18.

the nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleagues attention to these oversights. The colleague tells the nurse that standard precautions and gloves are unnecessary unless the client is known to have tested positive for the human immunodeficiency virus. which is the most appropriate action for the nurse to take? A. Ignore it because its not directly the nurses problem B. Document the problem in writing for the manager C. Talk to other staff members to ascertain their practices. D. Instruct the clients to remind this colleague to wear gloves. RATIONALE: The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasnt changed therefore, the appropriate action is to bring the problem to the managers attention. Its unproductive to talk with other staff members about the situation because they dont have the authority to bring the colleagues practice into compliance. The nurse should never point out to a client that another staff memberss practice isnt meeting standards. 19. an adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for the client is also his friend. The nurse tells the clients parents about the diagnosis; after all they know their son is the nurses friend. Several weeks later the nurse receives a letter from the clients attorney that the nurse has committed an intentional tort. Which intentional tort has this nurse committed? A. Fraud B. Defamation of Character C. Assault and Battery D. Breech of confidentiality RATIONALE: A Nurse shouldnt disclose a confidential information about a client to a third party who has no legal rights to know, doing so is a breech of confidentiality. Defamation of character in injuring someones reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the clients will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment. 20. A nurse accidentally administers 40 mg of propanolol (inderal) to a client instead of 10 mg. although the client exhibits no adverse reactions to the larger dose, the nurse should: A. Call the facilitys attorney B. Inform the clients family C. Complete an incident report D. Do nothing because the clients condition is stable. RATIONALE:

The nurse should file an incident report. Incident reports highlight areas of potential liability. Its then the risk managers responsibility to notify the facilitys attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve quality of care received by clients in a particular facility. Taking no action isnt an acceptable option. 21. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that hes impotent and says hes concerned about its effect on his marriage. In planning this clients care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality B. Provide time for privacy C. Provide support for the spouse or significant other D. Suggest referral to a sex counselor or other appropriate professional RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the clients care. The nurse doesnt provide sex counseling. 22. The nurse is assigned to care for eight clients. Two non professionals are assigned to work with the nurse. Which statement is valid in this situation? A. The nurse may assign the two non professionals to work independently with a client assignment B. Then nurse is responsible to supervise assistive personnel. C. Non professionals arent responsible for their own actions D. Non professionals dont require training before they work with clients. RATIONALE: Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. Its essential that assistive personnel must be adequately trained to perform all tasks theyre assigned to perform. 23.Policy and procedure dictates that handwashing is a requirement when caring for clients. Which statement about handwashing is true? A. Frequent handwashing reduces transmission of pathogens from one client to another B. Wearing gloves is a substitute for handwashing C. Bar soap, which is generally available, shouldnt be used for handwashing D. Waterless products shouldnt be used in situations where running water is unavailable RATIONALE: Whether gloves are worn or not, hand washing is required before and after the client contact because hand washing reduces the risk of cross-contamination. Bar

soap, shouldnt be used because its a potential carrier of bacteria. Soap dispensers are preferable, but they must also be checked for bacteria, when water is unavailable, the nurse should wash using a liquid sanitizer. 24. The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection? A. The presence of an indwelling catheter B. Rectal temperature of 100f (37.8c) C. Red, warm, tender incision D. White blood cell (wbc) count of 8000/ml RATIONALE: Redness, warmth and tenderness in the incision area would lead the nurse to suspect a postoperative infection. The presence of an invasive device predisposes a client to infection but alone doesnt indicate infection. A rectal temperature of 100f would be a normal expectation in a postoperative client because of inflammatory process. A normal WBC count ranges from 4000-10000/ml. 25. The nurse is caring for a client with a fracture hip. The client is combative, confused and trying to get out of bed. The nurse should: A. Leave the client and get help B. Obtain a physicians order to restrain the client C. read the facilitys policy on restraints D. Order soft restraints from the storeroom. RATIONALE: Its mandatory in most settings to have a physicians order before restraining a client. A client should never be alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints and nurse should be familiar with the facilitys policy. 26. The nurse is assessing a client for the risk of falls. The nurse should collect: A. Gait and balance information B. The agencys restraint policy C. the familys psychosocial history D. The clients dietary preferences RATIONALE: Assessing the clients gait and balance helps determine the risk for falls. The facilitys policy on restraints isnt relevant to a risk assessment for falls. Assessing the familys psychosocial history and the clients dietary preferences are important but not as important as gait and balance in relation to the risk of falls. 27. The nurse is caring for a bedridden, elderly adult. To prevent Pressure ulcers, which intervention should the nurse include in the plan of care? A. Turn and reposition the client a minimum of every 8 hours

B. Vigorously massage lotion into bony prominences C. Post a turning schedule at the clients bedside D. Slide the client, rather than lifting when turning RATIONALE: A turning schedule with a signing sheet will help ensure that the client gets turned and, thus help prevent pressure ulcers. Turning should occur every 1-2 hours not every 8 hours for client s who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage. Which could damage capillaries. When moving the client, the nurse should lift rather than slide the client to avoid shearing. 28. The nurse is caring for a client with late stage alzheimers disease. The clients wife tells the nurse that the client has become very dependent. The clients wife feels guilty if she takes any time for herself because the client cries out for her. The nurse should develop which of the following outcomes to assist the clients wife? A . The caregiver learns to explain to the client why she needs time for herself. B. The caregiver distinguishes obligations she must fulfill from those that cant be controlled or limited C. the caregiver leaves the client at home alone for short periods of time to encourage independence D. The caregiver avoids asking other family members to help for fear of imposing on them. RATIONALE: The caregiver must learn to distinguish obligations that she must fulfill and limit those that arent necessary. The caregiver can tell the client when she leaves but she shouldnt expect that the client will remember or wont become angry with her for leaving. The caregiver shouldnt leave the client home alone for any length of time because it may compromise the clients safety. The nurse can provide support to the primary caregiver if she needs to ask other family members for assistance. 29. The nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery. He tells the nurse that he doesnt wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that describes the clients problem is: A. Hopelessness B. Powerlessness C. body image disturbance D. Fear RATIONALE: Body image disturbance is a negative perception of self that makes healthful functioning more difficult. The defining characteristics for this nursing diagnosis include undergoing a change in body structure or function, hiding or overexposing a body part not looking at a body part and responding verbally or nonverbally to the actual or perceived change in structure or function. This client may have any of the

other diagnoses, but the signs and symptoms described in the case most closely match the defining characteristics for body image disturbance. 30. the nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. Shes in her 30s and has two young children. Although shes worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping? A. tell the clients spouse or partner to be supportive while she recovers. B. Encourage the client to proceed with the next phase of treamtment C. Recommend that the client remain cheerful for the sake of her children D. Refer the client to the American cancer societys reach for recovery program or another support program. RATIONALE: The client isnt withdrawn or showing other signs of anxiety or depression. Therefore the nurse can probably safely approach her about talking with others who have had similar experiences. Either through reach for recovery or another formal support group. The nurse may educate the clients spouse or partner and listen to concerns, but the nurse shouldnt tell the clients spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration and fear. She cant be expected to be cheerful at all times. 31. The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that hell be undesirable to his wife and he becomes tearful. He expresses that hes spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptom, which nursing diagnosis would be most appropriate for planning purposes? A. Low self-esteem, situational B. Neglect, unilateral C. Social isolation D. Loneliness RATIONALE: The signs and symptoms stated in this case are all found in the client with low selfesteem. The diagnosis of neglect occurs in neurologic illness or trauma when the client shows a lack of awareness of a body part. This client is at risk for social isolation and loneliness, but there is no indication in the case study that these diagnoses are present. 32. A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward god, his church, and the clergy. Which intervention isnt appropriate for this client? A. Acknowledging the clients spiritual distress B. Inviting the clients clergyman to visit him

C. Encouraging the client to discuss religious beliefs and practices. D. Encouraging the client to discuss concerns with the clergy RATIONALE: The nurse shouldnt invite his clergyman to visit the client unless the client specifically asks to see that member of the clergy. Acknowledging the clients spiritual distress may help the nurse build a therapeutic relationship with the client. Encouraging the client to discuss religious beliefs and practices is a first step in developing a plan for the client. Its also appropriate for the nurse to encourage the client to discuss his concerns with the clergy. 33. The nurse is working in a support group for clients with acquired Immunodeficiency syndrome(AIDS). Which point is the most important for the nurse to stress? A. Avoiding the use of recreational drugs and alcohol B. Refraining from telling anyone about the diagnosis C. Following safer sex practices D. Telling potential sex partners about the diagnosis, as required by law. RATIONALE: Its essential that AIDS clients follow safer-sex-practices to prevent transmission of the human immunodeficiency virus. Although its helpful avoid using recreational drugs and alcohol, for purpose of avoiding transmission its more important that IV drug users use clean needles and dispose of used needles. Whether the AIDS client chooses to tell anyone about an AIDS diagnosis is the clients decision; there is no legal obligation to do so. 34. The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first: A. B. C. D. Establish unresponsiveness Call for help Open the airway Assess the client for a carotid pulse

RATIONALE: The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths and check for carotid pulse. 35. The nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Which medication would be used to treat his bradycardia. A. B. C. D. Atropine Dobutamine (Dobutrex) Bretylium (Bretylol) Lidocaine (Xylocaine)

RATIONALE: IV push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Bretylium is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, Ventricular tachycardia and ventricular fibrillation. 36. The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement by: A. B. C. D. Suctioning the tracheostomy tube frequently. Using a cuffed tracheostomy tube. Using the minimal air leak technique with cuff pressure less than 25 cm H2O. Keeping the tracheostomy tube plugged.

RATIONALE: To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but wont prevent tracheal dilation. Use of a cuffed tube alone wont prevent tracheal dilation. The tracheostomy shouldnt be plugged to prevent tracheal dilation. This technique is when weaning the patient from tracheal support. 37. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates the ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: A. B. C. D. Limit oral fluid intake for 1-2 weeks. Report the presence of fine, sandlike particles through nephrostomy tube Notify the physician about cloudy or foul smelling urine Report bright pink urine within 24 hours after the procedure

RATIONALE: The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris Is normal due to residual stone products. Hematuria is common after lithotripsy. 38. The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions and sodium bicarbonate to be used to treat: A. B. C. D. Hypernatremia Hypokalemia Hyperkalemia Hypercalcemia

RATIONALE: Hyperkalemia is a common complication of acute renal failure. Its life threatening if immediate action isnt taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac

arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia dont usually occur with acute renal failure and arent treated with glucose, insulin or sodium bicarbonate. 39. The nurse is providing homecare instructions to a client who has recently had a skin graft. Its most important that the client remember to: A. B. C. D. Use cosmetic camouflage technique Protect the graft from direct sunlight Continue physical therapy Apply lubricating lotion to the graft site

RATIONALE: To avoid burning and sloughing, the client must protect the graft from direct sunlight. The other three inventions are all helpful to the client and his recovery but are less important. 40. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should: A. Apply suction to the nasogastric (NG) tube every hour. B. Clamp the nasogastric (NG) tube if the client complains of nausea C. Irrigate the nasogastric (NG) tube gently with normal saline solution D. Reposition the nasogastric (NG) tube if pulled out. RATIONALE: The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can cause bleeding. Suction should be applied continuously- not every hour. The nasogastric (NG) tube shouldnt be clamped postoperatively because secretions and gas will accumulate, stressing the suture line. 41. A client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the clients leg is pain-free, without redness or edema. The nurses actions reflect which step of the nursing process. A. B. C. D. Assessment Analysis Implementation Evaluation

RATIONALE: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the clients history, physical examination and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into action.

42. The nurse is caring for a client who recently underwent a total hip replacement. The nurse should: A. B. C. D. Ease the client onto a low toilet seat Allow the clients legs to be crossed at the knees when out of bed Use soft chairs when the client is sitting out of bed Limit client hip flexion when sitting

RATIONALE: Instruct the client to limit hip flexion to 90 degrees while sitting. Supply an elevated toilet seat so the client can sit without having to flex his hip more than 90 degrees. Instruct the client not to cross his legs, to avoid dislodging or dislocating the prosthesis. Caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable. 43. The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should do all the following except: A. Position the client to prevent airway obstruction B. Keep the client in one position to decrease bleeding C. Administer IV fluid as ordered and monitor the client for signs of fluid volume excess D. Maintain the client in a quiet environment RATIONALE: The nurse shouldnt keep the client in one position but rather carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk for bleeding. 44. When caring for a client whos being treated for hyperthyroidism. Its important to: A. Provide extra blankets and clothing to keep the client warm B. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy C. Balance the clients period of activity and rest D. Encourage the client to be active to prevent constipation RATIONALE: A Client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, its important to keep the environment cool and teach the client how to manage his physical reactions to heat. Clients with hypothyroidism, not hyperthyroidism complain of cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid replacement therapy often feel lethargic and sluggish, and are prone to constipation. Therefore, the nurse should encourage clients with hypothyroidism to be more active to prevent constipation.

45. Which intervention should the nurse try first with a client who exhibits signs of sleep disturbance? A. Administer sleeping medications before bedtime. B. Ask the client each morning to describe the quality of sleep during previous night C. Teach the client relaxation techniques, such as guided imagery, meditation, progressive muscle relaxation D. Provide the client with normal sleep aids, such as pillows, back rubs and snacks. RATIONALE: The nurse should begin with the simplest interventions such as pillows or snacks before interventions that require greater skill. Such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a sleep assessment especially if common sense-intervention fail. 46. When preparing a client for an enema, the nurse should help him into the: A. B. C. D. Left lateral sims position Prone position Right lateral sims position Right fowlers position

RATIONALE: Left lateral sims position will facilitate the flow of gravity into the descending colon. Only if this position is contraindicated will the nurse place the client on his back or right side. The prone position isnt used when giving an enema. If the client cant lie flat, semi fowlers position may be used. 47.the nurse is caring for a client with a right ankle sprain. When applying cold to a clients injury the nurse should: A. B. C. D. Apply it immediately after the injury occurs Use sterile technique Secure the cooling device with pins so that the device doesnt fall off Discontinue any application longer than 3 hours

RATIONALE: Apply cold immediately to minimize edema. Use sterile technique when applying cold to any open wound or when applying cold to the eyes. Dont secure cooling device with pins because an accidental puncture could allow cold fluids to leak out and burn the clients skin. Cold applications should be left on for longer than 1 hour at a time because of the risk of reflexive vasodilation. 48. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to: A. Avoid focusing on his weight

B. Increase his activity level C. Follow a regular diet D. Continue leading a high stress lifestyle RATIONALE: The client should be encouraged to increase his activity level. Maintaining an ideal weight, following a low cholesterol, low sodium diet and avoiding stress are all important factors in decreasing the risk of atherosclerosis. 49. The nurse is teaching a client diagnosed with basal cell epithelioma is: A. B. C. D. Immunosuppression Radiation Exposure Exposure to the sun Burns

RATIONALE: The sun is the best known and most common cause of basal cell epithelioma. Immunosuppression, radiation and burns are less common causes. 50. The nurse is giving instructions to a client who is going home with a cast on his leg. Which point is most critical? A. B. C. D. Using crutches properly Exercising joints above and below the cast as ordered Avoiding walking on a leg cast without the physicians permission Reporting signs of impaired circulation

RATIONALE: Although all of these interventions are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may exercise above and below the cast as the physician orders. The client should be told not to walk on the cast without the physicians permission. 51. The client undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the client is most at risk for: A. B. C. D. Atelectasis Anemia Dehydration Peripheral edema

RATIONALE: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood

or if he continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema. But the client is most at risk for atelectasis. 52. The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: A. B. C. D. Helping him communicate Keeping his airway patent Encouraging him to perform activities of daily living Preventing him from developing an infection

RATIONALE: Maintaining a patent airway is the most basic and most critical human need. All other interventions are important to the clients well being, but theyre not as important as having sufficient oxygen to breathe. 53. The nurse is working on a surgical floor. The nurse must logroll a client following a: A. B. C. D. Laminectomy Thoracotomy Hemorrhoidectomy Cystectomy

RATIONALE: A client who has had a spinal surgery such as laminectomy must be logrolled to keep the spinal column straight when turning. Thoracotomy and cystectomy clients may turn themselves or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure and the client may resume normal activities immediately after the surgery. 54. A Client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following? A. B. C. D. Avoid lifting objects weighing more than 5 lb (2.25 kg) Lie on your abdomen when in bed Keep rooms brightly lit Avoid straining during bowel movement or bending at the wrist

RATIONALE: The client should avoid straining, lifting heavy objects and coughing harshly because these activities increase ocular pressure. Typically the client is instructed to avoid lifting objects weighing more than 15 lb(7kg) not 5 lb. instruct the client when lying in bed to lie on either the side or back. The client should avoid bright light by wearing sunglasses. 55. When caring for a client with the nursing diagnosis impaired swallowing related to neuromuscular impairment, the nurse should:

A. B. C. D.

Position the client in a supine position Elevate the head of the bed 90 degrees during meals Encourage the client to remove dentures Enourage thin liquids for dietary intake

RATIONALE: The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position not a supine position when lying down to reduce the risk for aspiration. Encourage the client to wear properly fitted dentures to enhance his chewing ability. Thickened liquids not thin liquids decrease aspiration risk. 56. When performing an assessment, the nurse identifies the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion and the clients reluctance to move. These signs and symptoms indicate which nursing diagnosis? A. B. C. D. Health seeking behavior Mobility impairment Sensory or perceptual impairment Knowledge deficit

RATIONALE: Mobility impairment is a limitation of physical movement and is identified by the characteristics found in this client. Health seeking behavior is a state in which a client in stable health actively seeks ways to alter personal health habits or the environment in order to move toward optimal health. Sensory or perceptual alterations are changes in the characteristics of incoming stimuli. Knowledge deficit exists when the client requires further teaching. 57. before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review? A. B. C. D. Fluid intake for the last 24 hours Baseline arterial blood gas (ABG) levels Prior outcomes of weaning Electrocardiogram (ECG) results

RATIONALE: Before weaning a client from mechanical ventilation, its important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the clients record and the nurse can refer them before the weaning process begins. 58. the nurse is teaching a client with genital herpes. Education for this client should include an explanation of:

A. B. C. D.

The need for the use of petroleum products Why the disease is only transmittable when visible lesions are present. The option of disregarding safer-sex-practices now that hes already infected. The importance of informing his partner of the disease

RATIONALE: Clients with genital herpes should inform their partners of the disease. Petroleum products should be avoided because they can cause the virus to spread. The notion that genital herpes is only transmittable when visible lesions are present is false. Anyone not in a long term, monogamous relationship regardless of current health status should follow safer sex practices. 59. A 25 year old client asks the nurse how often and when she should perform breast self examinations. The nurse should tell her: A. B. C. D. Every month, timing isnt important Every month, 7-10 days after menses starts Every month, 7-10 days before menses starts Self breast examinations arent necessary until after the first mammography

RATIONALE: Breast self examinations should be performed every month, 7-10 days after menses start. Timing is important and breast self examinations are recommended for all women. 60. A male client should be taught about testicular examinations: A. B. C. D. When sexual activity starts After age 60 After age 40 Before age 20

RATIONALE: Testicular cancer commonly occurs in men between ages 20-30. A male client should be taught how to perform testicular self examinations before age 20, preferably when he enters his teens. 61. When performing an abdominal assessment, the nurse should follow which examination sequence? A. B. C. D. Inspection, auscultation, percussion and palpation Inspection, auscultation, palpation and , percussion Inspection, percussion, palpation and auscultation Inspection, palpation, percussion and auscultation

RATIONALE: The correct sequence for abdominal assessment is Inspection, auscultation, percussion and palpation because this sequence prevents altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is Inspection, palpation, percussion and auscultation

62. The nurse is providing breast cancer education at a community facility. The American cancer society recommends that women get mammograms: A. B. C. D. Yearly after age 40 After the birth of the first child and every 2 years thereafter After the first menstrual period and annually thereafter Every 3 years ages 20 and 40 and annually thereafter

RATIONALE: The American cancer society recommends a mammogram yearly for women over age 40. The other statements are incorrect. Its recommended that women between ages 20 and 40 have a professional breast self examinations (not a mammogram) every 3 years. 63. A client asks the nurse what PSA is. The nurse should reply that it stands for: A. B. C. D. Prostate specific antigen, used to screen for prostate cancer Protein serum antigen, used to determine protein levels Pneumococcal strep antigen, a bacteria that causes pneumonia Papanicolau specific antigen, used to screen for cervical cancer.

64. The nurse is providing teaching to a client whos at risk for coronary artery disease. The nurse tells the client that coronary artery disease has many risk factors. Risk factors that can be controlled or modified include: A. B. C. D. Gender, obesity, family history and smoking Inactivity, stress, gender and smoking Obesity, inactivity, diet and smoking Stress, family history and obesity

RATIONALE: The risk factors for coronary artery disease that can be controlled or modified include obesity, inactivity, diet, stress and smoking. Gender and family history are risk factors that cant be controlled. 65. The nurse is performing an admission assessment on a client admitted with a diagnosis of small bowel obstruction. When assessing the clients pulse rate, the nurse should: A. B. C. D. Always count for 30 seconds and multiply by 2 Count the apical pulse only Count for 60 seconds Count for 15 seconds and multiply by 4

RATIONALE: When assessing a pulse rate, the nurse should count for 60 seconds. Counting for 30 seconds then multiplying by 2 isnt always accurate. The radical pulse may be assessed as well as the apical. Counting for 15 seconds and multiplying by 4 isnt enough time to adequately assess the regularity of the pulse.

66. When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to: A. B. C. D. Initiate a stream of urine. Breathe deeply Turn to the side Hold the labia or shaft of penis

RATIONALE: When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doint this will relax the urinary sphincter. Initiating a stream of urine isnt recommended during catheter insertion. Turning to the side or holding the labia or penis wont ease insertion and doing so may contaminate the sterile field. 67. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action: A. B. C. D. Destroys the odor proof seal Wont affect the colostomy system Is appropriate for relieving the gas in a colostomy system Destroys the moisture barrier seal

RATIONALE: Any hole, no matter how small, will destroy the odor proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas. 68. The nurse must administer an enema to an adult client. The appropriate depth for inserting an enema into an average sized adult is: A. B. C. D. 1 to 2 3 to 4 4 to 6 6 to 8

69. A client is prescribed Transcutaneous Electrical Nerve Stimulation (TENS) for pain relief. The rationale for using TENS is to: A. B. C. D. Help relax tense muscles Prevent stiffness and further loss of mobility Reduce swelling and inflammation Block painful stimuli travelling over small nerve fibers.

RATIONALE: The rationale for using TENS for pain relief is to block painful stimuli travelling over small nerve fibers. Massage is used to relax tense muscles. Range of motion exercises are used to prevent stiffness and further loss of mobility. Elevation and repositioning are used to reduce swelling and inflammation.

70. The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that: A. B. C. D. Overhydration causes the skin to tent Dehydration causes the skin to appear edematous and spongy Inelastic skin turgor is a normal part of aging Normal skin turgor is moist and boggy

RATIONALE: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration causes inelastic skin with tenting. Overhydration, not dehydration causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. 71. The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include: A. B. C. D. Coma or seizures Sunken eyeballs and poor skin turgor Increased heart rate with hypotension Thirst or confusion

RATIONALE: Early signs and symptoms of dehydration include thirst, irritability, confusion and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor and increased heart rate with hypotension are all later signs. 72. A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to: A. B. C. D. Prevent leaning Distribute weight away from the involved side Maintain stride length Prevent edema

RATIONALE: Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Use of a cane wont maintain stride length or prevent edema. 73. The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb: A. Isnt necessary B. Should begin immediately postoperatively C. Should begin the day after surgery D. Begins at a rehabilitation center. RATIONALE:

Exercise should begin the day after surgery. Exercise is necessary to maintain the muscle tone of the remaining limb. Immediately after the surgery, the client usually isnt alert enough to participate and may be in too much pain. Exercise needs to begin before discharge to a rehabilitation center. 74. The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to: A. B. C. D. Decrease the possibility of absorption on the nurses skin Allow distribution of medication Prevent soiling of the clients clothes Avoid administering more than the prescribed dose

RATIONALE: The nurse should remove previously applied topical medications before applying new medications to prevent accumulation of medication that exceeds the prescribed dose. Wearing gloves will decrease the possibility of absorption on the nurses skin. Spreading topical medications evenly will allow for distribution of medication. Placing a dressing, if allowable, over the medication will prevent soiling of clients clothes. 75. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the: A. B. C. D. Conjunctival sac Pupil Sclera Vitreous Humor

RATIONALE: The nurse should instill the eyedrop into the conjunctival sac where absorption can best take place. The pupil permits light to enter the eye. The sclera maintains the eyes shape and size. The vitreous humor maintains the retinas placement and the shape of the eye. 76. the nurse is administering eardrops to an adult client before instilling the drops, the nurse should gently pull the: A. B. C. D. Auricle down and back Tragus down and back Auricle up and back Tragus up and back

RATIONALE: To straighten ear canal in an adult client to instill eardrops, gently pull the auricle up and back. Repositioning the tragus wont straighten the ear canal. Pull the auricle down and back for a child.

77. The nurse is teaching a client about using vaginal medications. The nurse should instruct the client to: A. Use a tampon after insertion to increase medical absorption. B. Release and pull up on the applicator before removal C. Never refrigerate suppositories. D. Use only a water-soluble lubricant when inserting a suppository. RATIONALE: The nurse should instruct the client to use only a water-soluble lubricant when inserting a suppository. Tampons shouldnt be used because the tampon will absorb some medication, making the medication less effective. When removing the applicator, the client should keep the plunger depressed. Suppositories may be refrigerated to keep their from. 78. the nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication: A. B. C. D. In the cheek On the tip of the tongue Under the tongue Under the lower lid of the eye

RATIONALE: Sublingual medication should be placed under the tongue. Buccal medication should be placed in the cheek. Eyedrops should be instilled in the lower lid in the conjunctival sac. Oral medications should be placed on the tongue and swallowed. 79. A client has an order of 5,000 U of subcutaneous (sc) heparin, every 12 hours. When injecting heparin SC, the nurse should: A. B. C. D. Aspirate after injection Use the Z track method Use a 90 degree angle to insert Always use the same injection site

RATIONALE: When injecting heparin SC, The nurse shouldnt aspirate. Rather, the nurse should inject at a 90 degree angle and rotate injection sites. The Z-Track method is used for IM injections that may irritate. 80. The nurse is preparing a client for insertion of an IV catheter. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should: A. B. C. D. Choose a proximal site Choose a distal site Have the client hold his arm over his head Leave the tourniquet on for at least 5 minutes

RATIONALE:

When selecting a site for insertion of an IV catheter, the nurse should choose a distal site- not a proximal site. Doing so leaves the upper veins available for subsequent cannulations. Have the client hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. 81. The nurse is performing an assessment on a client who has developed a paralytic ileus. The clients bowel sounds will be: A. B. C. D. Hyperactive Hypoactive High-pitched Blowing

RATIONALE: If a paralytic ileus occurs, bowel sounds will be hypoactive or absent. Hyperactive bowel sounds may signify hunger, intestinal obstruction or diarrhea. High Pitched sounds may signify dilated bowel. A blowing sound maybe a bruit from a partially obstructed abdominal aorta. 82. The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: A. B. C. D. Encouraging ambulation to prevent pooling of blood Providing warmth to the extremity Elevating the extremity to prevent pooling of blood Forcing blood into the deep venous system.

RATIONALE: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isnt a function of the stockings. Antiembolism stockings could possible provide warmth but isnt how they prevent DVT. Elevating the extremity will decrease edema but wont prevent DVT. 83. The nurse is caring for a client whos hypoglycemic. This client will have a blood glucose level: A. B. C. D. Below 70 mg/dl Between 70 and 120 mg/dl Between 120 and 180 mg/dl Over 180 mg/dl

RATIONALE: A blood glucose level under 70 mg/dl is considered hypoglycemic. A normal blood glucose level is between 70 and 120 mg/dl. Over 120 mg/dl indicates hyperglycemia 84. A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care?

A. B. C. D.

Cover the cast with a blanket until the cast dries. Keep your right leg elevated above heart level Use a knitting needle to scratch itched inside the cast A foul smell from the cast is normal

RATIONALE: The leg should be elevated to promote venous return and prevent edema. The cast shouldnt be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection. 85. The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should: A. B. C. D. Use commercial preparations to remove corns Cut toenails by rounding edges Wash and inspect feet daily Walk barefoot at least once a day

RATIONALE: Diabetic clients should wash their feet daily to allow for daily inspection of the feet. The client should wear nonconstrictive shoes. Corns should be treated by a podiatrist- not with commercial preparations. Nails should be filed straight across. Clients with diabetes mellitus should never walk barefoot. 86. The nurse is teaching a group of patient care attendants about infection control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is: A. B. C. D. Wearing gloves Administering antibiotics Washing hands Assigning private rooms for clients

RATIONALE: Handwashing is the first line of intervention for preventing the spread of infections. Antibiotics should be initiated when an organism is identified. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. 87. A client receiving total parenteral nutrition is prescribed a 24-hour urine specimen, the collection time should: A. B. C. D. Start with the first voiding Start after a known voiding Always be with first morning routine Always be the last evenings void as the last sample

RATIONALE:

When initiating a 24 hour urine specimen, have the client void, then start the timing. The collection should start on an empty bladder. The exact time the test starts isnt important but theyre commonly started in the morning.