Appendix C Answers and Rationales For NCLEX Style Review Questions PDF

a p p e n d i x
Answers and Rationales for NCLEX-Style

Review Questions
Chapter 2
Need: Safe, Effective Care Environment; Step in the Nursing

Process: Data Collection.
1. Correct Answer: 3. Rationale: The first step in the nursing process

is assessment. Data collection precedes determining needs, setting goals, and developing a plan for care. Category of Client Need:
3. Correct Answer: 2. Rationale: An incident report is a tool for risk
Safe, Effective Care Environment; Step in the Nursing Process:

Implementation.
2. Correct Answer: 2. Rationale: A licensed practical nurse works

under the direction of a registered nurse. A registered nurse can delegate the task of acquiring basic information from the client to a licensed
practical nurse, but the registered nurse is responsible for ensuring that
the admission database is complete. The registered nurse is responsible for identifying nursing diagnoses and developing the initial plan of
care for preventing, reducing, or resolving the nursing diagnoses. The
registered nurse delegates implementation of the plan of care to the
licensed practical nurse and encourages the licensed practical nurse to
make future contributions to the initial care plan. Category of Client
Need: Safe, Effective Care Environment; Step in the Nursing Process:
Implementation.
3. Correct Answer: 1. Rationale: Ineffective airway clearance reflects

a problem affecting breathing, a basic physiologic need. The remaining
diagnoses affect other levels of Maslows hierarchy. Ineffective coping
affects needs of safety and security. Deficient diversional activity
affects self-actualization. Interrupted family processes affect the need
for love and belonging. Category of Client Need: Safe, Effective Care
Environment; Step in the Nursing Process: Implementation.
management; it helps to determine measures for preventing potentially litigious incidents. It also is a tool that could be used in court in
a nurse or health agencys defense. Fall precautions are implemented
when the nurse determines that a client is at risk for falling; they are
overdue after a fall. The nurse gives the nursing supervisor the written incident report; it is not a part of the clients medical record. The
physician is informed of the incident, may examine the client, and
determines if the clients family is notified. Category of Client Need:
Implementation.
Chapter 4
1. Correct Answer: 2. Rationale: The highest priority for client care is
relief of labored breathing. Breathing is a basic physiologic need. Feeling powerless affects the need for security. Family support is an issue
that affects the need for love and belonging. Issues of self-esteem follow the others in the list. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Planning.
2. Correct Answer: 4. Rationale: Initial examination by a family practice physician is the first step in primary care. The family practice
physician may then refer the client for secondary or tertiary care. Category of Client Need: Safe, Effective Care Environment; Step in the
Nursing Process: Implementation.
Chapter 3
1. Correct Answer: 4. Rationale: The first step when a nurse suspects another of stealing narcotics is to report the information to the
immediate nursing supervisor. Providing specific observations and
facts is important. Once the information is validated, the nursing
supervisor is responsible for proceeding with other possible legal and
ethical actions. It is unethical to damage the character of a colleague
by discussing the situation prematurely. Category of Client Need:
Implementation.
2. Correct Answer: 3. Rationale: An advance directive is a written

statement identifying a competent persons wishes concerning end-oflife health care. The advance directive is valuable to the nurse and
physicians because it will guide them in managing the clients care.
Proof of insurance is important to the billing department of the health
care agency. The clients date of birth and social security number may
be useful to a social worker for determining if the client qualifies for
Medicare or other services from social agencies. Category of Client
3. Correct Answer: 2. Rationale: A referral to a home health nursing

organization before discharge helps to maintain health care from an
acute care agency to home care without appreciable interruption. The
other three organizations are examples of insurance plans for facilitation of third party payers of health care. Category of Client Need:
Implementation.
Chapter 5
1. Correct Answer: 3. Rationale: Primary prevention involves eliminating the potential for an illness. Stress-management techniques help
to reduce the release of norepinephrine and epinephrine and promote
normal blood pressure. Blood pressure assessment is a secondary preventive measure that provides a means for early diagnosis. It is premature to give a client information about medications before a diagnosis
is made. Teaching about the hazards of hypertension can motivate a
client to implement measures to reduce health risks but offering the
client a tool, like methods for stress management, is best. Category of
833
834
APPENDIX C Answers and Rationales for NCLEX-Style Review Questions
Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Planning.
2. Correct Answer: 1. Rationale: According to Holmes and Rahes

Social Readjustment Rating Scale, death of a spouse is the most stressful event a person experiences. The other examples are significant
stressors but less intense than the death of a spouse. Category of
Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Assessment.
3. Correct Answer: 4. Rationale: Denial is a coping mechanism in

which a person rejects objective information and believes something
else is true. Denial protects the ego from dealing with threatening
information. Somatization is a coping mechanism in which a person
manifests an emotional stressor via a physical disorder or symptom.
Regression is manifested by behaving in a manner characteristic of a
younger age. Displacement involves expressing ones anger toward
something or someone unlikely to retaliate. Category of Client Need:
Psychosocial Integrity; Step in the Nursing Process: Assessment.
Chapter 6
1. Correct Answer: 4. Rationale: Determining a clients food preferences forms the basis for menu planning and dietary selections within
the prescribed restrictions of the clients therapeutic diet. Incorporating cultural preferences, if they exist, promotes the potential for compliance with a diet. Although the trends in the clients blood glucose
level and knowledge of drug therapy are important, they are secondary
to preparation for diet teaching. Once he or she has identified the
clients food preferences, the nurse personalizes the exchange list by
emphasizing the allowed amounts of those foods that the client is
accustomed to eating. Category of Client Need: Health Promotion
and Maintenance; Step in Nursing Process: Planning.
2. Correct Answer: 2. Rationale: Clients who have retained their Asian

culture will feel most comfortable if the nurse maintains a distance just
beyond arms reach. People from non-Anglo cultures often find physical closeness with strangers to be discomforting. Touch also may provoke anxiety; it is important to explain when and how a client will be
touched if that is necessary. A position within the doorway to the room
is too distant during an interview regardless of the clients culture.
Category of Client Need: Psychosocial Integrity; Step in Nursing
Process: Implementation.
3. Correct Answer: 1. Rationale: Dark-blue pigmented areas, known

as Mongolian spots, are common on the lower back and buttocks of
dark-skinned infants and children. The pigmentation tends to fade by
the time a child is 5 years of age. The nurse who is unfamiliar with this
normal physiologic variation may misinterpret it as a sign of physical
abuse. This case does not warrant informing Child Protective Services
or the physician. There is no justification for examining other children
in the home for abuse. Category of Client Need: Safe, Effective Care
feelings of the clients statement. The nurse avoids any emotional support or involvement by offering to arrange contact with the surgeon.
Giving advice and disagreeing with the client are nontherapeutic forms
of communication. Client Need: Psychosocial Integrity; Step in the
2. Correct Answer: 3. Rationale: The best therapeutic nursing action

is to facilitate the clients discussion of his feelings. Reading literature
on an emotional topic and thinking privately may help some people,
but they are not as effective as verbalizing thoughts for most people. If
the client requests a second opinion, the nurse should pursue it; however, it is inappropriate for the nurse to initiate the suggestion. Doing
so is considered false reassurance because it implies that the nurse
believes the present medical regimen is less than optimal and that other
alternatives can change the outcome. Client Need: Psychosocial
Integrity; Step in the Nursing Process: Implementation.
3. Correct Answer: 2. Rationale: The nurse performs the role of educator by providing explanations to a client who is unfamiliar with hospital equipment. Explanations are best in simple, understandable terms.
Once informed, the client has a basis for interpreting and coping with
what are unique experiences. The client is unlikely to understand what
the name of a heart rhythm implies. Administering a tranquilizer or distracting the client with a magazine does not help to prevent a similar
fearful response if the situation recurs. Client Need: Psychosocial
4. Correct Answer: 2. Rationale: 2. The nurse delegates tasks within

the nursing assistants legal scope of job performance. Administering
medications, collaborating with laboratory personnel about diagnostic
test results, and performing physical assessments are nursing responsibilities. The nurse could delegate those to another licensed nurse or
a nursing student who has demonstrated competencies in these skills.
Client Need: Safe, Effective Care Environment; Step in the Nursing
Chapter 8
1. Correct Answer: 1. Rationale: Before the nurse can proceed with
teaching, he or she should assess the childs height and weight to
determine if the child is within norms for his or her age group. Another
pertinent assessment is determining if the child has any food allergies
or health problems affected by food. A food pyramid is a useful guideline for normal, healthy nutrition, but serving sizes require modification for a child especially if he or she is underweight or overweight. It
is inappropriate for the nurse to plan 1 weeks menus without knowing what the mother usually prepares for the family and the budget for
purchasing groceries. Recipes are the mothers personal choice and various cookbooks are available from resources other than the nurses own
collection. Category of Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Assessment.
Environment; Step in Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: Directly observing the clients perfor-
4. Correct Answer: 2. Rationale: When a cultural practice is not
mance is the best method for evaluating if he or she learned the information. The client may correctly describe the importance of performing
breathing exercises, yet not actually perform the skill. The client may
say he or she is performing the exercises even if this is untrue. Monitoring the respiratory rate is not the best technique for determining if,
when, and how often the client is performing the exercises because the
rate changes in response to many variables such as current level of activity and oxygenation status. Category of Client Need: Physiological
unsafe or potentially injurious to the client, it is best to incorporate the

clients belief system along with the scientific regimen for treatment.
Implying that the clients cultural practices are not beneficial is an
example of ethnocentrism. The tribal elder has not claimed to be a
physician; rather, he or she is performing a ritual with a long cultural
tradition. Category of Client Need: Psychosocial Integrity; Step in
Integrity; Step in the Nursing Process: Evaluation.
Chapter 7
1. Correct Answer: 1. Rationale: Paraphrasing is a therapeutic communication technique by which the nurse lets the client know empathetically that he or she has understood both the content and the
3. Correct Answer: 1. Rationale: Using dolls or puppets as a teaching

aid is the most appropriate strategy for a preschoolers cognitive ability. Pamphlets and diagrams are too abstract for a child of this age. The
preschooler might confuse use of a videotape as a form of entertainment rather than personal instruction. Category of Client Need: Safe,
Effective Care Environment; Step in the Nursing Process: Planning.
Chapter 9
1. Correct Answer: 2. Rationale: Publicly identifying the names of
clients violates their right to confidentiality. The number of clients
assigned to each nursing team member depends on the persons knowledge and experience and the clients acuity level. Posting the names of
staff demonstrates respect for the right of clients to know who is managing their care. The Kardex is a resource that the nurse and members
of the nursing team use frequently for current information about
clients. Category of Client Need: Safe, Effective Care Environment;
Step in the Nursing Process: Implementation.
2. Correct Answer: 1. Rationale: Inserting information on a record

that suggests the documentation was entered earlier is legally problematic because it could be interpreted as falsifying a record. If the
writer recalls information omitted earlier, the best practice is to identify the time the note is being written and write late entry for [insert
date and time]. . . . Misspelled words, a color of ink that is contrary to
the agencys documentation policy, and failure to identify ones title are
practices that require improvement but they are not as serious to cases
involving a lawsuit. Category of Client Need: Safe, Effective Care
Chapter 10
1. Correct Answer: 2. Rationale: Under the privacy and security components added to the Health Insurance Portability and Accountability
Act (HIPAA), a healthcare institution must protect clients health information. Permission must be obtained before sharing health information
with any third party. When interacting directly with a client, it is
respectful to use the clients surname unless permission has been given
otherwise. A clients surname is not used in public locations like an elevator or cafeteria. When communicating with staff, referring to
a client by a room number disregards the clients unique identity.
All medical records, which are kept confidential, contain both the
clients name and medical record number. Category of Client Need:
Implementation.
2. Correct Answer: 3. Rationale: The federal Patient Self-determination

Act ensures clients right to have advance directives declaring their
wishes regarding life-sustaining treatment. If a client has not prepared
a document of this nature, the nurse provides information and an
accompanying form with which to do so. Social security numbers are
not medically necessary. A clients Medicare status and information
about health insurance are important for collecting third-party payment for health care, but the information is obtained by personnel in
the admitting or business office of the health care agency. Category of
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is not likely to create sufficient exercise to significantly alter the pulse

rate; therefore, a 15-minute delay is not necessary. Blood pressure can
be assessed in a lying, sitting, or standing position. To evaluate trends
in blood pressure, all measurements are taken consistently on the same
arm and body position. Category of Client Need: Physiological
Integrity; Step in the Nursing Process: Data Collection.
2. Correct Answer: 2. Rationale: Shivering takes place at the onset of

a fever as a physiologic measure for assisting the hypothalamus to reach
a higher set point. Covering the client provides comfort and shortens
the period of chilling. Once the temperature reaches a plateau, the extra
covers can be removed. Fluid replacement and facilitating evaporation
with adequate circulation of environmental air are appropriate when
diaphoresis occurs in the later phase of a fever. Rest conserves energy
to compensate for an elevated metabolic rate caused by the fever, but it
is not the most important nursing action in response to shivering. Category of Client Need: Physiological Integrity; Step in the Nursing
3. Correct Answer: 3. Rationale: A thready pulse, also classified as a

1+ pulse, is one that is not easily felt and disappears with slight pressure. A normal pulse is easily felt and disappears when moderate pressure is applied. A weak pulse is stronger than a thready pulse and
disappears with light pressure. Although the pulsation may be difficult
to detect, the term diminished is not a standard descriptive term.
Category of Client Need: Physiological Integrity; Step in the Nursing
4. Correct Answer: 3. Rationale: According to the American Heart

Association, the length of the bladder of a blood pressure cuff should
be at least 80% and up to 100%. A blood pressure cuff bladder that measures 40% or 60% of the forearm is an inaccurate size for assessing
blood pressure. A cuff whose bladder measures 100% is the maximum
size and is therefore appropriate to use, but it is not the minimum standard. Category of Client Need: Physiological Integrity; Step in the
Nursing Process: Data Collection.
5. Correct Answer: 2. Rationale: Orthostatic or postural hypotension

is a drop in blood pressure that results in lightheadedness, dizziness,
and even syncope (fainting) when a client with circulatory problems,
dehydration, or using a diuretic, antihypertensive, or other drug
assumes an upright position. Rising gradually provides time for baroreceptors to stimulate increased blood flow to the brain to prevent or
reduce symptoms. Increasing fluid intake, if not contraindicated, is
more appropriate than limiting fluid intake. Remaining on bedrest is
unnecessary and may cause problems associated with inactivity.
Ambulating is not contraindicated but should be temporarily postponed until the client is no longer experiencing symptoms. Category
of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.
Client Need: Safe Effective Care Environment; Step in Nursing

Chapter 12
3. Correct Answer: 2. Rationale: Anxiety is usually manifested via

sympathetic nervous system stimulation. Of the four choices, restlessness and disturbed sleep correlate most with anxiety. Being quiet and
withdrawn, eating less than expected, and missing family members suggests depression or loneliness. Category of Client Need: Psychosocial
1. Correct Answer: 3. Rationale: If a cough is productive, it is impor-
Chapter 11
1. Correct Answer: 3. Rationale: To obtain an accurate oral temperature, the assessment is delayed 30 minutes after the client has consumed
hot or cold beverages or food. Unless the client is taking medication that
affects heart rate, has a slow or irregular pulse, or the radial pulse is difficult to assess, there is no reason to obtain an apical-radial rate. Eating
tant to document the color, odor, amount, and viscosity of sputum

raised. Other data that may help the physician make a diagnosis include
the onset, duration, precipitating factors, and relief measures that relate
to the cough. The clients family history may or may not correlate with
the clients current condition. The clients heart rate may be elevated if
his or her temperature is elevated or oxygenation status is compromised,
but a focused assessment of the heart rate is less critical than is the characteristics of sputum. Measures the client is using to manage his or her
cough are helpful, but the characteristics of the sputum are more significant for the diagnostic process. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
2. Correct Answer: 2. Rationale: There is more than one correct description for how breast self-examination is performed, but all include palpating the breasts from the outer margins toward the nipple. Category
836
of Client Need: Health Promotion/Maintenance; Step in the Nursing

Process Implementation.
Client Need: Health Promotion & Maintenance; Step in Nursing

3. Correct Answer: 4. Rationale: Changes in pupil response indicate

increasing intracranial pressure. The other assessments are appropriate, but they do not provide the most critical information about the
clients neurologic status. Category of Client Need: Physiological
3. Correct Answer: 2. Rationale: Maintaining or gaining weight is the

best evidence that a clients nutritional needs are being met. The client
could remain alert yet be malnourished. Because eating food is both an
emotional as well as physical phenomenon, well-nourished, satiated
people may feel hungry when they see, smell, or think about food. The
clients tolerance of pain may increase with improved nutrition, but it
is not the best criterion for determining the outcome of a nutritional regimen. Category of Client Need: Physiological Integrity; Step in Nurs-
Integrity; Step in Nursing Process: Data Collection.
4. Correct Answer: 1. Rationale: The S1 heart sound is heard best by

auscultating the apical area, which is at the fifth intercostal space in the
left midclavicular line. The S2 heart sound is best heard at the second
intercostal space to the right of the sternum. The examiner may hear a
splitting of the S1 and S2 heart sounds with the stethoscope in the other
locations. Category of Client Need: Physiological Integrity; Step in
the Nursing Process: Data Collection.
5. Correct Answer: 2. Rationale: A Snellen chart is used to test far

vision. Clients stand 20 feet from the chart and are asked to read letters
that progressively become smaller. A Jaeger chart requires that the
client read various sizes of print and is used to test near vision. Ishihara
plates are used to test color vision. A tangent screen is used to assess the
peripheral visual field. This test requires that the client indicate when
he or she sees a stimulus in his peripheral vision. Category of Client
Need: Health Promotion/Maintenance; Step in the Nursing Process:
Implementation.
ing Process: Evaluation.
4. Correct Answer: 3. Rationale: A clear liquid diet includes fat-free

bouillon, tea or coffee, flavored gelatin, fruit ices, carbonated beverages
like ginger ale, and some clear fruit juices like apple and grape. Honey
and sugar also may be used. No milk or milk products are permitted.
Category of Client Need: Physiological Integrity; Step in Nursing
5. Correct Answer: 3. Rationale: Red meat, liver, and egg yolk are good
dietary sources of iron. Dairy products are low in iron, but high in calcium. Citrus fruits are high in vitamin C. Yellow vegetables like carrots
and squash are a source of vitamin A. Category of Client Need: Health
Promotion & Maintenance; Step in Nursing Process: Implementation.
Chapter 15
Chapter 13
1. Correct Answer: 1. Rationale: An anesthetic is not administered to
clients undergoing a sigmoidoscopy. Clients can eat lightly before a sigmoidoscopy. A flexible sigmoidoscope is used more commonly than one
that is rigid. The sigmoidoscope is inserted through the anus and traverses the rectum to the sigmoid area of the lower bowel. Clients can
take medications that do not interfere with the test findings prior to a
sigmoidoscopy. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Evaluation.
2. Correct Answer: 2. Rationale: Anything containing metal is removed

before a chest x-ray. The metal object may be misinterpreted as diseased
tissue. Fasting is not required before a chest x-ray. No contrast dye is
given before or during a chest x-ray. Analgesia (pain medication) is not
usually necessary because there is no discomfort from the chest x-ray
itself. Category of Client Need: Safe, Effective Care Environment;
1. Correct Answer: 1. Rationale: To evaluate trends in weight that may

reflect deficient or excess fluid volumes, the nurse weighs the client at
the same time daily using the same scale each time. The amount of clothing is similar at each weighing. If the time of weighing is consistent, the
amount of food or liquids that the client has been consuming is not
likely to vary considerably. It is important to collaborate with the client,
but obtaining the weight is not omitted or postponed for frivolous reasons. Category of Client Need: Physiological Integrity; Step in the
Nursing Process: Planning.
2. Correct Answer: 1. Rationale: Soy sauce is high in sodium and,

therefore, is restricted on a low-sodium diet. Lemon juice and onion
powder (not salt) can be used liberally. Maple syrup is not restricted
for its sodium content but may be limited if the client needs to lose
weight. Category of Client Need: Health Promotion/Maintenance;
Step in the Nursing Process: Evaluation.
Chapter 14
3. Correct Answer: 1. Rationale: A unit of packed blood cells contains

similar numbers of blood cells in less fluid volume. A unit of packed red
blood cells is prepared by removing approximately two-thirds of the
plasma from 1 unit of whole blood. Administration of packed red blood
cells is preferred for clients who need a blood transfusion but for whom
additional water within the circulatory system is hazardous. Typically
the candidate for packed blood cells is someone prone to excess fluid volume. Packed red blood cells pose the same risk for an allergic transfusion
reaction as whole blood. Neither a transfusion of packed red blood cells
nor whole blood stimulates the bone marrow to produce more red blood
cells. Category of Client Need: Health promotion/maintenance; Step
1. Correct Answer: 1. Rationale: When the mucous membrane of the
4. Correct Answer: 4. Rationale: A person with A, Rh-positive blood
oral cavity is inflamed, it is best to eliminate foods that are acidic, salty,
spicy, dry, or very hot. Other than tomato soup, none of the other foods
has these characteristics. Category of Client Need: Physiological
type would have an incompatibility reaction if transfused with AB, Rhpositive blood. Type O is referred to as the universal donor. In an emergency, anyone can receive type O blood. People who are Rh positive can
receive compatible blood types that are either Rh positive or Rh negative.
The reverse is not true; in other words, a person who is Rh negative
should never be given Rh-positive blood. Category of Client Need:
Step in the Nursing Process: Planning.
3. Correct Answer: 1. Rationale: Douching in the days before obtaining a specimen for a Pap test interferes with accurate test results because
it removes cervical cells. None of the other instructions is necessary
before a pelvic examination and Pap test. Category of Client Need:
Implementation.
Integrity; Step in Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: Chewing food thoroughly helps the

bolus to descend through the esophagus. Restricting dietary intake to
baby food is unnecessary and could contribute to constipation. Drinking liquids helps to keep the mouth moist. Liquids are thickened if a
client has weakness or paralysis of the tongue or pharynx. Eliminating
dairy products will not promote the ability to swallow. Category of
in the Nursing Process: Implementation.
Physiological Integrity; Step in the Nursing Process: Implementation.
5. Correct Answer: 2. Rationale: Hypotension is one sign of a serious

blood transfusion reaction. In a serious transfusion reaction, urine
production is decreased. Swelling and pale skin at the infusion site are

indications of a problem with the administration of the blood rather
than a reaction to the blood. Category of Client Need: Physiological
837
of etiologies may cause. Carbon monoxide is an odorless gas. The

pulse rate may be rapid and irregular with carbon monoxide poisoning, but this finding is not as specific as cherry-red skin. Category of
Client Need: Physiological Integrity; Step in the Nursing Process:
Data Collection.
Chapter 16
1. Correct Answer: 3 Rationale: Hair conditioner is not recommended for those infected with head lice because it coats the hair and
protects the nits (eggs) attached to shafts of hair. Pediculocide shampoos are effective, but some contain strong neurotoxic or carcinogenic
chemicals that may be harmful for clients who are pregnant, nursing,
younger than 2 years, or who have open wounds, epilepsy, or asthma.
Manual removal with a fine-toothed combing tool is best for removal
of nits and live lice. The water temperature is of no consequence as
long as it is not so hot as to burn the scalp. Category of Client Need:
Health Promotion and Maintenance; Step in the Nursing Process:
Evaluation.
2. Correct Answer: 2. Rationale: Psoriasis is characterized by areas of

redness covered with silvery scales. Areas affected usually include the
elbows, knees, and scalp, although other areas also are affected. No
other choice is a characteristic description of psoriasis. Category of
Data Collection.
3. Correct Answer: 1. Rationale: Soaking or immersing in water with

substances like oatmeal or cornstarch relieves itching. Rough fibers, like
wool, irritate the skin and contribute to itching. Bathing or showering
frequently with soap removes skin oils and adds to or causes itching.
Rubbing the skin creates skin irritation and contributes to itching and
skin discomfort. Category of Client Need: Physiological Integrity; Step
2. Correct Answer: 3. Rationale: A restraint alternative is one in

which the client can release himself or herself independently. A
restraint that fastens behind the client does not facilitate being released
without the assistance of another person. Restraints or restraint alternatives may both be made from cloth or nylon. Although it is beneficial
to communicate with the client and family in an effort to maintain
safety and promote cooperation, their use may be implemented as a
nursing decision. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
3. Correct Answer: 4. Rationale: Falls, more than any other injury,

are the most common accident that older adults experience. Although
older adults experience poisonings from incorrect self-administration
of medication or inability to read labels, thermal burns, and electrical
shock, the incidence of these types of injuries is less than those that
result from falls. Category of Client Need: Safe, Effective Care
4. Correct Answer: 1. Rationale: If an alert person has ingested an

excessive amount of a non-caustic, non-corrosive, non-petroleum substance, the first step in preventing complications is to induce vomiting.
Notifying emergency medical services, who will transport the client, is
subsequently prudent. Personnel in the emergency department may
perform lavage and administer activated charcoal. Emergency department personnel will notify the clients personal physician following
treatment. The administration of an antacid generally is not indicated
in poisonings. Category of Client Need: Physiological Integrity; Step
5. Correct Answer: 1. Rationale: According to the Omnibus Budget
Chapter 17
1. Correct Answer: 3. Rationale: Keeping the bed in low position
while making an occupied bed predisposes to muscle strain and back
injury. Loosening the linen, wearing gloves to avoid contact with blood
or body fluids, and rolling the client to the far side are appropriate
actions. Category of Client Need: Safe, Effective Care Environment;
Step in the Nursing Process: Evaluation.
2. Correct Answer: 2. Rationale: Gloves are essential barrier garments

for avoiding contact with blood and body fluids. The nurse may choose
to reuse any linen that is not soiled. A flat or fitted sheet can be used.
The application of a blanket is based on the clients preference. Category of Client Need: Safe, Effective Care Environment; Step in the
3. Correct Answer: 2. Rationale: Duplicating sleep rituals facilitates

sleep. Hypnotic drugs may cause paradoxical excitement, interfere
with REM sleep, and cause daytime drowsiness. Sleeping medication
may be appropriate occasionally, but routine administration is discouraged. Exercise helps to relieve stress and promotes relaxation but
when performed near bedtime, it may stimulate wakefulness. Schedules for retiring and rising from sleep should remain as consistent as
possible. Category of Client Need: Physiological Integrity; Step in
the Nursing Process: Planning.
Reconciliation Act (1987), which applies to the use of restraints in longterm care facilities, and most healthcare agency policies, the nurse must
obtain a medical order for using a restraint. The order must be renewed
every 24 hours thereafter. It is good judgment to report the need to
restrain a client to the nursing supervisor who may temporarily send
additional personnel to assist with the care of clients. Sedatives are considered a form of chemical restraint that may further jeopardize the
clients safety. There may be a charge for a restraint, but failure to do so
does not compromise the legality of their use. Category of Client Need:
Implementation.
Chapter 19
1. Correct Answer: 2. Rationale: Asking the client to rate the pain
using a numeric scale helps the nurse to assess its intensity. The nurse
can use the rating scale later to evaluate the effectiveness of any painrelieving interventions used. Noting whether or not the client can stop
moving is not the best assessment technique because a cooperative
client may make an effort to stop moving despite the continuation of
severe pain. Perspiration is a physiologic sign that may accompany
pain. Because other factors can trigger perspiration, however, its presence or absence is not the best assessment. Administering an analgesic
is an intervention, not a form of assessment. Category of Client Need:
Physiological Integrity; Step in the Nursing Process: Data Collection.
Chapter 18
1. Correct Answer: 2. Rationale: Carbon monoxide diffuses and
binds with hemoglobin more readily than oxygen. It causes a victims
skin to appear cherry red. Eye medication could cause dilated pupils
or this could be an ominous sign of brain anoxia, which any number
2. Correct Answer: 2. Rationale: Phantom pain, a phenomenon that

some who have an amputated limb experience, is a type of neuropathic pain. Referred pain is discomfort experienced in a location distant from the actual area of pathology. Visceral pain is discomfort
arising from internal organs. Cutaneous pain is discomfort that originates at the skin level. Category of Client Need: Health promotion/
maintenance; Step in the Nursing Process: Implementation.
838
3. Correct Answer: 2. Rationale: A client in acute pain is most likely

to have a rapid pulse rate, rapid respiratory rate, and rising blood pressure. Pain is least likely to influence body temperature. Category of
than maintaining intact skin. Supporting the breasts and applying

warm compresses will provide comfort but will have no effect on preventing the transmission of microorganisms elsewhere. Category of

Data Collection.
Client Need: Health Promotion/Maintenance; Step in the Nursing

4. Correct Answer: 2. Rationale: It is best to control pain before it escalates. When pain is intense, relief is more difficult to achieve. Administering pain-relieving drugs on a routine schedule rather than when it
becomes absolutely necessary can reduce peaks and valleys of pain. The
goal is to keep a terminal client comfortable yet not dull his or her consciousness or ability to communicate. To avoid potentially lethal side
effects, there must be time enough between doses for the drug to be
metabolized and excreted; therefore, giving the medication on demand
is not appropriate. Asking the physician to order a high dose may be premature. Doses of opioid medications are titrated upward as tolerance
develops. Category of Client Need: Physiological Integrity; Step in
2. Correct Answer: 3. Rationale: Using individual bath linen and performing frequent handwashing are techniques for preventing the transmission of infectious microorganisms that may be present in eye
secretions. Eating a nutritious diet and using sunglasses to filter ultraviolet light are healthful behaviors, but they are unrelated to the clients
disorder. The use of aspirin is not contraindicated; in fact, a mild analgesic may relieve some of the clients discomfort. Category of Client
the Nursing Process: Implementation.
Chapter 20
1. Correct Answer: 2. Rationale: Of the choices provided, restlessness
is the most indicative sign of early hypoxia. Blood loss is expected; if it
is profuse or prolonged, it may eventually affect the red blood cells
oxygen-carrying capacity. Clients with compromised oxygenation are
more likely to manifest tachycardia than an irregular heart rhythm.
Thirst is a sign of fluid volume deficit. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
2. Correct Answer: 4. Rationale: Oxygen saturation is measured in

percent. The normal SpO2 is 95% to 100%. Oxygen that is dissolved in
blood (SaO2) is measured by obtaining a specimen of arterial blood. The
normal PaO2 is 80 to 100 mm Hg. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Evaluation.
3. Correct Answer: 2. Rationale: The reservoir bag of a partial

rebreathing mask should remain partially filled during inspiration. If
the bag collapses completely, the equipment may be faulty. The nurse
should report this information to the respiratory therapy department.
The mask has been applied properly if it covers the mouth and nose
and the strap fits the head snugly. Moisture is likely to accumulate
because the oxygen is humidified. This is not significant information
to report. The nurse can temporarily wipe the moisture away and reapply the mask. Category of Client Need: Physiological Integrity;

Implementation.
3. Correct Answer: 4. Rationale: Swabbing the earlobes mechanically

removes microorganisms from the area. The use of alcohol, which is an
antimicrobial agent, inhibits the growth of pathogens that may remain.
Using quality metal, such as 14-carat gold, tends to reduce local inflammation resulting from hypersensitivity. Leaving the earrings in place
temporarily and turning them facilitates the formation of a well-healed
channel. Category of Client Need: Health Promotion/Maintenance;
4. Correct Answer: 1. Rationale: A client who is immunosuppressed is

at high risk for infection. Handwashing is the best technique for reducing the spread of microorganisms. The clients needs must be met and
that is never circumvented because the client is immunosuppressed.
Maintaining adequate nourishment and assessing blood pressure are
components of good nursing care; however, these actions are not as critical in relation to the problem of immunosuppression. Category of
Implementation.
5. Correct Answer: 3. Rationale: Respiratory infections are most

commonly spread to a susceptible host through droplet transmission.
There may be organisms on inadequately sterilized dental instruments, but these are more likely to transmit a bloodborne infection
when a clients gums (gingiva) are traumatized during dental procedures. Generally only immunosuppressed clients acquire opportunistic infections from their own microorganisms. Category of Client
Implementation.
Chapter 22
4. Correct Answer: 1. Rationale: Giving oxygen at greater than 3 L/min

to a client with chronic respiratory disease interferes with the brains
response to the hypoxic drive to breathe. The stimulus to breathe in a
person with chronic obstructive lung disease, like emphysema, comes
from low levels of oxygen rather than higher than normal levels of carbon dioxide. Administering high percentages of oxygen would depress
the clients respiratory center. Category of Client Need: Physiological
5. Correct Answer: 1. Rationale: Until the lung has expanded, the fluid
in the water-seal chamber rises and falls with respirations, which is
called tidaling. There should be 2 cm of water in the water-seal chamber at all times; if it is lower, the nurse must add water. Continuously
bubbling fluid is an indication that the drainage system may have a leak.
Drainage from the chest is usually dark red blood. Category of Client
Need: Physiological Integrity; Step in the Nursing Process: Evaluation.
Chapter 21
1. Correct Answer: 4. Rationale: Gloves are the most important personal protective item in this situation. Nurses wear gloves whenever
there is a possibility for contact with body fluids or blood. Because the
nurse must hold the container, the hands need protection. In addition
to the gloves, it is acceptable to don any or all of the other items. To
avoid being splashed or sprayed, the nurse may choose to wear a face
shield and cover gown. The nurse bases the choice of additional items
on his or her judgment as to the potential for contact with blood or body
fluid by some other means such as splashing into the eyes, nose, or
mouth, or onto the uniform. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: Before removing the gloves, the nurse

unfastens the waist closure located at the front of the cover gown. If
there is no front waist closure, the nurse removes the gloves; after handwashing, he or she removes the mask and unfastens the tie of the gown
at the neckline. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
3. Correct Answer: 4. Rationale: Vinyl gloves may be substituted for

1. Correct Answer: 3. Rationale: Cleaning with soap and water is one
of the best methods for reducing the transmission of microorganisms.
Eating more sources of protein is a healthful measure but less specific
latex gloves; because they are more permeable, two pairs should be
worn (see Chapter 21). Neither rinsing the gloves with tap water nor
applying petroleum-based ointment will eliminate an allergic reaction
839
to latex. It is unsafe to work unprotected when there is a potential for

contact with blood or body fluids that contain blood. Category of
if they are positively resolved, the clients rehabilitation will be

delayed if he or she develops contractures and immobile joints. Cate-

gory of Client Need: Physiological integrity; Step in the Nursing

Process: Planning.
4. Correct Answer: 2. Rationale: Influenza is transmitted by droplet

infection. Avoiding crowded places reduces the numbers of people to
whom a susceptible person is exposed. All the other suggestions are
good health practices, but none is as definitive as avoiding crowds. Cat-
3. Correct Answer: 4. Rationale: The machine is used primarily to
egory of Client Need: Health Promotion/Maintenance Step in the

restore full ROM. Clients with joint replacement surgery are reluctant to
exercise the operative joint because of pain. Exercise tones and strengthens muscles and relieves dependent swelling by promoting venous
circulation; however, these are considered secondary benefits. It is
appropriate for the nurse to administer a prescribed analgesic before the
client uses the machine. Category of Client Need: Health Promotion/
Maintenance; Step in the Nursing Process: Implementation.
Chapter 23
1. Correct Answer: 2. Rationale: A Sims position is best used for procedures involving the rectum and lower gastrointestinal tract. A lithotomy position is used for cystoscopy and vaginal examination. A supine
position facilitates assessment of structures on the anterior of the body.
Fowlers position is used for many reasons, one of which is improving
ventilation. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: A Fowlers position promotes

abdominal wound drainage via gravity. Neither a lithotomy, supine, or
Trendelenberg position promotes the collection of wound drainage in
the abdominal area. Category of Client Need: Physiological Integrity
3. Correct Answer: 2. Rationale: To facilitate turning a client, it is

helpful if the client flexes a knee prior to rolling onto his or her side.
Holding ones breath may increase discomfort if it is accompanied by
bearing down. It is difficult to turn a client who is curled up in a ball.
Turning a client like a log is appropriate in cases when the spine has
been fused, but it is not appropriate for most clients who have had
surgery. Category of Client Need: Physiological Integrity; Step in the
Nursing Process: Planning.
4. Correct Answer: 4. Rationale: A trochanter roll helps to prevent

external rotation of the hip. It will not prevent adduction, abduction,
or flexion. Category of Client Need: Physiological Integrity Step in
5. Correct Answer: 3. Rationale: A trapeze is an item that allows the

client to help move and lift himself or herself. Encouraging the client
to participate actively helps to maintain muscular strength and reduces
the effort the nurse must provide when moving and positioning the
client. A bed cradle is used to keep linen off the lower extremities. A
bed board is used to support the clients spine. Lower side rails promote
safety. Category of Client Need: Physiological Integrity; Step in the
Chapter 24
1. Correct Answer: 2. Rationale: A client performs isometric exercises
by tensing and releasing muscles. They do not involve any appreciable
movement of a joint. The quadriceps muscles are on the anterior of the
thigh. All the other options in this item describe isotonic exercises that
involve joint movement. Category of Client Need: Health Promotion/
Maintenance; Step in the Nursing Process: Evaluation.
2. Correct Answer: 3. Rationale: The long-term outcomes following

a stroke often are determined by aggressive nursing efforts to maintain musculoskeletal function. Rehabilitation begins on admission
with functional positioning, active and passive exercise, and early
physical and occupational therapy. Managing bowel and bladder elimination will not have the same effects as the development of musculoskeletal deformities. Helping the client cope with changes in body
image and grieving are appropriate nursing responsibilities. But even
4. Correct Answer: 2. Rationale: The length of time the client used the
machine provides additional documentation of the clients response to
treatment. Inspecting and documenting the appearance of the wound,
the drainage on the dressing, and the presence and quality of arterial
pulses are important data to record; however, this information is more
pertinent to general physical assessment findings. Category of Client
5. Correct Answer: 1. Rationale: A stress ECG demonstrates the extent

to which the heart tolerates and responds to the additional demands
placed on it during exercise. The hearts ability to continue adapting is
related to the adequacy of blood supplied to the myocardium through
the coronary arteries. If the client develops chest pain, dangerous cardiac rhythm changes, or significantly elevated blood pressure, the diagnostic testing is stopped. Category of Client Need: Health Promotion/
Chapter 25
1. Correct Answer: 4. Rationale: The nurse holds and supports a wet
cast with the palms of the hands. Using the fingers is likely to cause
indentations in the cast. The inward dents create pressure areas on the
underlying tissue. After application of the cast, it dries while supported
on a soft surface. A wet cast on a hard surface can become flattened.
2. Correct Answer: 2. Rationale: Fiberglass casts have several advantages, one of which is that they tend to weigh less than plaster casts.
Fiberglass casts dry more quickly, are more durable, and are less likely
to soften if they become wet. They are no less flexible or less restrictive than plaster casts. The major disadvantage is that they are more
expensive than casts made of plaster of Paris. Category of Client
Implementation.
3. Correct Answer: 3. Rationale: The nurse assesses circulation in an

extremity by performing the blanching test to determine capillary refill
time. After releasing pressure on the nailbed, the color normally
returns within 2 to 3 seconds. The nurse also performs this assessment
on the opposite extremity. If the capillary refill time is similar in both
extremities, the cast or tissue swelling is not a factor. Asking if the cast
feels heavy or palpating it to feel the temperature are not techniques
for assessing circulation. Determining if there is space between the
cast and the skin is not a totally reliable assessment technique. If the
circulation is impaired because of compartment syndrome, there may
still be room to insert a finger at the margins of the cast. Category of
Data Collection.
4. Correct Answer: 4. Rationale: Purulent drainage is sometimes referred

to as pus. This drainage is a collection of fluid containing white blood cells
and pathogens. White blood cells indicate that the body is attempting to
destroy and remove infecting microorganisms. Serous drainage is clear; it
is made up of plasma or serum. Bloody drainage indicates trauma. Mucoid
840
drainage is sticky, transparent, and released from mucous membranes.
2. Correct Answer: 4. Rationale: The nurse obtains permission from

a minors parent or guardian. Minors cannot give legal consent under

most circumstances. If permission is obtained over the telephone, at
least two people must hear the verbal consent and co-sign as witnesses
to what they heard. Category of Client Need: Safe, Effective Care
5. Correct Answer: 3. Rationale: To maintain countertraction, the

clients foot must never press against the foot of the bed. If this is
observed, the nurse helps to pull the client back toward the head of the
bed. The weights must always hang free rather than rest on the floor
or bed. The body must be in alignment with the pull of the traction. The
traction rope must move freely within the groove of the pulley. Category of Client Need: Physiological Integrity; Step in the Nursing
Chapter 26
1. Correct Answer: 1. Rationale: In a three-point partial weight-bearing
gait, the client advances the weaker leg and walker together. He uses
his hands to support most of the weight while lifting and advancing
the stronger leg. Category of Client Need: Health Promotion/
Maintenance; Step in the Nursing Process: Evaluation.
2. Correct Answer: 3. Rationale: A cane is always held on the uninvolved side. By doing so, the client can transfer or redistribute body
weight from the painful joint to the hand with the cane when taking a
step. Covering the top with a rubber cap, wearing supportive shoes, and
maintaining good posture are all appropriate techniques when using a
cane. Category of Client Need: Health Promotion/Maintenance; Step
in the Nursing Process: Evaluation.
3. Correct Answer: 2. Rationale: The hip of a client who has undergone a total hip replacement (arthroplasty) is maintained in a position
of abduction. If the client flexes the hip more than 90 or adducts the
hip, the prosthetic femoral head may become dislocated. A triangular
foam wedge generally is kept between the clients legs while in bed.
3. Correct Answer: 4. Rationale: Jewelry is removed preoperatively,

itemized, identified, and locked in a secure area. Another alternative is
to give the clients valuables to a member of the family. The nurse has
a responsibility to document in the clients record the items that were
taken and how they are being kept secure. Some agencies give the client
a receipt for his property. If a client asks that a wedding ring be left on,
the nurse can secure it to the finger or hand with tape or a strip of
gauze. To reduce a reservoir of microorganisms, it is best to remove and
safeguard the ring. The ring is subject to theft if left in the bedside
stand. Security guards usually are not responsible for safekeeping of
personal valuables. Category of Client Need: Safe, Effective Care
4. Correct Answer: 1. Rationale: Once preoperative medication is

given, the side rails are raised and the client is instructed to remain in
bed. Elimination and oral hygiene are accomplished prior to giving the
preanesthetic drugs. A narcotic makes it difficult for the client to
remain alert during attempts to teach leg exercises. Category of Client
5. Correct Answer: 3. Rationale: A dropping blood pressure frequently suggests that the client is going into shock. A systolic pressure
of 90 to 100 mm Hg indicates shock is approaching. Below 80 mm Hg,
shock is present. Other signs of shock include a rapid, thready pulse;
pale, cold, and clammy skin; rapid respirations; a falling body temperature; restlessness; and a decreased level of consciousness. Category
of Client Need: Physiological Integrity; Step in the Nursing Process:
Data Collection.
4. Correct Answer: 3. Rationale: Almost immediately after surgery, the

nurse encourages a client to lift up using the trapeze because the muscles that most need strengthening prior to ambulating with crutches are
those in the arms, neck, shoulders, chest, and back. The client also may
squeeze rubber balls and perform arm push-ups. Doing arm push-ups
involves placing the palms flat on the bed and raising the buttocks. Balancing between parallel bars occurs later in rehabilitation. Standing
and transferring maintain strength and tone of lower leg muscles, but
they are not subjected to as much physical work as the muscles in the
upper body. Category of Client Need: Physiological Integrity; Step in
Chapter 28
receptacle or container, like the nurses glove, to prevent the transmission of infectious microorganisms. A clean glove is used to remove
soiled dressings. Tape is pulled toward the wound to prevent separating the healing edges. Wounds are always cleansed so as to
carry microorganisms and debris away from the incision. Category of
5. Correct Answer: 3. Rationale: If crutches are measured and fitted

appropriately, there is room for at least two fingers between the axillae
and the axillary bars of the crutches. Prolonged pressure under the arm
affects circulation or impairs nerve function, resulting in permanent
paralysis. All of the other observations are indications that the crutch
length and the position of the handgrips are correct. Category of
Evaluation.
Chapter 27
1. Correct Answer: 4. Rationale: To reduce the potential for infection,
hair is shaved after the client is transferred from the nursing unit to the
surgical department. Shaving the night before facilitates colonization
of microorganisms within skin abrasions. If the skin preparation is performed on the nursing unit, it is better to do so before administering
sedation and after a shower. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Planning.
1. Correct Answer: 2. Rationale: An open drain relies on gravity to

remove exudates, which the dressing then absorbs. The lithotomy,
recumbent, and Trendelenberg positions do not promote the collection of wound drainage near the abdominal drain. Category of
Implementation.
2. Correct Answer: 3. Rationale: Soiled dressings are enclosed in a

Implementation.
3. Correct Answer: 1. Rationale: To establish negative pressure, the

nurse eliminates air and drainage from the bulb reservoir and caps the
vent before releasing the squeezed bulb. A Jackson-Pratt drain is an
example of a closed drainage device. The Jackson-Pratt device could
drain by gravity, not negative pressure, if the drainage valve were left
open. The nurse never fills the bulb reservoir with normal saline. The
nurse secures the reservoir to the skin with tape; however, this is to
prevent tension on the tubing and possibly pulling it from its insertion
site. Category of Client Need: Safe, Effective Care Environment;
4. Correct Answer: 2. Rationale: Wet-to-dry dressings provide a means

for debriding the ulcerated areas of necrotic tissue. Although covering
impaired skin reduces the entrance of microorganisms, absorbs drainage,

and protects the skin, they are not the primary reasons for use. Category
of Client Need: Health Promotion/Maintenance; Step in the Nursing
5. Correct Answer: 3. Rationale: The appearance of pink tissue indicates the formation of granulation tissue, which consists of capillaries
and fibrous collagen that seals and nourishes the tissue. Increased
drainage suggests that cellular death is continuing or the wound is
infected. Relief of discomfort is a positive sign; however, some ulcers are
not severely painful even in the acute stage. White or black wound margins suggest an extension of cell death. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Evaluation.
841
Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
2. Correct Answer: 4. Rationale: The client should not restrict fluid

intake, which potentially can lead to fluid imbalance. Concentrated
urine also is more likely to foster renal stone formation. Inadequate fluid
intake does contribute to constipation, but that is not the main reason
to discourage the incontinent client from limiting fluid intake. Although
the client is invested in achieving the desired goal, it is unsafe to encourage fluid restriction as a means of reaching the expected outcome. Category of Client Need: Health Promotion/Maintenance; Step in the
3. Correct Answer: 3. Rationale: Providing space between the penis and
Chapter 29
1. Correct Answer: 4. Rationale: The distance from the nose (N) to the
earlobe (E) to the xiphoid process (X) is called the NEX measurement.
It is used to determine the approximate distance to the stomach. None
of the other landmarks are correct for approximating the length for
nasogastric tube insertion. Category of Client Need: Safe, Effective
bottom of the catheter prevents irritation to the urinary meatus and promotes drainage of urine. Lubrication is not appropriate because it interferes with maintaining the catheter in place. External catheters are
similar to latex condoms; they stretch to fit. Therefore, measuring the
penis is unnecessary. The foreskin of an uncircumcised male is never left
in a retracted position because it could have a tourniquet effect and interfere with circulation of blood to the tissue. Category of Client Need:
4. Correct Answer: 1. Rationale: Anchoring an indwelling retention
2. Correct Answer: 3. Rationale: Placing the chin to the chest helps to
catheter to the males abdomen eliminates pressure and irritation at the

penoscrotal angle. Pressure in this area predisposes to fistula formation.
The nurse passes the catheter and tubing over a clients leg to prevent
obstruction of urinary drainage from compression of the tubing. It is
appropriate to fasten the drainage tubing to the bed so that there is a
straight line from the bed to the collection bag and to insert the catheter
into a drainage collection bag. Neither of these nursing actions, however,
prevents the formation of a penoscrotal fistula. Category of Client Need:
direct a tube into the esophagus rather than the lower airway. The
nurse gives the client water to sip to make breathing deeply difficult. A
sniffing position is appropriate when first inserting the tube into a
clients nose. Coughing occurs as a reflex if the tube enters the airway;
it is a helpful sign that the tube must be raised from its present location.
Category of Client Need: Safe, Effective Care Environment; Step in
3. Correct Answer: 2. Rationale: Determining if the pH of fluid aspirated from the tube is within the range of gastric pH helps to validate
that the distal tip of the tube is located within the stomach. A portable
x-ray is an accurate method, but the cost and unnecessary radiation
exposure make it less appropriate unless the tube is a small diameter
feeding tube. Liquids are never instilled until placement has been verified. Feeling for air is an unacceptable technique for determining
placement. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
4. Correct Answer: 2. Rationale: Slight bleeding, clear serum drainage,

or both (serosanguineous) is a normal finding that the nurse can expect
immediately after insertion of a gastrostomy tube. Milky drainage suggests an infection; if it occurs after feedings have been initiated, it may
indicate leakage of formula. Gastric secretions may appear green, especially if they are mixed with bile, but this finding is abnormal. Bright
bloody drainage indicates arterial rather than darker venous or capillary bleeding. Category of Client Need: Physiological Integrity; Step
in the Nursing Process: Data Collection.
5. Correct Answer: 2. Rationale: Clients with nasogastric tubes that

connect to suction are generally NPO (nothing by mouth). The nurse
can provide ice chips sparingly to keep a clients mouth moist but not
in amounts that will cause an electrolyte imbalance. Giving water or
other fluids, which are subsequently removed from the stomach, is
likely to dilute and deplete electrolyte levels. Category of Client Need:
Physiological Integrity; Step in the Nursing Process: Planning.
Chapter 30
1. Correct Answer: 1. Rationale: Although all the assessments are
appropriate when caring for a client having problems with urinary
elimination, the most important assessment in continence retraining
is keeping a log of the clients pattern of urinary elimination. The
nurse analyzes and uses recorded data to schedule toilet activities to
initially correspond with the clients filling and emptying patterns.
5. Correct Answer: 3. Rationale: When instructing a female client

about collecting a clean-catch urine specimen, the nurse explains that
the initial portion of the voided stream is discarded and a portion that
follows is collected as the specimen. He or she instructs a female to
cleanse the urethral area from front to back; males cleanse the penis
using a circular motion. The specimen is collected in a sterile container.
The antimicrobial agent is used for cleansing and is not mixed with the
urine specimen. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 31
1. Correct Answer: 1. Rationale: Long-term use of laxatives repeatedly subjects the bowel to artificial stimulation, causing it to become
sluggish. Stool softeners are less harsh than laxatives; however, it is
best to determine the cause of the constipation and treat the etiology
with life-style changes rather than continue to rely on pharmaceutical interventions. Daily enemas are just as habituating as laxative
abuse. Dilating the anal sphincter is not usually a technique for promoting bowel elimination. Category of Client Need: Health Promotion/
2. Correct Answer: 1. Rationale: A client with a fecal impaction tends

to expel liquid stool around the hardened mass. Bad breath is not
usually a sign of constipation or fecal impaction. If halitosis is chronic,
the nurse should suspect dental disease, ineffective oral hygiene, or
esophageal diverticula. Headaches have been anecdotally associated
with constipation, but a relationship has not been proven scientifically.
Loss of appetite may be either a cause or effect of impaired bowel elimination. Its presence does not necessarily indicate a fecal impaction.
3. Correct Answer: 1. Rationale: Activity promotes the movement of

gas toward the anal sphincter where it can be released. Carbonated
842
beverages can increase gas accumulation. Restricting food is inappropriate. It may prevent additional gas from forming, but it does not help
to eliminate what is already present. Narcotic analgesics tend to slow
peristalsis and contribute to the retention of stool and intestinal gas.
Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
4. Correct Answer: 3. Rationale: Interrupting the instillation of the

enema solution allows time for the bowel to adjust to the distention.
Rapidly instilling the remaining solution may cause the client to lose
control of elimination. Taking deep breaths or panting rather than
holding the breath relieves some discomfort. To finish administering
the remaining enema solution, the nurse needs to reinsert the withdrawn tip. Category of Client Need: Physiological Integrity; Step in
5. Correct Answer: 2. Rationale: A normal healthy stoma appears

bright red or pink because of its rich blood supply. If the stoma is light
pink or dusky blue, the blood supply to the tissue is compromised. A
tan stoma is atypical even in non-Caucasians; further assessments are
necessary to determine the cause. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
Chapter 32
1. Correct Answer: 4. Rationale: The abbreviation q.i.d. indicates
that the drug must be administered four times a day. The abbreviation for once a day is q.d. The abbreviation for every other day is
q.o.d. The abbreviation for three times a day is t.i.d. Category of
2. Correct Answer: 3. Rationale: The nurse uses the formula
D/H X Q = Amount to administer and accurately calculates that the

amount to administer is 12 tablet. It is best if the tablet is scored to facilitate giving half of the prescribed amount, but devices can separate
tablets into two portions. Generally if a 250 mg tablet of the prescribed
drug is available, the pharmacist would most likely have provided that
dose. There is no reason to consult the physician. The nurse may wish
to use a drug reference to determine if other dosages of the drug are
available, but this is not the best nursing action in this situation. Category of Client Need: Safe, Effective Care Environment; Step in the
3. Correct Answer: 2. Rationale: Asking the client to identify herself

by name is the safest action. The nurse also obtains an identification
bracelet and attaches it to the clients wrist as soon as possible. A confused client or one that is hearing impaired may respond, Yes, when
asked if she is Anna Jones, whether that is true or not. Although a
nursing assistant may know the identity of the client, the best choice
is to have the client provide self-identification. Category of Client
4. Correct Answer: 4. Rationale: Offering a few sips of water before

administering medications helps to moisten the oral cavity and facilitates swallowing oral medications. Nurses never soften capsules by
placing them in water before administration or tell the client to chew
a capsule. Opening a capsule can cause the client to experience an
unpleasant taste. Category of Client Need: Physiological Integrity;
5. Correct Answer: 3. Rationale: Nurses never add oral medications

to a bag of tube feeding formula because doing so may delay the full
dosage for a prolonged period as the formula instills. The other actions
described are correct techniques when administering oral medications through a nasogastric feeding tube. Category of Client Need:
Implementation.
Chapter 33
1. Correct Answer: 3. Rationale: Tilting the head backward allows gravity and head positioning to locate and maintain the liquid nasal medication within the nasopharynx. Bending forward causes loss of medication
before it can provide a therapeutic effect. None of the other prescribed
positions help to distribute nasal medications where they are intended
for use. Category of Client Need: Health Promotion/Maintenance;
2. Correct Answer: 3. Rationale: Instilling vaginal medication before

bedtime aids in retaining the medication for a substantial time. If that is
not possible, instruct the client to recline for 10 to 30 minutes afterward.
The client should insert the applicator 2 to 4 inches within the vagina.
The best position for instilling a vaginal drug is dorsal recumbent. Using
gloves is a personal choice when self-administering vaginal medication.
Gloves are required when a nurse administers vaginal medication into
a client. Category of Client Need: Health Promotion/Maintenance;
3. Correct Answer: 4. Rationale: Eye drops and ointments are placed

in the exposed lower conjunctival sac. If placed on the cornea, they may
cause discomfort and reflex blinking. Medication may be absorbed systemically when instilled at the inner canthus. Placing eye drops and
ointments at the outer canthus makes it difficult to distribute them in
the eye. Category of Client Need: Physiological Integrity; Step in the
4. Correct Answer: 1. Rationale: Liquid and ointment otic (ear) preparations are warmed to room temperature if they have been stored in a
cool or cold area. Instilling cold medication into the ear is uncomfortable. Unless the dropper is grossly covered with obvious debris, it is not
necessary to clean it routinely. There is no limit on the maximum volume instilled within the ear. The anatomic size of the ear canal and the
prescribed dose of medication are guidelines for how much drug is
administered. Category of Client Need: Physiological Integrity; Step
5. Correct Answer: 1. Rationale: Maintaining a position with the head

tilted to the side or a side-lying position, which was the body position at
the time of medication administration, facilitates movement of the drug
to the lowest area of the ear canal. Cotton is loosely inserted within the
ear to collect drainage and any excess volume of medication. The
eustachian tube does connect the middle ear with the pharynx; however, if the tympanic membrane is intact, blowing the nose does not
displace the medication. The temperature of beverages does not affect
the instilled ear drop(s). Category of Client Need: Physiological
Chapter 34
1. Correct Answer: 4. Rationale: The dorsogluteal site is located in the
buttock. The hip is the location of the ventrogluteal site. The deltoid
site is located in the arm. The vastus lateralis and rectus femoris are
injection sites located in the thigh. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
2. Correct Answer: 1. Rationale: Pointing the toes inward reduces discomfort when giving an injection into the dorsogluteal site. Tightening
muscles increases discomfort. Crossing the legs or flexing the knees
places the client in an awkward position and does not relieve discomfort. Category of Client Need: Physiological Integrity; Step in the
3. Correct Answer: 1. Rationale: When administering an injection

using the Z-track technique, the nurse pulls the tissue laterally until it
is taut. He or she holds the tissue in that position during the injection
as well. The nurse does not release the position of the tissue until after

withdrawing the needle. Category of Client Need: Physiological
4. Correct Answer: 4. Rationale: When administering an intradermal

injection, the nurse inserts the needle between the layers of skin at
approximately a 10- to 15-degree angle. He or she gives subcutaneous
injections at either a 45- or 90-degree angle depending on the clients
size. The nurse gives intramuscular injections at a 90-degree angle. It
is incorrect to give any injection by inserting the needle at a 180-degree
angle. Category of Client Need: Physiological Integrity; Step in the
843
barrier against skin contact and absorption. Avoiding powdered gloves

prevents inhalation of the drug on particles of powder. Handwashing
is appropriate before and after contact with a client, but it is not necessary to wash hands for 5 minutes. Distancing oneself from the client
is important when the client is being treated with an implanted source
of radiation, not chemotherapy. It is unnecessary to wear a high efficiency air filter respirator when caring for a client receiving intravenous antineoplastic drugs. Category of Client Need: Safe, Effective
5. Correct Answer: 3. Rationale: The client must take care to avoid

mixing the intermediate-acting insulin that contains an additive with
the short-acting additive-free insulin. The additive-free insulin is always
withdrawn first. The actions described in the other options are safe and
appropriate for mixing two different types of insulin. Category of
Client Need: Health Promotion/Maintenance; Step in the Nursing
Process: Evaluation.
Chapter 35
1. Correct Answer: 2. Rationale: Whenever two medications are combined, the nurse must consult a reference to determine if the two drugs
or the drug and solution are compatible. Some drug-drug and drugsolution combinations will cause a physical change such as a precipitate
to form. Not all drugs are diluted before administration by intravenous
bolus. When instilling an intravenous medication by bolus administration, the nurse interrupts the infusing solution for seconds at a time
while instilling the drug through the port. Flushing a port with normal
saline is unnecessary unless there may be a drug-drug or drug-solution
interaction. Category of Client Need: Physiological Integrity; Step in
2. Correct Answer: 4. Rationale: To determine if the IV catheter is

within the vein, the nurse aspirates with the plunger of the syringe containing the medication. The negative pressure created by pulling back the
plunger causes blood to enter the distal end of the tubing, confirming that
the catheter is still in the vein. Edema with or without a change in the
rate of infusion indicates that the intravenous catheter is no longer in the
vein but has become displaced within the interstitial space. Redness
along the course of a vein indicates phlebitis. If the skin around an infusing IV solution feels cooler than adjacent skin areas, it could mean that
the solution is infiltrating into the tissue; warmer skin than adjacent
areas could mean that the client has phlebitis. Category of Client Need:
3. Correct Answer: 2. Rationale: Sterile normal saline generally is
Chapter 36
1. Correct Answer: 3. Rationale: When assessing a cough, the nurse
determines if it is productive or nonproductive. If productive, it is
important to document the color, odor, amount, and viscosity of sputum raised. Other data that may aid the physician in making a diagnosis include onset, duration, contributing factors, and relief measures
that apply to the clients symptoms. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
2. Correct Answer: 1. Rationale: Increased fluid intake thins respiratory secretions. Increased moisture in inspired air through humidification also helps. Changing positions improves circulation and prevents
pooling of respiratory secretions. A high-protein diet contributes to tissue growth and repair. Rest relieves fatigue and activity intolerance.
3. Correct Answer: 4. Rationale: Obtaining a sputum specimen is

easiest when the client first awakens in the morning or following an
aerosol treatment. Secretions tend to accumulate in the respiratory
tract during the night. Pooled secretions are more easily raised especially if the client is not fatigued from activity. Forced coughing after
a meal can lead to vomiting. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.
4. Correct Answer: 3. Rationale: The vent on a suction catheter is not

occluded until after the catheter is fully inserted and being withdrawn.
This reduces the potential for hypoxemia. Closing the vent before insertion or when just inside the inner cannula prolongs the time during
which oxygen is removed from the airway. Coughing may or may not
coincide with the proper time to occlude the vent. Therefore, it is not
used as a criterion for this action. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
5. Correct Answer: 2. Rationale: Airway suctioning should not extend

beyond 10 to 15 seconds. Some suggest holding ones own breath during suctioning to become aware of the air hunger the client is experiencing. Suctioning for too little time does not effectively clear the
airway. Suctioning beyond 10 to 15 seconds causes hypoxemia. Cate-
used to flush a port of an intermittent infusion device before and after

its use. Some agencies may continue to use a flush of heparin, although
research shows that practice is necessary only for some types of central
venous catheters. Bateriostatic water is hypotonic and may cause blood
cells in the area to swell. Neither isopropyl alcohol nor hydrogen peroxide is used to flush an intermittent infusion device. Category of
gory of Client Need: Physiological Integrity; Step in the Nursing


Implementation.
Chapter 37
4. Correct Answer: 1. Rationale: Implanted central venous catheters

have the greatest protection against infection because they are sealed
beneath the skin. Implanted catheters are designed for long-term use
because they can sustain approximately 2000 punctures. They can
remain in place for several years, but they eventually are removed. A
dressing is applied only when the port is pierced and the catheter is
being used. Category of Client Need: Health Promotion/Maintenance;
5. Correct Answer: 4. Rationale: To avoid self-contamination while

administering an antineoplastic drug by intravenous instillation, the
nurse wears one or two pairs of nonpowdered gloves, which provide a
1. Correct Answer: 1. Rationale: A person with a stroke is at high risk

for choking and aspirating a bolus of food as a result of hemiparalysis
(half-sided paralysis) of the muscles that control the face, tongue, and
throat. People who have had a full mouth extraction do not have
impaired swallowing; they initially receive liquids and soft or pureed
foods that do not require chewing. A client with a biopsy of a tongue
lesion also may receive a diet with modified texture but should not have
significantly impaired ability to chew or swallow food. The term facial
cosmetic surgery is vague because it does not identify specifically the
extent of the procedure. Nevertheless, it is unlikely that this type of
surgery would interfere with chewing or swallowing. Category of
844

Planning.
2. Correct Answer: 2. Rationale: Products manufactured in or imported

to the United States on or after January 1, 1995 must comply with the
Child Safety Protection Act (CSPA). Before purchasing any toy, consumers should look for and heed the age recommendations identified.
The greatest danger may be with homemade stuffed animals or dolls.
The child is at risk for accidental choking with any toy that has small
parts or pieces that can be broken off or separated. Soft, stuffed animals
or dolls with buttons or plastic eyes are not as safe as those with painted
or printed features. The gel in a teething ring, which is ultimately a
semi-liquid, generally is sealed securely. A 6 month old is not capable of
reaching the objects on a mobile provided it is suspended at an acceptable height above a crib. A ball less than 1 34 inches is a safety risk for a
child younger than 3 years, but one that is 5 inches in diameter is generally safe. Category of Client Need: Health Promotion/Maintenance;
3. Correct Answer: 3. Rationale: Inability to speak or make vocal sounds

indicates occlusion of the passageway between the upper and lower airway. The nurse also looks for the universal choking sign. Audible wheezing, ability to cough, and efforts to clear the throat are signs that suggest
a partial airway obstruction. The Heimlich maneuver is recommended
when airway obstruction is complete and the victim is conscious. If the
victim is unconscious, the rescuer administers chest compressions. Category of Client Need: Physiological Integrity; Step in the Nursing
The recovery position is used when breathing and circulation have

been restored. Loosening a belt is unnecessary during resuscitation
attempts. A rescuer gives two rescue breaths initially then administers
a sequence of 15 chest compressions followed by two breaths when performing CPR. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 38
1. Correct Answer: 3. Rationale: Spontaneous breathing is related to
a functioning brain stem. Brain death is based on evidence that the
whole brain including the brain stem is no longer functioning. Unresponsiveness is not the most conclusive criterion, although it supports
the cluster of data suggesting neurological dysfunction. A client with a
urine output less than 100 mL/24 hours is anuric, but the clients brain
may not be permanently affected. Bilateral dilated pupils are more ominous than unequal pupils are. Category of Client Need: Physiological
2. Correct Answer: 2. Rationale: The bargaining stage is evidenced by

negotiating an extension to life to reach or accomplish some future
event. Denial is a stage in which the terminal client refuses to believe
valid information. Anger is a stage characterized by retaliation for feeling victimized. Depression occurs when the client is saddened by the
inevitable end to life. When the client reaches the stage of acceptance,
he or she is at peace with the finality of life. Category of Client Need:
4. Correct Answer: 3. Rationale: After a quick initial assessment, the
Psychosocial Integrity; Step in the Nursing Process: Evaluation.
nurse summons emergency service personnel. The nurse may delegate

this task to others while implementing the next steps, which include
early CPR followed by early cardiac defibrillation. When emergency service personnel arrive, they provide interventions considered advanced
life support measures such as endotracheal intubation and emergency
drug therapy. Category of Client Need: Physiological Integrity; Step in
3. Correct Answer: 3. Rationale: Organ harvesting cannot occur
the Nursing Process: Data Collection.
5. Correct Answer: 3. Rationale: The nurse must ensure that no one

is touching the victim before administering the shock from the AED.
unless the deceased clients next of kin gives permission to do so. This
is true even if the client signed an organ donor card prior to death.
After obtaining permission from the next of kin, the organ procurement officer notifies the transplant team who will harvest and transport the organs. The client must be declared dead by standard medical
criteria, but organ procurement cannot proceed based on this alone.

Appendix C Answers and Rationales For NCLEX Style Review Questions PDF

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Appendix C Answers and Rationales For NCLEX Style Review Questions PDF

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Answers and Rationales for NCLEX-Style

Need: Safe, Effective Care Environment; Step in the Nursing

1. Correct Answer: 3. Rationale: The first step in the nursing process

3. Correct Answer: 2. Rationale: An incident report is a tool for risk

Safe, Effective Care Environment; Step in the Nursing Process:

2. Correct Answer: 2. Rationale: A licensed practical nurse works

3. Correct Answer: 1. Rationale: Ineffective airway clearance reflects

2. Correct Answer: 3. Rationale: An advance directive is a written

3. Correct Answer: 2. Rationale: A referral to a home health nursing

APPENDIX C Answers and Rationales for NCLEX-Style Review Questions

2. Correct Answer: 1. Rationale: According to Holmes and Rahes

3. Correct Answer: 4. Rationale: Denial is a coping mechanism in

2. Correct Answer: 2. Rationale: Clients who have retained their Asian

3. Correct Answer: 1. Rationale: Dark-blue pigmented areas, known

2. Correct Answer: 3. Rationale: The best therapeutic nursing action

4. Correct Answer: 2. Rationale: 2. The nurse delegates tasks within

Environment; Step in Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Directly observing the clients perfor-

4. Correct Answer: 2. Rationale: When a cultural practice is not

unsafe or potentially injurious to the client, it is best to incorporate the

Integrity; Step in the Nursing Process: Evaluation.

3. Correct Answer: 1. Rationale: Using dolls or puppets as a teaching

APPENDIX C Answers and Rationales for NCLEX-Style Review Questions

2. Correct Answer: 1. Rationale: Inserting information on a record

2. Correct Answer: 3. Rationale: The federal Patient Self-determination

is not likely to create sufficient exercise to significantly alter the pulse

2. Correct Answer: 2. Rationale: Shivering takes place at the onset of

3. Correct Answer: 3. Rationale: A thready pulse, also classified as a

4. Correct Answer: 3. Rationale: According to the American Heart

5. Correct Answer: 2. Rationale: Orthostatic or postural hypotension

Client Need: Safe Effective Care Environment; Step in Nursing

3. Correct Answer: 2. Rationale: Anxiety is usually manifested via

1. Correct Answer: 3. Rationale: If a cough is productive, it is impor-

Integrity; Step in the Nursing Process: Data Collection.

tant to document the color, odor, amount, and viscosity of sputum

APPENDIX C Answers and Rationales for NCLEX-Style Review Questions

of Client Need: Health Promotion/Maintenance; Step in the Nursing

Client Need: Health Promotion & Maintenance; Step in Nursing

3. Correct Answer: 4. Rationale: Changes in pupil response indicate

3. Correct Answer: 2. Rationale: Maintaining or gaining weight is the

Integrity; Step in Nursing Process: Data Collection.

4. Correct Answer: 1. Rationale: The S1 heart sound is heard best by

5. Correct Answer: 2. Rationale: A Snellen chart is used to test far

ing Process: Evaluation.

4. Correct Answer: 3. Rationale: A clear liquid diet includes fat-free

2. Correct Answer: 2. Rationale: Anything containing metal is removed

1. Correct Answer: 1. Rationale: To evaluate trends in weight that may

2. Correct Answer: 1. Rationale: Soy sauce is high in sodium and,

3. Correct Answer: 1. Rationale: A unit of packed blood cells contains

1. Correct Answer: 1. Rationale: When the mucous membrane of the

4. Correct Answer: 4. Rationale: A person with A, Rh-positive blood

Step in the Nursing Process: Planning.

Integrity; Step in Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Chewing food thoroughly helps the

in the Nursing Process: Implementation.

Physiological Integrity; Step in the Nursing Process: Implementation.

5. Correct Answer: 2. Rationale: Hypotension is one sign of a serious

APPENDIX C Answers and Rationales for NCLEX-Style Review Questions

of etiologies may cause. Carbon monoxide is an odorless gas. The

2. Correct Answer: 2. Rationale: Psoriasis is characterized by areas of

3. Correct Answer: 1. Rationale: Soaking or immersing in water with

2. Correct Answer: 3. Rationale: A restraint alternative is one in