates that further teaching is necessary?

"The drops should go into the center of the lower eyelid."

"I should not let the drops flow from one eye into the other."
"I should squeeze my eye tightly after I put in the drop."
"I should tilt my head back to put in the drops."

1) The drop should be placed in the lower conjunctival sac. The client should wash hands
before instilling the drops. The client should look up while pulling the lower lid down when
instilling the drops.

2) The drops should not be permitted to flow across the nose into the opposite eye. The
dropper should not touch the eye.
3) CORRECT— The client should blink between drops but should not squeeze the eye tightly
because it would cause the drop to be expelled. The client should be instructed to press the
inner angle of the eye after instillation to prevent systemic absorption of the medication.

4) Tilting the head back helps position the client for proper placement of the eye drops.

43. The nurse assesses a 6-month old client during a well-baby checkup. Which finding does
the nurse expect during this assessment?

A pincer grasp.
Sitting with support.
Tripling of the birth weight.
Presence of the posterior fontanel.

1) The pincer grasp appears at 9 months of age.

2) CORRECT – A 6-month old client should sit up with support.

3) Tripling of the birth weight occurs by age 1.

4) The posterior fontanel closes by 2 to 3 months of age.

44. The school nurse assesses four school-age clients. Which client's parents will be
contacted first to pick up the child from school?

Child with a red rash on the cheeks that makes the face look like it has been slapped.
Child with a fever reporting headache, malaise, anorexia, and an earache when
chewing.
Child with an apparent upper respiratory infection and an inflamed conjunctiva with
swollen eyelids and watery drainage.
Child with clusters of small, erythematous, intensely pruritic papules in the antecubital
space.

1) The child with a red rash on the cheeks indicates fifth disease. This illness is most
contagious before the rash appears. Isolation is not required once the rash appears and the
child can attend school.

2) CORRECT – The child with a fever, headache malaise, anorexia, and ear pain with
chewing indicates probable mumps. The child is most communicable immediately before and
after the swelling begins.

3) The child with an upper respiratory infection and inflamed conjunctiva is demonstrating
symptoms of viral conjunctivitis. This child does not need to go home from school.
4) The child with pruritic papules is experiencing eczema. This child does not need to go
home from school.

45. A client is admitted to the psychiatric unit with a diagnosis of schizophrenia. The client
verbalizes to the nurse, “Someone wants to kill me tonight.” Which response by the nurse
is best?

“No one wants to kill you.”

“Why do you think that?”
“They don't know you are hospitalized, so you are safe.”
“It must feel frightening to think someone wants to hurt you.”

1) Arguing directly with the client about the delusion will make the client defensive.

2) Do not ask “why” questions, this will make the client defensive.

3) Delusions are persistent false beliefs. The nurse does not encourage discussion about
delusions as though they are fact.

4) CORRECT – Focus on the feelings the delusions generate, and avoid arguing about the
content of the delusion. Once a client describes the delusion, do not dwell on it.

46. The nurse is providing care to a client who is scheduled to undergo a craniotomy the
following day. Which client data does the nurse recognize as being an indication for insertion
of an indwelling urinary catheter? (Select all that apply.)

The client is diagnosed with severe urinary retention.

The client requires evaluation of residual urine volume.

The client is scheduled for a lengthy surgical procedure.

The client is at risk for developing a pressure ulcer.

The client requires strict monitoring of intake and output.

1) CORRECT – Indications for insertion of an indwelling urinary catheter include treatment

of urinary retention, as urinary retention may cause health alterations including urinary
tract infection (UTI) and kidney stones.

2) Measurement of residual urine is not a routine indication for insertion of an indwelling

urinary catheter. Preferred approaches include using a noninvasive device, such as a
bladder scanner, to estimate residual urine.

3) CORRECT – Lengthy surgical procedures performed under anesthesia may be an

indication for insertion of an indwelling urinary catheter.
4) Risk for developing a pressure ulcer is not an indication for insertion of an indwelling
urinary catheter. However, an existing pressure ulcer that cannot be kept clean may be an
indication for indwelling urinary catheter insertion.

5) CORRECT – Indications for indwelling urinary catheter include when accurate intake and
output are necessary to closely monitor fluid volume status.

47. The nurse in the pediatric clinic notes that several preschool children have received a
single dose of hepatitis B vaccine during infancy. Which of the following actions by the nurse
is MOST appropriate?

Inform the children’s parents that the children must start the hepatitis B series over
again.
Note the immunization in the child’s history.
Contact the physician.
Make an appointment for the children to continue the series of hepatitis B vaccine.

Strategy: Determine the outcome of each answer. Is it appropriate?

1) do not start series over again

2) hepatitis B immunization is a series of three injections

3) no reason to contact the physician

4) CORRECT— continue immunization series; total of three doses given; should schedule
the third dose 3 to 4 months after the second dose; second dose usually given 1 to 2
months after first dose

48. The nurse provides care for a client who is preoperative for a discectomy/laminectomy.
The client has a history of obesity and sleep apnea. The nurse administers diazepam 10 mg
orally for pain reported as 9 out of 10 on a numerical pain scale. Which additional action
is appropriate for the nurse to take? (Select all that apply.)

Administer narcotic analgesic as prescribed.

Perform frequent respiratory checks if the client is drowsy.

Ambulate the client to the bathroom to void.

Inform anesthesiology of administration of oral medication.

Reassess the client for pain level and anxiety.

1) Administering a narcotic is inappropriate as it may worsen respiratory issues of the client.

2) CORRECT — Benzodiazepines may exacerbate apneic episodes and the nurse must
monitor the client closely.

3) The client should have been taken to the bathroom to void before administering the
benzodiazepine. It is unsafe to ambulate after administration of this medication.

4) CORRECT — A client should remain NPO (nil per os, or nothing by mouth) prior to
surgery, except for a sip of water with the medication.

5) CORRECT — The nurse should reassess for pain using the numeric scale and anxiety at
appropriate intervals.

49. A client being discharged from the postpartum care area requests perineal pads,
diapers, wipes, and perineal spray. Which response is the best for the nurse to make to this
client?

"I will be glad to get these supplies for you."

"Why don't you stop at the store on the way home?"
"I don't think that you need any more supplies."
"What items do you need during the next hour?"

1) The nurse is responsible for maintaining costs of the care area. Many insurance
companies consider ordering extra supplies the day of discharge as stockpiling and may
refuse to pay the bill.

2) The client does need to be responsible for obtaining needed items, but this response is
not therapeutic.

3) Saying that the client does not need any more supplies is argumentative and not
therapeutic.

4) CORRECT— Offering supplies for one hour provides for the client's immediate needs in a
cost-effective way.

50. The nurse cares for a client diagnosed with thrombocytopenia due to acute lymphocytic
leukemia. The nurse should assign this client

to a private room so she will not infect other clients and health care workers.
to a private room so she will not be infected by other patients and health care
workers.
to a semiprivate room so she will experience stimulation during her hospitalization.
to a semiprivate room so she will have the opportunity to express her feelings about
her illness.
Strategy: Think about each answer.

1) poses no threat to others

2) CORRECT— protects patients from exogenous bacteria; risk for developing infection
from others due to depressed WBC count; alters ability to fight infection

3) should be placed in a private room

4) should be placed in a private room; ensure that client has opportunity to express feeling
about illness

51. The nurse receives report on a client admitted to the unit with a new diagnosis of
abdominal aortic aneurysm (AAA). When teaching the client measures to reduce the risk of
complications associated with AAA, which instruction does the nurse include?

Elevate the lower extremities above the level of the heart.

Encourage the increase of fluid intake and dietary fiber.
Utilize proper lifting techniques.
Avoid wearing a seatbelt while driving.

1) The modified Trendelenberg position is contraindicated because it increases pressure in

the aortic artery, which may increase the risk of rupture.

2) CORRECT – Increasing intake of fiber and fluid prevents constipation and the need for
straining with bowel movements. This increased intra-abdominal pressure presents a risk of
rupture.

3) Instruct the client not to lift heavy objects, which may increase intra-abdominal pressure
and lead to rupture of the aneurysm.

4) Never instruct a client not to wear a seatbelt. This increases likelihood of a fatality should
the client be involved in a motor vehicle collision.

52. The nurse plans care for an older adult client with pernicious anemia who lives at home.
Which goal is the most important for the client?

Obtain household help during recuperative period.

Increase dietary intake of green leafy vegetables.
Receive monthly vitamin B12 injections.
Begin a program of moderate exercise.
1) Although rest is important, it is not the most important goal. Symptoms of pernicious
anemia include pallor, slight jaundice, glossitis, fatigue, weight loss, paresthesias of the
hands and feet, and disturbances of balance and gait.

2) Pernicious anemia is caused by failure to absorb vitamin B12 because of a deficiency of

intrinsic factor from the gastric mucosa. Increasing the intake of green leafy vegetables
increases the level of vitamin K but does not change the inrinsic factor.

3) CORRECT— Pernicious anemia is caused by failure to absorb vitamin B12because of a

deficiency of intrinsic factor from the gastric mucosa. For the client with pernicious anemia,
vitamin B12 is given on a monthly basis. Without it, death may occur within 1–3 years.

4) It is important that client balance rest and activity. However, it is more important for the
client to receive vitamin B12 injections.

53. The nurse provides discharge teaching to a client with myasthenia gravis. Which client
statement indicates further teaching is needed?

"I should take a shower and wash my hair in the morning."

"I should use paper and pencil to communicate with my husband."
"I should avoid places that I know will be crowded."
"I should plan my day around an afternoon rest period."

1) The client should perform essential motor activities early in the day and take medications
prior to activity.

2) CORRECT— The client is able to speak. Written communication is not necessary.

3) The client should avoid situations that could cause an infection.

4) Frequent rest periods are essential with myasthenia gravis. Symptoms of this disorder
include muscular weakness produced by repeated movements, diplopia, ptosis, impaired
speech, dysphagia, and respiratory distress. The disease also has periods of remission and
exacerbation.

54. After a major power outage, a confused client with an unsteady gait arrives at a
portable emergency response station. Which action does the nurse take first?

Determine where the client lives.

Assess the client's level of consciousness.
Assist the client to the nearest chair.
Assign the client a triage number.
1) Establishing the client's demographic data is not the first priority. The nurse should first
provide for client safety and assess the client's physical condition.

2) This is an appropriate assessment, but should be done after the nurse ensures the
client's safety.

3) CORRECT— The client has an unsteady gait and is at risk for falling. The nurse should
ensure client safety before beginning the assessment.

4) The nurse should first ensure client safety. After an assessment, the nurse can triage the
client.

55. The nurse provides care to a client diagnosed with diabetes mellitus. As the nurse
prepares to administer the client's prescribed lispro insulin, the client's son states, "Another
nurse already gave my mom her insulin." Which nursing action is mostappropriate?

Return the unused insulin to the client's medication supply drawer.

Document insulin administration on behalf of the client's previous nurse.
Contact the nurse from the previous shift.
Recheck the client's serum glucose level.

1) If the medication is prepared in a sealed, unit-dose package, returning the insulin to the
client's drawer may be acceptable. However, additional information is needed to confirm
that the client has already received the prescribed insulin.

2) Documenting on behalf of another nurse is illegal and unethical. Additional information is

needed to confirm that the client has already received the prescribed insulin. In the event
that the client already received the insulin dose, the nurse who administered the insulin is
required to document the medication administration.

3) CORRECT — Contacting the client's previous nurse is the safest action, as this action will
allow for confirmation that the prescribed insulin dose was already administered.

4) In the event that the client's previous nurse already administered the prescribed insulin,
the medication may not yet have taken effect. Contacting the nurse from the previous shift
is the safest action.

56. The nurse provides discharge planning for a group of clients. For which client does the
nurse request a health care provider's referral for home health care services?

A client who reports incisional pain 48 hours following an appendectomy.

A client diagnosed with diabetes mellitus who had a cardiac catheterization 8 hours
earlier.
A client who reports left knee pain 72 hours following a left total knee arthroplasty.
A client diagnosed with heart failure who underwent diuresis 4 days earlier.
1) Incisional pain 48 hours post-operative is an expected finding that does not warrant a
home health referral. Discharge instructions should include administering analgesics as
prescribed and seeking medical treatment for increasing pain or any worsening in the
client's condition.

2) Clients who undergo cardiac catheterization typically do not require an overnight hospital
stay unless complications develop. The client is not likely to require home health care
services. Discharge instructions should include instructing the client not to bend, strain, or
lift heavy objects for 24 hours. The client should observe for the puncture site for bleeding,
swelling, or new bruising, and seek medical treatment if complications develop or any
worsening in the client's condition is noted.

3) Post-operative pain is an expected outcome. A referral for home health care services is
not likely to be required. Discharge instructions should include administering analgesics as
prescribed and seeking medical treatment for increasing pain or any other worsening of the
client's condition.

4) CORRECT— The client is at risk for complications related to heart failure and altered fluid
balance. As such, requesting a referral for home health services is warranted to ensure the
client's safety. Skilled nursing care will include assessing the client for decreased circulating
volume, hypotension, tachycardia, and signs or symptoms of hypokalemia.

57. A client diagnosed with a seizure disorder and weighing 38 lb is prescribed diazepam
0.05 mg/kg by mouth now. Which amount of the medication in milligrams will the nurse
administer to this client? (Record your answer using two decimal places. Follow
appropriate rounding rules.)

Your Response:
Correct Response:0.86
mg
58. A patient diagnosed with type 2 diabetes mellitus is treated for hypertension with
propanolol (Inderal). History reveals that the patient is diagnosed with glaucoma and is
allergic to sulfa. The nurse is MOST concerned if an order was written for which of the
following medications?

Glycerin (Osmoglyn).
Pilocarpine (Isopto-Carpine).
Acetazolamide (Diamox).
Timolol maleate (Timoptic).

Strategy: "Nurse is MOST concerned" indicates a complication.

(1.) should be questioned but not of most concern; osmotic agent; diuretic; increases
osmolarity of the blood, extracting fluid from extracellular space into the bloodstream,
including aqueous humor and vitreous humor from the anterior chamber of the eye, thus
decreasing intraocular pressure; glycerin needs to be used with caution in diabetics because
it can cause hyperglycemia

(2.) no need to question this order; direct-acting parasympathetic function causing miosis

(3.) CORRECT—contraindicated; cross-sensitivity can occur due to allergy to antibacterial

sulfonamides and sulfonamide derivatives

(4.) should be questioned, but not priority; beta blockers given for systemic use, such as
propanolol and atenolol, can enhance the therapeutic and toxic effects of beta blockers
prescribed for ophthalmic use

59. The home care nurse visits a client diagnosed with a CVA who uses a condom catheter
because of incontinence. The nurse is MOST concerned if which of the following is observed?

The penis and surrounding skin are red and irritated.

The urine output for 8 hours is 500 cc.
The penis appears swollen and dark in color.
The condom keeps slipping off the penis.

Strategy: “MOST concerned” indicates a complication.

1) may indicate allergy to the latex; remove condom, notify health care provider, allow skin
to heal before reapplying

2) appropriate output
3) CORRECT— indicates impaired circulation; condom was applied improperly, adhesive
was applied too tightly, or condom is too small; assess circulation 30 minutes after catheter
is applied and then every 4 hours

4) not the priority; should be reapplied as necessary

60. A newborn weighing 3250 gm is prescribed IV digoxin 0.025 mg/kg in three divided
doses over 24 hours. The medication available is 100 mcg/mL. Which amount of medication
in milliliters will the nurse administer for one dose? (Record your answer using two
decimal places. Follow appropriate rounding rules.)

Your Response:
Correct Response:0.27
mL

61. The nurse admits an older adult client to the unit. The client demonstrates decreased
ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action
is most appropriate?

Prepare a schedule of activities and monitor the client's participation in the activities.
 Encourage the client to choose the client's own activities.
Allow the client time to get acclimated to the milieu before scheduling activities.
Allow the client to rest quietly to restore energy level.

1) CORRECT— The client displays symptoms of depression. For the client with depression,
a regular daily routine of scheduled activities provides structure and decreases the amount
of problem solving required. Participating in activities will increase self-esteem and assist
the client to engage with others.

2) The client is having difficulty making decisions. Choosing or planning the client's own
activities will increase social isolation, increase impairment, and decrease self-esteem.

3) This will increase social isolation.

4) The client is having difficulty making decisions. Allowing the client to rest quietly will
increase social isolation, increase impairment, and decrease self-esteem.

62. During a well-baby checkup, the nurse evaluates the reflexes of the 6-month-old child.
The nurse is most concerned if which finding is observed?

Presence of a positive Babinski reflex.

Extrusion reflex when feeding.
Able to grasp objects voluntarily.
Rolls from abdomen to back at will.

Strategy: MOST concerned indicates a complication.

(1) disappears at approximately 1 year of age

(2) correct—extrusion reflex disappears between 3 and 4 months of age

(3) normal occurrence at this age level

(4) normal occurrence at this age level

63. The nurse cares for clients on the medical/surgical unit. The nurse instructs a nursing
assistant to put elastic stockings on a client scheduled for surgery. It is MOST important for
the nurse to follow up on which of the following statements if made by the nursing
assistant?

“I will apply talcum powder to the client’s feet and legs before applying the stockings.”
“I will elevate the client’s legs before applying the stockings.”
“The client has obese thighs.”
 “I will make sure there are no wrinkles in the stockings.”

Strategy: “MOST important” indicates discrimination is required to answer the question.

1) allows for easier application of the stockings

2) prevents stagnation of blood in the lower extremities

3) CORRECT— may decrease venous return because of constriction around thighs

4) can cause irritation to the skin

64. The nurse assesses the client who has a distended bladder. Because the client is unable
to void, the health care provider orders catheterization with a straight single-use catheter.
After the catheter is inserted, the nurse performs which activity next?

Clamps catheter after 1000 mL of urine has drained.

Keeps the client in a prone position.
Asks the client to take deep breaths.
Assesses if client has had the problem before.

Strategy: next indicates priority.

1) CORRECT— rapid decompression of the bladder can result in bladder wall damage
causing hematuria; if more than 1000 mL of urine is in the bladder, the health care provider
should be contacted for instructions regarding the amount of urine to drain at what intervals

2) positioning is not relevant to proper care of the client with a distended bladder; prone
position would not be possible during catheterization

3) taking deep breaths is helpful during catheter insertion, but is not related to
decompression of the bladder

4) asking if this has happened before is relevant to the care of the client, but would more
likely be asked before catheter insertion; the focus is on the immediate problem of what to
do after the catheter is inserted

65. The nurse educates a client about family planning and contraceptive methods. Which
information does the nurse include in the teaching session? (Select all that apply.)

Breastfeeding is as effective as oral contraceptives for preventing pregnancy.

Barrier contraceptive devices can prevent sexually transmitted infections (STIs).

 Some medications can decrease the effectiveness of oral contraceptives.

A vasectomy is an easily-reversed method of male contraception.

Using a diaphragm increases the risk for urinary tract infection (UTI).

1) Although research suggests breastfeeding may delay the return of regular ovulatory
cycles, breastfeeding does not guarantee the prevention of ovulation. Women who are
breastfeeding should use a standard form of contraception if pregnancy prevention is
desired.

2) CORRECT – Male and female condoms can be effective in the prevention of pregnancy
and STIs.

3) CORRECT – Antibiotics can decrease the effectiveness of oral contraceptives.

4) Reversal of vasectomy is expensive. In addition, the reversal procedure is not always

successful.

5) CORRECT – Use of a diaphragm is linked to an increased risk for developing a UTI.

Clients with a history of frequent UTI may be advised to consider forms of birth control
other than the diaphragm.

66. The nurse in the outpatient clinic performs a physical assessment of a client. Identify
the location where the nurse palpates the client’s dorsalis pedis pulse.

Strategy: Remember anatomy.

The dorsalis pedis artery is located on the top of the foot in line with the groove between
extensor tendons of the great toe and the first toe.

67. The physician prescribes ampicillin 125 mg IM q6h for a 76-year-old woman. The
injection site selected by the nurse should depend on which of the following?
 The size of the muscle mass.
The total number of injections ordered.
The position of the patient in bed.
The gauge of the needle.

Strategy: Determine how each answer relates to an IM injection.

1) CORRECT— must be injected deeply into large muscle mass; injection too close to nerve
or blood vessel causes neurovascular damage; best site for adult upper outer quadrant of
buttocks, best site for children midlateral thigh

2) would not determine site; with multiple injections, sites should be rotated

3) safety is most important consideration, not comfort

4) varies with type of medication, not site of injection or size of person

68. The nurse provides care for a client who is in balanced suspension traction. The client
reports pain in the affected extremity, and the nurse administers the prescribed pain
medication. One hour later, the client tells the nurse that the pain is unrelieved. Which
action should the nurse first take?

Contact the health care provider.

Turn on the client's radio.
Ask client to rate pain using a numeric rating scale.
Perform a neurovascular assessment.

1) The nurse needs to complete a neurovascular assessment before contacting the health
care provider.

2) Distraction can be used to help the client cope with pain. However, the nurse should first
determine the cause of pain by conducting a neurovascular assessment.

3) The client says pain is unrelieved. The nurse should conduct a neurovascular assessment
to determine the cause of pain before re-evaluating the client's pain.

4) CORRECT— Pain that is unrelieved by medication is a sign of acute compartment

syndrome. The nurse needs to perform a neurovascular assessment before taking other
action.

69. The nurse identifies the nursing diagnoses of excessive fluid volume, impaired gas
exchange, and activity intolerance for a client with heart failure. Which finding validates
these nursing diagnoses? (Select all that apply.)
 Dyspnea on exertion.

Wheezes on auscultation.

Thick green sputum.

Crackles on auscultation.

Fatigue and weakness.

1) CORRECT – Shortness of breath indicates the presence of fluid in the lungs, which
decreases gas exchange. Heart failure causes fluid retention.

2) Wheezes on auscultation is not connected with fluid retention. Wheezing indicates airway
obstruction.

3) Thick green sputum is not connected with fluid retention. This finding indicates an
infection.

4) CORRECT – Pulmonary congestion causes crackles in the lungs. Since heart failure
causes fluid retention, excess fluid back up in the lungs, causing crackles to occur.

5) CORRECT – Fatigue and weakness are associated with cardiac dysfunction. Because of a
drop in cardiac output, the body uses energy to maintain cardiac function. Excess fluid
increases the amount of work the heart has to perform.

70. A client is brought to the emergency department by a family member who reports that
the client had a sudden onset of decreased level of consciousness, blurred vision, headache,
and slurred speech. Which action does the nurse take?

Elevate the head of the bed 90 degrees.

Obtain a finger-stick blood glucose level.
Pad the side rails of the patient's bed.
Obtain a urine specimen from the patient.

1) The client is unlikely to tolerate this position with these symptoms, and it may also be at
risk for injury if unable to self-support this position.

2) CORRECT – Assessment of other possible underlying causes that can be quickly and
easily corrected should be ruled out first, such as hypoglycemia, which may present with
similar symptoms. The client's symptoms are suggestive of a possible TIA or CVA.

3) Padding the rails is not indicated because there has been no report of seizure activity.

4) There is no evidence to suggest a urine sample is indicated.

71. The nurse cares for an elderly client 24 hours after an abdominal hysterectomy. The
nurse asks the client if she is experiencing any pain. The client states, “No, I am just fine.”
Which of the following responses by the nurse is BEST?

“That’s good. Please let me know if your abdomen starts hurting.”

“I see that you have not used your PCA pump. Are you sure that you aren’t in pain?”
“You are doing such a good job. If it were me, I would be using the pain medication.”
“Look at this faces pain scale. Point to the picture that shows how you feel now.”

Strategy: “BEST” indicates priority.

1) should validate client’s statement; client may be denying pain

2) second best answer; nurse is making observation about client’s use of PCA pump, but
validates by asking a yes/no question

3) focus is on nurse and not client

4) CORRECT— allows nurse to assess client’s perception of pain and validate client’s denial
of pain

72. A 21-year-old college student diagnosed with asthma falls on the running track while
preparing for a track meet. Use of the inhaler restores breathing and equilibrium. Since this
is the third time this has occurred in 3 weeks, the college health center nurse is called to
the scene. The student is conscious, alert, and oriented. Blood pressure is 120/82 mm Hg,
pulse is 84 bpm, and respirations are 14/min. The coach asks the student to go to the
emergency department to obtain medical evaluation to assess whether continued training is
safe. The student refuses to seek medical evaluation. It is MOST appropriate for the nurse
to take which of the following actions?

Contact the student’s parents to obtain consent for hospital evaluation and any needed
treatment.
Call an ambulance and ask the student who he wants to accompany him to the hospital.
Tell the student he does not have to seek medical evaluation if he does not want to.
Suggest the coach remove the student from the training roster unless the student
consents to be medically evaluated.

Strategy: "MOST appropriate" indicates that discrimination is required to answer the

question.

(1.) student has the right to refuse treatment; he is of legal age, living away from home,
conscious and oriented

(2.) student has the right to refuse treatment

(3.) CORRECT—student is of legal age to refuse treatment; even if he were not, he is living
away from home so may be considered an emancipated minor with rights equivalent to legal
age; a competent adult can refuse emergency treatment, and that refusal must be
respected by all

(4.) may be appropriate response to the coach but nurse should direct comments to the
student, who has the right to refuse treatment

73. The nurse cares for a client diagnosed with hepatitis A. The client complains of fatigue,
anorexia, and intolerance to odors. It is MOST important for the nurse to recommend which
of the following?

“Eat small, frequent feedings.”

“Restrict the amount of protein that you eat.”
“Decrease your caloric intake to 1,400 calories per day.”
“Limit your alcohol intake to 3 oz of wine per day.”

Strategy: Determine the outcome of each answer. Is it desired?

1) CORRECT— because of anorexia, client unable to eat large meals; encourage client to
eat all meals and snacks; if client has nausea later in the day, offer morning meals that are
rich in nutrients

2) should eat protein sources such as milk, meat, and eggs; protein restricted if impending
hepatic coma

3) should increase calories to 2,000 to 3,000 calories per day to meet energy needs

4) do not ingest alcohol during episode of hepatitis and for 6 months after recovery

74. During a nonstress test (NST), the nurse observes several late decelerations. Which
nursing action is most appropriate?

Reposition the client on her right side.

Notify the health care provier for further evaluation.
Document these results in the nurse’s notes.
Stop the oxytocin immediately.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it
desired?

(1) does not resolve the immediate problem

(2) correct—appearance of any decelerations of the fetal heart rate (FHR) during NST
should be immediately evaluated by the health care provider

(3) does not resolve the immediate problem

(4) incorrect for this test; oxytocin is not used for the nonstress test

75. A client has a neurogenic bladder following a spinal cord injury. In planning a bladder
training program, the nurse anticipates the physician will prescribe which of the following
medications?

Diphenhydramine (Benadryl).
Diazepam (Valium).
Dicyclomine (Bentyl).
Bethanechol (Urecholine).

Strategy: Think about the action of each drug.

1) antihistamine; promotes urinary retention

2) antianxiety medication; may cause nausea, but no change to urinary system

3) anticholinergic; promotes urinary retention

4) CORRECT— cholinergic or parasympathomimetic used to treat functional urinary

retention; mimics action of acetylcholine