QB 8

1. During the initial period following a spinal cord injury, it is MOST important for the nurse
to take which of the following actions?

Prevent contractures and atrophy.

Prevent urinary tract infections.
Promote rehabilitation.
Prevent flexion or hyperextension of the spine.

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

1) although important, not a priority in the immediate post-injury period

2) infection generally occurs as a result of prolonged immobility; important, but not the
priority

3) safety and surviving injury take priority; begin when client’s condition stabilizes

4) CORRECT— primary goal is to protect spine from strain and further damage while injury
heals

2. The nurse cares for the client in the emergency department (ED). The nurse reviews the
health care provider's orders and notes that Digoxin 1.25 mgPO now has been ordered for
the client. Which action by the nurse is BEST?

Administer the medication as ordered.

Notify the health care provider.
Ask another nurse if the dosage is appropriate
Ask the patient if this is her daily dosage

Strategy: Determine the outcome of each answer.

1) inappropriate; digoxin is a cardiac glycoside; oral loading dose is 0.75 mg - 1.25 mg and
should be administered in divided doses over 24 hours

2) CORRECT— ensure the five rights of drug administration; nurse needs to clarify order; if
digitalizing dose, give in divided doses over 24 hours; if maintenance dose, dose is incorrect

3) nurse administering the medication should clarify order with health care provider

4) nurse should clarify order with health care provider

3. The home care nurse visits the young adult with a diagnosis of hepatitis A. Which
statement, if made by the client to the nurse, indicates that further teaching is needed?

"I have been very careful to wash my hands after I go to the bathroom."
"I have had to take acetaminophen several times this week for this sinus infection I
have."
"I have been very careful not to handle my child’s toys or eating utensils."
"My spouse has been preparing all of the meals since I have been sick."

Strategy: "Further teaching is needed" indicates you are looking for an incorrect response.

1) because hepatitis A is spread by the oral-rectal route, it is important to protect others by

practicing good handwashing techniques and avoiding contact with items that will be placed
in others’ mouths

2) CORRECT — client should be cautioned about taking any drugs not approved by the
health care provider; may become dangerous because of the liver’s inability to detoxify and
excrete them

3) because hepatitis A is spread by the oral-rectal route, it is important to protect others by

practicing good handwashing techniques and avoiding contact with items that will be placed
in others’ mouths

4) because hepatitis A is spread by the oral-rectal route, it is important to protect others by

practicing good handwashing techniques and avoiding contact with items that will be placed
in others’ mouths

4. The nurse admits a client with nuchal rigidity and photophobia. Which of the following
actions should the nurse take FIRST?

Place client on droplet precautions.

Monitor for increased intracranial pressure.
Prepare the client for a lumbar puncture.
Set up seizure precautions.

Strategy: “FIRST” indicates priority.

1) CORRECT— has symptoms of meningitis; Haemophilus influenzae and Neisseria

meningitidis (either known or suspected) require droplet precautions; place client on droplet
precautions until diagnosis is confirmed or eliminated to protect other clients and staff

2) caused by accumulation of purulent exudate; important to assess for changes in LOC;

preventing spread of infection takes priority
3) bacterial culture and Gram staining of CSF is done

4) important to protect client from injury; priority is preventing spread of infection

5. The physician orders propranolol (Inderal) for a client with type 1 diabetes mellitus
(IDDM). The client asks the nurse if there is anything special she needs to know about this
medication since she takes NPH and regular insulin each morning. Which of the following
responses by the nurse is BEST?

“Inderal potentiates the action of insulin and may increase the number of episodes of
hypoglycemia you experience.”
“Inderal interferes with the action of the insulin and may cause you to experience
hyperglycemia.”
“Inderal may mask symptoms of hypoglycemia, removing your body’s early warning
system.”
“Inderal has no effect on your body’s metabolism other than to lower your blood
pressure.”

Strategy: Think about each answer.

1) no effect on blood sugar levels

2) no effect on blood sugar levels

3) CORRECT— beta-blockers bind beta-adrenergic receptor sites, which prevents

adrenaline from causing symptoms and glycogenolysis

4) will lower BP, but also interferes with body’s response to hypoglycemia

6. The nurse provides care for a client who had a transurethral resection of the prostate
(TURP). The client has a 3-way urinary catheter connected by gravity with continuous
bladder irrigation (CBI) of normal saline. When assessing the client following surgery, the
nurse is alert for which observations? Select all that apply.

Elevated temperature.

Bladder spasms.

Leaking fluid around the catheter.

Hypertension.

Hemorrhage.

Urge to void.
Strategy: Think about each answer and how it relates to the stem of the question.

1) CORRECT — an elevated temperature may indicate an infection, which is a complication

of TURP

2) CORRECT — bladder spasms often occur when manual irrigation of the bladder is done,
usually because of blood clots

3) CORRECT — leaking fluid from the urethra around the catheter is concerning

4) hypertension is not a common problem following TURP unless there are other underlying
problems; should be alert for hypotension which is an indication of hemorrhage

5) CORRECT — hemorrhage is the greatest danger following TURP; clots are common in the
first 36 hours; continuous irrigation helps keep the clots small and passable

6) the urge to void is an expected observation following a TURP related to the large balloon
size of the indwelling catheter and the tension placed on the catheter to control bleeding

7. The visiting nurse evaluates the progress of the client recently diagnosed with type 1
diabetes. As part of the treatment plan, the client receives Humulin N 32 units and Humulin
R 8 units each morning. Which action, if performed by the client while preparing the
morning insulin injection, requires an intervention by the nurse?

After drawing up 8 units of Humulin R, the client adds Humulin N to the syringe for a
total of 40 units.
The client draws up 32 units of the clear insulin followed by 8 units of cloudy insulin for
a total of 40 units.
Initially, the client injects air into the Humulin N vial without drawing up any insulin.
The client injects air into each bottle of insulin equal to the amount of insulin to be
withdrawn.

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

(1) clear insulin always drawn up first

(2) correct—Humulin R is clear and drawn up first, only 8 units are ordered; Humulin N is
cloudy

(3) allows you to withdraw medication later

(4) allows you to withdraw medication later

8. The nurse returns to the desk in the prenatal clinic and finds four phone messages. Which
of the following messages should the nurse return FIRST?
 A multigravida at 12 weeks’ gestation experiencing heavy white vaginal discharge.
A primigravida at 17 weeks’ gestation states that she has not felt the baby move.
A primigravida at 22 weeks’ gestation complains of feeling dizzy and clammy when
lying on her back.
A multigravida at 32 weeks’ gestation experiencing malaise and bilateral dependent
and facial edema.

Strategy: Determine the most unstable client.

1) leukorrhea caused by hyperplasia of vaginal mucosa, normal finding

2) normal finding for primigravida

3) vena cava syndrome; instruct client to lie on side

4) CORRECT— symptoms of pre-eclampsia that require evaluation

9. The nurse receives hand-off communication from the previous shift about assigned clients
with mental health disorders. Which client will the nurse see first?

Client with mania and bipolar disease threatening to sue the primary nurse for
negligence.
Client with depression stating that things are better and that he will be leaving soon.
Client with delusions stating a plan to kill the spouse after being discharged.
Client with schizophrenia denying hearing voices.

1) Anger, grandiosity, and litigious threats are symptomatic of bipolar mania. This client is
not a priority.

2) CORRECT – The client with depression who states that things are better and will be
leaving soon may be an indirect suicide threat with a plan. The nurse must clarify the
client's statement, as this client can be in immediate danger.

3) The client threatening to kill the spouse should be seen second. The nurse has the "duty
to warn," even though the client is unable to carry out the threat immediately due to being
hospitalized.

4) Denying the hearing of voices indicates an improvement in the disease process.

10. The home care nurse visits a client diagnosed with dementia. The client lives with a son
and his family. The nurse identifies which stressor is MOST critical to the family?

The client is unwilling to eat with the family.

 The client does not recognize family members.
The family is not aware of community resources available to them.
The client is incontinent.

Strategy: Discrimination is required to answer the question.

1) offer finger foods that client can walk with

2) CORRECT— confirms a deteriorating condition and increases the feelings of loss among
the family members

3) making family aware of community resources is important, but dealing with a parent who
does not recognize family members is more stressful

4) adds to the stress; toilet early in morning, after meals and snack, and before bedtime

11. The nurse on the neurology unit prepares a client for discharge after an exacerbation of
multiple sclerosis. Which statement from the client to the nurse indicates that teaching is
successful?

"When I exercise, I push beyond feeling tired and then stop."

"When my muscles are spastic, I will take a hot bath."
"I will sleep on my stomach as much as I can."
"I will be firm and steady when I stretch a spastic leg open."

1) Overexertion must be avoided because it will cause fatigue and exacerbate symptoms.
Exercises for muscle strengthening done to the point of fatigue can actually cause further
paresis or weakness, numbness, and decreased coordination.

2) Heat and humidity, whether environmental or a hot bath or shower, can aggravate the
fatigue. Fatigue can precipitate and/or intensify multiple sclerosis symptoms.

3) CORRECT – Sleeping prone may minimize spasm of the flexor muscles of the hips and
knees of a person with multiple sclerosis. If these spasms are not relieved, joint
contractions will occur as well as pressure ulcers on the sacrum and hips from difficulty
obtaining a correct position.

4) A spastic extremity should not be forced open. Instead, it should be gently rotated in the
direction it is being pulled and then gradually rotated in the opposite direction, which is
usually outward since spasticity usually is into an adducted position. These rotations are
repeated, going a little farther each time.

12. A client experiences a flail chest from a motor vehicle crash. Which finding does the
nurse expect when assessing this client?
 Chest on the affected side expands outward during inspiration and is pulled inward
during expiration.
Chest on the affected side is pulled inward during inspiration and bulges outward
during expiration.
A sucking sound is heard on inspiration and expiration.
Absent or restricted movement noted on the affected side.

1) Expansion outward during inspiration and pulling inward during expiration describes
normal movement of the chest during respirations.

2) CORRECT— A flail chest is caused by fractures of multiple adjacent ribs, causing the
chest wall to become unstable and respond paradoxically. The chest then pulls in during
inspiration and bulges outward during expiration.

3) A sucking sound on inspiration and expiration describes a sucking chest wound.

4) Absent or restricted movement on the affected side describes a pneumothorax.

13. The nurse receives a report on clients in the psychiatric unit. The nurse is concerned if
which actions were performed by the off-going nurse?

Select all that apply.

The RN assessed the suicidal client every 15 minutes.

The RN administered ziprasidone to a violent client.

The RN placed the client in a dimly lit room after the client did not eat all of the
provided meal.
The RN allowed the suicidal client to remain in street clothes.

The RN initiated a signed PRN order for physical restraints.

"nurse is concerned" indicates incorrect actions by the off-going nurse

1) CORRECT — client should have 1:1 supervision at all times

2) appropriate to use chemical restraint when client is a risk to harm self/others

3) CORRECT — seclusion is never punitive; rather, goal is safety of client and others

4) CORRECT — all clothing and personal belongings should be secured to minimize

potential for self-harm
5) CORRECT — restraints are never PRN orders; use alternative measures prior to use of
restraints (reorientation, family involvement, frequent assistance with toileting)

14. The nurse cares for a client 24 hours post surgery after a thyroidectomy. Which of the
following statements if made by the client to the nurse requires an immediate intervention?

“I have been having some muscle spasms in my legs and my lips are tingling.”
“I think I am getting a cold because I have been coughing and sneezing all night.”
“I am still having pain around the incision.”
“My voice is still hoarse.”

Strategy: “Immediate intervention” indicates a complication.

1) CORRECT— client is at risk for hypocalcemia, which may be manifested by tetany and
result in airway obstruction, respiratory arrest, cardiac dysrhythmias, and cardiac arrest

2) though the nurse should reinforce the need to protect the suture line and possibly obtain
an order for medication, circulation takes precedence over the surgical incision

3) though it is important to offer effective pain management, it is not unusual for a patient
to experience pain 24 hours post surgery; hypocalcemia takes precedence over pain

4) not uncommon for a patient to experience hoarseness post surgery and is initially likely
secondary to edema or the use of an endotracheal tube. If the hoarseness was persistent it
could indicate laryngeal nerve damage, but is not likely a concern 24 ho

15. The nurse at an outpatient clinic provides nutritional counseling to an 18-year-old client
who wants to gain weight. The client is 6'2" tall and weighs 170 pounds. The nurse
determines that teaching is effective when the client makes which statement?

"I eat mostly fresh fruits and vegetables."

"I eat bread at each meal."
"I use low-fat salad dressings."
"I like to snack on pecans and raisins."

1) While fruits and vegetables provide vitamins, minerals, and fiber, they are low in calories.
Ideally, the client's diet should include foods that add both nutrition and calories.

2) Bread adds carbohydrates to the diet. However, only certain types of bread add
significant nutritional value. Healthy strategies for weight gain include eating foods that are
high in nutritional value and relatively high in calories.
3) Low-fat salad dressing may or may not be nutritious. However, this food item does not
add calories to the diet. The ideal approach to healthy weight gain involves adding both
calories and nutrition.

4) CORRECT— The ideal approach to healthy weight gain includes adding foods that are
both rich in nutrition and relatively high in calories. Pecans are a relatively high-calorie food
that contain vitamins and minerals, as well as in protein, which is needed to build muscle.
Raisins are high in fiber, iron, and potassium, and do not contain saturated fat or
cholesterol.

16. The client undergoes a total laryngectomy. The nurse instructs the client and spouse
how to suction the laryngectomy tube. Which observation indicates to the nurse that
teaching is effective?

The client takes several deep breaths before the suction catheter is inserted.
The spouse selects a Yankauer tonsil tip catheter to suction the laryngectomy tube.
The spouse applies suction while introducing the sterile catheter into the stoma.
The spouse suctions the mouth and then the laryngectomy tube.

Strategy: "Teaching was effective" indicates a correct action.

(1)correct— hyperoxygenates and prevents anoxia

(2) used for oral suctioning of mouth

(3) apply suction only as catheter is withdrawn

(4) suction laryngectomy tube and then mouth

17. The nurse supervises care on a medical/surgical unit. The nurse notes that after a lab
technician has drawn a blood specimen from a client, there are drops of blood on the floor
and the wall next to the needle container. Which of the following actions should the nurse
take FIRST?

Contact the laboratory supervisor to report the incident.

Contact the nurse manager to report the incident.
Call housekeeping to clean and disinfect the area.
Counsel the laboratory technician about appropriate technique.

Strategy: Determine the outcome of each answer.

1) nurse should stay in chain of command and notify the nurse’s supervisor

2) second action; nurse’s responsibility to communicate to the nurse manager

3) CORRECT— priority is cleaning up the contaminated area

4) responsibility of the laboratory supervisor

18. The nurse supervises care on the medical surgical unit. Which situation should the nurse
attend to first?

A nursing assistive personnel (NAP) enters the room of the client diagnosed
withPneumocystis jiroveci pneumonia wearing gown, mask, and gloves.
The client who has just returned to the unit after a right pneumonectomy is placed in a
room with the client diagnosed with chronic obstructive pulmonary disease.
The family of the client reports that the toilet is overflowing in the client's bathroom.
The client diagnosed with tuberculosis is ready for discharge and waiting for discharge
instructions.

Strategy: Determine which situation will cause the most harm to the client.

1) should be using standard precautions; NAP needs to be counseled on appropriate

precautions; not the most unstable situation

2) CORRECT— postoperative clients are considered “clean” or uncontaminated and should

not be placed with the client that is considered “dirty” or contaminated

3) potential problem; actual problems take priority

4) psychosocial need; physical needs take priority

19. The nurse instructs a client recovering from a right above-the-knee amputation (AKA).
Which information does the nurse include in the client's teaching plan? (Select all that
apply.)

A prosthesis will be fitted in about 3 months.

Phantom limb pain is common after extremity amputation.

Maintain the prone position several times daily.

No exercise or ambulation is allowed for several weeks.

Anti-seizure medications may help with phantom limb pain.

1) After an AKA, a prosthesis may be fitted immediately or delayed until the site is
completely healed.

2) CORRECT – Phantom limb pain occurs frequently in clients recovering from an

amputation of an extremity.
3) CORRECT – The prone position helps prevent contractures when recovering from an
AKA.

4) When recovering from an AKA, early ambulation is encouraged with or without a

prosthetic limb.

5) CORRECT – Anti-seizure medications are effective for neuropathic pain and may be
prescribed if required.

20. The nurse receives hand-off communication on assigned clients from the previous shift.
Which client will the nurse assess first?

Client in sickle-cell crisis with an infiltrated intravenous access line.

Client with leukemia who has received 0.5 unit of packed red blood cells.
Client scheduled for a bronchoscopy.
Client complaining of a leaky colostomy bag.

1) CORRECT – For the client with sickle-cell crisis, intravenous fluids are critical to reduce
clotting and reduce pain. This client is the priority.

2) There is no indication that the client with leukemia receiving blood is unstable.

3) There is no indication that the client scheduled for a bronchoscopy is unstable.

4) There is no indication that the client with a leaky colostomy bag is unstable.

21. The nurse provides care for the client diagnosed with active tuberculosis (TB). It is
important for the nurse to take which action?

Restrict visitors to immediate family only while hospitalized.

Ensure the client's isolation cart is at the nurse's station.
Wear a mask and gloves when in direct contact with the client.
Dispose of waste articles, such as tissues, every shift.

1) Immediate family has probably already been exposed to the client’s tuberculosis. The
nurse will want to limit visitors, but visitors are allowed as long as they take proper
precautions.

2) The isolation cart is to be placed at the client's doorway, not at the nurse's station.

3) CORRECT – Airborne precautions are required. Airborne precautions include the use of
an N-95 mask when in the room with the client.

4) The nurse removes the client's waste on a continual basis to reduce the spread of TB.
22. The wellness nurse finishes a class series on memory improvement at the community
center. A 68-year-old female participant who appears alert, oriented, well-groomed, and
intellectually curious approaches the nurse. In the process of discussing memory issues, the
68-year-old says that while her memory concerns seem to be common and the same as
those of other seniors at the center, there is something "strange" that has been happening
lately. "I am seeing thing that are not there. It is always people. I am awake and sitting
down and I know they are not there, but I see them." When asked if the people she sees
say anything or appear to be like anyone she knows, she says no. Which of the following
responses should the nurse make FIRST?

"Has anyone in your family ever been diagnosed with schizophrenia?"

"What medications have you been taking recently?"
"Don’t worry. You may actually have been asleep and dreaming."
"The Alzheimer’s organization offers some tests you may want to take."

Strategy: Assess before implementing.

(1.) assessment; not appropriate; is a closed-ended question requiring only a yes or no

answer; also implies the hallucination is a symptom of schizophrenia

(2.) CORRECT—some medications can cause confusion and hallucinations

(3.) implementation; dismisses the woman’s concerns with "don’t worry" and blocks further
communication

(4.) implementation; inappropriate response, both factually and in terms of tone and
implications

23. The nurse providing care for diabetic clients has just received a report. Which client
does the nurse see first?

An irritable teenager who reports fatigue.

A client whose breath smells fruity and who reports thirst.
A client with a BP of 120/50 mm Hg and who reports frequent urination and thirst.
A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch.

Strategy: Determine the most unstable client.

1) irritability and fatigue indicate hypoglycemia; these symptoms are seen with a gradual
decline into hypoglycemia

2) CORRECT— fruity-smelling breath indicates metabolic acidosis from ketosis; this

increases the risk of injury to the client
3) the blood pressure is normal and frequent urination and thirst are symptoms of diabetes

4) hot, dry skin indicate dehydration caused by hyperglycemia; this is the first stage of
diabetic ketoacidosis and this client should be seen second

24. A client requests information on nonpharmacologic methods of birth control. In planning

the client's care, which method is most effective and needs to be included when providing
education?

Calendar method.
Coitus interruptus.
Basal body temperature evaluation.
Symptothermal method.

1) The calendar method is based on regularity of ovulation, which can vary. This method
requires periodic abstinence from intercourse during fertile periods. This method is not the
most effective.

2) Coitus interruptus has the man withdraw the penis before ejaculation occurs to avoid
depositing sperm into vagina. This is one of the least reliable methods of birth control.

3) A woman's temperature drops immediately before ovulation and almost always increases
and remains elevated for several days after. This method is not the most reliable method of
birth control because the woman's temperature may vary.

4) CORRECT— The symptothermal method combines cervical mucus evaluation and basal
body temperature evaluation. Any time a method of birth control can be used in
combination with another, the rate of effectiveness increases. Therefore, this method is the
most effective.

25. The nurse performs a physical assessment on an infant. When assessing the infant, it is
MOST important for the nurse to take which of the following actions LAST?

Evaluate genitalia.
Assess ears and mouth.
Assess deep tendon reflexes.
Obtain heart and respiratory rates.

Strategy: Determine outcome of each answer.

1) should proceed in a general head to toe direction

2) CORRECT— more traumatic/invasive, which may induce crying; nurse should perform
auscultation and less aggressive assessments first while patient is calm and quiet
3) should be completed as each body part is examined

4) should be done while infant is calm and quiet

26. The nurse is caring for several clients receiving chemotherapy. Which clients
require immediate follow-up by the nurse? Select all that apply.

The client with lung cancer and who reports finding clumps of hair on the pillow this
morning.
The client with pancreatic cancer and who was unable to complete the physical therapy
session due to fatigue.
The client with bladder cancer and who is reporting moderate pain.
The client with stomach cancer whose vital signs are BP 132/80 mm Hg, pulse 96
bpm, respirations 20 breaths/min, T 100.4oF (38oC).
The client with prostate cancer and who is vomiting and has decreased urinary
output.
The client with breast cancer and who has facial swelling.

Strategy: "Require immediate follow-up" indicates something is wrong. Determine the

outcome of each nursing observation. Does it require the nurse to intervene?

1) this is an expected effect of chemotherapy; the nurse should allow the client to verbalize
feelings and offer support as needed; information about obtaining a wig, toupee, or soft
head covering should be provided

2) fatigue is expected with chemotherapy; nurse should structure the client's day to provide
periods of rest between routine care and therapy sessions

3) pain is expected with cancer; nurse should plan to assess and intervene as soon as
possible for this client, but it is not an immediate need

4) CORRECT — this client has an elevated temperature and should be assessed and the
health care provider notified immediately; neutropenia is a common adverse effect of
chemotherapy and puts the client at risk for life-threatening infection

5) CORRECT — this client is showing signs of dehydration, and vomiting will only
exacerbate the problem; nurse should assess the client and notify the health care provider
immediately

6) CORRECT — swelling of the face and eyes, and distention of neck and chest veins are
signs of superior vena cava syndrome; nurse should assess for this obstructive emergency
and notify the health care provider immediately

27. The nurse cares for the client with a bleeding duodenal ulcer. The nurse
is mostconcerned if the client reported taking which medication?
 Ranitidine hydrochloride 150 mg PO.
Metoclopramide hydrochloride 15 mg PO.
Sucralfate 1 gm PO.
Famotidine 20 mg PO.

Strategy: Think about the action of each medication.

(1) inhibits action of histamine at receptor site of parietal cells, decreasing gastric acid
secretion; used for short-term treatment of duodenal and gastric ulcers

(2) correct—stimulates motility of upper gastrointestinal tract, contraindicated with

possible hemorrhage of gastrointestinal tract; used to treat nausea of chemotherapy

(3) adheres to and protects ulcer surface by forming a barrier; used for short-term
treatment of duodenal ulcer

(4) inhibits action of histamine at receptor site of parietal cells, decreasing gastric acid
secretion; used for treatment of duodenal ulcer

28. The nurse provides care to a client diagnosed with acute renal failure secondary to
severe kidney infection. During the oliguric phase, which assessment finding does the nurse
expect to observe? (Select all that apply.)

Urine specific gravity is 1.039.

Azotemia.

Pruritus.

Nausea.

Serum potassium (K+) is 6 mEq/L.

1) Normal urine specific gravity ranges from 1.010 to 1.030. During the oliguric phase of
acute renal failure, urine specific gravity typically decreases (if the primary cause is
prerenal) or remains within normal limits (if the primary cause is intrarenal).

2) CORRECT – Azotemia, which is a classic sign of acute renal failure, refers to the buildup
of nitrogenous waste products in the bloodstream. Hallmarks of azotemia include increased
serum BUN and increased serum creatinine.

3) CORRECT – With acute renal failure, pruritus (itching) may occur. Although some
scientists believe a buildup of urea in the bloodstream contributes to this condition, research
has not yet conclusively identified the cause of pruritus in relationship to kidney
dysfunction.
4) CORRECT – With acute renal failure, the buildup of metabolic waste products in the
bloodstream may cause nausea and vomiting.

5) CORRECT – Normal potassium (K+) ranges from 3.5 to 5 mEq/L. Acute renal failure
causes impaired filtration of fluid and electrolytes. During the oliguric phase, an increase in
serum potassium (hyperkalemia) is typically seen.

29. The LPN/LVN delegates tasks to the nursing assistive personnel (NAP). The nurse
intervenes if which action is observed? (Select all that apply.)

The NAP administers prescribed eye ointment.

The NAP provides catheter care.

The NAP delegates client ambulation to another NAP.

The NAP takes a phone prescription from a health care provider.

The NAP stocks the department with supplies.

The NAP listens to breath sounds.

1) CORRECT – Medication administration is not within the NAP's scope of practice.

2) This task is appropriate for the NAP after the nurse assesses the condition of client's
catheter and perineal tissues.

3) CORRECT – It is not within the NAP's scope of practice to re-delegate tasks.

4) CORRECT – Phone prescriptions should be received by the nurse, not the NAP.

5) This task is within the NAP's scope of practice.

6) CORRECT – Assessment is not within the NAP's scope of practice.

30. The nurse in the outpatient clinic cares for a client diagnosed with tuberculosis. The
nurse expects to find which of the following in the client record?

“Client complains of low-grade fever and night sweats.”

“Client complains of an increased heart rate and palpitations.”
“Client complains of pleuritic chest pain and feelings of doom.”
“Client complains of edema and anorexia.”

Strategy: Think about each answer.

1) CORRECT— other signs/symptoms include progressive fatigue, lethargy, nausea,
anorexia, and weight loss

2) symptoms of pheochromocytoma caused by hypersecretion of the adrenal medulla

3) symptoms of pulmonary embolism

4) indication of heart failure

31. The nurse provides care to several hospitalized clients. Which clients does the nurse
monitor closely for the development of pneumonia? (Select all that apply.)

A client who has experimented with cigarettes.

A client diagnosed with cystic fibrosis.

A client diagnosed with Addison disease.

An adult client diagnosed with hypertension.

A client with a fractured rib due to an auto accident.

A client in Buck traction due to a fractured hip.

1) Habitual cigarette smoking is a risk factor for pneumonia. Smoking on occasion is not
related to increased lung infection risk. This client does not require close monitoring for
pneumonia.

2) CORRECT— Underlying lung disease is a risk factor for pneumonia. Cystic fibrosis causes
chronic obstructive pulmonary disease and excess mucous production, as well as pancreatic
exocrine deficiency.

3) Hyposecretion of adrenal hormones is not a risk factor of lung infections. This client does
not require close monitoring for pneumonia.

4) Hypertension is not a risk factor for the development of lung infections. This client does
not require close monitoring for pneumonia.

5) CORRECT— The pain of a fractured rib causes shallow breathing and easily leads to
pneumonia due to lack of lung expansion.

6) CORRECT— This client in Buck traction will be on bed rest, which decreases lung
expansion. Therefore, the nurse should monitor this client closely for the development of
pneumonia.

32. A client returns from surgery after a thyroidectomy. Which observation causes the nurse
the most concern?

Moderate amount of serosanguinous drainage on the neck dressing.

 Verbal expression of moderate pain at the incision site.
Hand tremors and facial twitching.
Nasogastric tube draining a moderate amount of clear fluid.

1) Hemorrhage is a complication after a thyroidectomy but a moderate amount of drainage

is expected due to the placement of the drain. The nurse needs to check for accumulation of
drainage at the back of the client's neck.

2) Moderate pain at the incision site is expected and pain medication should be provided as
prescribed.

3) CORRECT— Hand tremors and facial twitching indicate tetany. This occurs because of
the accidental removal of the parathyroid glands, which regulate calcium balance. This
finding should be reported to the health care provider.

4) A moderate amount of clear fluid draining from the nasogastric tube is an expected
finding.

33. The nurse screens the 8-month-old girl in a well-baby clinic. The nurse
is mostconcerned if the infant's mother makes which statement?

"My daughter has almost doubled her birth weight."

"When I walk in the room, my child smiles at me."
"When she is around her grandpa, my child cries."
"My daughter can't quite say "mama" yet."

Strategy: "MOST concerned" indicates you are looking for something wrong.

(1) correct—weight should double by 5 months of age

(2) begins to recognize parents at 6 months of age

(3) begins to fear strangers at 6 months, increases until 9 months of age

(4) begins to say "dada" and "mama" with meaning at 10 months of age

34. The nurse provides care for clients at the local eye care center. Which phone message
should the nurse return first from clients who are 24 hours postoperative after intracapsular
cataract extraction?

A client asks if it is appropriate to take acetaminophen for discomfort in the operative

eye.
A client reports feeling light-headed when assuming a standing position.
 A client reports mild itching in the operative eye.
A client states that eyelid is swollen and the client is having difficulty seeing with the
affected eye.

1) Discomfort in the operative eye is expected. The nurse needs to encourage the client to
take acetaminophen. This phone message should not be returned first.

2) The client may be light-headed when standing after surgery. The nurse needs to instruct
the client to change positions slowly. Although important to address, this concern is not the
priority and this phone message should not be returned first.

3) Mild itching to the operative eye is expected due to stitches. This phone message should
not be returned first.

4) CORRECT— A complaint of a swollen eyelid and difficulty seeing may indicate a bacterial
infection. This phone message is priority and needs to be returned first

35. A client is being discharged after a liver transplant with cyclosporine oral solution as one
of the prescribed medications. Which statement made by the client indicates further
teaching is necessary?

"I will report cold symptoms to my health care provider."

"I will store the cyclosporine solution at room temperature."
"I will take the cyclosporine with meals exactly as prescribed."
"I will mix the cyclosporine in a glass of grapefruit juice."

1) Cold symptoms such as fever, sore throat, and fatigue can be symptoms of an infection
in an immunosuppressed client, and should be reported immediately. This statement
indicates understanding of the information presented.

2) The solution should be stored at room temperature in a tightly closed container and
protected from light. This statement indicates understanding of the information presented.

3) Taking the medication with meals prevents nausea, vomiting, and GI irritation. Take
exactly as prescribed. This statement indicates understanding of the information presented.

4) CORRECT – Grapefruit juice and cyclosporine should not be taken together because the
juice causes the bioavailability of cyclosporine to increase by 20 to 200%. It is even advised
by some that no drinking of grapefruit juice should occur when a patient is on this drug. The
medication is always mixed in glass, not plastic, and with a room temperature liquid, such
as orange or apple juice.

36. The nurse provides teaching for a client diagnosed with heart failure. Which client
statement indicates to the nurse that teaching is effective?
 "Low-fat cottage cheese is a good snack."
"I can continue using prepared salad dressings."
"I will increase the amount of celery I eat every day."
"I will continue to eat my favorite canned green peas."

1) Cottage cheese contains 816 mg of sodium per serving, making it a poor choice for a
client with heart failure. Clients with heart failure should follow a low-sodium diet,
restricting their sodium to less than 2 g (2000 mg) of sodium daily.

2) Many prepared salad dressings contain added sodium (e.g., regular ranch dressing
contains 122 mg per teaspoon). The client should avoid using prepared dressing and instead
utilize small amount of olive oil and balsamic vinegar to flavor salad.

3) CORRECT — Two stalks of celery contain 62 mg of sodium, making them an appropriate

snack for a low-sodium diet. The nurse should encourage the client to choose fresh
vegetables, which are low in sodium.

4) Many canned vegetables contain added sodium (e.g., canned peas contain 317 mg per
serving). The nurse should instruct the client to avoid canned vegetables.

37. The nurse cares for clients on the medical/surgical floor. Because of a staffing shortage,
an RN has been reassigned from postpartum. Which of the following clients should the nurse
give to the reassigned nurse?

A client admitted with facial trauma after an auto accident.

A client diagnosed with a heat stroke.
A client having a systemic reaction to latex.
A client with progressive systemic sclerosis experiencing Raynaud’s phenomenon.

Strategy: Assign stable clients with expected outcomes.

1) requires close monitoring to assess for a patent airway; assess eye functioning, observe
for neurological changes; not a stable client

2) dehydration and hyperthermia, place in air-conditioned room, lie flat with legs elevated,
administer oxygen; not a stable client

3) potential anaphylactic reaction; not a stable client

4) CORRECT— chronic connective tissue disease that caused inflammation, fibrosis, and
sclerosis of the skin and vital organs; stable client who can be assigned to the reassigned
RN

38. The client diagnosed with dehydration is treated with intravenous normal saline. Which
response demonstrates a therapeutic effect of the saline? Select all that apply.
 Crackles noted in the lungs.

Blood pressure increases.

The pulse rate decreases.

Urine output increases.

Hematocrit level increases.

Strategy: Determine the outcome of each answer choice. Does the answer choice indicate
the desired therapeutic effect?

1) crackles in lungs indicate excess fluid volume, unexpected response; may indicate
overhydration

2) CORRECT— hypotension may indicate decreased fluid volume, expected response

3) CORRECT— increased pulse may indicate decreased fluid volume, expected response

4) CORRECT— urine output decreases with hypovolemia, expected response

5) HCT increases with dehydration, unexpected response

39. The nurse in the outpatient surgery prepares a 2-year-old child for a myringotomy for
placement of tympanostomy tubes. It is most important for the nurse to take which action?

Use bright objects to distract the toddler during the preoperative assessment.
Allow the toddler to play with a toy stethoscope before auscultation.
Demonstrate the use of the stethoscope before auscultation.
Give the toddler choices when possible during the preoperative assessment.

Strategy: Topic of question is unstated.

1) more appropriate for an infant than a toddler

2) CORRECT— allows the child to become familiar with equipment; decreases fear of the
unfamiliar objects; explain procedures by telling toddler what will see, hear, taste, and feel

3) ineffective because of developmental age; more appropriate for preschool age child

4) appropriate for a school age child

40. A patient receiving phenelzine sulfate (Nardil) is diagnosed with Cushing syndrome and
found to be hypokalemic. Which of the following foods is BEST for the nurse to recommend
the patient add to the diet?

Banana and raisin fruit salad.

Spinach and tuna fish salad.
Whole-wheat bread and cream cheese.
Guacamole and brown rice.

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

(1.) high in potassium, but bananas are also high in tyramine; when tyramine is ingested
with a monoamine oxidase inhibitor (MAOI) such as Nardil, it can cause a hypertensive crisis

(2.) CORRECT—both are high in potassium and neither is contraindicated with monoamine
oxidase inhibitors (MAOI); most vegetables are acceptable with MAOIs

(3.) not high in potassium; whole-wheat bread is likely to have yeast, which is
contraindicated with MAOIs; cream cheese is one of a few cheeses that is acceptable with
MAOIs

(4.) avocados high in potassium and tyramine; when ingested with an MAOI such as Nardil,
can cause a hypertensive crisis; brown rice is an acceptable grain with an MAOI because it
does not contain yeast

41. The nurse in the outpatient clinic receives a call from the parent of a teenager
diagnosed with infectious mononucleosis. The mother complains that her child seems angry
and depressed since developing mononucleosis. Which of the following responses by the
nurse is MOST appropriate?

“Why do you think your child is angry?”

“Teens become frustrated because of feeling weak and fatigued.”
“Would you like the physician to talk with your child?”
“My child had mono and was crabby all the time.”

Strategy: Remember therapeutic communication.

1) nontherapeutic; do not ask “why” questions

2) CORRECT— because of teen’s active life style, may react with anger and depression to
the weakness and fatigue; allow teen to vent and reassure teen that activities can be
resumed after the acute phase

3) passing the buck; nurse should respond to the situation

4) nontherapeutic; focus is on nurse and not the client

42. The nurse cares for a client receiving albuterol (Proventil) 2 puffs, and beclomethasone
(Vanceril) 2 puffs through inhalers. The nurse should include which of the following
statements when counseling the client?

“Use the Proventil inhaler and then use the Vanceril inhaler.”
“Use the Vanceril inhaler and then the Proventil inhaler.”
“You should take 1 puff of each inhaler, wait a minute, and then repeat the process.”
“Either inhaler can be used first as long as you wait 2 minutes between puffs.”

Strategy: Determine the outcome of each answer.

1) CORRECT— Proventil is a bronchodilator that opens the passageways so the steroid

medication (Vanceril) can get into the bronchioles

2) steroids won’t be able to penetrate unless the bronchioles are opened by the
bronchodilator

3) dilate the bronchioles first; side effects of Proventil include tremors, headache,
hyperactivity, tachycardia; teach client correct use of inhaler

4) incorrect action; side effects of Vanceril include fungal infections, dry mouth, throat
infections; taper slowly, check growth and development with high-dose and prolonged use
in children, during times of stress systemic steroids may be needed, gargle or rinse mouth
after each use

43. The nurse provides care for a client who is in Buck's traction due to a fractured right
hip. Which action is most important for the nurse to take when providing care for this
client?

Assess for pain at regular intervals.

Encourage the client to move from side to side.
Allow the weights to hang freely at all times.
Provide routine pin care.

1) Although pain assessment is important, the nurse needs to ensure the weights are
hanging freely for the traction to work. If proper traction is applied, it will decrease the
client's pain.

2) With Buck's traction, the client should not twist from side to side. The nurse needs to
encourage the client to move unaffected areas.
3) CORRECT— Weights need to hang freely to maintain proper traction. This is the most
important action for the nurse to take.

4) Buck's traction is a form of skin traction. Traction is applied by using a foam boot. Pins
are not used with Buck's traction.

44. The home health nurse visits a patient who has human immunodeficiency virus disease
(HIV) and lives alone in an apartment. Which of the following observations of the home
environment MOST concerns the nurse?

The patient has a cat, two birds, and a tropical fish tank, and the patient says, "I don’t
know what I would do without my pets to keep me company."
There is an open pitcher of water in the refrigerator, and the patient says, "I know it is
important for me to drink fluids, so I always keep water handy."
There are silk houseplants and flowers throughout the apartment, and the patient says,
"I’m not much of a gardener but I love nature, so I pretend all these are real."
The dishwasher is broken and the apartment water pressure is low, and the patient
says, "Getting the maintenance person to make any repairs is almost impossible."

Strategy: "MOST concerns the nurse" indicates that something is wrong.

(1.) CORRECT—people who are immunocompromised are at risk for infection; various
fungi, protozoa, and bacteria can be in the excrement of pets such as birds, cats, tropical
fish, turtles, reptiles; this means contact with the excrement—such as through birdcages,
cat litter, or the fish tank—should be avoided; if impossible to avoid contact, gloves should
be worn while handling and hands washed immediately after; breathing deeply during any
of these processes should be avoided because organisms may be inhaled, e.g., "dust" from
changing cat litter

(2.) should drink fluids; encouraged to keep pitcher in refrigerator to prevent bacterial
growth

(3.) silk flowers do not harbor bacteria, fungi, etc., do not need tending, and do not result in
possible cuts and dirt-related infections as would real plants and flowers; nature scenes and
sounds can be very soothing

(4.) of concern, but not most; patient needs liberal access to water for bathing, sponge-
bathing, handwashing, toileting, and washing of dishes and clothes

45. The nurse assesses a group of clients to determine their risk for health care acquired
infections. Place the clients in order of greatest risk to least risk. All options must be
used.

Your Response

INCORRECT
 Correct Answer

 An 86-year-old client who has cancer and a WBC of 2,000/mm3.

 A 90-year-old client who has difficulty eating and is severely underweight.
 A 52-year-old client diagnosed with urinary retention and who has an indwelling urinary
catheter in place.
 A 62-year-old client who is obese and has altered sensation of the feet and lower legs.

Strategy: Determine the risk factors in each question.

1) 2 risk factors; advanced age and leukopenia; immunocompromised; high risk

2) 2 risk factors; advanced age and malnutrition; malnutrition less risk than
immunocompromised

3) 1 risk factor; indwelling urinary catheter

4) no risk factors; obesity and altered sensation not risk factors for health care acquired
infections

46. The nurse admits an infant with a diagnosis of respiratory syncytial virus (RSV). In
which room will the nurse place the child?

A semiprivate room with an infant diagnosed with influenza.

A semiprivate room with an infant diagnosed with Kawasaki syndrome.
A private room with sleeping accommodations.
A private room without sleeping accommodations.

1) The infant with RSV should be placed on contact and droplet precautions and should not
be assigned to a room with an infant with influenza, who should be placed on droplet
precautions. Both infants are at risk of contracting an additional infection.

2) Kawasaki syndrome is an acute systemic vasculitis and is treated with intravenous

immune globulin and salicylate therapy. The infant requires standard precautions. However,
the infant with RSV should be placed on contact and droplet precautions, and should not be
placed with the infant with Kawasaki syndrome to avoid the spread of infection.

3) CORRECT— Respiratory syncytial virus (RSV) causes bronchiolitis and requires contact
and droplet precautions. Given the age of the infant, sleeping accommodations are
appropriate for the parents. Parents should be encouraged to stay with and soothe the
infant to prevent excessive stress on the infant, which will predispose them to crying and
hypoxia.

4) The nurse should provide sleeping accommodations for the parents.

47. The nurse provides care to a client experiencing an acute manic episode. Which
behavior does the nurse identify as being most characteristic of this disorder?

Agitation, grandiose delusions, euphoria, difficulty concentrating.

Difficulty in decision-making, preoccupation with self, distorted perceptions.
Paranoia, hallucinations, disturbed thought processes, hypervigilance.
Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.

1) CORRECT – Characteristic behaviors associated with an acute manic episode include

agitation, grandiose delusions, euphoria, and concentration problems. Mania is a mood of
extreme euphoria and is manifested by more extreme levels of behavior.

2) Difficulty in decision-making, preoccupation with self, and distorted perceptions are

characteristics of depression.

3) Paranoia, hallucinations, disturbed thought processes, and hypervigilance are

characteristics of schizophrenia.

4) Fear of going crazy, somatic complaints, difficulties with intimacy, and increased anxiety
are characteristics of personality disorders.

48. The nurse instructs the mother of a young child about how to check the capillary refill
on her child’s casted left foot. The nurse determines that further teaching is necessary if the
mother states which of the following?

“The color of the nailbed should be pink within 3 seconds after I release the pressure.”
“The nailbed will be white when I press on it.”
“This should not be painful to my son.”
“There should be no change in color when I press on the nailbed.”

Strategy: “Further teaching is necessary” indicates incorrect information.

1) normal capillary refill, indicates adequate circulation

2) blanches due to pressure

3) is not painful

4) CORRECT— pressure should cause the nail to blanch

49. The community health nurse provides care to a client and the client's toddler. The client
reports that the spouse recently had a positive tuberculin skin test (TST, or Mantoux test).
Which information does the nurse provide to the client?

"You and your child should be scheduled to have chest x-rays."

"Children are are low risk for contracting tuberculosis."
"You and your child should have tuberculosis skin testing as soon as possible."
"Infants and toddlers should not receive skin testing for tuberculosis."

1) Because the spouse's TST was positive, further evaluation of the spouse should include a
chest x-ray. For the client and child, initial testing should include a TST, not a chest x-ray.

2) Tuberculosis (TB) has increased significantly among children and infants. Compared to
adults, children and infants are at higher risk for developing life-threatening forms of TB.

3) CORRECT— For individuals who have been in contact with persons known or suspected
of having active tuberculosis (TB), immediate skin testing is warranted.

4) Tuberculosis skin testing is considered safe for infants and children.

50. A client receives theophylline IV for an acute respiratory problem. Which observation
alerts the nurse to withhold the medication and notify the health care provider?

Hypertension.
Unresponsiveness.
Polyuria.
Tachycardia.

Strategy: Think about each answer and how it relates to theophylline.

1) does not result from a theophylline overdose

2) does not result from a theophylline overdose

3) does not result from a theophylline overdose

4) CORRECT— adverse effect of theophylline; levels above 20 mcg/L are considered toxic;
after long-term use, clients may tolerate higher blood concentration; other adverse effects
include hypotension, nausea, vomiting

51. The nurse reviews the records of clients in the medical clinic. The nurse identifies which
of the following clients is MOST at risk to develop type 2 diabetes?
 A 26-year-old African American who follows a weight reduction diet and exercises 3
times per week.
A 36-year-old Caucasian who delivered an 8-lb infant, and whose mother-in-law has
type 1 diabetes.
A 46-year-old Asian American who has a history of hypertension and whose blood
cholesterol is within normal limits.
A 56-year-old Native American who is 5'8" tall, weighs 200 lb, and has 2 siblings with
type 2 diabetes.

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

1) 1 risk factor — African American; weight reduction and exercise prevent type 2 diabetes

2) no risk factors — infants weighing more than 9 lb and family history (parents or siblings)
are risk factors

3) 3 risk factors — age greater than 45, Asian American, and history of hypertension

4) CORRECT— 4 risk factors–age greater than 45, Native American, obesity, and family
history of diabetes; instruct to reduce calories, maintain low-fat diet, and exercise regularly

52. The nurse observes a client have a tonic clonic seizure lasting about 90 seconds,
followed by a period of decreased consciousness lasting 2 minutes. Then the client begins to
have another seizure. It is MOST important for the nurse to take which of the following
actions?

Administer diazepam (Valium) as ordered.

Monitor serum glucose levels closely.
Assess the client’s blood pressure and pulse.
Remove excessive clothing.

Strategy: Determine whether it is appropriate to assess or implement.

1) CORRECT— implementation; give IV to stop seizure activity; support ABCs, protect

client from injury, provide oxygen, establish an IV access

2) not a priority; decreased risk of injury is priority

3) not necessary

4) loosen restrictive clothing; protect client from injury

53. The client with osteomyelitis is going home with a central venous access device (CVAD).
The nurse provides discharge teaching. Which client statements require further instruction
by the nurse? Select all that apply.

"I'm going to wear bigger shirts so I don't accidentally pull this catheter out when I
change clothes."
"If the dressing over this catheter gets loose, I'll tape it back down."

"I will wash my hands before touching the catheter or any of the medication."

"If the catheter starts to fall out, I will gently reinsert it."

"If I see blood in the catheter, I will call my home care nurse."

"I'll put all these supplies in the trash as soon as I'm done with them."

Strategy: "Require further instruction" indicates incorrect information. Determine the

outcome of each answer. Is it incorrect?

1) needs to find ways to avoid accidental catheter removal

2) CORRECT — the client must be taught to call the home health nurse if the sterile
dressing becomes loose, damp, or soiled

3) appropriate hand hygiene will minimize infection risk

4) CORRECT — the client should be instructed to apply pressure with sterile gauze if the
catheter becomes dislodged and to avoid reinserting it

5) client should also call the home care nurse if the infusion slows or stops

6) CORRECT — the client should be taught proper disposal of sharps and contaminated
items; all IV therapy trash should be treated as a potential biohazard and should not be put
in regular household trash

54. A client follows a lacto-vegetarian eating plan. Which recommendation is appropriate for
the nurse to suggest to this client?

Limit the intake of eggs to three per week.

Increase consumption of breads and pastas.
Increase intake of beans, legumes, and nuts.
Supplement diet with calcium and magnesium tablets.

1) People who follow a lacto-vegetarian eating plan consume milk and dairy products but do
not eat eggs.
2) Increasing the consumption of bread and pasta will not increase amino acids and protein
stores to support the client's health needs.

3) CORRECT— The client should increase the intake of protein from other sources, such as
seeds, tofu, and dark green vegetables, along with beans, legumes, and nuts.

4) Since the client consumes dairy products, calcium and magnesium consumption should
not be a problem.

55. The nurse provides care for a client receiving ibuprofen 400 mg PO 4 times daily. The
nurse instructs the client about the medication. Which statement from the client indicates to
the nurse the need to provide further teaching?

"I will take this medication on an empty stomach."

"I will tell my dentist that I am taking this medication."
"I should report any ringing in my ears to the health care provider."
"I should call if my stools become dark black in color."

1) CORRECT – Non-steroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal (GI)

distress and should be taken with meals. Failure to do so can lead to GI ulcers and
bleeding.

2) Non-steroidal anti-inflammatory drugs (NSAIDs) reduce platelet adhesiveness,

predisposing client to bleeding. The dentist should know the client takes this medication.

3) Ear ringing is an adverse reaction to NSAIDs, and the medication should probably be
stopped.

4) Tarry stools indicate bleeding from the GI tract, a known adverse reaction to NSAID
therapy. The medication should be stopped immediately, and the health care provider is
notified.

56. The nurse reviews laboratory values for a group of clients. Which results does the nurse
report to the health care provider? (Select all that apply.)

Positive nitrates in the urinalysis of a client receiving chemotherapy.

An activated partial thromboplastin (aPTT) level of 78 in a client receiving an
intravenous heparin infusion.
A blood urea nitrogen (BUN) level of 68 mg/dL (24.3 mmol/L) in a client diagnosed
with kidney failure receiving hemodialysis.
A blood glucose level of 140 mg/dL (7.77 mmol/L) in a client diagnosed with diabetes
mellitus receiving intravenous methylprednisolone.
A serum potassium level of 3.3 mEq/dL (3.3 mmol/L) in a client receiving intravenous
antibiotics.
1) CORRECT — The presence of nitrates indicates an infection caused by E. coli. Since the
client is receiving chemotherapy, the client is at risk for myelosuppression.

2) The aPTT is normally 25–39 seconds. Since the client is receiving an infusion of heparin,
the level of 78 is within the therapeutic range.

3) A BUN level of 68 mg/dL is abnormal, but is expected for a client diagnosed with end-
stage kidney disease.

4) CORRECT — Corticosteroids may cause hyperglycemia. Special care should be used in

treating clients diagnosed with diabetes mellitus.

5) CORRECT — Antibiotics can destroy the normal flora of the gastrointestinal tract leading
to diarrhea and the excretion of potassium. The level of 3.3 mEq/dL (3.3 mmol/L) is below
normal and indicates a potassium loss.

57. The nurse provides discharge teaching for the client being treated with permethrin.
Which client statements indicate correct understanding of the medication? Select all that
apply.

"I will leave the cream on my hair for 10 minutes before I rinse it out."

"I will use the cream daily until the nits are gone."

"I plan to wash all my bed linens with bleach."

"The cream may cause redness on my scalp and skin."

"I will check all my family members because this condition is easily spread."

"This medication should make my itching stop."

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

1) CORRECT— this is appropriate use of permethrin

2) permethrin is used once a week until nits and lice are gone

3) linens should be washed in hot water and dried in the dryer; it is not necessary to use
bleach

4) CORRECT— erythema is a potential adverse effect of permethrin

5) CORRECT— lice and scabies spread easily and all contacts should be checked

6) CORRECT— once lice and nits are killed, clients should no longer experience pruritus
58. The nurse cares for the client in the clinic. The health care provider's orders read:
"sulindac 200 mg PO bid for 14 days." The nurse should instruct the client to report which
symptom immediately to the health care provider?

Nervousness.
Photophobia.
Ecchymosis of the extremities.
Slight edema of the feet.

Strategy: Determine the cause of each answer and how it relates to sulindac.

(1) side effect but not most important

(2) not side effect

(3) correct—should notify health care provider if easy bruising or prolonged bleeding occurs

(4) does cause sodium retention, but not most importante

59. The nurse care for a client in labor. During auscultation of the fetal heart rate the nurse
assesses a rate of 59 beats per minute. Which action should the nurse take FIRST?

Turn the mother on her right side, increase the intravenous flow rate, and call the
physician.
Turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
Call the physician, and make preparations for an immediate emergency cesarean
section.
Position the mother in Trendelenburg's position, administer oxygen, and force fluids.

Strategy: "FIRST" indicates that this is a priority question. All answers are implementations.
Determine the outcome of each answer choice. Is it desired?

(1) should be placed on left side to increase blood flow to the uterus

(2) correct—persistent fetal bradycardia may indicate cord compression or separation of

the placenta but always indicates fetal distress; left side reduces compression of vena cava
and aorta

(3) should be done after positioning client

(4) this position is used only if there is cord prolapsed

60. The nursing assistive personnel (NAP) reports to work on the oncology unit with a
cough, a runny nose, and has an elevated temperature. The NAP reports having no sick
 leave and being the breadwinner of the family. Which response by the nurse
is most appropriate?

"Did you take a flu shot?"

"Can you work at the desk and help the unit secretary with the charts?"
"I will call one of the other units where clients are less vulnerable."
"I'm sorry, but you will have to go home."

1) All health care personnel should take an annual flu shot, but is not relevant to this
conversation. The issue is immunosuppressed client safety from pathogens.

2) Influenza is spread by droplets, and even though the NAP will not be caring for clients,
the NAP will still come in contact with other staff members. Clients in oncology are
immunocompromised.

3) A hospital is full of immunocompromised clients, not just on an oncology unit.

4) CORRECT— During community outbreaks of the flu, it is responsible management to

exclude staff with febrile infections from caring for high-risk clients.

61. The nurse provides care for clients in the gastroenterology clinic. In which order does
the nurse rank these clients regarding the risk for developing colorectal cancer? (Arrange
in order from greatest to least risk of developing colorectal cancer. All options
must be used.)

Your Response

INCORRECT

Correct Answer

 42-year-old African-American male, drinks two servings of alcohol daily, high intake of processed
meats.
 45-year-old African-American female, smokes cigarettes, physically inactive.
 37-year-old Caucasian male, high intake of red meats, great uncle diagnosed with colorectal cancer.
 29-year-old Caucasian female, follows vegetarian diet, history of inflammatory bowel disease.

A 42-year-old African-American male who drinks two servings of alcohol daily and has a
high intake of processed meats has four risk factors for the development of colorectal
cancer: race, sex (being male), alcohol intake (four drinks or more per week) and diet high
in processed meats. The 45-year-old African-American female who smokes cigarettes and is
physically inactive has three risk factors: race, cigarette smoker, and physical inactivity. The
37-year-old Caucasian male has two risk factors: sex and a diet high in red meats (seven or
more servings per week). A first-degree relative with history of colorectal cancer is risk
factor, but not a great uncle. The 29-year-old Caucasian female who follows a vegetarian
diet but has a history of inflammatory bowel disease has only one risk factor: the personal
history inflammatory bowel disease. The diet high in fruits and vegetables lowers the risk.

62. A graduate nurse expresses difficulty with time management when providing client care.
Which is the best response from the graduate nurse's preceptor?

"I have some ideas to help you better manage your time."
"How much practice did you get in school taking care of groups of clients?"
"What ideas do you have as to the reasons for your time management difficulties?"
"Tell me how you feel about time in general."

1) The nurse should assess before offering interventions.

2) Asking about practice in time management during school is relevant. However, the nurse
needs to first assess the graduate nurse's perception about why there is a time
management problem.

3) CORRECT – The best first step is to assess the graduate nurse's perception of difficulty
before offering solutions. This approach conveys respect, and allows for free expression and
analysis of the problem.

4) Asking how the graduate nurse feels about time in general obtains information about a
larger framework and possible cultural issues. The assessment should be focused.

63. The nurse performs discharge teaching for an elderly female diagnosed with peripheral
arterial insufficiency. It is MOST important for the nurse to include which of the following
instructions?

“Soak in a tub of hot water twice a day.”

“Apply a heating pad to your abdomen once a day.”
“Elevate your legs above the level of your heart four times per day.”
“Sit for a total of 6 hours per day with your feet resting on the floor.”

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

1) can result in burning because vascular problems result in decreased sensation of the
lower extremities

2) CORRECT— will cause a reflex vasodilation of the extremities; safer than placing direct
heat on the extremities
3) decreases venous congestion by countering the pull of gravity; position extremities below
the heart to promote arterial circulation

4) moderate amount of walking promotes blood flow and the development of collateral
circulation; feet resting on floor is appropriate to promote arterial circulation

64. The nurse provides care for a client diagnosed with postural hypotension. The nurse
includes which intervention in the client's plan of care? (Select all that apply.)

Teach the client energy conservation techniques.

Encourage the client to increase fluid intake.

Maintain the client on a low-sodium diet.

Encourage the client to maintain bed rest.

Instruct the client to rise slowly.

1) CORRECT — Hypotension can cause generalized weakness. The client should implement
energy conservation techniques to prevent excessive exertion and an increase in symptoms.

2) CORRECT — Increased fluid intake may correct hypotension related to decreased fluid
volume.

3) Sodium will cause fluid retention, thereby increasing blood volume and blood pressure.

4) The client will need to improve exercise tolerance slowly.

5) CORRECT — A slow rise to the standing position may prevent falls.

65. The nurse plans care assignments for the upcoming shift on a medical surgical unit.
Which client does the nurse assign to the LPN/LVN? (Select all that apply.)

The client newly diagnosed with herpes zoster.

The client being treated for Clostridium difficile infection.

The client being admitted with chronic obstructive pulmonary disease and pneumonia.

The client receiving intravenous heparin for a deep vein thrombosis.

The client with a history of dementia with sundowning.

1) This client has a newly diagnosed infectious process and requires ongoing assessment
and evaluation for complications. The nurse should be assigned this client.
2) CORRECT— This is a stable client with predictable outcomes and may be delegated to
the LPN/LVN.

3) A new admission requires that the nurse perform the initial assessment and use the
nursing process to plan care. New admissions cannot be delegated.

4) The client is in unstable condition and there is a high likelihood for complications,
including pulmonary emboli. The client is receiving a medication requiring careful monitoring
and adjustment of the drip rate. This client's care cannot be delegated.

5) CORRECT— This is a stable client with predictable outcomes and may be delegated to
the LPN/LVN.

66. The nurse instructs a client receiving acyclovir (Zovirax). The nurse determines that
teaching is effective if the client states which of the following?

“The medication will cure my disease.”

“I should take this medication with food.”
“I’m glad that I only have to take this once a day.”
“I can apply lotion on the lesions if they begin to hurt.”

Strategy: “Teaching is effective” indicates correct information.

1) virus lays dormant in ganglia; medication is not a cure

2) CORRECT— may cause nausea and vomiting; antiviral used to treat herpes

3) given 5 times/day

4) OTC lotions and creams may delay healing and cause spread of lesions

67. The nurse instructs a client receiving digoxin and furosemide daily. The nurse
determines teaching is effective if the client makes which statement?

“I will eat alfalfa sprouts on my salad.”

“I will eat more cabbage with my meals.”
“I will eat half a grapefruit every morning.”
“I will eat bananas every day.”

Strategy: “Teaching is effective” indicates correct information.

1) client vulnerable to develop hypokalemia from digoxin and furosemide; should increase
potassium in the diet; alfalfa sprouts and lettuce are low in potassium
2) cabbage is a vegetable low in potassium; high potassium vegetables include broccoli,
spinach, and potatoes

3) low in potassium

4) CORRECT— high in potassium, other fruits high in potassium include cantaloupe and
oranges

68. A client is placed on gentamicin sulfate (Garamycin) IV q 8 hours. It is MOST important

for the nurse to respond to which of the following statements made by the client?

“My wife tells me my hearing has changed.”

“My vision is blurred when I read the paper.”
“Food just doesn’t taste as good to me.”
“Look at this rash on my arms.”

Strategy: “MOST important to respond” indicates a potential complication.

1) CORRECT— decreased hearing and vertigo occur as a result of involvement of the eighth
cranial nerve, which is caused by gentamicin (Garamycin) toxicity

2) gentamicin is an aminoglycoside; nephrotoxic

3) not toxic effect of this antibiotic

4) rash may indicate hypersensitivity reaction; more important to respond to changes in

hearing

69. The nurse provides care for clients in the emergency department. Four patients come in
at the same time. Which client does the nurse see first?

A 6-month old with vomiting and diarrhea.

A 2-year old with a temperature of 101°F (38°C).
A 20-year old at 8 weeks' gestation reporting vaginal spotting.
A 32-year old reporting nausea and vomiting for several hours.

1) CORRECT – This client is at significant risk for dehydration and electrolyte imbalances
due to the small body mass, inability to compensate effectively, and loss from both upper
and lower GI sources. This client is the priority.

2) Obtain a prescription for an antipyretic and monitor until the health care provider (HCP)
can evaluate the client
3) Spotting can be caused by a drop the progesterone level, and there is a potential for a
spontaneous abortion. Encourage the client to rest and offer reassurance until the HCP can
evaluate the client.

4) The average healthy young adult's body can adequately compensate for dehydration over
the short term. The client may require an injection of anti-emetic to stop the vomiting.

70. A client is prescribed IV aminocaproic acid 4 grams now. The label reads 250 mg/mL.
Which amount in milliliters will the nurse provide to the client? (Record your answer
rounding to the nearest whole number.)

Your Response:
Correct Response:16
mL

Ratio/Proportion:

Dimensional Analysis:

71. The nurse provides discharge teaching to a client with multiple sclerosis. Which
instruction is most important for the nurse to include?

Ambulate as tolerated every day.

Avoid overexposure to heat or cold.
Perform stretching and strengthening exercises.
Participate in social activities.

1) Although the client should be encouraged to ambulate as tolerated, this is not the most
important instruction.
2) CORRECT—Overexposure to heat or cold may cause damage related to the changes in
sensation. Extremes in temperature can also exacerbate multiple sclerosis symptoms.

3) The client should be encouraged to participate in an exercise program that includes

range-of-motion (ROM), stretching, and strengthening exercises, but this is not the most
important instruction.

4) The client should be encouraged to continue usual activities as much as possible,

including social activities. However, this is not the most important instruction.

72. A client, walking down the hall in the outpatient clinic, suddenly collapses. The nurse
notes that he does not move his extremities. Which of the following actions should the
nurse take FIRST?

Check the client’s carotid pulse.

Call for help.
Determine if the client is responsive.
Begin cardiopulmonary resuscitation.

Strategy: “FIRST” indicates priority.

1) assessment; first determine responsiveness

2) assess before implementing

3) CORRECT— determine responsiveness before intervening

4) assess first

73. A client is prescribed cefuroxime 250 mg by mouth every 12 hours. The medication is
available in 125 mg/tablet. Which number of tablets will the nurse administer to the client
for one dose? (Record your answer rounding to the nearest whole number.)

Your Response:
Correct Response:2
tablets
 74. The nurse provides care for a client diagnosed with spinal cord injury at the level of T1.
The nurse notes profuse sweating, and the client reports a pounding headache and nasal
stuffiness. In which order does the nurse provide care for this client? (Arrange the
nursing actions in the proper order. All options must be used.)

Your Response

INCORRECT

Correct Answer

 Place the client in a sitting position.

 Check the Foley catheter tubing for kinks or obstruction.
 Monitor the blood pressure every 10 to 15 minutes.
 Label the chart with a visible note about the risk for autonomic dysreflexia.
 Instruct the client about how to prevent autonomic dysreflexia.

Autonomic dysreflexia is reaction of the autonomic (involuntary) nervous system to

overstimulation. It occurs in clients with spinal cord lesions above the level of T6 after spinal
shock has subsided. Indications include pounding headache, profuse sweating (especially of
forehead), nasal congestion, piloerection and hypertension. Nursing care includes placing
client in sitting position to help lower the blood pressure. Catheterize or irrigate an existing
catheter to reestablish patency and check the rectum for a fecal mass. Administer
hydralazine hydrochloride IV slowly if symptoms are not relieved. Place instructions on the
client's record for awareness of all staff. Lastly, instruct the client regarding symptoms,
causes, and methods for relief.
75. The nurse cares for a patient with a history of a heart murmur who has been receiving
clozapine (Clozaril) for 2 weeks. The nurse reviews discharge instructions. The nurse knows
that teaching is successful if the patient verbalizes which of the following?

“I will return to the lab in one week to have my white blood count taken.”
“I can take 2 pills the next morning if I miss my dose.”
“I will limit my intake of sodium to 2 mg a day.”
“I will increase my dose if I am feeling ‘ moody’.”

Strategy: “Teaching is successful” indicates correct information.

1) CORRECT— if WBCs fall below 2000/mm 3 , the drug will be discontinued; risk of
agranulocytosis, potentially life threatening; Clozaril is an atypical antipsychotic; side effects
include leukopenia, gram-negative septicemia, drowsiness, tachycardia, and hypotension

2) must take medication as directed by physician and not increase or decrease dose

3) sodium intake does not change the efficacy of the drug

4) don’t increase or decrease dosage; notify physician of changes in behavior