1.

The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." "I place my infant in the middle of the li!in" room floor on a ) blanket to play with my 4 year old while I make supper in the kitchen." "$y sleepin" baby lies so cute in the crib with the little buttocks #) stuck up in the air while the four year old naps on the sofa." "I ha!e the 4 year-old hold and help feed the four month-old a %) bottle in the kitchen while I make supper." &e!iew Information' The correct answer is %' "I ha!e the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." The infant seat is to be placed on the rear seat. (mall children and infants are not to be left unsuper!ised. Infants are to be placed on their "back when they "o back" to sleep or are lyin" in a crib. A 4 year-old could assist with the care of an infant with proper super!ision. This enhances bondin" with the infant and the de!elopmental needs of the preschooler to "help" and not feel left out. ). *pon completin" the admission documents+ the nurse learns that the ,- year-old client does not ha!e an ad!ance directi!e. .hat action should the nurse take? A) &ecord the information on the chart ) /i!e information about ad!ance directi!es #) Assume that this client wishes a full code %) &efer this issue to the unit secretary &e!iew Information' The correct answer is ' /i!e information about ad!ance directi!es 0or each admission+ nurses should re1uest a copy of the current ad!ance directi!e. If there is none+ the nurse must offer information about what an ad!ance directi!e implies. It is then the client2s choice to si"n it. In option 1 3ust recordin" the information is not sufficient. In option 4 the nurse should not assume that the client has been informed of choices for emer"ency care. In option 4 this represents an inappropriate dele"ation approach. 4. A nurse administers the influen5a !accine to a client in a clinic. .ithin 16 minutes after the immuni5ation was "i!en+ the client complains of itchy and watery eyes+ increased an7iety+ and difficulty breathin". The nurse e7pects that the first action in the se1uence of care for this client will be to A) $aintain the airway ) Administer epinephrine 1'1888 as ordered #) $onitor for hypotension with shock %) Administer diphenhydramine as ordered &e!iew Information' The correct answer is ' Administer epinephrine 1'1888 as ordered .All the answers are correct "i!en the circumstances. The correct se1uence of care is to administer the epinephrine+ then maintain airway. In the early sta"es of anaphyla7is+ when the patient has not lost consciousness and is normatensi!e+ administerin" the epinephrine and then applyin" the o7y"en+ watchin" for hypotension and shock are later responses. The pre!ention of a se!ere crisis is maintained by usin" diphenhydramine. 4. .hich of these children at the site of a disaster at a child day care center would the tria"e nurse put in the "treat last" cate"ory? An infant with intermittent buld"in" anterior fontonel between cryin" episodes A toddler with se!ere deep abrasions o!er 9,: of the body A preschooler with 1 lower le" fracture and the other le" with an upper le" fracture A school-a"e child with sin"ed eyebrows and hair on the arms &e!iew Information' The correct answer is ' A toddler with se!ere deep abrasions o!er 9,: of the body .This child has the least chance of sur!i!al. (e!ere deep abrasions are to be thou"ht of as second and third de"ree burns. The child has "reat risk of shock and infection combined. 6. .hen admittin" a client to an acute care facility+ an identification bracelet is sent up with the admission form. In the e!ent these do not match+ the nurse2s best action is to chan"e whiche!er item is incorrect to the correct information use the bracelet and admission form until a replacement is supplied notify the admissions office and wait to apply the bracelet make a corrected identification bracelet for the client &e!iew Information' The correct answer is #' notify the admissions office and wait to apply the bracelet The Admissions ;ffice has the responsibility to !erify the client2s identity and keep all the records in the system consistent. $akin" the chan"es puts the client at risk for misidentification. *sin" an incorrect identification bracelet is unsafe. $akin" a new bracelet on the unit is not appropriate. <. The nurse is ha!in" difficulty readin" the health care pro!ider=s written order that was written ri"ht before the shift chan"e. .hat action should be taken?

>ea!e the order for the oncomin" staff to follow-up #ontact the char"e nurse for an interpretation Ask the pharmacy for assistance in the interpretation #all the pro!ider for clarification &e!iew Information' The correct answer is %' #all the pro!ider for clarification &elyin" on anyone else==s interpretation is !ery risky. .hen in doubt+ check it out with the person who wrote the ille"ible order. ;rder entry systems help to minimi5e this problem. -. An adult client is found to be unresponsi!e on mornin" rounds. After checkin" for responsi!eness and callin" for help+ the ne7t action that should be taken by the nurse is to' A) check the cartoid pulse ) deli!er 6 abdominal thrusts #) "i!e ) rescue breaths %) open the client=s airway &e!iew Information' The correct answer is %' open the client==s airway Accordin" to the A #s of #?& the first step in rescuin" an unresponsi!e !ictim after checkin" responsi!eness and callin" for help is to open the !ictims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed+ after breathin" is e!aluated. The need for abdominal thrusts is determined by inability to achie!e chest rise when !entilation is attempted. ,. A client has an order for 1888 ml of %6. o!er an , hour period. The nurse disco!ers that ,88 ml has been infused after 4 hours. .hat is the priority nursin" action? A) Ask the client if there are any breathin" problems ) @a!e the client !oid as much as possible #) #heck the !ital si"ns %) Ausculate the lun"s &e!iew Information' The correct answer is %' Ausculate the lun"s All of the options would be part of the e!aluation for the effects of the lar"e amount of fluid in a short period of time. @owe!er the worst result is heart failure with lun" con"estion so the auscultation of the lun"s is the priority action. The se1uence of actions would be 4 1 4 ). 9. 0ollowin" chan"e-of-shift report on an orthopedic unit+ which client should the nurse see first? 1< year-old who had an open reduction of a fractured wrist 18 hours a"o )8 year-old in skeletal traction for ) weeks since a motor cycle accident -) year-old reco!erin" from sur"ery after a hip replacement ) hours a"o -6 year-old who is in skin traction prior to planned hip pinnin" sur"ery. &e!iew Information' The correct answer is #' -) year-old reco!erin" from sur"ery after a hip replacement ) hours a"o >ook for the client who is in the least stable condition. The client who returned from sur"ery ) hours a"o is at risk for hemorrha"e and should be seen first. The 1< year-old should be seen ne7t because it is still the first post-op day. The -6 year-old in skin traction should be seen ne7t. The client who can safely be seen last is the )8 year-old who is ) weeks post-in3ury. 18. A nurse obser!es a family member administer a rectal suppository by ha!in" the client lie on the left side for the administration. The family member pushed the suppository until the fin"er went up to the second knuckle. After 18 minutes the client was told by the family member to turn to the ri"ht side and the client did this. .hat is the appropriate comment for the nurse to make? .hy don2t we now ha!e the client turn back to the left side. That was done correctly. %id you ha!e any problems with the insertion? >et2s check to see if the suppository is in far enou"h. %id you feel any stool in the intestinal tract? &e!iew Information' The correct answer is ' That was done correctly. %id you ha!e any problems with the insertion? >eft side-lyin" position is the optimal position for the client recei!in" rectal medications. %ue to the position of the descendin" colon+ left side-lyin" allows the medication to be inserted and mo!e alon" the natural cur!e of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 18 to 16 minutes. The other responses are incorrect since no data is in the stem to support such comments. 11. A client with a dia"nosis of $ethicillin resistant (taphylococcus aureus A$&(A) has died. .hich type of precautions is the appropriate type to use when performin" postmortem care? A) airborne precautions ) droplet precautions #) contact precautions %) compromised host precautions &e!iew Information' The correct answer is #' contact precautions The resistant bacteria remain ali!e for up to 4 days post death. Therefore+ contact precautions must still be implemented. Also label the body so that the funeral home staff can protect themsel!es as well. /own and "lo!es are re1uired. 1). The nurse is re!iewin" with a client how to collect a clean catch urine specimen. .hich se1uence is appropriate teachin"?

A) Boid a little+ clean the meatus+ then collect specimen ) clean the meatus+ be"in !oidin"+ then catch urine stream #) #lean the meatus+ then urinate into container %) Boid continuously and catch some of the urine &e!iew Information' The correct answer is ' clean the meatus+ be"in !oidin"+ then catch urine stream A clean catch urine is difficult to obtain and re1uires clear directions. Instructin" the client to carefully clean the meatus+ then !oid naturally with a steady stream pre!ents surface bacteria from contaminatin" the urine specimen. As startin" and stoppin" flow can be difficult+ once the client be"ins !oidin" it==s best to 3ust slip the container into the stream. ;ther responses are not correct techni1ue. 14. The pro!ider orders >ano7in Adi"o7in) 8.1)6 m" po and furosomide 48 m" e!ery day. .hich of these foods would the nurse reinforce for the client to eat at least daily? A) spa"hetti ) watermelon #) chicken %) tomatoes &e!iew Information' The correct answer is ' watermelon .atermelon is hi"h in potassium and will replace any potassium lost by the diuretic. The other foods are not hi"h in potassium. 14. A nurse is stuck in the hand by an e7posed needle. .hat immediate action should the nurse take? A) >ook up the policy on needle sticks ) #ontact employee health ser!ices #) Immediately wash the hands with !i"or %) Cotify the super!isor and risk mana"ement &e!iew Information' The correct answer is #' Immediately wash the hands with !i"or The immediate action of !i"orously washin" will help remo!e possible contamination. Then the se1uence would then be options 4+ 1+ ). 16. As the nurse obser!es the student nurse durin" the administration of a narcotic anal"esic I$ in3ection+ the nurse notes that the student be"ins to "i!e the medication without first aspiratin". .hat should the nurse do? A) Ask the student' ".hat did you for"et to do?D ) (top. Tell me why aspiration is needed. #) >oudly state' EFou for"ot to aspirate.D .alk up and whisper in the student2s ear E(top. Aspirate. Then %) in3ect.D &e!iew Information' The correct answer is %' .alk up and whisper in the student2s ear E(top. Aspirate. Then in3ect.D This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with I$ in3ections is to pre!ent the in3ection of the dru" directly into the blood stream. ;ption 4 protects the client and is the most professional. 1<. A client with /uillain arre is in a nonresponsi!e state+ yet !ital si"ns are stable and breathin" is independent. .hat should the nurse document to most accurately describe the client=s condition? A) #omatose+ breathin" unlabored ) /lascow #oma (cale ,+ respirations re"ular #) Appears to be sleepin"+ !ital si"ns stable %) /lascow #oma (cale 14+ no !entilator re1uired &e!iew Information' The correct answer is ' /lascow #oma (cale ,+ respirations re"ular The /lascow #oma (cale pro!ides a standard reference for assessin" or monitorin" le!el of consciousness. Any score less than 14 indicates a neurolo"ical impairment. *sin" the term comatose pro!ides too much room for interpretation and is not !ery precise. 1-. A client enters the emer"ency department unconscious !ia ambulance from the client2s work place. .hat document should be "i!en priority to "uide the direction of care for this client? The statement of client ri"hts and the client self determination act ;rders written by the health care pro!ider A notari5ed ori"inal of ad!ance directi!es brou"ht in by the partner The clinical pathway protocol of the a"ency and the emer"ency department &e!iew Information' The correct answer is #' A notari5ed ori"inal of ad!ance directi!es brou"ht in by the partner This document specifies the client==s wishes. 1,. The char"e nurse has a health care team that consists of 1 ?C+ 1 unlicensed assisti!e personnel A*A?) and 1 ?C nursin" student. .hich assi"nment should be 1uestioned by the nurse mana"er? An admission at the chan"e of shifts with atrial fibrillation and heart failure - ?C #lient who had a ma3or stroke < days a"o - ?C nursin" student A child with burns who has packed cells and albumin IB runnin" char"e nurse

An elderly client who had a myocardial infarction a week a"o - *A? &e!iew Information' The correct answer is A' An admission at the chan"e of shifts with atrial fibrillation and heart failure - ?C The care for a new admissions should be performed by an &C. (ince the client was admitted at the chan"e of shifts+ the stability of the client would not ha!e been established. The char"e nurse should take this client. The ?C could monitor the IB fluids in option #. Tasks that do not re1uire independent 3ud"ment should be dele"ated. The nurse may dele"ate the care for a stable client to a *A?. 19. A mother brin"s her 4 month-old into the clinic+ complainin" that the child seems to be spittin" up all the time and has a lot of "as. The nurse e7pects to find which of the followin" on the initial history and physical assessment? A) Increased temperature and lethar"y ) &estlessness and increased mucus production #) Increased sleepin" and listlessness %) %iarrhea and poor skin tur"or &e!iew Information' The correct answer is ' &estlessness and increased mucus production This infant could be e7periencin" "astroesopha"eal reflu7+ or could be aller"ic to the formula. &estlessness+ irritability and increased mucus production can de!elop if an aller"y is present. (oy based formula is often recommended. )8. As the nurse takes a history of a 4 year-old with neuroblastoma+ what comments by the parents re1uire follow-up and are consistent with the dia"nosis? A) "The child has been listless and has lost wei"ht." ) "The urine is dark yellow and small in amounts." #) "#lothes are becomin" ti"hter across her abdomen." %) ".e notice muscle weakness and some unsteadiness." &e!iew Information' The correct answer is #' "#lothes are becomin" ti"hter across her abdomen." ;ne of the most common si"ns of neuroblastoma is increased abdominal "irth. The parents== report that clothin" is ti"ht is si"nificant+ and should be followed by additional assessments. )1. A 1< year-old enters the emer"ency department. The tria"e nurse identifies that this teena"er is le"ally married and si"ns the consent form for treatment. .hat would be the appropriate action by the nurse? Ask the teena"er to wait until a parent or le"al "uardian can be contacted .ithhold treatment until telephone consent can be obtained from the partner &efer the teena"er to a community pediatric hospital emer"ency department ?roceed with the tria"e process in the same manner as any adult client &e!iew Information' The correct answer is %' ?roceed with the tria"e process in the same manner as any adult client $inors may become known as an "emancipated minor" throu"h marria"e+ pre"nancy+ hi"h school "raduation+ independent li!in" or ser!ice in the military. Therefore+ this client+ who is married+ has the le"al capacity of an adult. )). A newly admitted elderly client is se!erely dehydrated. .hen plannin" care for this client+ which task is appropriate to assi"n to an unlicensed assisti!e personnel A*A?)? #on!erse with the client to determine if the mucuous membranes are impaired &eport hourly outputs of less than 48 mlGhr $onitor client=s ability for mo!ement in the bed #heck skin tur"or e!ery 4 hours &e!iew Information' The correct answer is ' &eport output of less than 48 mlGhr .hen directin" a *A?+ the nurse must communicate clearly about each dele"ated task with specific instructions on what must be reported. ecause the &C is responsible for all care-related decisions+ only implementation tasks should be assi"ned because they do not re1uire independent 3ud"ment. )4. The nurse has admitted a 4 year-old with the dia"nosis of possible rheumatic fe!er. .hich statement by the parent would cause the nurse to suspect an association with this disease? ;ur child had chickenpo7 < months a"o. (trep throat went throu"h all the children at the day care last month. oth ears were infected o!er 4 months a"e. >ast week both feet had a fun"al skin infection. &e!iew Information' The correct answer is ' (trep throat went throu"h all the children at the day care last month. H!idence supports a stron" relationship between infection with /roup A streptococci and subse1uent rheumatic fe!er Ausually within ) to < weeks). Therefore+ the history of playmates reco!erin" from strep throat would indicate that the child dia"nosed with rheumatic fe!er most likely also had strep throat. (ometimes+ such an infection has no clinical symptoms. )4. A nurse assi"ned to a manipulati!e client for 6 days becomes aware of feelin"s for a reluctance to interact with the client. The ne7t action by the nurse should be to %iscuss the feelin" of reluctance with an ob3ecti!e peer or super!isor >imit contacts with the client to a!oid reinforcement of the manipulati!e beha!ior

#onfront the client about the ne"ati!e effects of beha!iors on other clients and staff %e!elop a beha!ior modification plan that will promote more functional beha!ior &e!iew Information' The correct answer is A' %iscuss the feelin" of reluctance with an ob3ecti!e peer or super!isor The nurse who e7periences stress in the therapeutic relationship can "ain ob3ecti!ity throu"h super!ision. The nurse must attempt to disco!er attitudes and feelin"s in the self that influence the nurseclient relationship. )6. A client is bein" treated for paranoid schi5ophrenia. .hen the client became loud and boisterous+ the nurse immediately placed him in seclusion as a precautionary measure. The client willin"ly complied. The nurse2s action A) $ay result in char"es of unlawful seclusion and restraint ) >ea!es the nurse !ulnerable for char"es of assault and battery #) .as appropriate in !iew of the client2s history of !iolence %) .as necessary to maintain the therapeutic milieu of the unit &e!iew Information' The correct answer is A' $ay result in char"es of unlawful seclusion and restraint (eclusion should only be used when there is an immediate threat of !iolence or threatenin" beha!ior to the staff+ the other clients+ or the client upon himself. )<. A client has been admitted to the #oronary #are *nit with a myocardial infarction. .hich nursin" dia"nosis should ha!e priority? A) ?ain related to ischemia ) &isk for altered elimination' constipation #) &isk for complication' dysrhythmias %) An7iety related to pain &e!iew Information' The correct answer is A' ?ain related to ischemia ?ain is related to ischemia+ and relief of pain will decrease myocardial o7y"en demands+ reduce blood pressure and heart rate and relie!e an7iety. ?ain also stimulates the sympathetic ner!ous system and increased preload+ further increasin" myocardial demands. )-. The pro!isions of the law for the Americans with %isabilities Act re1uire nurse mana"ers to A) $aintain an en!ironment free from associated ha5ards ) ?ro!ide reasonable accommodations for disabled indi!iduals #) $ake all necessary accommodations for disabled indi!iduals %) #onsider both mental and physical disabilities &e!iew Information' The correct answer is ' ?ro!ide reasonable accommodations for disabled indi!iduals The law is desi"ned to permit persons with disabilities access to 3ob opportunities. Hmployers must e!aluate an applicant2s ability to perform the 3ob and not discriminate on the basis of a disability. Hmployers also must make "reasonable accommodations." ),. A 4) year-old male client refuses to take propranolol hydrochloride AInderal) as prescribed. .hich client statement s from the assessment data is likely to e7plain his noncompliance? A) "I ha!e problems with diarrhea." ) "I ha!e difficulty fallin" asleep." #) "I ha!e diminished se7ual function." %) "I often feel 3ittery." &e!iew Information' The correct answer is #' "I ha!e diminished se7ual function." Inderal+ beta-blockin" a"ent used in hypertension+ prohibits the release of epinephrine into the cellsI this may result in hypotension which results in decreased libido and impotence. )9. A school-a"ed child has had a lon" le" Ahip to ankle) synthetic cast applied 4 hours a"o. .hich statement from the mother indicates that teachin" has been inade1uate? "I will keep the cast for the ne7t day unco!ered to pre!ent burnin" of the skin." "I can apply an ice pack o!er the area to relie!e itchin" inside the cast." "The cast should be propped on at least ) pillows when my child is lyin" down." "I think I remember that standin" cannot be done until after -) hours." &e!iew Information' The correct answer is %' "I think I remember that standin" cannot be done until after -) hours." Applyin" ice is a safe method of relie!in" the itchin". (ynthetic casts will typically set up in 48 minutes and dry in a few hours. Thus+ standin" can be done within the initial )4 hours. .ith plaster casts the set up and dryin" time+ especially in a lon" le" cast which is thicker than an arm cast+ can take up to -) hours to dry. oth types of cast "i!e off a lot of heat when dryin" and it is preferred to keep the cast unco!ered in the initial )4 hours. #lients may complain of chillin" from the wet cast and therefore can simply be co!ered li"htly with a sheet or blanket.

48. .hich statement best describes time mana"ement strate"ies applied to the role of a nurse mana"er? A) (chedule staff efficiently to co!er the needs on the mana"ed unit ) Assume a fair share of direct client care as a role model #) (et daily "oals with a prioriti5ation of the work %ele"ate tasks to reduce work load associated with direct care and %) meetin"s &e!iew Information' The correct answer is #' (et daily "oals with a prioriti5ation of the work Time mana"ement strate"ies include settin" "oals and prioriti5ation . This is similar to time mana"ement of direct care for clients 41. The pediatric clinic nurse e7amines a toddler with a tentati!e dia"nosis of neuroblastoma. 0indin"s obser!ed by the nurse that is associated with this problem include which of these? A) >ymphedema and ner!e palsy ) @earin" loss and ata7ia #) @eadaches and !omitin" %) Abdominal mass and weakness &e!iew Information' The correct answer is %' Abdominal mass and weakness #linical manifestations of neuroblastoma include an irre"ular abdominal mass that crosses the midline+ weakness+ pallor+ anore7ia+ wei"ht loss and irritability. 4). A 16 year-old client has been placed in a $ilwaukee race. .hich statement from the adolescent indicates the need for additional teachin"? A) "I will only ha!e to wear this for < months." ) "I should inspect my skin daily." #) "The brace will be worn day and ni"ht." %) "I can take it off when I shower." &e!iew Information' The correct answer is A' "I will only ha!e to wear this for < months." The brace must be worn lon"-term+ durin" periods of "rowth+ usually for 1 to ) years. It is used to correct cur!ature of the spine. 44. The nurse mana"er has been usin" a decentrali5ed block schedulin" plan to staff the nursin" unit. @owe!er+ staff ha!e asked for many chan"es and e7ceptions to the schedule o!er the past few months. The mana"er considers selfschedulin" knowin" that this method will A) Impro!e the 1uality of care ) %ecrease staff turno!er #) $inimi5e the amount of o!ertime payouts %) Impro!e team morale &e!iew Information' The correct answer is %' Impro!e team morale Curses are more satisfied when opportunites e7ist for autonomy and control. The nurse mana"er becomes the facilitator of schedulin" rather than the decisionmaker of the schedule when self-schedulin" e7ists. 44. A client is admitted to the emer"ency room followin" an acute asthma attack. .hich of the followin" assessments would be e7pected by the nurse? A) %iffuse e7piratory whee5in" ) >oose+ producti!e cou"h #) Co relief from inhalant %) 0e!er and chills &e!iew Information' The correct answer is A' %iffuse e7piratory whee5in" In asthma+ the airways are narrowed - creatin" difficulty "ettin" air in and a whee5in" sound. 46. The nurse mana"er hears a health care pro!ider loudly critici5e one of the staff nurses within the hearin" of others. The employee does not respond to the health care pro!ider=s complaints. The nurse mana"er=s ne7t action should be to .alk up to the health care pro!ider and 1uietly state' "(top this unacceptable beha!ior." Allow the staff nurse to handle this situation without interference Cotify the of the other administrati!e persons of a breech of professional conduct &e1uest an immediate pri!ate meetin" with the health care pro!ider and staff nurse &e!iew Information' The correct answer is %' &e1uest an immediate pri!ate meetin" with the health care pro!ider and staff nurse Asserti!e communication respects the needs of all parties to e7press themsel!es+ but not at the e7pense of others. The nurse mana"er needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. 4<. A client is admitted to a !oluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for ) days and now states EI demand to be released nowJD The appropriate action is for the nurse to A) Fou cannot be released because you are still suicidal. ) Fou can be released only if you si"n a no suicide contract. >et2s discuss your decision to lea!e and then we can prepare you #) for dischar"e. Fou ha!e a ri"ht to si"n out as soon as we "et an order from the %) health care pro!ider=s dischar"e order. &e!iew Information' The correct answer is #' >et2s discuss your decision to lea!e and then we can prepare you for dischar"e.

#lients !oluntarily admitted to the hospital ha!e a ri"ht to demand and obtain release. %iscussin" the decision initially allows an opportunity for other inter!entions. 4-. A client is admitted with infecti!e endocarditis AIH). .hich symptom would alert the nurse to a complication of this condition? A) %yspnea ) @eart murmur #) $acular rash %) @emorrha"e &e!iew Information' The correct answer is ' @eart murmur >ar"e+ soft+ rapidly de!elopin" !e"etations attach to the heart !al!es. They ha!e a tendency to break off+ causin" emboli and lea!in" ulcerations on the !al!e leaflets. These emboli produce symptoms of cardiac murmur+ fe!er+ anore7ia+ malaise and neurolo"ic se1uelae of emboli. 0urthermore+ the !e"etations may tra!el to !arious or"ans such as spleen+ kidney+ coronary artery+ brain and lun"s and obstruct blood flow. 4,. A nurse admits a premature infant who has respiratory distress syndrome. In plannin" care+ nursin" actions are based on the fact that the most likely cause of this problem stems from the infant=s inability to A) (tabili5e thermore"ulation ) $aintain al!eolar surface tension #) e"in normal pulmonary blood flow %) &e"ulate intracardiac pressure &e!iew Information' The correct answer is ' $aintain al!eolar surface tension &espiratory distress syndrome is primarily a disease related to the de!elopmental delay in lun" maturation. Althou"h many factors may lead to the de!elopment of the problem+ the central factor is the lack of a normally functionin" surfactant system in the al!eolar sac from immaturity in lun" de!elopment since the infant is premature. 49. An 1, year-old client is admitted to intensi!e care from the emer"ency room followin" a di!in" accident. The in3ury is suspected to be at the le!el of the )nd cer!ical !ertebrae. The nurse=s priority assessment should be A) &esponse to stimuli ) ladder control #) &espiratory function %) $uscle weakness &e!iew Information' The correct answer is #' &espiratory function (pinal in3ury at the #-) le!el results in 1uadriple"ia. .hile the client will e7perience all of the problems identified+ respiratory assessment is a priority. 48. The nurse is carin" for a client who was successfully resuscitated from a pulseless dysrhythmia. .hich of the followin" assessments is #&ITI#A> for the nurse to include in the plan of care? A) @ourly urine output ) .hite blood count #) lood "lucose e!ery 4 hours %) Temperature e!ery ) hours &e!iew Information' The correct answer is A' @ourly urine output #lients who ha!e had an episode of decreased "lomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces "lomerular perfusion. ?re-renal failure occurs when the effecti!e arterial blood !olume falls. H7amples of this phenomena include a drop in circulatin" blood !olume as in a cardiac arrest state or in low cardiac perfusion states such as con"esti!e heart failure associated with a cardiomyopathy. #lose obser!ation of hourly urinary output is necessary for early detection of this condition. 41. The char"e nurse on the ni"ht shift at an ur"ent care center has to deal with admittin" clients of a hi"her acuity than usual because of a lar"e fire in the area. .hich style of leadership and decision-makin" would be best in this circumstance? A) Assume a decision-makin" role ) (eek input from staff #) *se a non-directi!e approach %) (hared decision-makin" with others &e!iew Information' The correct answer is A' Assume a decisionmakin" role Authoritarian leadership assumes that decision-makin" is the role of the leader with little input by subordinates. This style is best used in emer"ency situations or as a tria"e nurse. 4). The nurse admittin" a 6 month-old who !omited 9 times in the past < hours should obser!e for si"ns of which o!erall imbalance? A) $etabolic acidosis ) $etabolic alkalosis #) (ome increase in the serum hema"lobin %) A little decrease in the serum potassium &e!iew Information' The correct answer is ' $etabolic alkalosis

Bomitin" causes loss of acid from the stomach. ?rolon"ed !omitin" can result in e7cess loss of acid and lead to metabolic alkalosis. ;ptions c and d are corrrect answers but not the best answer since they are too "eneral. 44. .hich acti!ity can the &C ask an unlicensed assisti!e personnel A*A?) to perform? A) Take a history on a newly admitted client ) Ad3ust the rate of a "astric tube feedin" #) #heck the blood pressure of a ) hours post operati!e client %) #heck on a client recei!in" chemotherapy &e!iew Information' The correct answer is #' #heck the blood pressure of a ) hours post operati!e client *A?s must be assi"ned tasks that re1uire no nursin" 3ud"ment or decision makin" situations. Bital si"ns on stable clients are commonly assi"ned to unlicensed staff. 44. A child is in3ured on the school play"round and appears to ha!e a fractured le". The first action the school nurse should take is A) #all for emer"ency transport to the hospital ) Immobili5e the limb and 3oints abo!e and below the in3ury #) Assess the child and the e7tent of the in3ury %) Apply cold compresses to the in3ured area &e!iew Information' The correct answer is #' Assess the child and the e7tent of the in3ury .hen applyin" the nursin" process+ assessment is the first step in pro!idin" care. The 6 "?s" of !ascular impairment can be used as a "uide Apain+ pulse+ pallor+ paresthesia+ paralysis). 46. .hen inter!iewin" the parents of a child with asthma+ it is most important to "ather what information about the child=s en!ironment? A) @ousehold pets ) Cew furniture #) >ead based paint %) ?lants such as cactus &e!iew Information' The correct answer is A' @ousehold pets Animal dander is a !ery common aller"en affectin" persons with asthma. ;ther tri""ers may include pollens+ carpetin" and household dust. 4<. An ,8 year-old client admitted with a dia"nosis of possible cerebral !ascular accident has had a blood pressure from 1,8G118 to 1<8G188 o!er the past ) hours. The nurse has also noted increased lethar"y. .hich assessment findin" should the nurse report immediately to the health care pro!ider? A) (lurred speech ) Incontinence #) $uscle weakness %) &apid pulse &e!iew Information' The correct answer is A' (lurred speech #han"es in speech patterns and le!el of conscious can be indicators of continued intercranial bleedin" or e7tension of the stroke. 0urther dia"nostic testin" may be indicated. 4-. A 4 year-old child is brou"ht to the clinic by his "randmother to be seen for "scratchin" his bottom and wettin" the bed at ni"ht." ased on these complaints+ the nurse would initially assess for which problem? A) Aller"ies ) (cabies #) &e"ression %) ?inworms &e!iew Information' The correct answer is %' ?inworms (i"ns of pinworm infection include intense perianal itchin"+ poor sleep patterns+ "eneral irritability+ restlessness+ bed-wettin"+ distractibility and short attention span. (cabies is an itchy skin condition caused by a tiny+ ei"ht-le""ed burrowin" mite called (arcoptes scabiei . The presence of the mite leads to intense itchin" in the area of its burrows. 4,. A -) year-old client with osteomyelitis re1uires a < week course of intra!enous antibiotics. In plannin" for home care+ what is the most important action by the nurse? In!esti"atin" the client=s insurance co!era"e for home IB antibiotic A) therapy %eterminin" if there are ade1uate hand washin" facilities in the ) home Assessin" the client=s ability to participate in self care andGor the #) reliability of a care"i!er %) (electin" the appropriate !enous access de!ice &e!iew Information' The correct answer is #' Assessin" the client==s ability to participate in self care andGor the reliability of a care"i!er The co"niti!e ability of the client as well as the a!ailability and reliability of a care"i!er must be assessed to determine if home care is a feasible option. 49. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of ha!in" another baby with a neural tube defect. .hat is the best response by the nurse? A) "0olic acid should be taken before and after conception." ) "$ulti!itamin supplements are recommended durin" pre"nancy." #) "A well balanced diet promotes normal fetal de!elopment." %) "Increased dietary iron impro!es the health of mother and fetus."

&e!iew Information' The correct answer is A' "0olic acid should be taken before and after conception." The American Academy of ?ediatrics recommends that all childbearin" women increase folic acid from dietary sources andGor supplements. There is e!idence that increased amounts of folic acid pre!ents neural tube defects. 68. A ?C is assi"ned to care for a newborn with a neural tube defect. .hich dressin" if applied by the ?C would need no further inter!ention by the char"e nurse? A) Telfa dressin" with antibiotic ointment ) $oist sterile nonadherent dressin" #) %ry sterile dressin" that is occlusi!e %) (terile occlusi!e pressure dressin" &e!iew Information' The correct answer is ' $oist sterile nonadherent dressin" efore sur"ical closure the sac is pre!ented from dryin" by the application of a sterile+ moist+ nonadherent dressin" o!er the defect. %ressin"s are chan"ed fre1uently to keep them moist. 61. A nurse is pro!idin" a parentin" class to indi!iduals li!in" in a community of older homes. In discussin" formula preparation+ which of the followin" is most important to pre!ent lead poisonin"? A) *se ready-to-feed commercial infant formula ) oil the tap water for 18 minutes prior to preparin" the formula #) >et tap water run for ) minutes before addin" to concentrate %) uy bottled water labeled "lead free" to mi7 the formula &e!iew Information' The correct answer is #' >et tap water run for ) minutes before addin" to concentrate *se of lead-contaminated water to prepare formula is a ma3or source of poisonin" in infants. %rinkin" water may be contaminated by lead from old lead pipes or lead solder used in sealin" water pipes. >ettin" tap water run for se!eral minutes will diminish the lead contamination. 6). A client is admitted to the rehabilitation unit followin" a #BA and mild dyspha"ia. The most appropriate inter!ention for this client is K A) ?osition client in upri"ht position while eatin" ) ?lace client on a clear li1uid diet #) Tilt head back to facilitate swallowin" refle7 %) ;ffer fin"er foods such as crackers or pret5els &e!iew Information' The correct answer is A' ?osition client in upri"ht position while eatin" An upri"ht position facilitates proper chewin" and swallowin". 64. The nurse e7plains an auto"raft to a client scheduled for e7cision of a skin tumor. The nurse knows the client understands the procedure when the client says+ "I will recei!e tissue fromL A) a tissue bank." ) a pi"." #) my thi"h." %) synthetic skin." &e!iew Information' The correct answer is #' my thi"h." Auto"rafts are done with tissue transplanted from the client==s own skin. 64. The nurse is carin" for a newborn with tracheoesopha"eal fistula. .hich nursin" dia"nosis is a priority? A) &isk for dehydration ) Ineffecti!e airway clearance #) Altered nutrition %) &isk for in3ury &e!iew Information' The correct answer is ' Ineffecti!e airway clearance The most common form of TH0 is one in which the pro7imal esopha"eal se"ment terminates in a blind pouch and the distal se"ment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus+ a priority is maintainin" an open airway+ pre!entin" aspiration. ;ther nursin" dia"noses are then addressed. 66. A client has been hospitali5ed after an automobile accident. A full le" cast was applied in the emer"ency room. The most important reason for the nurse to ele!ate the casted le" is to A) ?romote the client=s comfort ) &educe the dryin" time #) %ecrease irritation to the skin %) Impro!e !enous return &e!iew Information' The correct answer is %' Impro!e !enous return Hle!atin" the le" both impro!es !enous return and reduces swellin". 6<. %urin" the initial home !isit a nurse is discussin" the care of a newly dia"nosed client with Al5heimer=s disease with family members. .hich of these inter!entions would be most helpful at this time? A) >ea!e a book about rela7ation techni1ues ) .rite out a daily e7ercise routine for them to assist the client to do

#) >ist actions to impro!e the client=s daily nutritional intake %) (u""est communication strate"ies &e!iew Information' The correct answer is %' (u""est communication strate"ies Al5heimer==s disease+ a pro"ressi!e chronic illness "reatly challen"es care"i!ers. %urin" the initial !isit the nurse can be of "reatest assistance in helpin" family to use communication strate"ies to enable identification of lan"ua"e chan"es in the client. y use of select !erbal and non!erbal communication strate"ies the client2s aberrant beha!ior may be minimi5ed. 6-. The nurse is teachin" a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) $aintain pre!ious calorie intake ) Meep a candy bar a!ailable at all times #) &educe carbohydrates intake to )6: of total calories %) Meep a re"ular schedule of meals and snacks &e!iew Information' The correct answer is %' Meep a re"ular schedule of meals and snacks #urrently+ calorie-controlled diets with strict meal plans are rarely su""ested for clients who ha!e diabetes. Try to incorporate schedule or food chan"es into clients== e7istin" dietary patterns. @elp clients learn to read labels and identify specific canned foods+ fro5en entrees+ or other foods which are acceptable and those which should be a!oided. 6,. The mother of a ) month-old baby calls the nurse ) days after the first %Ta?+ I?B+ @epatitis and @I immuni5ations. (he reports that the baby feels !ery warm+ cries inconsolably for as lon" as 4 hours+ and has had se!eral shakin" spells. In addition to referrin" her to the emer"ency room+ the nurse should document the reaction on the baby=s record and e7pect which immuni5ation to be most associated to the findin"s in the infant? A) %Ta? ) @epatitis #) ?olio %) @. Influen5a &e!iew Information' The correct answer is A' %Ta? The ma3ority of reactions occur with the administration of the %Ta? !accination. #ontradictions to "i!in" repeat %Ta? immuni5ations include the occurrence of se!ere side effects after a pre!ious dose as well as si"ns of encephalopathy within - days of the immuni5ation. 69. The nurse is teachin" a class on @IB pre!ention. .hich of the followin" should be emphasi5ed as increasin" risk? A) %onatin" blood ) *sin" public bathrooms #) *nprotected se7 %) Touchin" a person with AI%( &e!iew Information' The correct answer is #' *nprotected se7 ecause @IB is spread throu"h e7posure to bodily fluids+ unprotected intercourse and shared dru" paraphernalia remain the hi"hest risk for infection. <8. The char"e nurse is plannin" assi"nments on a medical unit. .hich client should be assi"ned to the unlicensed assisti!e presonnel A*A?)? A client with A) %ifficulty swallowin" after a mild stroke ) an order of enemas until clear prior to colonoscopy #) an order for a post-op abdominal dressin" chan"e %) transfer orders to a lon" term facility &e!iew Information' The correct answer is ' an order of enemas until clear prior to colonoscopy The *A? can be assi"ned routine tasks which ha!e predictable outcomes. <1. A < year-old child is seen for the first time in the clinic. *pon assessment+ the nurse finds that the child has deformities of the 3oints+ limbs+ and fin"ers+ thinned upper lip+ and small teeth with faulty enamel. The mother states' D$y child seems to ha!e problems in learnin" to count and reco"ni5in" basic colors.D ased on this data+ the nurse suspects that the child is most likely showin" the effects of which problem? A) #on"enital abnormalities ) #hronic to7oplasmosis #) 0etal alcohol syndrome %) >ead poisonin" &e!iew Information' The correct answer is #' 0etal alcohol syndrome $a3or features of fetal alcohol syndrome consist of facial and associated physical features+ such as small head circumference and brain si5e Amicrocephaly)+ small eyelid openin"s+ a sunken nasal brid"e+ an e7ceptionally thin upper lip+ a short+ upturned nose and a smooth skin surface between the nose and upper lip. Bision difficulties include nearsi"htedness Amyopia). ;ther findin"s are mental retardation+ delayed de!elopment+ abnormal beha!ior such as short attention span+ hyperacti!ity+ poor impulse control+ e7treme ner!ousness and an7iety. $any beha!ioral problems+ co"niti!e impairment and psychosocial deficits are also associated with this syndrome. <). The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. .hich assessment findin" would cause the nurse to call the health care pro!ider immediately? A) ?rolon"ed inspiration with each breath ) H7piratory whee5es that are suddenly absent in 1 lobe #) H7pectoration of lar"e amounts of purulent mucous

%) Appearance of the use of abdominal muscles for breathin" &e!iew Information' The correct answer is ' H7piratory whee5es that are suddenly absent in one lobe Acute asthma is characteri5ed by e7piratory whee5es caused by obstruction of the airways. .hee5es are a hi"h pitched musical sounds produced by air mo!in" throu"h narrowed airways. #lients often associate whee5es with the feelin" of ti"htness in the chest. @owe!er+ sudden cessation of whee5in" is an omnious or bad si"n that indicates an emer"ency in that the small airways are now collasped. <4. The nurse is plannin" a meal plan that would pro!ide the most iron for a child with anemia. .hich dinner menu would be best? A) 0ish sticks+ french fries+ banana+ cookies+ milk ) /round beef patty+ lima beans+ wheat roll+ raisins+ milk #) #hicken nu""ets+ macaroni+ peas+ cantaloupe+ milk %) ?eanut butter and 3elly sandwich+ apple slices+ milk &e!iew Information' The correct answer is ' /round beef patty+ lima beans+ wheat roll+ raisins+ milk Iron rich foods include red meat+ fish+ e"" yolks+ "reen leafy !e"etables+ le"umes+ whole "rains+ and dried fruits such as raisins. This dinner is the best choice+ hi"h in iron and is appropriate for a toddler. <4. A 18 year-old client is reco!erin" from a splenectomy followin" a traumatic in3ury. The clients laboratory results show a hemo"lobin of 9 "Gd> and a hematocrit of ), percent. The best approach for the nurse to use is to A) >imit milk and milk products ) Hncoura"e bed acti!ities and "ames #) ?lan nursin" care around len"thy rest periods %) ?romote a diet rich in iron &e!iew Information' The correct answer is #' ?lan nursin" care around len"thy rest periods The initial priority for this client is rest due to the inability of red blood cells to carry o7y"en. <6. The nurse plannin" care for a 1) year-old child with sickle cell disease in a !aso-occlusi!e crisis of the elbow should include which one of the followin" as a priority? A) >imit fluids ) #lient controlled anal"esia #) #old compresses to elbow %) ?assi!e ran"e of motion e7ercise &e!iew Information' The correct answer is ' #lient controlled anal"esia $ana"ement of a crisis is directed towards supporti!e and symptomatic treatment. The priority of care is pain relief. In a 1) year-old child+ client controlled anal"esia promotes ma7imum comfort. <<. As the nurse pro!ides dischar"e teachin" to the parents of a 16 month-old child with Mawasaki disease. The child has recei!ed immuno"lobulin therapy. .hich instruction would be appropriate? A) @i"h doses of aspirin will be continued for some time ) #omplete reco!ery is e7pected within se!eral days #) Acti!e ran"e of motion e7ercises should be done fre1uently %) The measles+ mumps and rubella !accine should be delayed &e!iew Information' The correct answer is %' The measles+ mumps and rubella !accine should be delayed %ischar"e instructions for a child with Mawasaki %isease should include immuno"lobulin therapy may interfere with the body==s ability to form appropriate amounts of antibodies and li!e immuni5ations should be delayed. <-. The nurse is "i!in" instructions to the parents of a child with cystic fibrosis. The nurse would emphasi5e that pancreatic en5ymes should be taken A) ;nce each day ) 4 times daily after meals #) .ith each meal or snack %) Hach time carbohydrates are eaten &e!iew Information' The correct answer is #' .ith each meal or snack ?ancreatic en5ymes should be taken with each meal and e!ery snack to allow for di"estion of all foods that are eaten. <,. The nurse is assessin" an , month-old infant with a malfunctionin" !entriculoperitoneal shunt. .hich one of the followin" manifestations would the infant be most likely to e7hibit? A) >ethar"y ) Irritability #) Ce"ati!e $oro %) %epressed fontanel &e!iew Information' The correct answer is ' Irritability (i"ns of II#? Aincreased intracranial pressure) in infants include bul"in" fontanel+ instability+ hi"h-pitched cry+ and cries when held.

Bital si"n chan"es include pulse that is !ariable+ i.e.+ rapid+ slow and boundin"+ or feeble. &espirations are more often slow+ deep+ and irre"ular. <9. The nurse is performin" a physical assessment on a toddler. .hich of the followin" should be the first action? A) ?erform traumatic procedures ) *se minimal physical contact #) ?roceed from head to toe %) H7plain the e7am in detail &e!iew Information' The correct answer is ' *se minimal physical contact The nurse should approach the toddler slowly and use minimal physical contact initially so as to "ain the toddler==s cooperation. e fle7ible in the se1uence of the e7am+ and "i!e only brief simple e7planations 3ust prior to the action. -8. A client has been tentati!ely dia"nosed with /ra!es= disease Ahyperthyroidism). .hich of these findin"s noted on the initial nursin" assessment re1uires 1uick inter!ention by the nurse? A) A report of 18 pounds wei"ht loss in the last month ) A comment by the client "I 3ust can=t sit still." The appearance of eyeballs that appear to "pop" out of the client=s #) eye sockets %) A report of the sudden onset of irritability in the past ) weeks &e!iew Information' The correct answer is #' The appearance of eyeballs that appear to "pop" out of the client==s eye sockets H7ophthalmos or protrudin" eyeballs is a distincti!e characteristic of /ra!es== %isease. It can result in corneal abrasions with se!ere eye pain or dama"e when the eyelid is unable to blink down o!er the protrudin" eyeball. Hye drops or ointment may be needed. -1. .hich serum blood findin"s with diabetic ketoacidosis alerts the nurse that immediate action is re1uired? A) p@ below -.4 ) ?otassium of 6.8 #) @#T of <8 %) ?a ;) of -9: &e!iew Information' The correct answer is #' @#T of <8 This hi"h @#T is indicati!e of se!ere dehydration which re1uires priority attention in diabetic ketoacidosis. .ithout sufficient hydration all systems of the body are at risk for hypo7ia from a lack of or slu""ish circulation. In the absence of insulin+ which facilitates the transport of "lucose into the cell+ the body breaks down fats and proteins to supply ener"y ketones+ a by-product of fat metabolism. These accumulate causin" metabolic acidosis Ap@ N -.4)+ which would be the second concern for this client. The potassium and ?a;) are near normal. -). The nurse is preparin" the teachin" plan for a "roup of parents about risks to toddlers. The nurse plans to e7plain proper communication in the e!ent of accidental poisonin". The nurse should plan to tell the parents to first state what substance was in"ested and then what information should be the priority for the parents to communicate? A) The parents= name and telephone number ) The currency of the immuni5ation and aller"y history of the child The estimated time of the accidental poisonin" and a confirmation #) that the parents will brin" the containers of the in"ested substance %) The affected child=s a"e and wei"ht &e!iew Information' The correct answer is %' The affected child==s a"e and wei"ht All of the abo!e information is important. @owe!er+ once the substance is stated the a"e and wei"ht is a priority. This "i!es the appropriate healthcare pro!iders an opportunity to calculate the needed dosa"e for an antidote while the child is bein" transported to the emer"ency department. After this information+ the time of the accidental poisonin" is ne7t in importance to report. -4. A ) year-old child is brou"ht to the health care pro!ider=s office with a chief complaint of mild diarrhea for ) days. Cutritional counselin" by the nurse should include which statement? A) ?lace the child on clear li1uids and "elatin for )4 hours ) #ontinue with the re"ular diet and include oral rehydration fluids #) /i!e bananas+ apples+ rice and toast as tolerated %) ?lace C?; for )4 hours+ then rehydrate with milk and water &e!iew Information' The correct answer is ' #ontinue with the re"ular diet and include oral rehydration fluids #urrent recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids. -4. The nurse is teachin" an elderly client how to use $%I=s Amulti-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. .hat is the nurse=s best recommendation to impro!e deli!ery of the medication? A) Cebuli5ed treatments for home care ) Addin" a spacer de!ice to the $%I canister #) Askin" a family member to assist the client with the $%I %) &e1uest a !isitin" nurse to follow the client at home &e!iew Information' The correct answer is ' Addin" a spacer de!ice to the $%I canister If the client is not usin" the $%I properly+ the medication can "et trapped in the upper airway+ resultin" in dry mouth and throat irritation. *sin" a spacer will allow

more dru" to be deposited in the lun"s and less in the mouth. It is especially useful in the elderly because it allows more time to inhale and re1uires less eye-hand coordination. -6. .hich of the followin" manifestations obser!ed by the school nurse confirms the presence of pediculosis capitis in students? A) (cratchin" the head more than usual ) 0lakes e!ident on a student=s shoulders #) ;!al pattern occipital hair loss %) .hitish o!al specks stickin" to the hair &e!iew Information' The correct answer is %' .hitish o!al specks stickin" to the hair %ia"nosis of pediculosis capitis is made by obser!ation of the white e""s Anits) firmly attached to the hair shafts. Treatment includes shampoo application+ such as lindane for children o!er ) years of a"e+ and meticulous combin" and remo!al of all nits. -<. .hen parents call the emer"ency room to report that a toddler has swallowed drain cleaner+ the nurse instructs them to call for emer"ency transport to the hospital. .hile waitin" for an ambulance+ the nurse would su""est for the parents to "i!e sips of which substance? A) Tea ) .ater #) $ilk %) (oda &e!iew Information' The correct answer is ' .ater (mall amounts of water will dilute the corrosi!e substance prior to "astric la!a"e. --. A client is scheduled for an IB? AIntra!enous ?yelo"ram). .hich of the followin" data from the client2s history indicate a potential ha5ard for this test? A) &efle7 incontinence ) Aller"ic to shellfish #) #laustrophobia %) @ypertension &e!iew Information' The correct answer is ' Aller"ic to shellfish It is important to know if the client has an aller"y to iodine or shellfish. If the client does+ they may ha!e an aller"ic reaction to the IB? contrast dye in3ected durin" the procedure. -,. The nurse is preparin" a handout on infant feedin" to be distributed to families !isitin" the clinic. .hich notation should be included in the teachin" materials? A) (olid foods are introduced 1 at a time be"innin" with cereal ) 0inely "round meat should be started early to pro!ide iron #) H"" white is added early to increase protein intake %) (olid foods should be mi7ed with formula in a bottle &e!iew Information' The correct answer is A' (olid foods are introduced 1 at a time be"innin" with cereal (olid foods should be added 1 at a time between 4-< months. If the infant is able to tolerate the food+ another may be added in a week. Iron fortified cereal is the recommended first food. -9. The nurse is carin" for a client with sickle cell disease who is scheduled to recei!e a unit of packed red blood cells. .hich of the followin" is an appropriate action for the nurse when administerin" the infusion? (torin" the packed red cells in the medicine refri"erator while A) startin" IB ) (low the rate of infusion if the client de!elops fe!er or chills #) >imit the infusion time of each of the unit to a ma7imum of 4 hours %) Assess !ital si"ns e!ery 16 minutes throu"hout the entire infusion &e!iew Information' The correct answer is #' >imit the infusion time of each of the unit to a ma7imum of four hours Infuse the specified amount of blood within 4 hours. If the infusion will e7ceed this time+ the blood should be di!ided into appropriately si5ed 1uantities. ,8. A client with a documented pulmonary embolism has the followin" arterial blood "ases' ?;) - -8 mm h"+ ?#;) - 4) mm h"+ p@ - -.46+ (a;) - ,-:+ @#;4 - )). ased on this data+ what is the first nursin" action? A) &e!iew other lab data ) Cotify the health care pro!ider #) Administer o7y"en %) #alm the client &e!iew Information' The correct answer is #' Administer o7y"en The client has a low ?#;) due to increased respiratory rate from the hypo7emia and si"ns of respiratory alkalosis. Immediate inter!ention is indicated. ,1. A client dia"nosed with hepatitis # discusses his health history with the admittin" nurse. The nurse should reco"ni5e which statement by the client as the most important? A) I "ot back from #entral America a few weeks a"o.

) I had the best raw oysters last week. #) I ha!e many different se7 partners. %) I had a blood transfusion 16 years a"o. &e!iew Information' The correct answer is %' I had a blood transfusion 16 years a"o. The client who was transfused prior to blood screenin" for hepatitis # may show findin"s many years later. ;ptions b and c are associated with risk of hepatitis . ,). A client is reco!erin" from a thyroidectomy. .hile monitorin" the client=s initial post operati!e condition+ which of the followin" should the nurse report immediately? A) Tetany and paresthesia ) $ild stridor and hoarseness #) Irritability and insomnia %) @eadache and nausea &e!iew Information' The correct answer is A' Tetany and paresthesia ecause the parathyroid "land may be dama"ed in this sur"ery+ secondary hypocalcemia may occur. 0indin"s of hypoparathyroidism include tetany+ paresthesia+ muscle cramps and sei5ures. ,4. A client is admitted with a ri"ht upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? A) Ce"ati!e room !entilation ) 0ace mask with sheild #) ?articulate respirator mask %) Airborne precautions &e!iew Information' The correct answer is #' ?articulate respirator mask Ti"ht fittin"+ hi"h-efficiency masks are re1uired when carin" for clients who ha!e suspected communicable disease of the airborne !ariety. ,4. A client had )8 m" of >asi7 Afurosemide) ?; at 18 A$. .hich would be essential for the nurse to include at the chan"e of shift report? A) The client lost ) pounds in )4 hours ) The client2s potassium le!el is 4 mH1Gliter. #) The client2s urine output was 1688 cc in 6 hours %) The client is to recei!e another dose of >asi7 at 18 ?$ &e!iew Information' The correct answer is #' The client2s urine output was 1688 cc in fi!e hours Althou"h all of these may be correct information to include in report+ the essential piece would be the urine output. ,6. The nurse is carin" for a client with a colostomy. %urin" a teachin" session+ the nurse recommends that the pouch be emptied A) .hen it is 1G4 to 1G) full ) ?rior to meals #) After each fecal elimination %) At the same time each day &e!iew Information' The correct answer is A' .hen it is 1G4 to 1G) full If the pouch becomes more than half full it may separate from the flan"e. ,<. >actulose A#hronulac) has been prescribed for a client with ad!anced li!er disease. .hich of the followin" assessments would the nurse use to e!aluate the effecti!eness of this treatment? A) An increase in appetite ) A decrease in fluid retention #) A decrease in lethar"y %) A reduction in 3aundice &e!iew Information' The correct answer is #' A decrease in lethar"y >actulose produces and acid en!ironment in the bowel and traps ammonia in the "utI the la7ati!e effect then aids in remo!in" the ammonia from the body. This decreases the effects of hepatic encephalopathy+ includin" lethar"y and confusion. ,-. The mother of a 4 month-old infant tells the nurse that she wants to chan"e from formula to whole milk and add cereal and meats to the diet. .hat should be emphasi5ed as the nurse teaches about infant nutrition? A) (olid foods should be introduced at 4-4 months ) .hole milk is difficult for a youn" infant to di"est #) 0luoridated tap water should be used to dilute milk %) (upplemental apple 3uice can be used between feedin"s &e!iew Information' The correct answer is ' .hole milk is difficult for a youn" infant to di"est #ow==s milk is not "i!en to infants youn"er than 1 year because the tou"h+ hard curd is difficult to di"est. Also it contains little iron and creates a hi"h renal solute load. ,,. The nurse is assessin" a 66 year-old female client who is scheduled for abdominal sur"ery. .hich of the followin" information would indicate that the client is at risk for thrombus formation in the post-operati!e period? A) Hstro"en replacement therapy ) 18: less than ideal body wei"ht #) @ypersensiti!ity to heparin %) @istory of hepatitis &e!iew Information' The correct answer is A' Hstro"en replacement therapy Hstro"en increases the hypercoa"ualability of the blood and increased the risk for de!elopment of thrombophlebitis.

,9. The nurse is plannin" dischar"e for a 98 year-old client with musculo-skeletal weakness. .hich inter!ention should be included in the plan and would be most effecti!e for the pre!ention of falls? A) ?lace ni"htli"hts in the bedroom ) .ear eye"lasses at all times #) Install "rab bars in the bathroom %) Teach muscle stren"thenin" e7ercises &e!iew Information' The correct answer is A' ?lace ni"htli"hts in the bedroom ecause more falls occur in the bedroom than any other location+ be"in there. @owe!er+ work in partnership with the client and family so they are willin" to mo!e furniture+ lamp cords+ and stora"e areasI add li"htin"I remo!e throw ru"sI and decrease other en!ironmental ha5ards. 98. An , year-old client is admitted to the hospital for sur"ery. The child2s parent reports the followin" aller"ies. ;f these aller"ies which one should all health care personnel be aware of? A) (hellfish ) $olds #) alloons %) ?erfumed soap &e!iew Information' The correct answer is #' alloons Aller"y to balloons indicates a late7 aller"y. All personnel in contact with the child will need to be aware of this condition and use nonlate7 "lo!es. 91. The nurse is carin" for a client who is post-op followin" a thoracotomy. The client has ) chest tubes in place+ connected to 1 chest drain. The nursin" assessment re!eals bubblin" in the water seal chamber when the client cou"hs. .hat is the most appropriate nursin" action? A) #lamp the chest tube ) #all the sur"eon immediately #) #ontinue to monitor the client to see if the bubblin" increases %) Instruct the client to try to a!oid cou"hin" &e!iew Information' The correct answer is #' #ontinue to monitor the client to see if the bubblin" increases ubblin" associated with cou"hin" after lun" sur"ery is to be e7pected as small amounts of air escape the pleural space when pressures inside the chest increase with cou"hin". $onitorin" is the only nursin" action re1uired. 9). The nurse is reinforcin" teachin" to a )4 year-old woman recei!in" acyclo!ir AOo!ira7) for a @erpes (imple7 Birus type ) infection. .hich of these instructions should the nurse "i!e the client? A) #omplete the entire course of the medication for an effecti!e cure e"in treatment with acyclo!ir at the onset of symptoms of ) recurrence (top treatment if she thinks she may be pre"nant to pre!ent birth #) defects #ontinue to take prophylactic doses for at least 6 years after the %) dia"nosis &e!iew Information' The correct answer is ' e"in treatment with acyclo!ir at the onset of symptoms of recurrence .hen the client is aware of early symptoms+ such as pain+ itchin" or tin"lin"+ treatment is !ery effecti!e. $edications for herpes simples do not cure the diseaseI they simply decrease the le!el of symptoms. 94. An , year-old child is hospitali5ed durin" the edema phase of minimal chan"e nephrotic syndrome. The nurse is assistin" in choosin" the lunch menu. .hich menu is the best choice? A) olo"na sandwich+ puddin"+ milk ) 0rankfurter+ baked potato+ milk #) #hicken strips+ corn on the cob+ milk %) /rilled cheese sandwich+ apple+ milk &e!iew Information' The correct answer is #' #hicken strips+ corn on the cob+ milk This menu is lowest in sodium. Ideally+ low fat milk would be a!ailable. 94. The nurse is teachin" parents about accidental poisonin" in children. .hich point should be emphasi5ed? A) #all the ?oison #ontrol #enter once the situation is identified ) Hmpty the child=s mouth in any case of possible poisonin" #) @a!e the child mo!e minimally if a to7ic substance was inhaled %) %o not induce !omitin" if the poison is a hydrocarbon &e!iew Information' The correct answer is ' Hmpty the child==s mouth in any case of possible poisonin" Hmptyin" the mouth of poison interferes with further in"estion and should be done first to limit contact with the substance. Cote that all of the actions are correct. @owe!er option is the priority to emphasi5e. 96. .hich of the followin" findin"s contraindicate the use of haloperidol A@aldol) and warrant withholdin" the dose?

A) %rowsiness+ lethar"y+ and inacti!ity ) %ry mouth+ nasal con"estion+ and blurred !ision #) &ash+ blood dyscrasias+ se!ere depression %) @yper"lycemia+ wei"ht "ain+ and edema &e!iew Information' The correct answer is #' &ash+ blood dyscrasias+ se!ere depression &ash and blood dyscrasias are side effects of anti-psychotic dru"s. A history of se!ere depression is a contraindication to the use of neuroleptics. 9<. The nurse is plannin" care for a 14 year-old client returnin" from scoliosis correcti!e sur"ery. .hich of the followin" actions should recei!e priority in the plan? A) Antibiotic therapy for 18 days ) Teach client isometric e7ercises for le"s #) Assess mo!ement and sensation of e7tremities %) Assist to stand up at bedside within the first )4 hours &e!iew Information' The correct answer is #' Assess mo!ement and sensation of e7tremities 0ollowin" correcti!e sur"ery for scoliosis+ neurolo"ical status re1uires special attention and assessment+ especially that of the e7tremities. 9-. A 4 year-old child dia"nosed as ha!in" celiac disease attends a day care center. .hich of the followin" would be an appropriate snack? A) #heese crackers ) ?eanut butter sandwich #) ?otato chips %) Banilla cookies &e!iew Information' The correct answer is #' ?otato chips #hildren with celiac disease should eat a "luten free diet. /luten is found mainly in "rains of wheat and rye and in smaller 1uantities in barley and oats. #orn+ rice+ soybeans and potatoes are di"estible in persons with celiac disease. 9,. A client with moderate persistent asthma is admitted for a minor sur"ical procedure. ;n admission the peak flow meter is measured at 4,8 litersGminute. ?ost-operati!ely the client is complainin" of chest ti"htness. The peak flow has dropped to )88 litersGminute. .hat should the nurse do first? A) Cotify the health care pro!ider ) Administer the prn dose of Albuterol #) Apply o7y"en at ) liters per nasal cannula %) &epeat the peak flow readin" in 48 minutes &e!iew Information' The correct answer is ' Administer the prn dose of Albuterol ?eak flow monitorin" durin" e7acerbations of asthma is recommended for clients with moderate-to-se!ere persistent asthma to determine the se!erity of the e7acerbation and to "uide the treatment. A peak flow readin" of less than 68: of the client==s baseline readin" is a medical alert condition and a short-actin" betaa"onist must be taken immediately. 99. .hat findin" si"nifies that children ha!e attained the sta"e of concrete operations A?ia"et)? A) H7plores the en!ironment with the use of si"ht and mo!ement ) Thinks in mental ima"es or word pictures #) $akes the moral 3ud"ement that "stealin" is wron"" %) &easons that homework is time-consumin" yet necessary &e!iew Information' The correct answer is #' $akes the moral 3ud"ment that "stealin" is wron"" The sta"e of concrete operations is depicted by lo"ical thinkin" and moral 3ud"ments. 188. The nurse is carin" for a 1- month-old with acetaminophen poisonin". .hich of the followin" lab reports should the nurse re!iew first? A) ?rotime A?T) and partial thromboplastin time A?TT) ) &ed blood cell and white blood cell counts #) lood urea nitro"en and creatinine clearance %) >i!er en5ymes AA(T and A>T) &e!iew Information' The correct answer is %' >i!er en5ymes AA(T and A>T) ecause acetaminophen is to7ic to the li!er and causes hepatic cellular necrosis+ li!er en5ymes are released into the blood stream and serum le!els of those en5ymes rise. ;ther lab !alues are re!iewed as well. 181. The nurse is teachin" parents about diet for a 4 month-old infant with "astroenteritis and mild dehydration. In addition to oral rehydration fluids+ the diet should include A) 0ormula or breast milk ) roth and tea #) &ice cereal and apple 3uice %) /elatin and "in"er ale &e!iew Information' The correct answer is A' 0ormula or breast milk The usual diet for a youn" infant should be followed. 18). The nurse instructs the client takin" de7amethasone A%ecadron) to take it with food or milk. .hat is the physiolo"ical basis for this instruction? A) &etards pepsin production ) (timulates hydrochloric acid production #) (lows stomach emptyin" time %) %ecreases production of hydrochloric acid

&e!iew Information' The correct answer is ' (timulates hydrochloric acid production %ecadron increases the production of hydrochloric acid+ which may cause "astrointestinal ulcers. 184. The nurse is plannin" care for a 4 month-old infant immediately postoperati!e followin" placement of a !entriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention ) $aintain infant in an upri"ht position #) e"in formula feedin"s when infant is alert %) ?ump the shunt to assess for proper function &e!iew Information' The correct answer is A' Assess for abdominal distention The child is obser!ed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperati!e ileus as a complication of distal catheter placement. 184. The mother of a ) year-old hospitali5ed child asks the nurse=s ad!ice about the child=s screamin" e!ery time the mother "ets ready to lea!e the hospital room. .hat is the best response by the nurse? "I think you or your partner needs to stay with the child while in the A) hospital." ) ";h+ that beha!ior will stop in a few days." "Meep in mind that for the a"e this is a normal response to bein" in #) the hospital." "Fou mi"ht want to "sneak out" of the room once the child falls %) asleep." &e!iew Information' The correct answer is #' "Meep in mind that for the a"e this is a normal response to bein" in the hospital." The protest phase of separation an7iety is a normal response for a child this a"e. In toddlers+ a"es 1 to 4+ separation an7iety is at its peak 186. .hen carin" for a client recei!in" warfarin sodium A#oumadin)+ which lab test would the nurse monitor to determine therapeutic reponse to the dru"? A) leedin" time ) #oa"ulation time #) ?rothrombin time %) ?artial thromboplastin time &e!iew Information' The correct answer is #' ?rothrombin time #oumadin is ordered daily+ based on the client==s prothrombin time A?T). This test e!aluates the ade1uacy of the e7trinsic system and common pathway in the clottin" cascadeI #oumadin affects the Bitamin M dependent clottin" factors. 18<. The nurse is carin" for a 4 year-old ) hours after tonsillectomy and adenoidectomy. .hich of the followin" assessments must be reported immediately? A) Bomitin" of dark emesis ) #omplaints of throat pain #) Apical heart rate of 118 %) Increased restlessness &e!iew Information' The correct answer is %' Increased restlessness &estlessness and increased respiratory and heart rates are often early si"ns of hemorrha"e. 18-. The nurse admits a - year-old to the emer"ency room after a le" in3ury. The 7-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this in3ury. The appropriate response by the nurse should be which of these statements? "The in3ury is e7pected to heal 1uickly because of thin A) periosteum." K ) "In some instances the result is a retarded bone "rowth." #) " one "rowth is stimulated in the affected le"." %)

189. %urin" the check up of a ) month-old infant at a well baby clinic+ the mother e7presses concern to the nurse because a flat pink birthmark on the baby=s forehead and eyelid has not "one away. .hat is an appropriate response by the nurse? A) "$on"olian spots are a normal findin" in dark-skinned children." ) "?ort wine stains are often associated with other malformations." "Telan"iectatic ne!i are normal and will disappear as the baby #) "rows." "The child is too youn" for consideration of sur"ical remo!al of %) these at this time." &e!iew Information' The correct answer is #' Telan"iectatic ne!i are normal and will disappear as the baby "rows Telan"iectatic ne!i+ salmon patch or stork bite birthmarks are a normal !ariation and the facial ne!i will "enerally disappear by a"es 1 to ) years. 118. A client has returned to the unit followin" a renal biopsy. .hich of the followin" nursin" inter!entions is appropriate? A) Ambulate the client 4 hours after procedure ) $aintain client on C?; status for )4 hours #) $onitor !ital si"ns %) #han"e dressin" e!ery , hours &e!iew Information' The correct answer is #' $onitor !ital si"ns The potential complication of this procedure is internal hemorrha"e. $onitorin" !ital si"ns is critical to detect early indications of bleedin". 111. A client has been admitted with a fractured femur and has been placed in skeletal traction. .hich of the followin" nursin" inter!entions should recei!e priority? A) $aintainin" proper body ali"nment ) 0re1uent neuro!ascular assessments of the affected le" #) Inspection of pin sites for e!idence of draina"e or inflammation Applyin" an o!er-bed trape5e to assist the client with mo!ement in %) bed &e!iew Information' The correct answer is ' 0re1uent neuro!ascular assessments of the affected le" The most important acti!ity for the nurse is to assess neuro!ascular status. #ompartment syndrome is a serious complication of fractures. ?rompt reco"nition of this neuro!ascular problem and early inter!ention may pre!ent permanent limb dama"e. 11). The nurse is teachin" a client newly dia"nosed with asthma how to use the metered-dose inhaler A$%I). The client asks when they will know the canister is empty. The best response is A) %rop the canister in water to obser!e floatin" ) Hstimate how many doses are usually in the canister #) #ount the number of doses as the inhaler is used %) (hake the canister to detect any fluid mo!ement &e!iew Information' The correct answer is A' %rop the canister in water to obser!e floatin" %roppin" the canister into a bowl of water assesses the amount of medications remainin" in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and be"ins to tip o!er. (ome of the newer canisters ha!e counters. 114. .hile teachin" the family of a child who will take phenytoin A%ilantin) re"ularly for sei5ure control+ it is most important for the nurse to teach them about which of the followin" actions? A) $aintain "ood oral hy"iene and dental care ) ;mit medication if the child is sei5ure free #) Administer acetaminophen to promote sleep %) (er!e a diet that is hi"h in iron &e!iew Information' The correct answer is A' $aintain "ood oral hy"iene and dental care (wollen and tender "ums occur often with use of phenytoin. ;ral hy"iene and re"ular !isits to the dentist should be emphasi5ed. 114. A - month pre"nant woman is admitted with complaints of painless !a"inal bleedin" o!er se!eral hours. The nurse should prepare the client for an immediate A) Con stress test ) Abdominal ultrasound #) ?el!ic e7am %) P-ray of abdomen &e!iew Information' The correct answer is ' Abdominal ultrasound The standard for dia"nosis of placenta pre!ia+ which is su""ested in the client==s history+ is abdominal ultrasound. 116. The nurse is assessin" a 1- year-old female client with bulimia. .hich of the followin" laboratory reports would the nurse anticipate? A) Increased serum "lucose ) %ecreased albumin #) %ecreased potassium %) Increased sodium retention &e!iew Information' The correct answer is #' %ecreased potassium In bulimia+ loss of electrolytes can occur in addition to si"ns and symptoms of star!ation and dehydration.

"This type of injury shows more rapid union than that of younger children."

&e!iew Information' The correct answer is ' "In some instances the result is a retarded bone "rowth." An epiphyseal A"rowth) plate fracture in a - year-old often results in retarded bone "rowth. The le" often will be different in len"th. 18,. A client recei!in" chlorproma5ine @#> AThora5ine) is in psychiatric home care. %urin" a home !isit the nurse obser!es the client smackin" her lips alternately with "rindin" her teeth. The nurse reco"ni5es this assessement findin" as what? A) %ystonia ) Akathesia #) rady dysknesia %) Tardi!e dyskinesia &e!iew Information' The correct answer is %' Tardi!e dyskinesia (i"ns of tardi!e dyskinesia include smackin" lips+ "rindin" of teeth and "fly catchin"" ton"ue mo!ements.

11<. An ,8 year-old client on di"italis A>ano7in) reports nausea+ !omitin"+ abdominal cramps and halo !ision. .hich of the followin" laboratory results should the nurse analy5e first? K A) ?otassium le!els ) lood p@ #) $a"nesium le!els %) lood urea nitro"en &e!iew Information' The correct answer is A' ?otassium le!els The most common cause of di"italis to7icity is a low potassium le!el. #lients must be tau"ht that it is important to ha!e ade1uate potassium intake especially if takin" diuretics that enhance the loss of potassium while they are takin" di"italis preparations. 11-. The nurse carin" for a 9 year-old child with a fractured femur is told that a medication error occurred. The child recei!ed twice the ordered dose of morphine an hour a"o. .hich nursin" dia"nosis is a priority at this time? A) &isk for fluid !olume deficit related to morphine o!erdose ) %ecreased "astrointestinal mobility related to mucosal irritation Ineffecti!e breathin" patterns related to central ner!ous system #) depression %) Altered nutrition related to inability to control nausea and !omitin" &e!iew Information' The correct answer is #' Ineffecti!e breathin" patterns related to central ner!ous system depression &espiratory depression is a life-threatenin" risk in this o!erdose. 11,. The nurse notes that a ) year-old child reco!erin" from a tonsillectomy has an temperature of 9,.) de"rees 0ahrenheit at ,'88 A$. At 18'88 A$ the child=s mother reports that the child "feels !ery warm" to touch. The first action by the nurse should be to A) &eassure the mother that this is normal ) ;ffer the child cold oral fluids #) &eassess the child=s temperature %) Administer the prescribed acetaminophen &e!iew Information' The correct answer is #' &eassess the child==s temperature A child==s temperature may ha!e rapid fluctuations. The nurse should listen to and show respect for what parents say. 119. The nurse is teachin" a newly dia"nosed asthma client on how to use a peak flow meter. The nurse e7plains that this should be used to A) %etermine o7y"en saturation ) $easure forced e7piratory !olume #) $onitor atmosphere for presence of aller"ens %) ?ro!ide metered doses for inhaled bronchodilator &e!iew Information' The correct answer is ' $easure forced e7piratory !olume The peak flow meter is used to measure peak e7piratory flow !olume. It pro!ides useful information about the presence andGor se!erity of airway obstruction. 1)8. The nurse is performin" a pre-kinder"arten physical on a 6 yearold. The last series of !accines will be administered. .hat is the preferred site for in3ection by the nurse? A) Bastus intermedius ) /luteus rainlinus #) Bastus lateralis %) %orso"luteaI &e!iew Information' The correct answer is #' Bastus lateralis Bastus lateralis+ a lar"e and well de!eloped muscle+ is the preferred site+ since it is remo!ed from ma3or ner!es and blood !essels. 1)1. A couple e7perienced the loss of a - month-old fetus. In plannin" for dischar"e+ what should the nurse emphasi5e? A) To discuss feelin"s with each other and use support persons ) To focus on the other healthy children and mo!e throu"h the loss To seek causes for the fetal death and come to some safe #) conclusion To plan for another pre"nancy within ) years and maintain physical %) health &e!iew Information' The correct answer is A' To discuss feelin"s with each other and use support persons To communicate in a therapeutic manner+ the nurse==s "oal is to help the couple be"in the "rief process by su""estin" they talk to each other+ seek family 1)). The parents of a 4 year-old hospitali5ed child tell the nurse+ E.e are lea!in" now and will be back at < ?$.D A few hours later the child asks the nurse when the parents will come a"ain. .hat is the best response by the nurse? A) "They will be back ri"ht after supper." ) "In about ) hours+ you will see them." #) "After you play awhile+ they will be here." %) ".hen the clock hands are on < and 1)." &e!iew Information' The correct answer is A' "They will be back ri"ht after supper."

Time is not completely understood by a 4 year-old. ?reschoolers interpret time with their own frame of reference. Thus+ it is best to e7plain time in relationship to a known+ common e!ent. 1)4. The nurse is pro!idin" instructions for a client with asthma. .hich of the followin" should the client monitor on a daily basis? A) &espiratory rate ) ?eak air flow !olumes #) ?ulse o7imetry %) (kin color &e!iew Information' The correct answer is ' ?eak air flow !olumes The peak airflow !olume decreases about )4 hours before clinical manifestations. 1)4. Therapeutic nurse-client interaction occurs when the nurse A) Assists the client to clarify the meanin" of what the client has said ) Interprets the client2s co!ert communication #) ?raises the client for appropriate feelin"s and beha!ior %) Ad!ises the client on ways to resol!e problems &e!iew Information' The correct answer is A' Assists the client to clarify the meanin" of what the client has said #larification is a facilitatin"Gtherapeutic communication strate"y. Intrepretation or chan"in" the focusGsub3ect+ "i!in" appro!al+ and ad!isin" are nontherapeuticGbarriers to communication. 1)6. A 14 month-old child in"ested half a bottle of aspirin tablets. .hich of the followin" would the nurse e7pect to see in the child? A) @ypothermia ) Hdema #) %yspnea %) Hpista7is &e!iew Information' The correct answer is %' Hpista7is A lar"e dose of aspirin inhibits prothrombin formation and lowers platelet le!els. .ith an o!erdose+ clottin" time is prolon"ed. 1)<. The nurse is carin" for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to "roin cast. 4< hours after sur"ery+ the client suddenly becomes confused+ short of breath and spikes a temperature of 184 de"rees 0ahrenheit. The first assessment the nurse should perform is A) ;rientation to time+ place and person ) ?ulse o7imetry #) #irculation to casted e7tremity %) lood pressure &e!iew Information' The correct answer is ' ?ulse o7imetry &estlessness+ confusion+ irritability and disorientation may be the first si"ns of fat embolism syndrome followed by a !ery hi"h temperature. The nurse needs to confirm hypo7ia first. 1)-. .hich nursin" inter!ention will be most effecti!e in helpin" a withdrawn client to de!elop relationship skills? A) ;ffer the client fre1uent opportunities to interact with 1 person ?ro!ide the client with fre1uent opportunities to interact with other ) clients #) Assist the client to analy5e the meanin" of the withdrawn beha!ior %iscuss with the client the focus that other clients ha!e similar %) problems &e!iew Information' The correct answer is A' ;ffer the client fre1uent opportunities to interact with one person The withdrawn client is uncomfortable in social interaction. The nurse client relationship is a correcti!e relationship in which the client learns both tolerance and skills for relationships. 1),. The nurse is assessin" a client with a (ta"e ) skin ulcer. .hich of the followin" treatments is most effecti!e to promote healin"? A) #o!erin" the wound with a dry dressin" ) *sin" hydro"en pero7ide soaks #) >ea!in" the area open to dry %) Applyin" a hydrocolloid or foam dressin" &e!iew Information' The correct answer is %' Applyin" a hydrocolloid or foam dressin" .hile the pre!iously accepted treatment was a transparent co!er+ e!idence now indicates that the foam A%uo%erm) dressin"s work best.. 1)9. A female client is admitted for a breast biopsy. (he says+ tearfully to the nurse+ "If this turns out to be cancer and I ha!e to ha!e my breast remo!ed+ my partner will ne!er come near me." The nurse=s best response would be which of these statements? A) "I hear you sayin" that you ha!e a fear for the loss of lo!e." ) "Fou sound concerned that your partner will re3ect you." #) "Are you wonderin" about the effects on your se7uality?" %) "Are you worried that the sur"ery will chan"e you?" &e!iew Information' The correct answer is %' "Are you worried that the sur"ery will chan"e you?" This is a "eneral lead in type of response that encoura"es further discussion without focusin" on an area that the nurse+ but possibly not the client+ feels is a problem.

148. .hen teachin" suicide pre!ention to the parents of a 16 year-old who recently attempted suicide+ the nurse describes the followin" beha!ioral cue A) An"ry outbursts at si"nificant others ) 0ear of bein" left alone #) /i!in" away !alued personal items %) H7periencin" the loss of a boyfriend &e!iew Information' The correct answer is #' /i!in" away !alued personal items ,8: of all potential suicide !ictims "i!e some type of clue. These clues mi"ht lead one to suspect that a client is holdin" suicidal thou"hts or is de!elopin" a plan. 141. The nurse is carin" for a 4 year-old admitted after recei!in" burns to more than 68: of his body. .hich laboratory data should be re!iewed by the nurse as a priority in the first )4 hours? A) lood urea nitro"en ) @ematocrit #) lood "lucose %) .hite blood count &e!iew Information' The correct answer is A' lood urea nitro"en /lomerular filtration is decreased in the initial response to se!ere burns+ with fluid shift. Midney function must be monitored closely+ or renal failure may follow in a few days. 14). The nurse is assi"ned to care for a client who had a myocardial infarction A$I) ) days a"o. The client has many 1uestions about this condition. .hat area is a priority for the nurse to discuss at this time? A) %aily needs and concerns ) The o!er!iew cardiac rehabilitation #) $edication and diet "uideline %) Acti!ity and rest "uidelines &e!iew Information' The correct answer is A' %aily needs and concerns At the point of ) days post-$I the client education should be focused on the immediate needs and concerns for the day. 144. The nurse is preparin" a client with a deep !ein thrombosis A%BT) for a Benous %oppler e!aluation. .hich of the followin" would be necessary for preparin" the client for this test? A) #lient should be C?; after midni"ht ) #lient should recei!e a sedati!e medication prior to the test #) %iscontinue anti-coa"ulant therapy prior to the test %) Co special preparation is necessary &e!iew Information' The correct answer is %' Co special preparation is necessary This is a non-in!asi!e procedure and does not re1uire preparation. 144. .hile inter!iewin" a client+ the nurse notices that the client is shiftin" positions+ wrin"in" her hands+ and a!oidin" eye contact. It is important for the nurse to A) Ask the client what she is feelin" ) Assess the client for auditory hallucinations #) &eco"ni5e the beha!ior as a side effect of medication %) &e-focus the discussion on a less an7iety pro!okin" topic &e!iew Information' The correct answer is A' Ask the client what she is feelin" The initial step in an7iety inter!ention is obser!in"+ identifyin"+ and assessin" an7iety. 146. .hich statement made by a client indicates to the nurse that he may ha!e a thou"ht disorder? A) "I=m so an"ry about this. .ait until my partner hears about this." ) "I=m a little confused. .hat time is it?" #) "I can=t find my =mesmer= shoes. @a!e you seen them?" %) "I=m fine. It=s my dau"hter who has the problem." &e!iew Information' The correct answer is #' "I can==t find my ==mesmer== shoes. @a!e you seen them?" A Ceolo"ism is a new word self in!ented by a person and not readily understood by another that is often associated with a thou"ht disorder. 14<. The nurse is obser!in" a client with an obsessi!e-compulsi!e disorder in an inpatient settin". .hich beha!ior is consistent with this dia"nosis? A) &epeatedly checkin" that the door is locked ) Berbali5ed suspicions about thefts #) ?reference for consistent care "i!ers %) &epetiti!e+ in!oluntary mo!ements &e!iew Information' The correct answer is A' &epeatedly checkin" that the door is locked eha!iors that are repeated are symptomatic of obsessi!e-compulsi!e disorders. These beha!iors often interfere with normal function and employment.

14-. A youn" adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a "o!ernment official bein" followed by spies. ;n further 1uestionin"+ he re!eals that his warnin"s must be heeded to pre!ent nuclear war. .hat is the most therapeutic approach by the nurse? A) >isten 1uietly without comment ) Ask for further information on the spies #) #onfront the client on a delusion %) #ontact the "o!ernment a"ency &e!iew Information' The correct answer is A' >isten 1uietly without comment The client==s comments demonstrate "randiose ideas. The most therapeutic response is to listen but a!oid incorporation into the delusion. 14,. A client is admitted to a psychiatric unit with delusions. .hat findin"s can the nurse e7pect? A) 0li"ht of ideas and hyperacti!ity ) (uspiciousness and resistance to therapy #) Anore7ia and hopelessness %) ?anic and multiple physical complaints &e!iew Information' The correct answer is ' (uspiciousness and resistance to therapy #linical features of delusional disorder include e7treme suspiciousness+ 3ealousy+ distrust+ and belief that others intend to harm. 149. A client who is a former actress enters the day room wearin" a sheer ni"ht"own+ hi"h heels+ numerous bracelets+ bri"ht red lipstick and hea!ily rou"ed cheeks. .hich nursin" action is the best in response to the client2s attire? A) /ently remind her that she is no lon"er on sta"e ) %irectly assist client to her room for appropriate apparel #) Quietly point out to her the dress of other clients on the unit %) Tactfully e7plain appropriate clothin" for the hospital &e!iew Information' The correct answer is ' %irectly assist client to her room for appropriate apparel Allows the client to maintain self-esteem while modifyin" beha!ior. 148. @andshakin" is the preferred form of touch or contact used with clients in a psychiatric settin". The rationale behind this limited touch practice is that A) (ome clients misconstrue hu"s as an in!itation to se7ual ad!ances ) @andshakin" keeps the "esture on a professional le!el #) &efusal to touch a client denotes lack of concern %) Inappropriate touch often results in char"es of assault and battery &e!iew Information' The correct answer is A' (ome clients misconstrue hu"s as an in!itation to se7ual ad!ances Touch denotes positi!e feelin"s for another person. The client may interpret hu""in" and holdin" hands as a se7ual ad!ance. 141. A client with paranoid delusions stares at the nurse o!er a period of se!eral days. The client suddenly walks up to the nurse and shouts "Fou think you2re so perfect and pure and "ood." An appropriate response for the nurse is A) "Is that why you2!e been starrin" at me?" ) "Fou seem to be in a really bad mood." #) "?erfect? I don2t 1uite understand." %) "Fou are an"ry ri"ht now." &e!iew Information' The correct answer is %' "Fou are an"ry ri"ht now." The nurse reco"ni5es the underlyin" emotion with matter of fact attitude. 14). An important "oal in the de!elopment of a therapeutic inpatient milieu is to ?ro!ide a businesslike atmosphere where clients can work on A) indi!idual "oals ?ro!ide a "roup forum in which clients decide on unit rules+ ) re"ulations+ and policies ?ro!ide a testin" "round for new patterns of beha!ior while the #) client takes responsibility for his or her own actions %iscoura"e e7pressions of an"er because they can be disrupti!e to %) other clients &e!iew Information' The correct answer is #' ?ro!ide a testin" "round for new patterns of beha!ior while the client takes responsibility for his or her own actions A therapeutic milieu is purposeful and planned to pro!ide safety and a testin" "round for new patterns of beha!ior. 144. The nurse=s primary inter!ention for a client who is e7periencin" a panic attack is to A) %e!elop a trustin" relationship ) Assist the client to describe his e7perience in detail #) $aintain safety for the client %) Teach the client to control his or her own beha!ior &e!iew Information' The correct answer is #' $aintain safety for the client #lients who display si"ns of se!ere an7iety need to be super!ised closely until the an7iety is decreased because they may harm themsel!es or others. 144. .hich inter!ention best demonstrates the nurse=s sensiti!ity to a 1< yearold2s appropriate need for autonomy? A) Alertness for feelin"s re"ardin" body ima"e ) Allows youn" siblin"s to !isit ?ro!ides opportunity to discuss concerns without presence of #) parents %) H7plores his feelin"s of resentment to identify causes

&e!iew Information' The correct answer is #' ?ro!ides opportunity to discuss concerns without presence of parents This inter!ention pro!ides the teen with the opportunity to ha!e control and encoura"es decision makin". 146. A client with anore7ia is hospitali5ed on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findin"s that the nurse would e7pect to obser!e are A) rittle hair+ lanu"o+ amenorrhea ) %iarrhea+ nausea+ !omitin"+ dental erosion #) @yperthermia+ tachycardia+ increased metabolic rate %) H7cessi!e an7iety about symptoms &e!iew Information' The correct answer is A' rittle hair+ lanu"o+ amenorrhea ?hysical findin"s associated with anore7ia are brittle hair+ lanu"o+ and dehydration+ lowered metabolic rate and !ital si"ns. 14<. A depressed client in an assisted li!in" facility tells the nurse that "life isn=t worth li!in" anymore." .hat is the best response to this statement? A) "#ome on+ it is not that bad." ) "@a!e you thou"ht about hurtin" yourself?" #) "%id you tell that to your family?" %) "Think of the many positi!e thin"s in life." &e!iew Information' The correct answer is ' "@a!e you thou"ht about hurtin" yourself?" It is appropriate and necessary to determine if someone who has !oiced suicidal ideation is considerin" a suicidal act. This response is most therapeutic in the circumstances. 14-. A client+ reco!erin" from alcoholism+ asks the nurse+ ".hat can I do when I start reco"ni5in" relapse tri""ers within myself?" @ow mi"ht the nurse best respond? ".hen you ha!e the impulse to stop in a bar+ contact a sober A) friend and talk with him." ) "/o to an AA meetin" when you feel the ur"e to drink." "It is important to e7ercise daily and "et in!ol!ed in acti!ities that #) will cause you not to think about dru" use." K %) "Identify your relapse tri""ers as part of "ettin" better." &e!iew Information' The correct answer is %' "Identify your relapse tri""ers as part of "ettin" better." This option encoura"es the process of self e!aluation and problem sol!in". 14,. A client was admitted to the eatin" disorder unit with bulimia ner!osa. The nurse assessin" for a history of complications of this disorder e7pects A) &espiratory distress+ dyspnea ) acterial "astrointestinal infections+ o!erhydration #) $etabolic acidosis+ constricted colon %) %ental erosion+ parotid "land enlar"ement &e!iew Information' The correct answer is %' %ental erosion+ parotid "land enlar"ement %ental erosion related to pur"in" and parotid "land enlar"ement due to pur"in" are common complications. 149. A nurse enterin" the room of a postpartum mother obser!es the baby lyin" at the ed"e of the bed while the woman sits in a chair. The mother states+" This is not my baby+ and I do not want it." The nurse=s best response is "This is a common occurrence after birth+ but you will come to accept the baby." "$any women ha!e postpartum blues and need some time to lo!e the baby." ".hat a beautiful babyJ @er eyes are 3ust like yours." "Fou seem upsetI tell me what the pre"nancy and birth were like for you." &e!iew Information' The correct answer is %' "Fou seem upsetI tell me what the pre"nancy and birth were like for you." A non-3ud"mental+ open ended response facilitates dialo"ue between the client and nurse. 168. .hich of the followin" times is a depressed client at hi"hest risk for attemptin" suicide? A) Immediately after admission+ durin" one-to-one obser!ation - to 14 days after initiation of antidepressant medication and ) psychotherapy #) 0ollowin" an an"ry outburst with family %) .hen the client is remo!ed from the security room &e!iew Information' The correct answer is ' (e!en to 14 days after initiation of antidepressant medication and psychotherapy As the depression lessens+ the depressed client ac1uires ener"y to follow the plan. &esults for ?hysiolo"ical Adaptation

R Questions are numbered by the order in which they appeared in the test. R K &epresents the correct answer. 1. A man dia"nosed with epididymitis ) days a"o calls the nurse at a health clinic to discuss the problem. .hat information is most important for the nurse to ask about at this time? A) .hat are you takin" for pain and does it pro!ide total relief? K ) .hat does the skin on the testicles look and feel like? #) %o you ha!e any 1uestions about your care? %) %id you know a conse1uence of epididymitis is infertility? &e!iew Information' The correct answer is ' .hat does the skin on the testicles look and feel like? All of the 1uestions should be asked. @owe!er+ the one about the problem is the most important to start with at this time. ). A client has had heart failure. .hich inter!ention is most important for the nurse to implement prior to the initial admininstration of %i"o7in to this client? A) Assess the apical pulse+ countin" for a full <8 seconds ) Take a radial pulse+ countin" for a full <8 seconds #) *se the pulse readin" from the electronic blood pressure de!ice %) #heck for a pulse deficit &e!iew Information' The correct answer is A' Assess the apical pulse+ countin" for a full <8 seconds It is the nurse2s responsibility to take the client2s pulse before administerin" di"o7in. The correct techni1ue for takin" an apical pulse is to use the stethoscope and listen for a full <8 seconds. %i"o7in is held for a pulse below <8 beats per minute. &adial pulse or blood pressure are not part of the initial assessment before administerin" an initial dose of di"o7in. 4. A client is admitted with a tentati!e dia"nosis of con"esti!e heart failure. .hich of the followin" assessments would the nurse e7pect to be consistent with this problem? A) #hest pain ) ?allor #) Inspiratory crackles %) @eart murmur &e!iew Information' The correct answer is #' Inspiratory crackles In con"esti!e heart failure+ fluid backs up into the lun"s Acreatin" crackles) as a result of inefficient cardiac pumpin". 4. A nurse is pro!idin" care to a 1- year-old client in the post-operati!e care unit A?A#*) after an emer"ency appendectomy. .hich findin" is an early indication that the client is e7periencin" poor o7y"enation? A) Abnormal breath sounds ) #yanosis of the lips #) Increasin" pulse rate %) ?ulse o7imeter readin" of 9): &e!iew Information' The correct answer is #' Increasin" pulse rate The earliest si"n of poor o7y"enation is an increasin" pulse rate as a part of the body2s compensatory mechanism. Abnormal breath sounds and cyanosis are late si"ns of poor o7y"enation. ?ulse o7imetry readin" of 9): is normal. 6. .hich order can be associated with the pre!ention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis? Acti!e and passi!e ran"e of motion e7ercises twice a day H!ery 4 hours incenti!e spirometer #hest physiotherapy twice a day &epositionin" e!ery ) hours around the clock &e!iew Information' The correct answer is #' #hest physiotherapy twice a day These clients ha!e a potential for an inability to ha!e !oluntary and in!oluntary muscle mo!ement or acti!ity. Thus+ options 1 and ) are inade1uate with this problem in mind. ;ption 4 is not specific for pre!ention of complications associated with the lun". <. A client who was medicated with meperidine hydrochloride A%emerol) 188 m" and hydro7y5ine hydrochloride ABistaril Intramuscular) 68 m" I$ for pain related to a fractured lower ri"ht le" 1 hour a"o reports that the pain is "ettin" worse. The nurse should reco"ni5e that the client may be de!elopin" which complication? A) Acute compartment syndrome ) Thromboemolitic complications #) 0atty embolism %) ;steomyelitis &e!iew Information' The correct answer is A' Acute compartment syndrome Increasin" pain that is not relie!ed by narcotic anal"esics is an indication of compartment syndrome after a bone fracture and re1uires immediate action by the nurse. Thromboembolic complications include deep !ein thrombosis and pulmonary embolism which are not characteri5ed by increasin" pain at the site of in3ury. oth pulmonary embolism and fat embolism present with respiratory sudden findin"s. ;steomyelitis is a bone infection which could occur some time after the initial in3ury+ usually at least 4, to -) hours. -. The nurse is assessin" an , month-old child with atonic cerebral palsy. .hich statement from the mother supports the prescence of this problem? .hen I put my fin"er in the left hand the baby doesn2t respond with a "rasp. $y baby doesn2t seem to follow when I shake toys in front of the face.

.hen it thundered loudly last ni"ht the baby didn2t e!en 3ump. .hen I put the baby in a back lyin" position that2s how I find the baby. &e!iew Information' The correct answer is %' *nable to roll from back to stomach #erebral ?alsy is known as a condition whereby motor dysfunction occurs secondary to dama"e in the motor centers of the brain. Inability to roll o!er by , months of a"e would illustrate one delay in the infant==s attainment of de!elopmental milestones. ,. .hich statements by the client would indicate to the nurse an understandin" of the issues with end sta"e renal disease? I ha!e to "o at inter!als for epoetin A?rocrit) in3ections at the health department. I know I ha!e a hi"h risk of clot formation since my blood is thick from too many red cells. I e7pect to ha!e periods of little water with !oidin" and then sometimes to ha!e a lot of water. $y bones will be stron"er with this disease since I will ha!e hi"her calcium than normal. &e!iew Information' The correct answer is A' I ha!e to "o at inter!als for epoetin A?rocrit) in3ections at the health department. Anemia caused by reduced endo"enous erythropoietin production+ primarily end-sta"e renal disease is treated with subcutaneous in3ections of ?rocrit or Hpo"en to stimulate the bone marrow to produce red blood cells. 9. The nurse is carin" for a client with uncontrolled hypertension. .hich findin"s re1uire priority nursin" action? A) >ower e7tremity pittin" edema ) &ales #) Su"ular !ein distension %) .eakness in left arm &e!iew Information' The correct answer is %' .eakness in left arm In a client with hypertension+ weakness in the e7tremities is a si"n of cerebral in!ol!ement with the potential for cerebral infarction or stroke. #erebral infarctions account for about ,8: of the strokes in clients with hypertension. The remainin" 4 choices indicate mild fluid o!erload and are not medical emer"encies. 18. A ) year-old child is brou"ht to the emer"ency department at )'88 in the afternoon. The mother states' E$y child has not had a wet diaper all day.D The nurse finds the child is pale with a heart rate of 14). .hat assessment data should the nurse obtain ne7t? A) (tatus of the eyes and the ton"ue ) %escription of play acti!ity #) @istory of fluid intake %) %ietary patterns &e!iew Information' The correct answer is A' (tatus of skin tur"or #linical findin"s of dehydration include sunken eyes+ dry ton"ue+ lethar"y+ irritability+ dry skin+ decreased play acti!ity+ and increased pulse. The normal pulse rate in this a"e child is -8-118. 11. .hich information is a priority for the nurse to reinforce to an older client after intra!enous pyle"raphy? A) Hat a li"ht diet for the rest of the day &est for the ne7t )4 hours since the preparation and the test is ) tirin". %urin" wakin" hours drink at least 1 ,-ounce "lass of fluid e!ery #) hour for the ne7t ) days $easure the urine output for the ne7t day and immediately notify %) the health care pro!ider if it should decrease. &e!iew Information' The correct answer is %' $easure the urine output for the ne7t day and immediately notify the health care pro!ider if it should decrease. This information would alert to the complication of acute renal failure which may occur as a complication from the dye and the procedure. &enal failure occurs most often in elderly patients who are chronically dehydrated before the dye in3ection. 1). A client has altered renal function and is bein" treated at home. The nurse reco"ni5es that the most accurate indicator of fluid balance durin" the weekly !isits is A) difference in the intake and output ) chan"es in the mucous membranes #) skin tur"or %) weekly wei"ht &e!iew Information' The correct answer is %' weekly wei"ht The most accurate indicator of fluid balance in an acutely ill indi!idual is the daily wei"ht. A one-kilo"ram or ).) pounds of wei"ht "ain is e1ual to appro7imately 1+888 mls of retained fluid. ;ther options are considered as part of data collection+ but they are not the most accurate indicator for Tfluid balance. 14. A client has been dia"nosed with Oollin"er-Hllison syndrome. .hich information is most important for the nurse to reinforce with the client? It is a condition in which one or more tumors called "astrinomas form

in the pancreas or in the upper part of the small intestine Aduodenum) It is critical to report promptly to your health care pro!ider any findin"s of peptic ulcers Treatment consists of medications to reduce acid and heal any peptic ulcers and+ if possible+ sur"ery to remo!e any tumors .ith the a!era"e a"e at dia"nosis at 68 years the peptic ulcers may occur at unusual areas of the stomach or intestine &e!iew Information' The correct answer is ' It is critical to report promptly to your health care pro!ider any findin"s of peptic ulcers .Actions of option will enhance early treatment of the problems. 14. A primi"ra!ida in the third trimester is hospitali5ed for preeclampsia. The nurse determines that the client2s blood pressure is increasin". .hich action should the nurse take first? A) #heck the protein le!el in urine ) @a!e the client turn to the left side #) Take the temperature %) $onitor the urine output &e!iew Information' The correct answer is ' @a!e the client turn to the left side A priority action is to turn the client to the left side to decrease pressure on the !ena ca!a and promote ade1uate circulation to the placenta and kidneys. *rine protein le!el and output should be checked with each !oidin". Temperature should be monitored e!ery 4 hours or more often if indicated and no data in the stem support a check of temperature. 16. The nurse is carin" for a client in atrial fibrillation. The atrial heart rate is )68 and the !entricular rate is controlled at -6. .hich of the followin" findin"s is cause for the most concern? A) %iminished bowel sounds ) >oss of appetite #) A cold+ pale lower le" %) Tachypnea &e!iew Information' The correct answer is #' A cold+ pale lower le" This assessment su""ests the presence of an embolus probably from the atrial fibrillation. ?eripheral pulses should be checked immediately. 1<. The client with infecti!e endocarditis must be assessed fre1uently by the home health nurse. .hich findin" su""ests that antibiotic therapy is not effecti!e+ and must be reported by the nurse immediately to the healthcare pro!ider? A) Causea and !omitin" ) 0e!er of 184 de"rees 0ahrenheit A49.6 de"rees #elsius) #) %iffuse macular rash %) $uscle tenderness &e!iew Information' The correct answer is ' 0e!er of 184 de"rees 0 A49.6 de"rees #) ?ersistent+ prolon"ed fe!er may be an indication that the antibiotics are not effecti!e and may need to be chan"ed. 1-. A client who had a !asectomy is in the post reco!ery unit at an outpatient clinic. .hich of these points is most important to be reinforced by the nurse? *ntil the health care pro!ider has determined that your e3aculate doesn=t contain sperm+ continue to use another form of contraception. This procedure doesn=t impede the production of male hormones or the production of sperm in the testicles. The sperm can no lon"er enter your semen and no sperm are in your e3aculate. After your !asectomy+ strenuous acti!ity needs to be a!oided for at least 4, hours. If your work doesn=t in!ol!e hard physical labor+ you can return to your 3ob as soon as you feel up to it. The stitches "enerally dissol!e in se!en to ten days. The health care pro!ider at this clinic recommends rest+ ice+ an athletic supporter or o!er-the-counter pain medication to relie!e any discomfort. &e!iew Information' The correct answer is A' *ntil the health care pro!ider has determined that your e3aculate doesn==t contain sperm+ continue to use another form of contraception. All of these options are correct information. The most important point to reinforce is the need to take additional actions for birth control. 1,. A client who is to ha!e antineoplastic chemotherapy tells the nurses of a fear of bein" sick all the time and wishes to try accupuncture. .hich of these beliefs stated by the client would be incorrect about accupuncture? (ome needles "o as deep as 4 inches+ dependin" on where A) they=re placed in the body and what the treatment is for. The needles usually are left in for 16 to 48 minutes. In traditional #hinese medicine+ imbalances in the basic ener"etic ) flow of life U known as 1i or chi U are thou"ht to cause illness. The flow of life is belie!ed to flow throu"h ma3or pathways or K #) ner!e clusters in your body. y insertin" e7tremely fine needles into some of the o!er 488 acupuncture points in !arious combinations it is belie!ed that %) ener"y flow will rebalance to allow the body=s natural healin" mechanisms to take o!er. &e!iew Information' The correct answer is #' The flow of life is belie!ed to flow throu"h ma3or pathways or ner!e clusters in your body. The ma3or pathways are called meridians+ not ner!e clusters.

19. The nurse is discussin" with a "roup of students the disease Mawasaki. .hat statement made by a student about Mawasaki disease is incorrect? It also called mucocutaneous lymph node syndrome because it affects the mucous membranes Ainside the mouth+ throat and nose)+ skin and lymph nodes. In the second phase of the disease+ findin"s include peelin" of the skin on the hands and feet with 3oint and abdominal pain Mawasaki disease occurs most often in boys+ children youn"er than a"e 6 and children of @ispanic descent Initially findin"s are a sudden hi"h fe!er+ usually abo!e 184 de"rees 0ahrenheit+ which lasts 1 to) weeks &e!iew Information' The correct answer is #' Mawasaki disease occurs most often in boys+ children youn"er than a"e 6 and children of @ispanic descent Mawasaki disease occurs most often in boys+ children youn"er than a"e 6 and children of Asian descent+ particularly Sapanese. ;ther findin"s in the initial phase are e7tremely red eyes Acon3uncti!itis)+ a rash on the main part of the body Atrunk) and in the "enital area+ red+ dry+ cracked lipsI a red+ swollen ton"ue+ resemblin" a strawberryI swollen+ red skin on the palms of the hands and the soles of the feetI swollen lymph nodes in the neck. In the third phase the findin"s slowly "o away unless complications associated with the heart de!elop. The disease lasts from) to 1) weeks without treatment. .ith treatment+ the child usually impro!es within )4 hours. The cause of Mawasaki disease isn==t known. )8. A client has !iral pneumonia affectin" )G4 of the ri"ht lun". .hat would be the best position to teach the client to lie in e!ery other hour durin" first 1) hours after admission? (ide-lyin" on the left with the head ele!ated 18 de"rees (ide-lyin" on the left with the head ele!ated 46 de"rees (ide-lyin" on the ri"ht wil the head ele!ated 18 de"rees (ide-lyin" on the ri"ht with the head ele!ated 46 de"rees &e!iew Information' The correct answer is A' (ide-lyin" on the left with the head ele!ated 18 de"rees /ra!ity will draw the most blood flow to the dependent portion of the lun". 0or unilateral chest disease+ it is best to place the healthiest part of the lun" in the dependent position to enhance blood flow to the area where "as e7chan"e will be best. Bentilation would be minimally affected in the ri"ht dependent lun". This position also enhances the draina"e of the infected part of the lun". An ele!ation of 46 de"rees is counterproducti!e to therapeutic blood flow and the draina"e of secretions. )1. A client has an indwellin" catheter with continuous bladder irri"ation after under"oin" a transurethral resection of the prostate AT*&?) 1) hours a"o. .hich findin" at this time should be reported to the health care pro!ider? A) >i"ht+ pink urine ) occasional suprapubic crampin" #) minimal draina"e into the urinary collection ba" %) complaints of the feelin" of pullin" on the urinary catheter &e!iew Information' The correct answer is #' minimal draina"e into the urinary collection ba" ;ptions 1+ )+ and 4 are e7pected complaints after this procedure. ;ption 4 needs to be reported immediately since with minimal urinary draina"e put the client at risk for bladder rupture. The flow rate of the continuous irri"ation would need to be slowed until the health care pro!ider is notified. If an order to irri"ate the system is written+ sterile techni1ue would be used. )). A nurse is performin" #?& on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checkin" the client2s pulse and respirations+ what should be the function of the second nurse? A) &elie!e the nurse performin" #?& ) /o "et the code cart #) ?articipate with the compressions or breathin" %) Balidate the client=s ad!anced directi!e &e!iew Information' The correct answer is #' ?articipate with the compressions or breathin" ;nce #?& is started+ it is to be continued usin" the appro!ed techni1ue until such time as a pro!ider pronounces the client dead or the client becomes stable. American @eart Association studies ha!e shown that the ) person techni1ue is most effecti!e in sustainin" the client. It is not appropriate to relie!e the first nurse or to lea!e the room for e1uipment. The client2s ad!anced directi!es should ha!e been filed on admission and choices known prior to startin" #?&. )4. The nurse assesses a -) year-old client who was admitted for ri"ht sided con"esti!e heart failure. .hich of the followin" would the nurse anticipate findin"? A) %ecreased urinary output ) Su"ular !ein distention #) ?leural effusion %) ibasilar crackles

&e!iew Information' The correct answer is ' Su"ular !ein distention (i"ns of ri"ht sided heart failure include 3u"ular !ein distention+ ascites+ nausea and !omitin". )4. A client with heart failure has a prescription for di"o7in. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) #an predispose to dysrhythmias ) $ay lead to oli"uria #) $ay cause irritability and an7iety %) (ometimes alters conciousness &e!iew Information' The correct answer is A' #an predispose to dysrhythmias The nurse should be aware of a decrease in the client2s potassium le!els because low potassium can enhance the effects of di"o7in and predispose the client to dysrhythmias. The other options are seen in hyperkalemia. $uscle weakness occurs in both hyperkalemia and hypokalemia. )6. A nurse assesses a youn" adult in the emer"ency room followin" a motor !ehicle accident. .hich of the followin" neurolo"ical si"ns is of most concern? A) 0laccid paralysis ) ?upils fi7ed and dilated #) %iminished spinal refle7es %) &educed sensory responses &e!iew Information' The correct answer is ' ?upils fi7ed and dilated ?upils that are fi7ed and dilated indicate o!erwhemlin" in3ury and intrinsic dama"e to upper brain stem and is a poor pro"nostic si"n. )<. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a dia"nosis of !aso-occlusi!e crisis. .hich statements by the client would be most indicati!e of the etiolo"y of this crisis? "I knew this would happen. I=!e been eatin" too much red meat lately." "I really en3oyed my fishin" trip yesterday. I cau"ht ) fish." "I ha!e really been workin" hard practicin" with the debate team at school." "I went to the health care pro!ider last week for a cold and I ha!e "otten worse." &e!iew Information' The correct answer is %' "I went to the doctor last week for a cold and I ha!e "otten worse." Any condition that increases the body==s need for o7y"en or alters the transport of o7y"en+ such as infection+ trauma or dehydration may result in a sickle cell crisis. )-. .hich these findin"s would the nurse more closely associate with anemia in a 18 month-old infant? A) @emo"lobin le!el of 1) "GdI ) ?ale mucosa of the eyelids and lips #) @ypoacti!ity %) A heart rate between 148 to 1<8 &e!iew Information' The correct answer is ' ?ale mucosa of the eyelids and lips In iron-deficiency anemia+ the physical e7am re!eals a pale+ tired-appearin" infant with mild to se!ere tachycardia. ),. The nurse is carin" for a client in hypertensi!e crisis in an intensi!e care unit. The priority assessment in the first hour of care is A) @eart rate ) ?edal pulses #) >un" sounds %) ?upil responses &e!iew Information' The correct answer is %' ?upil responses The or"an most susceptible to dama"e in hypertensi!e crisis is the brain due to rupture of the cerebral blood !essels. Ceurolo"ic status must be closely monitored. )9. .hich of these clients who are all in the terminal sta"e of cancer is least appropriate to su""est the use of patient controlled anal"esia A?#A) with a pump? A) A youn" adult with a history of %own=s syndrome ) A teena"er who reads at a 4th "rade le!el #) An elderly client with numerous arthritic nodules on the hands %) A preschooler with intermittent episodes of alertness &e!iew Information' The correct answer is %' A preschooler with intermittent episodes of alertness A preschooler is most likely of these clients to ha!e difficulty with the use or understandin" of a ?#A pump. This child without a normal le!el of consciousness would not benefit from the use of a ?#A pump. 48. The nurse is about to assess a < month-old child with nonor"anic failure-tothri!e AC;0TT). *pon enterin" the room+ the nurse would e7pect the baby to be Irritable and "colicky" with no attempts to pull to standin" Alert+ lau"hin" and playin" with a rattle+ sittin" with support (kin color dusky with poor skin tur"or o!er abdomen ?ale+ thin arms and le"s+ uninterested in surroundin"s &e!iew Information' The correct answer is %' ?ale+ thin arms and le"s+ uninterested in surroundin"s %ia"nosis of C;0TT is made on anthropomorphic findin"s documentin" "rowth retardation which would lead the nurse to e7pect muscle-wastin" and paleness. In cases of C;0TT+ the cause may be a !ariety of psychosocial factors and these

children may be below normal in intellectual de!elopment+ lan"ua"e and social interactions. 41. As the nurse is speakin" with a "roup of teens which of these side effects of chemotherapy for cancer would the nurse e7pect this "roup to be more interested in durin" the discussion? A) $outh sores ) 0ati"ue #) %iarrhea %) @air loss &e!iew Information' The correct answer is %' @air loss The ma3or concern for adolescence is body ima"e so hair loss would be the most disturbin". 4). .hile carin" for a client who was admitted with myocardial infarction A$I) ) days a"o+ the nurse notes today=s temperature is 181.1 de"rees 0ahrenheit A4,.6 de"rees #elsius). The appropriate nursin" inter!ention is to A) #all the health care pro!ider immediately ) Administer acetaminophen as ordered as this is normal at this time #) (end blood+ urine and sputum for culture %) Increase the client=s fluid intake &e!iew Information' The correct answer is ' Administer acetaminophen as ordered as this is normal at this time >eukocytosis and fe!er are common startin" on day ) because of the inflammatory process associated with an acute $I. Cursin" inter!entions should focus on promotin" comfort. 44. A client is admitted for first and second de"ree burns on the face+ neck+ anterior chest and hands. The nurse=s priority should be A) #o!er the areas with dry sterile dressin"s ) Assess for dyspnea or stridor #) Initiate intra!enous therapy %) Administer pain medication &e!iew Information' The correct answer is ' Assess for dyspnea or stridor %ue to the location of the burns+ the client is at risk for de!elopin" upper airway edema and subse1uent respiratory distress. 44. .hich of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care pro!ider? A) I started my period and now my urine has turned bri"ht red. I am an diabetic and today I ha!e been "oin" to the bathroom ) e!ery hour. I was started on medicine yesterday for a urine infection. Cow my #) lower belly hurts when I "o to the bathroom. I went to the bathroom and my urine looked !ery red and it didn2t %) hurt when I went. &e!iew Information' The correct answer is %' I went to the bathroom and my urine looked !ery red and it didn2t hurt when I went. .ith this history this client needs to be seen that day since painless "ross hematuria is closely associated with bladder cancer. The other complaints can be handled o!er the phone. 46. A middle a"ed woman talks to the nurse in the health care pro!ider2s office about uterine fibroids also called leiomyomas or myomas. .hat statement by the woman indicates more education is needed? I am one out of e!ery 4 women that "et fibroids+ and of women my a"e V between the 48s or 48s+ fibroids occure more fre1uently. $y fibroids are noncancerous tumors that "row slowly. $y associated problems I ha!e had are pel!ic pressure and pain+ urinary incontinence+ fre1uent urination or urine retention and constipation. 0ibroids that cause no problems still need to be taken out. &e!iew Information' The correct answer is %' 0ibroids that cause no problems still need to be taken out. 0ibroids that cause no findin"s may re1uire only "watchful waitin"" with no treatment. ;nly when the client2s complaints become disturbin" to them would sur"ical inter!entions be considered 4<. An elderly client admitted after a fall be"ins to sei5e and loses consciousness. .hat action by the nurse is appropriate to do ne7t? K A) (tay with client and obser!e for airway obstruction ) #ollect pillows and pad the siderails of the bed #) ?lace an oral airway in the mouth and suction %) Announce a cardiac arrest+ and assist with intubation &e!iew Information' The correct answer is A' (tay with client and obser!e for airway obstruction 0or the client2s safety+ remain at the bedside and obser!e respirations and le!el of consciousness. ?repare to clear the airway if obstructed. %o not place anythin" in the client2s mouth. 0or safety+ do not lea!e the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the sei5ure

4-. A nurse is pro!idin" care to a primi"ra!ida whose membranes spontaneously ruptured A&;$) 4 hours a"o. >abor is to be induced. At the time of the &;$ the !ital si"ns were T-99., de"rees 0+ ?-,4+ &-)8+ ?-148G-,+ and fetal heart tones A0@T) 14, beatsGmin. .hich assessment findin"s taken now may be an early indication that the client is de!elopin" a complication of labor? A) 0@T 1<, beatsGmin ) Temperature 188 de"rees 0ahrenheit. #) #er!ical dilation of 4 %) ? 14,G,, &e!iew Information' The correct answer is A' 0@T 1<, beatsGmin An increase in 0@T may indicate maternal infection. The other assessment findin"s are normal. The ishop2s score of < indicates that induction of labor should be successful. 4,. A client with pneumococcal pneumonia had been started on antibiotics 1< hours a"o. %urin" the nurse2s initial e!enin" rounds the nurse notices a foul smell in the room. The client makes all of these statements durin" their con!ersation. .hich statement would alert the nurse to a complication? A) "I ha!e a sharp pain in my chest when I take a breath." ) "I ha!e been cou"hin" up foul-tastin"+ brown+ thick sputum." #) "I ha!e been sweatin" all day." %) "I feel hot off and on." &e!iew Information' The correct answer is ' "I ha!e been cou"hin" up foultastin"+ brown+ thick sputum." 0oul smellin" and tastin" sputum si"nals a risk of a lun" abscess. This puts the client is "ra!e dan"er since abscesses are often caused by anaerobic or"anisms. This client most likely would need a chan"e of antibiotics. (harp chest pain on inspiration called pleuritic pain is an e7pected findin" with this type of pneumonia. The other options are e7pected in the initial )4 to 4, hours of therapy for infections. 49. The nurse is performin" an assessment on a client in con"esti!e heart failure. Auscultation of the heart is most likely to re!eal A) (4 !entricular "allop ) Apical click #) (ystolic murmur %) (plit () &e!iew Information' The correct answer is A' (4 !entricular "allop An (4 !entricular "allop is caused by blood flowin" rapidly into a distended noncompliant !entricle. $ost common with con"esti!e heart failure. 48. .hich of these obser!ations made by the nurse durin" an e7cretory uro"ram indicate a complicaton? The client complains of a salty taste in the mouth when the dye is in3ected The client2s entire body turns a bri"ht red color The client states EI ha!e a feelin" of "ettin" warm.D The client "a"s and complains E I am "ettin" sick.D &e!iew Information' The correct answer is ' The client2s entire body turns a bri"ht red color This obser!ation su""est anaphala7is which results in massi!e !asodilation. ;ther findin"s would be immediate whee5in" andGor respiratory arrest. &esults for &eduction of &isk ?otential R Questions are numbered by the order in which they appeared in the test. R K &epresents the correct answer. 1. A client is dia"nosed with a spontaneous pneumothora7 necessitatin" the insertion of a chest tube. .hat is the best e7planation for the nurse to pro!ide this client? A) "The tube will drain fluid from your chest." ) "The tube will remo!e e7cess air from your chest." #) "The tube controls the amount of air that enters your chest." %) "The tube will seal the hole in your lun"." &e!iew Information' The correct answer is ' "The tube will remo!e e7cess air from your chest." The purpose of the chest tube is to create ne"ati!e pressure and remo!e the air that has accumulated in the pleural space. ). The nurse is re!iewin" laboratory results on a client with acute renal failure. .hich one of the followin" should be reported immediately? A) lood urea nitro"en 68 m"Gdl ) @emo"lobin of 18.4 m"Gdl #) Benous blood p@ -.48 %) (erum potassium < mH1G> &e!iew Information' The correct answer is %' (erum potassium < mH1G> Althou"h all of these findin"s are abnormal+ the ele!ated potassium is a life threatenin" findin" and must be reported immediately. 4. The nurse is carin" for a client under"oin" the placement of a central !enous catheter line. .hich of the followin" would re1uire the nurse2s immediate attention? A) ?allor ) Increased temperature #) %yspnea

%) In!oluntary muscle spasms &e!iew Information' The correct answer is #' %yspnea #lient2s ha!in" the insertion of a central !enous catheter are at risk for tension pneumothora7. %yspnea+ shortness of breath and chest pain are indications of this complication. 4. The nurse is performin" a physical assessment on a client who 3ust had an endotracheal tube inserted. .hich findin" would call for immediate action by the nurse? A) reath sounds can be heard bilaterally ) $ist is !isible in the T-?iece #) ?ulse o7imetery of ,, %) #lient is unable to speak &e!iew Information' The correct answer is #' ?ulse o7imetery of ,, ?ulse o7imetry should not be lower than 98. ?lacement will need to be checked+ as well as !entilator settin"s. 6. A nurse checks a client who is on a !olume-cycled !entilator. .hich findin" indicates that the client may need suctionin"? A) drowsiness ) complaint of nausea #) pulse rate of 9) %) restlessness &e!iew Information' The correct answer is %' restlessness &estlessness+ increased heart and respiratory rates+ and noisy e7piration su""est hypo7ia and are indications for suctionin". <. The most effecti!e nursin" inter!ention to pre!ent atelectasis from de!elopin" in a post operati!e client is to A) $aintain ade1uate hydration ) Assist client to turn+ deep breathe+ and cou"h #) Ambulate client within 1) hours %) (plint incision &e!iew Information' The correct answer is ' Assist client to turn+ deep breathe+ and cou"h %eep air e7cursion by turnin"+ deep breathin"+ and cou"hin" will e7pand the lun"s and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when cou"hin". @umidification+ hydration and nutrition all play a part in pre!entin" atelectasis followin" sur"ery. -. .hen carin" for a client with a post ri"ht thoracotomy who has under"one an upper lobectomy+ the nurse focuses on pain mana"ement to promote A) &ela7ation and sleep ) %eep breathin" and cou"hin" #) Incisional healin" %) &an"e of motion e7ercises &e!iew Information' The correct answer is ' %eep breathin" and cou"hin" The priority is postoperati!e respiratory toilet. This client will 1uickly de!elop profound atelectasis and e!entually pneumonia without ade1uate "as e7chan"e. This will only be achie!ed with the appropriate pain mana"ement. ,. A nurse is to collect a sputum specimen for acid-fast bacillus AA0 ) from a client. .hich action should the nurse take first? A) Ask client to cou"h sputum into container ) @a!e the client take se!eral deep breaths #) ?ro!ide a appropriate specimen container %) Assist with oral hy"iene &e!iew Information' The correct answer is %' Assist with oral hy"iene ;btain a specimen early in the mornin" after mouth care. The other responses follow this first action' the client should take se!eral deep breaths then cou"h into the appropriate container which is sterile for the A0 specimen of the sputum. 9. The nurse is carin" for a child immediately after sur"ical correction of a !entricular septal defect. .hich of the followin" nursin" assessments should be a priority? A) lanch nail beds for color and refill ) Assess for post operati!e arrhythmias #) Auscultate for pulmonary con"estion %) $onitor e1uality of peripheral pulses &e!iew Information' The correct answer is ' Assess for post operati!e arrhythmias The atrio!entricular bundle Abundle of @is)+ a part of the electrical conduction system of the heart+ e7tends from the atrio!entricular node alon" each side of the inter!entricular septum and then di!ides into ri"ht and left bundle branches. (ur"ical repair of a !entricular septal defect consists of a purse-strin" approach or a patch sewn o!er the openin". 18. A client has a history of chronic obstructi!e pulmonary disease A#;?%). As the nurse enters the client=s room+ his o7y"en is runnin"

at < liters per minute+ his color is flushed and his respirations are , per minute. .hat should the nurse do first? A) ;btain a 1)-lead HM/ ) ?lace client in hi"h 0owler=s position #) >ower the o7y"en rate %) Take baseline !ital si"ns &e!iew Information' The correct answer is #' >ower the o7y"en rate A low o7y"en le!el acts as a stimulus for respiration. A hi"h concentration of supplemental o7y"en remo!es the hypo7ic dri!e to breathe+ leadin" to increased hypo!entilation+ respiratory decompensation+ and the de!elopment of or worsenin" of respiratory acidosis. *nless corrected+ it can lead to the client==s death. 11. A 4 year-old has been hospitali5ed for )4 hours with skeletal traction for treatment of a fracture of the ri"ht femur. The nurse finds that the child is now cryin" and the ri"ht foot is pale with the absence of a pulse. .hat should the nurse do first? K A) Cotify the health care pro!ider ) &ead3ust the traction #) Administer the ordered prn medication %) &eassess the foot in fifteen minutes &e!iew Information' The correct answer is A' Cotify the health care pro!ider The findin"s are indicati!e of circulatory impairment. The health care pro!ider Aor practitioner) must be notified immediately. 1). The nurse is assessin" a client ) hours postoperati!ely after a femoral popliteal bypass. The upper le" dressin" becomes saturated with blood. The nurse=s first action should be to A) .rap the le" with elastic banda"es ) Apply pressure at the bleedin" site #) &einforce the dressin" and ele!ate the le" %) &emo!e the dressin"s and re-dress the incision &e!iew Information' The correct answer is #' &einforce the dressin" and ele!ate the le" &einforce the dressin"+ ele!ate the e7tremity to decrease blood flow into the e7tremity and thus decrease bleedin"+ and call the health care pro!ider immediately. This is an emer"ency post sur"ical situation. 14. A client is recei!in" e7ternal beam radiation to the mediastinum for treatment of bronchial cancer. .hich of the followin" should take priority in plannin" care? A) Hsopha"itis ) >eukopenia #) 0ati"ue %) (kin irritation &e!iew Information' The correct answer is ' >eukopenia #lients de!elop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most fre1uent cause of morbidity and death in clients with cancer. 14. A client has a chest tube in place followin" a left lower lobectomy inserted after a stab wound to the chest. .hen repositionin" the client+ the nurse notices )88 cc of dark+ red fluid flows into the collection chamber of the chest drain. .hat is the most appropriate nursin" action? A) #lamp the chest tube ) #all the sur"eon immediately #) ?repare for blood transfusion %) #ontinue to monitor the rate of draina"e &e!iew Information' The correct answer is %' #ontinue to monitor the rate of draina"e lood that comes in contact with the pleural space becomes defibrino"enated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client chan"es position. The dark color of the blood indicates it is not fresh bleedin" inside the chest. 16. A client has returned from a cardiac catheteri5ation. .hich one of the followin" assessments would indicate the client is e7periencin" a complication from the procedure? A) Increased blood pressure ) Increased heart rate #) >oss of pulse in the e7tremity %) %ecreased urine output &e!iew Information' The correct answer is #' >oss of pulse in the e7tremity >oss of the pulse in the e7tremity would indicate impaired circulation. 1<. A <8 year-old male client had a hernia repair in an outpatient sur"ery clinic. @e is awake and alert+ but has not been able to !oid since he returned from sur"ery < hours a"o. @e recei!ed 1888 m> of IB fluid. .hich action would be most likely to help him !oid? A) @a!e him drink se!eral "lasses of water ) #rede2 the bladder from the bottom to the top #) Assist him to stand by the side of the bed to !oid %) .ait ) hours and ha!e him try to !oid a"ain &e!iew Information' The correct answer is #' Assist him to stand by the side of the bed to !oid .hen a male is not able to use a urinal unassisted+ the client should stand by the side of the bed to !oid. This is the most desirable position for normal !oidin" for

male clients. Also "i!en his a"e he most likely has some de"ree of prostate enlar"ement which may interfere with !oidin". 1-. The nurse is carin" for a client who re1uires a mechanical !entilator for breathin". The hi"h pressure alarm "oes off on the !entilator. .hat is the first action the nurse should perform? %isconnect the client from the !entilator and use a manual resuscitation ba" ?erform a 1uick assessment of the client=s condition #all the respiratory therapist for help ?ress the alarm re-set button on the !entilator &e!iew Information' The correct answer is ' ?erform a 1uick assessment of the client==s condition A number of situations can cause the hi"h pressure alarm to sound. It can be as simple as the client cou"hin". A 1uick assessment of the client will alert the nurse to whether it is a more serious or comple7 situation that mi"ht then re1uire usin" a manual resuscitation ba" and callin" the respiratory therapist. 1,. The nurse is preparin" a client who will under"o a myelo"ram. .hich of the followin" statements by the client indicates a contraindication for this test? A) "I can=t lie in 1 position for more than thirty minutes." ) "I am aller"ic to shrimp." #) "I suffer from claustrophobia." %) "I de!eloped a se!ere headache after a spinal tap." &e!iew Information' The correct answer is ' "I am aller"ic to shrimp." A client under"oin" myelo"raphy should be 1uestioned carefully about aller"ies to iodine and iodine-containin" substances such as seafood. An aller"y to iodine or seafood may indicate sensiti!ity to the radiopa1ue contrast a"ent used in the test. An aller"y to iodine or seafood may indicate sensiti!ity to the radiopa1ue contrast a"ent used in the test. An aller"ic reaction could be as serious as sei5ures. 19. The health care pro!ider order reads "aspirate naso"astric feedin" AC/) tuber e!ery 4 hours and check p@ of aspirate." The p@ of the aspirate is 18. .hich action should the nurse take? A) @old the tube feedin" and notify the pro!ider ) Administer the tube feedin" as scheduled #) Irri"ate the tube with diet cola soda %) Apply intermittent suction to the feedin" tube &e!iew Information' The correct answer is A' @old the tube feedin" and notify the pro!ider A p@ of less than 4 indicates that the tube is appropriately placed in the stomach+ a hi"hly acidic en!ironment. A hi"her than 4 or more alkaline p@ indicates intestinal placement+ which is correct. )8. To pre!ent unnecessary hypo7ia durin" suctionin" of a tracheostomy+ the nurse must A) Apply suction for no more than 18 seconds ) $aintain sterile techni1ue #) >ubricate 4 to 4 inches of the catheter tip %) .ithdraw catheter in a circular motion &e!iew Information' Applyin" suction for more than 18 seconds may result in hypo7ia. Althou"h options )+ 4+ and 4 are important in durin" suctionin" a tracheostomy+ hypo7ia results from actions that decrease the o7y"en supply.

(kip &e!iew Information' The correct answer is %' pre!ent the dru" from tissue irritation %eep in3ection or O-track is a special method of "i!in" medications !ia the intramuscular route. *se of this techni1ue pre!ents irritatin" or stainin" medications from bein" tracked throu"h tissue. *se of O-track does not affect dose+ absorption+ or distribution of the dru". 4. A client with heart failure has >ano7in Adi"o7in) ordered. .hat would the nurse e7pect to find when e!aluatin" for the therapeutic effecti!eness of this dru"? A) diaphoresis with decreased urinary output ) increased heart rate with increase respirations #) impro!ed respiratory status and increased urinary output %) decreased chest pain and decreased blood pressure &e!iew Information' The correct answer is #' impro!ed respiratory status and increased urinary output %i"o7in+ a cardiac "lycoside+ is used in clients with heart failure to slow and stren"then the heartbeat. As cardiac output is impro!ed+ renal perfusion is impro!ed and urinary output increases. #lients can become to7ic on this dru"+ with the findin"s of this to7icity bein" bradycardia+ dysrhythmia+ !isual and /I disturbances. #lients bein" treated with di"o7in should ha!e their apical pulse e!aluated for 1 full minute prior to the administration of the dru". 4. .hile pro!idin" home care to a client with con"esti!e heart failure+ the nurse is asked how lon" diuretics must be taken. .hat is the nurse2s best response? "As you urinate more+ you will need less medication to control fluid." "Fou will ha!e to take this medication for about a year." "The medication must be continued so the fluid problem is controlled." "?lease talk to your health care pro!ider about medications and treatments." &e!iew Information' The correct answer is #' "The medication must be continued so the fluid problem is controlled." This is the most therapeutic response and "i!es the client accurate information. 6. A client is bein" dischar"ed with a prescription for chlorproma5ine AThora5ine). efore lea!in" for home+ which of these findin"s should the nurse teach the client to report? A) #han"e in libido+ breast enlar"ement ) (ore throat+ fe!er #) Abdominal pain+ nausea+ diarrhea %) %sypnea+ nasal con"estion &e!iew Information' The correct answer is ' (ore throat+ fe!er A sore throat and fe!er may be symptoms of a"ranulocytosis+ a side effect of chlorproma5ine AThora5ine). <. A client is reco!erin" from a hip replacement and is takin" Tylenol W4 e!ery 4 hours for pain. In checkin" the client+ which findin" su""ests a side effect of the anal"esic? A) ruisin" at the operati!e site ) Hle!ated heart rate #) %ecreased platelet count %) Co bowel mo!ement for 4 days (kip &e!iew Information' The correct answer is %' Co bowel mo!ement for 4 days .ith opioid anal"esics obser!e for respiratory depression+ sedation+ and constipation. ruisin" is not related to the anal"esic+ but could be the result of corticosteroids or pre!iously used anticoa"ulants. Hle!ated heart rate could be the result of bronchodilators. (ome antibiotics can lower platelet count. -. A client is bein" maintained on heparin therapy for deep !ein thrombosis. The nurse must closely monitor which of the followin" laboratory !alues? A) leedin" time ) ?latelet count #) Acti!ated ?TT %) #lottin" time &e!iew Information' The correct answer is #' Acti!ated ?TT @eparin is used to pre!ent further clots from bein" formed and to pre!ent the present clot from enlar"in". The Acti!ated ?rothromboplastin Time AA?TT) test is a hi"hly sensiti!e test to monitor the client on heparin. ,. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic "astrostomy A?H/) tube for the administration of feedin"s and medications. .hich nursin" action is appropriate? A) ?ul!eri5e all medications to a powdery condition ) (1uee5e the tube before usin" it to break up sta"nant li1uids #) #leanse the skin around the tube daily with hydro"en pero7ide %) 0lush ade1uately with water before and after usin" the tube (kip &e!iew Information' The correct answer is %' 0lush ade1uately with water before and after usin" the tube 0lushin" the tube before and after use not only pro!ides for "ood flow and keeps the tube patent+ it also pro!ides water to maintain hydration. .hile medications should be crushed to pass throu"h the tube+ it is flushin" that mo!es them throu"h. (ta"nant li1uids are reduced by flushin" after tube use. #leansin" is important+ but soap and water are sufficient without the added irritation of hydro"en pero7ide.

&esults for ?harmacolo"ical and ?arenteral Therapies R Questions are numbered by the order in which they appeared in the test. R K &epresents the correct answer. 1. An antibiotic I$ in3ection for a ) year-old child is ordered. The total !olume of the in3ection e1uals ).8 ml The correct action is to A) administer the medication in ) separate in3ections ) "i!e the medication in the dorsal "luteal site #) call to "et a smaller !olume ordered %) check with pharmacy for a li1uid form of the medication skip &e!iew Information' The correct answer is A' administer the medication in ) separate in3ections Intramuscular in3ections should not e7ceed a !olume of 1 ml for small children. $edication doses e7ceedin" this !olume should be split into ) separate in3ections of 1.8 ml each. In adults the ma7imum intramuscular in3ection !olume is 6 ml per site ). The nurse recei!es an order to "i!e a client iron by deep in3ection. The nurse know that the reason for this route is to A) enhance absorption of the medication ) ensure that the entire dose of medication is "i!en #) pro!ide more e!en distribution of the dru" %) pre!ent the dru" from tissue irritation

9. The nurse has "i!en dischar"e instructions to parents of a child on phenytoin A%ilantin). .hich of the followin" statements su""ests that the teachin" was effecti!e? ".e will call the health care pro!ider if the child de!elops acne." ";ur child should brush and floss carefully after e!ery meal." ".e will skip the ne7t dose if !omitin" or fe!er occur." ".hen our child is sei5ure-free for < months+ we can stop the medication." &e!iew Information' The correct answer is ' ";ur child should brush and floss carefully after e!ery meal." ?henytoin causes lymphoid hyperplasia that is most noticeable in the "ums. 0re1uent "um massa"e and careful attention to "ood oral hy"iene may reduce the "in"i!al hyperplasia. 18. Althou"h nonsteroidal anti-inflammatory dru"s such as ibuprofen A$otrin) are beneficial in mana"in" arthritis pain+ the nurse should caution clients about which of the followin" common side effects? A) *rinary incontinence ) #onstipation #) Cysta"mus %) ;ccult bleedin" &e!iew Information' The correct answer is %' ;ccult bleedin" Consteroidal anti-inflammatory dru"s taken for lon" periods of time may cause serious side effects+ includin" bleedin" in the "astrointestinal track. 11. The nurse is carin" for a client with clinical depression who is recei!in" a $A; inhibitor. .hen pro!idin" instructions about precautions with this medication+ which action should the nurse stress to the client as important? A) A!oid chocolate and cheese ) Take fre1uent naps #) Take the medication with milk %) A!oid walkin" without assistance &e!iew Information' The correct answer is A' A!oid chocolate and cheese 0oods hi"h in tryptophan+ tyramine and caffeine+ such as chocolate and cheese may precipitate hypertensi!e crisis. 1). A parent asks the school nurse how to eliminate lice from their child. .hat is the most appropriate response by the nurse? A) #ut the child=s hair short to remo!e the nits ) Apply warm soaks to the head twice daily #) .ash the child=s linen and clothin" in a bleach solution %) Application of pediculicides &e!iew Information' The correct answer is %' Application of pediculicides Treatment of head lice consists of application of pediculicides. ?ediculicides !ary+ and the directions must be followed carefully. 14. The nurse is teachin" a client about precautions with #oumadin therapy. The client should be instructed to a!oid which o!er-thecounter medication? A) Con-steroidal anti-inflammatory dru"s ) #ou"h medicines with "uaifenesin #) @istamine blockers %) >a7ati!es containin" ma"nesium salts &e!iew Information' The correct answer is A' Con-steroidal antiinflammatory dru"s $edications with C(AI%( may increase the response to #oumadin Awarfarin) and increase the risk of bleedin". 14. A client dia"nosed with cirrhosis of the li!er and ascites is recei!in" (pironolactone AAldactone). The nurse understands that this medication spares elimination of which element? A) (odium ) ?otassium #) ?hosphate %) Albumin &e!iew Information' The correct answer is ' ?otassium If ascites is present in the client with cirrhosis of the li!er+ potassiumsparin" diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys. 16. The nurse is carin" for a client recei!in" a blood transfusion who de!elops urticaria one-half hour after the transfusion has be"un. .hat is the first action the nurse should take? A) (top the infusion ) (low the rate of infusion #) Take !ital si"ns and obser!e for further deterioration %) Administer enadryl and continue the infusion &e!iew Information' The correct answer is A' (top the infusion This is an indication of an aller"y to the plasma protein. The first action of the nurse is to stop the transfusion.

1<. %ischar"e instructions for a client takin" alpra5olam APana7) should include which of the followin"? A) (edati!e hypnotics are effecti!e anal"esics (udden cessation of alpra5olam APana7) can cause rebound ) insomnia and ni"htmares #) #affeine be!era"es can increase the effect of sedati!e hypnotics A!oidance of e7cessi!e e7ercise and hi"h temperature is %) recommended &e!iew Information' The correct answer is ' (udden cessation of alpra5olam APana7) can cause rebound insomnia and ni"htmares (udden cessation of alpra5olam APana7) can cause rebound insomnia and ni"htmares. 1-. A client has recei!ed ) units of whole blood today followin" an episode of /I bleedin". .hich of the followin" laboratory reports would the nurse monitor most closely? A) leedin" time ) @emo"lobin and hematocrit #) .hite blood cells %) ?latelets &e!iew Information' The correct answer is ' @emo"lobin and hematocrit The post-transfusion hematocrit pro!ides immediate information about red cell replacement and about continued blood loss. 1,. A client is recei!in" intra!enous heparin therapy. .hat medication should the nurse ha!e a!ailable in the e!ent of an o!erdose of heparin? A) ?rotamine ) Amicar #) Imferon %) %iltia5em &e!iew Information' The correct answer is A' ?rotamine . ?rotamine binds heparin makin" it ineffecti!e. 19. The nurse has been teachin" a client with Insulin %ependent %iabetes $ellitus. .hich statement by the client indicates a need for further teachin"? A) "I use a slidin" scale to ad3ust re"ular insulin to my su"ar le!el." "(ince my eyesi"ht is so bad+ I ask the nurse to fill se!eral ) syrin"es." #) "I keep my re"ular insulin bottle in the refri"erator." K %) "I always make sure to shake the C?@ bottle hard to mi7 it well." &e!iew Information' The correct answer is %' "I always make sure to shake the C?@ bottle hard to mi7 it well." The bottle should by rolled "ently+ not shaken. )8. .hy is it important for the nurse to monitor blood pressure in clients recei!in" antipsychotic dru"s? A) ;rthostatic hypotension is a common side effect ) $ost antipsychotic dru"s cause ele!ated blood pressure This pro!ides information on the amount of sodium allowed in the #) diet %) It will indicate the need to institute antiparkinsonian dru"s &e!iew Information' The correct answer is A' ;rthostatic hypotension is a common side effect #lients should be made aware of the possibility of di55iness and syncope from postural hypotension for about an hour after recei!in" medication. &esults for asic #are and #omfort

1. The nurse is teachin" the client to select foods rich in potassium to help pre!ent di"italis to7icity. .hich choice indicates the client understands dietary needs? A) Three apricots ) $edium banana #) Ca!al oran"e %) aked potato &e!iew Information' The correct answer is %' aked potato. The baked potato contains <18 milli"rams of potassium. ). An ,< year-old nursin" home resident who has decreased mental status is hospitali5ed with pneumonic infiltrates in the ri"ht lower lobe. .hen the nurse assists the client with a clear li1uid diet+ the client be"ins to cou"h. .hat should the nurse do ne7t? Add a thickenin" a"ent to the fluids #heck the client2s "a" refle7 0eed the client only solid foods Increase the rate of intra!enous fluids &e!iew Information' The correct answer is ' #heck the client2s "a" refle7 .hen a new problem emer"es+ the nurse should perform appropriate assessment so that suitable nursin" inter!entions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lun". A loss or an impairment of the protecti!e cou"h refle7 can result in aspiration. 4. The nurse is plannin" care for a client with a #BA. .hich of the followin" measures planned by the nurse would be most effecti!e in pre!entin" skin breakdown? ?lace client in the wheelchair for four hours each day

?ad the bony prominence &eposition e!ery two hours $assa"e reddened bony prominence &e!iew Information' The correct answer is #' &eposition e!ery two hours #lients who are at risk for skin breakdown de!elop fewer pressure ulcers when turned e!ery two hours. y relie!in" the pressure o!er bony prominences at fre1uent scheduled inter!als+ blood flow is maintained to areas of potential in3ury. 4. A nurse is assessin" se!eral clients in a lon" term health care facility. .hich client is at hi"hest risk for de!elopment of decubitus ulcers? A -9 year-old malnourished client on bed rest An obese client who uses a wheelchair A client who had 4 incontinent diarrhea stools An ,8 year-old ambulatory diabetic client &e!iew Information' The correct answer is A' A -9 year-old malnourished client on bed rest .ei"hin" si"nificantly less than ideal body wei"ht increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus+ malnutrition is a ma3or risk factor for decubiti+ due in part to poor hydration and inade1uate protein intake. 6. #onstipation is one of the most fre1uent complaints of elders. .hen assessin" this problem+ which action should be the nurse=s priority? ;btain a complete blood count ;btain a health and dietary history &efer to a pro!ider for a physical e7amination $easure hei"ht and wei"ht &e!iew Information' The correct answer is ' ;btain a health and dietary history Initially+ the nurse should obtain information about the chronicity of and details about constipation+ recent chan"es in bowel habits+ physical and emotional health+ medications+ acti!ity pattern+ and food and fluid history. This information may su""est causes as well as an appropriate+ safe treatment plan. <. After a client has an enteral feedin" tube inserted+ the most accurate method for !erification of placement is A) Abdominal 7-ray ) Auscultation #) 0lushin" tube with saline %) Aspiration for "astric contents &e!iew Information' The correct answer is A' Abdominal 7-ray ?lacement should be !erified by radio"raph to determine that the tube is in the stomach or intestine rather than in the airways. -. A client was 3ust taken off the !entilator after sur"ery and has a naso"astric tube drainin" bile colored li1uids. .hich nursin" measure will pro!ide the most comfort to the client? Allow the client to melt ice chips in the mouth ?ro!ide mints to freshen the breath ?erform fre1uent oral care with a toothspon"e (wab the mouth with "lycerin swabs &e!iew Information' The correct answer is #' ?erform fre1uent oral care with a toothspon"e 0re1uent cleansin" and stimulation of the mucous membrane is important for a client with a naso"astric tube to pre!ent de!elopment of lesions and to promote comfort. Ice chips or mints could be contraindicated+ and do not stimulate the tissue. /lycerin swabs do not cleanse since they only moisturi5e ,. The nurse is instructin" a <6 year-old female client dia"nosed with osteoporosis. The most important instruction re"ardin" e7ercise would be to H7ercise doin" wei"ht bearin" acti!ities H7ercise to reduce wei"ht A!oid e7ercise acti!ities that increase the risk of fracture H7ercise to stren"then muscles and thereby protect bones &e!iew Information' The correct answer is A' H7ercise doin" wei"ht bearin" acti!ities .ei"ht bearin" e7ercises are beneficial in the treatment of osteoporosis. Althou"h loss of bone cannot be substantially re!ersed+ further loss can be "reatly reduced if the client includes wei"ht bearin" e7ercises alon" with estro"en replacement and calcium supplements in their treatment protocol. 9. The nurse has been teachin" a client with con"esti!e heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? #heese sandwich with a "lass of ): milk (liced turkey sandwich and canned pineapple #heesebur"er and baked potato $ushroom pi55a and ice cream

&e!iew Information' The correct answer is ' (liced turkey sandwich and canned pineapple (liced turkey sandwich is appropriate since it is not a hi"hly processed food and canned fruits are low in sodium. All other choices contain one or more hi"h sodium foods. 18. .hich bed position is preferred for use with a client in an e7tended care facility on falls risk pre!ention protocol? All 4 side rails up+ wheels locked+ bed closest to door >ower side rails up+ bed facin" doorway Mnees bent+ head sli"htly ele!ated+ bed in lowest position ed in lowest position+ wheels locked+ place bed a"ainst wall &e!iew Information' The correct answer is %' ed in lowest position+ wheels locked+ place bed a"ainst wall Co lon"er is it ad!isable to use the lower side rails. .ith all 4 side rails used it reflects inappropriate use of protecti!e restraints without an order. ?lacin" the bed a"ainst the wall permits "ettin" out of bed on only 1 side. >ockin" the wheels keeps the bed from slidin". Meepin" the bed in the lowest position Awithout bendin" limbs to restrict mo!ement) pro!ides a shorter distance to the "round if the client chooses to "et out of bed. If the side rails are used 4 pulled up are acceptable. If 4 are pulled up an order for protecti!e restraints is needed and has to usually be renewed in 4, to -) hours alon" with more fre1uent documentation. 11. .hen administerin" enteral feedin" to a client !ia a 3e3unostomy tube+ the nurse should administer the formula A) H!ery four to si7 hours ) #ontinuously #) In a bolus %) H!ery hour &e!iew Information' The correct answer is ' #ontinuously *sually "astrostomy and 3e3unostomy feedin"s are "i!en continuously to ensure proper absorption. @owe!er+ initial feedin"s may be "i!en by bolus to assess the client==s tolerance to formula. 1). The nurse is teachin" an ,- year-old client methods for maintainin" re"ular bowel mo!ements. The nurse would caution the client to AB;I% A) /lycerine suppositories ) 0iber supplements #) >a7ati!es %) (tool softeners &e!iew Information' The correct answer is #' >a7ati!es $ost elders are constipated because they ha!e used o!er-the-counter la7ati!es for a lon" time. In addition+ most do not eat enou"h fiber+ drink enou"h water+ or e7ercise ade1uately. Hlders are rarely constipated because of or"anic or patholo"ical reasons. 14. A client with diarrhea should a!oid which of the followin"? A) ;ran"e 3uice ) Tuna #) H""s %) $acaroni &e!iew Information' The correct answer is A' ;ran"e 3uice ;ran"e 3uice is contraindicated for a client with diarrhea because it increases the motility of the "astrointestinal tract. 14. .hich statement best describes the effects of immobility in children? Immobility pre!ents the pro"ression of lan"ua"e and fine motor de!elopment Immobility in children has similar physical effects to those found in adults #hildren are more susceptible to the effects of immobility than are adults #hildren are likely to ha!e prolon"ed immobility with subse1uent complications &e!iew Information' The correct answer is ' Immobility in children has similar physical effects to those found in adults #are of the immobile child includes efforts to pre!ent complications of muscle atrophy+ contractures+ skin breakdown+ decreased metabolism and bone deminerali5ation. (econdary alterations also occur in the cardio!ascular+ respiratory and renal systems. (imilar effects and alterations occur in adults. 16. A nurse is pro!idin" care to a <4 year-old client with pneumonia. .hich inter!ention promotes the client2s comfort? A) Increase oral fluid intake ) Hncoura"e !isits from family and friends #) Meep con!ersations short %) $onitor !ital si"ns fre1uently &e!iew Information' The correct answer is #' Meep con!ersations short Meepin" con!ersations short will promote the client2s comfort by decreasin" demands on the client2s breathin" and ener"y. Increased intake is not related to comfort. .hile the presence of family is supporti!e+ demands on the client to interact with the !isitors may interfere with the client2s rest. $onitorin" !ital si"ns is an important assessment but not related to promotin" the client2s comfort. 1<. After a myocardial infarction+ a client is placed on a sodium restricted diet. .hen the nurse is teachin" the client about the diet+ which meal plan would be the most appropriate 4 o5. broiled fish+ 1 baked potato+ X cup canned beets+ 1 oran"e+ and

milk 4 o5. canned salmon+ fresh broccoli+ 1 biscuit+ tea+ and 1 apple A bolo"na sandwich+ fresh e""plant+ ) o5 fresh fruit+ tea+ and apple 3uice 4 o5. turkey+ 1 fresh sweet potato+ 1G) cup fresh "reen beans+ milk+ and 1 oran"e &e!iew Information' The correct answer is %' 4 o5. turkey+ 1 fresh sweet potato+ 1G) cup fresh "reen beans+ milk+ and 1 oran"e #anned fish and !e"etables and cured meats are hi"h in sodium. This meal does not contain any canned fish andGor !e"etables or cured meats. 1-. The nurse is carin" for a - year-old with acute "lomerulonephritis AA/C). 0indin"s include moderate edema and oli"uria. (erum blood urea nitro"en and creatinine are ele!ated. .hat dietary modifications are most appropriate? A) %ecreased carbohydrates and fat ) %ecreased sodium and potassium #) Increased potassium and protein %) Increased sodium and fluids &e!iew Information' The correct answer is ' %ecreased sodium and potassium #hildren with A/C who ha!e edema+ hypertension oli"uria+ and a5otemia ha!e dietary restrictions limitin" sodium+ potassium+ fluids+ and protein. 1,. .hat nursin" assessment of a paraly5ed client would indicate the probable presence of a fecal impaction? A) ?resence of blood in stools ) ;o5in" li1uid stool #) #ontinuous rumblin" flatulence %) Absence of bowel mo!ements &e!iew Information' The correct answer is ' ;o5in" li1uid stool The correct answer it . .hen the bowel is impacted with hardened feces+ there is often a seepa"e of li1uid feces around the obstruction. This is often mistaken for uncontrolled diarrhea. 19. A client in a lon" term care facility complains of pain. The nurse collects data about the client2s pain. The first step in pain assessment is for the nurse to A) ha!e the client identify copin" methods ) "et the description of the location and intensity of the pain K #) accept the client2s report of pain %) determine the client2s status of pain &e!iew Information' The correct answer is #' Accept the client==s report of pain Althou"h the information abo!e is correct+ the first and most important piece of information in this client2s pain assessment is what the client is tellin" you about the pain --Ethe client2s reportD. )8. An ,6 year-old client complains of "enerali5ed muscle aches and pains. The first action by the nurse should be A) Assess the se!erity and location of the pain ) ;btain an order for an anal"esic #) &eassure him that this is not unusual for his a"e %) Hncoura"e him to increase his acti!ity &e!iew Information' The correct answer is A' Assess the se!erity and location of the pain $ost older adults ha!e 1 or more chronic painful illnesses+ and in fact+ they often must be asked about discomfort Arather than "pain") to re!eal the presence of pain. There is no real e!idence that pain of older adults is less intense than youn"er adults. It is important for the nurse to assess the pain thorou"hly before implementin" pain relief measures.

). A child is admitted to the pediatric unit with a dia"nosis of suspected menin"ococcal menin"itis. .hich admission orders should the nurse do first? A) Institute sei5ure precautions ) $onitor neurolo"ic status e!ery hour #) ?lace in respiratoryGsecretion precautions %) #efota7ime IB 68 m"Gk"Gday di!ided 1<h &e!iew Information' The correct answer is #' ?lace in respiratoryGsecretion precautions $enin"ococcal menin"itis has the risk of bein" a bacterial infection. The initial therapeutic mana"ement of acute bacterial menin"itis includes respiratoryGsecretions precautions+ initiation of antimicrobial therapy+ monitor neurolo"ical status alon" with !ital si"ns+ institute sei5ure precautions and lastly maintenance of optimum hydration. The first action is for nurses to take any necessary precautions to protect themsel!es and others from possible infection. Biral menin"itis usually does not re1uire protecti!e measures of isolation. 4. .hich of these nursin" dia"noses of 4 elderly clients would place 1 client at the "reatest risk for falls? (ensory perceptual alterations related to decreased !ision Alteration in mobility related to fati"ue Impaired "as e7chan"e related to retained secretions Altered patterns of urinary elimination related to nocturia &e!iew Information' The correct answer is %' Altered patterns of urinary elimination related to nocturia Cocturia is especially problematic because many elders fall when they rush to reach the bathroom at ni"ht. They may be confused or not fully alert. Inade1uate li"htin" can increase their chances of stumblin" and they may fall o!er furniture or carpets. 4. A nurse who is reassi"ned to the emer"ency department needs to understand that "astric la!a"e is a priority in which situation? An infant who has been identified to ha!e botulism A toddler who ate a number of ibuprofen tablets A preschooler who swallowed powdered plant food A school a"ed child who took a handful of !itamins &e!iew Information' The correct answer is A' An infant who has been identified to ha!e botulism #. botulinum forms a to7in in improperly processed foods in anaerobic conditions. It is a neuroto7in that impairs autonomic and !oluntary neurotransmission and causes muscular paralysis. 0indin"s appear within 4< hours of in"estion. e aware that all of the options may be candidates for "astric la!a"e or for acti!ated charcoal administration. 6. A newly admitted adult client has a dia"nosis of hepatitis A. The char"e nurse should reinforce to the staff members that the most si"nificant routine infection control strate"y+ in addition to handwashin"+ to be implemented is which of these? Apply appropriate si"ns outside and inside the room Apply a mask with a shield if there is a risk of fluid splash .ear a "own to chan"e soiled linens from incontinence @a!e "lo!es on while handlin" bedpans with feces &e!iew Information' The correct answer is %' @a!e "lo!es on while handlin" bedpans with feces The specific measure to pre!ent the spread of hepatitis A is careful handlin" and protection while handlin" fecal material. All of the other actions are correct but not the most si"nificant. <. .hich of these clients with associated lab reports is a priority for the nurse to report to the public health department within the ne7t )4 hours? A) An infant with a posti!e culture of stool for (hi"ella An elderly factory worker with a lab report that is positi!e for K ) acid-fast bacillus smear A youn" adult commercial pilot with a positi!e histopatholo"ical #) e7amination from an induced sputum for ?neumocystis carinii A middle-a"ed nurse with a history of !aricella-5oster !irus and %) with crops of !esicles on an erythematous base that appear on the skin &e!iew Information' The correct answer is ' An elderly factory worker with a lab report that is positi!e for acid-fast bacillus smear Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophyla7is for a desi"nated time. ;ptions a and d may need contact isolation precautions. ;ption c findin"s may indicate the initial sta"e of the autoimmune deficency syndrome AAI%(). -. A client is dia"nosed with methicillin resistant staphylococcus aureus pneumonia. .hat type of isolation is most appropriate for this client? A) &e!erse ) Airbourne #) (tandard precautions %) #ontact &e!iew Information' The correct answer is %' #ontact #ontact precautions or ody (ubstance Isolation A (I) in!ol!es the use of barrier protection Ae.". "lo!es+ mask+ "own+ or protecti!e eyewear as appropriate) whene!er direct contact with any body fluid is e7pected. .hen determinin" the type of isolation to use+ one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin

&esults for (afety and Infection #ontrol 1. A )8 year-old client has an infected le" wound from a motorcycle accident+ and the client has returned home from the hospital. The client is to keep the affected le" ele!ated and is on contact precautions. The client wants to know if !isitors can come. The appropriate response from the home health nurse is that' A) Bisitors must wear a mask and a "own There are no special re1uirements for !isitors of clients on contact ) precautions Bisitors should wash their hands before and after touchin" the #) client %) Bisitors should wear "lo!es if they touch the client &e!iew Information' The correct answer is #' Bisitors should wash their hands before and after touchin" the client /own and "lo!es are worn by persons comin" in contact with the wounds or infected e1uipment. Bisitors should wash their hands before and after touchin" the client.

resistant staphylococcus aureus A$&(A). ecause the or"anism is limited to the sputum in this e7ample+ precautions are taken if contact with the patient==s sputum is e7pected. A pri!ate room and contact precautions + alon" with "ood hand washin" techni1ues+ are the best defenses a"ainst the spread of $&(A pneumonia. ,. The school nurse is teachin" the faculty the most effecti!e methods to pre!ent the spread of lice in the school. The information that would be most important to include would be which of these statements? "The treatment re1uires reapplication in , to 18 days." " eddin" and clothin" can be boiled or steamed." #hildren are not to share hats+ scar!es and combs. Cit combs are necessary to comb out nits. &e!iew Information' The correct answer is #' E#hildren are not to share hats+ scar!es and combs.D @ead lice li!e only on human bein"s and can be spread easily by sharin" hats+ combs+ scar!es+ coats and other items of clothin" that touch the hair. All of the options are correct statements. @owe!er they do not best answer the 1uestion of how to pre!ent the spread of lice in a school settin". 9. %urin" the care of a client with a salmonella infection+ the primary nursin" inter!ention to limit transmission is which of these approaches? .ash hands thorou"hly before and after client contact .ear "lo!es when in contact with body secretions %ouble "lo!e when in contact with feces or !omitus .ear "lo!es when disposin" of contaminated linens &e!iew Information' The correct answer is A' .ash hands thorou"hly before and after client contact /ram-ne"ati!e bacilli cause (almonella infection. Two million new cases appear each year. >ack of sanitation is the primary means of contamination. Thorou"h handwashin" can pre!ent the spread of salmonella. Cote that all of the options are correct actions. @owe!er+ the primary action is to wash the hands. 18. A nurse is reinforcin" teachin" with a client about compromised host precautions. The client is recei!in" fil"rastim ACeupo"en) for neutropenia. The selection of which lunch su""ests the client has learned about necessary dietary chan"es? "rilled chicken sandwich and skim milk roast beef+ mashed potatoes+ and "reen beans peanut butter sandwich+ banana+ and iced tea barbe1ue beef+ baked beans+ and cole slaw &e!iew Information' The correct answer is ' roast beef+ mashed potatoes+ and "reen beans The client has correctly selected an appropriate lunch and appears to ha!e knowled"e of restrictions. >ow "ranulocyte counts and susceptibility to infection are e7pected. #ompromised host precautions re1uire that foods are either cooked or canned. ;ptions 1+ 4 and 4 do not demonstrate learnin"+ as raw fruits+ !e"etables+ and milk are to be a!oided. 11. After an e7plosion at a factory one of the workers approaches the nurse and says EI am an unlicensed assisti!e personnel A*A?) at the local hospital.D .hich of these tasks should the nurse assi"n to this worker who wants to help durin" the care of the wounded workers? A) /et temperatures ) Take blood pressure #) ?alpate pulses %) #heck alertness &e!iew Information' The correct answer is #' ?alpate pulses The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated+ those clients would need to be seen first. 1). .hich of these clients would the nurse recommend to keep in the hospital durin" an internal disaster at the a"ency? An adolescent dia"nosed with sepsis - days a"o with !ital si"ns A) maintained within low normal A middle-a"ed woman documented to ha!e had an ) uncomplicated myocardial infarction 4 days a"o An elderly man admitted ) days a"o with an acute e7acerbation #) of ulcerati!e colitis A youn" adult in the second day of treatment for an o!erdose of K %) acetometaphen &e!iew Information' The correct answer is %' A youn" adult in the second day of treatment for an o!erdose of acetometaphen 5the correct answer is %. An o!erdose of Tylenol re1uires close obser!ation for 4 to 4 days as well as $ucomyst oral treatement for as lon". A risk of li!er failure e7ists within this time period. 14. The mother of a toddler who is bein" treated for pesticide poisonin" asks' E.hy is acti!ated charcoal used? .hat does it do?D .hat is the nurse=s best response? "Acti!ated charcoal decreases the systemic absorption of the poison from the stomach."

"The charcoal absorbs the poison and forms a compound that doesn=t hurt your child." "This substance helps to "et the poison out of the body by the "astrointestinal system." "The action may bind or inacti!ate the to7ins or irritants that are in"ested by children or adults." &e!iew Information' The correct answer is ' "The charcoal absorbs the poison and forms a compound that doesn==t hurt your child." All of the options are correct responses. @owe!er+ option b is most accurate information to answer the mother2s 1uestion and about the effecti!eness of acti!ated charcoal. The lan"ua"e is appropriate for a parent==s understandin". 14. The nurse is to administer a new medication to a client. .hich actions are in the best interest of the client? Berify the order for the medication. ?rior to "i!in" the medication the nurse should say "?lease state your name?" *pon enterin" the room the nurse should ask' ".hat is your name? .hat aller"ies do you ha!e?" then check the client=s name band and aller"y band As the room is entered say ".hat is your name?" then check the client=s name band Berify the client=s aller"ies on the admission sheet and order. Berify the client=s name on the name plate outside the room then as the nurse enters the room ask the client ".hat is your first+ middle and last name?" &e!iew Information' The correct answer is ' *pon enterin" the room the nurse should ask' ".hat is your name? .hat aller"ies do you ha!e?" then check the client==s name band and aller"y band A dual check is consistently done for a client==s name. This would in!ol!e !erbal and !isual checks. (ince this is a new medication an aller"y check is appropriate. 16. (e!eral clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? Autoimmune deficiency syndrome AAI%() with cytome"alo!irus A#$B) A positi!e purified protein deri!ati!e with an abnormal chest 7-ray A tentati!e dia"nosis of !iral pneumonia with producti!e brown sputum Ad!anced carcinoma of the lun" with hemoptasis &e!iew Information' The correct answer is ' A positi!e purified protein deri!ati!e with an abnormal chest 7-ray The client who must be placed in airborne precautions is the client with a positi!e ??% Apurified protein deri!ati!e) who has a positi!e 7-ray for a suspicious tuberculin lesion. A sputum smear for acid fast bacillus would be done ne7t. #$B usually causes no si"ns or symptoms in children and adults with healthy immune systems. .hen si"ns and symptoms do occur+ they==re often similar to those of mononucleosis+ includin"' sore throat+ fe!er+ muscle aches+ fati"ue. /ood handwashin" is recommended for #$B. 1<. A client is scheduled to recei!e an oral solution of radioacti!e iodine A141I). In order to reduce ha5ards+ the priority information for the nurse to include durin" the instructions to the client is which of these statements? In the initial 4, hours a!oid contact with children and pre"nant women+ and after urination or defecation flush the commode twice. *se disposable utensils for ) days and if !omitin" occurs within 18 hours of the dose+ do so in the toilet and flush it twice. Four family can use the same bathroom that you use without any special precautions. %rink plenty of water and empty your bladder often durin" the initial 4 days of therapy. &e!iew Information' The correct answer is A' EIn the initial 4, hours a!oid contact with children and pre"nant women+ and after urination or defecation flush the commode twice.D The client==s urine and sali!a are radioacti!e for )4 hours after in"estion+ and !omitus is radioacti!e for < to , hours. The client should drink 4 to 4 liters a day for the initial 4, hours to help remo!e the a"ent from the body. (taff should limit contact with hospitali5ed clients to 48 minutes per day per person. 1-. .hich approach is the best way to pre!ent infections when pro!idin" care to clients in the home settin"? @andwashin" before and after e7amination of clients .earin" nonpowdered late7 free "lo!es to e7amine the client *sin" a barrier between the client=s furniture and the nurse=s ba" .earin" a mask with a shield durin" any eyeGmouthGnose e7amination &e!iew Information' The correct answer is A' @andwashin" @andwashin" remains the most effecti!e way to a!oid spreadin" infection. @owe!er+ too often nurses do not practice "ood handwashin" techni1ues and do not teach families to do so. Curses need to wash their hands before and after touchin" the client and before enterin" the nursin" ba". All of the options are correct. The se1uence for priority actions would be options a+ c+ b+ and d. 1,. A 18 year-old child has a history of epilepsy with tonic-clonic sei5ures. The school nurse should instruct the classroom teacher that if the child e7periences a sei5ure in the classroom+ the most important action durin" the sei5ure would be to $o!e any chairs or desks at least 4 feet away from the child Cote the se1uence of mo!ements with the time lapse of the e!ent ?ro!ide pri!acy as much as possible to minimi5e fi"htenin" the other children ?lace the hands or a folded blanket under the head of the child

&e!iew Information' The correct answer is %' ?lace the hands or a folded blanket under the head of the child The priority durin" sei5ure acti!ity is to protect the person from physical in3ury. ?lace a pillow+ folded blanket or your hands under the child==s head to pre!ent harm to the head. The other body parts are of less risk of in3ury. The se1uence of actions abo!e would be options d+ a+ b+ and c in order of priority. 19. A mother calls the hospital hot line and is connected to the tria"e nurse. The mother proclaims' EI found my child with odd stuff comin" from the mouth and an unmarked bottle nearby.D .hich of these comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosi!e substance? Ask the child if the mouth is burnin" or throat pain is present Take the child2s pulse at the wrist and see if the child is has trouble breathin" lyin" flat. .hat color is the child2s lips and nails and has the child !oided today? @as the child had !omitin" or diarrhea or stomach cramps yet? &e!iew Information' The correct answer is A' EAsk the child if the mouth is burnin" or throat pain is presentD >ocal irritation of tissues indicates a corrosi!e poisonin". The other comments may be helpful for the o!erall child2s condition. @owe!er+ the 1uestion is about the concern for a caustic substance. )8. The nurse is assi"ned to a client newly dia"nosed with acti!e tuberculosis. .hich of these protocols would be a priority for the nurse to implement? @a!e the client cou"h into a tissue and dispose in a separate ba" Instruct the client to co!er the mouth with a tissue when cou"hin" &einforce for all to wash their hands before and after enterin" the room ?lace client in a ne"ati!e pressure pri!ate room and ha!e all who enter the room use masks with shields &e!iew Information' The correct answer is %' ?lace client in a ne"ati!e pressure pri!ate room and ha!e all who enter the room use masks with shields A client with acti!e tuberculosis should be hospitali5ed in a ne"ati!e pressure room to pre!ent respiratory droplets from lea!in" the room when the door is opened. Tuberculosis AT ) is caused by sporeformin" mycobacteria+ more often $ycobacterium tuberculosis. In de!eloped countries the infection is airborne and is spread by inhalation of infected droplets. In underde!eloped countries AAfrica+ Asia+ (outh America)+ transmission also occurs by in"estion or by skin in!asion+ particularly when bo!ine T is poorly controlled. &esults for $ana"ement of #are 1. The char"e nurse is plannin" assi"nments on a medical unit. .hich client should be assi"ned to the ?C? A) Test a stool specimen for occult blood ) Assist with the ambulation of a client with a chest tube #) Irri"ate and redress a le" wound %) Admit a client from the emer"ency room &e!iew Information' The correct answer is #' Irri"ate and redress a le" wound The ?C is a licensed pro!ider and can perform this comple7 task. ;ptions A and could be dele"ated to a *A? and option % re1uires an &C. ). .hen assessin" a client+ it is important for the nurse to be informed about cultural issues related to the client=s back"round because Cormal patterns of beha!ior may be labeled as de!iant+ immoral+ or insane The meanin" of the client=s beha!ior can be deri!ed from con!entional wisdom ?ersonal !alues will "uide the interaction between persons from ) cultures The nurse should rely on her knowled"e of different de!elopmental mental sta"es &e!iew Information' The correct answer is A' Cormal patterns of beha!ior may be labeled as de!iant+ immoral+ or insane #ulture is an important !ariable in the assessment of indi!iduals. To work effecti!ely with clients+ the nurse must be aware of a cultural distincti!e 1ualities. 4. The nurse is responsible for se!eral elderly clients+ includin" a client on bed rest with a skin tear and hematoma from a fall ) days a"o. .hat is the best care assi"nment for this client? Assi"n an &C to pro!ide total care of the client Assi"n a nursin" assistant to help the client with self-care acti!ities %ele"ate complete care to an unlicensed assisti!e personnel (uper!ise a nursin" assistant for skin care &e!iew Information' The correct answer is %' (uper!ise a nursin" assistant for skin care. The nursin" assistant can inspect the skin while "i!in" hy"iene care+ but the nurse should super!ise skin care since assessment and analysis are needed.

4. The nursin" student is discussin" with a preceptor the dele"ation of tasks to an unlicensed assisti!e personnel A*A?). .hich tasks+ dele"ated to a *A?+ indicates the student needs further teachin" about the dele"ation process? Assist a client post cerebral !ascular accident to ambulate 0eed a ) year-old in balanced skeletal traction #are for a client with dischar"e orders #ollect a sputum specimen for acid fast bacillus &e!iew Information' The correct answer is #' #are for a client with dischar"e orders The &C is the best person to do teachin" or e!aluation that is needed at time of dischar"e. 6. After workin" with a !ery demandin" client+ an unlicensed assisti!e personnel A*A?) tells the nurse+ "I ha!e had it with that client. I 3ust can2t do anythin" that pleases him. I2m not "oin" in there a"ain." The nurse should respond by sayin" "@e has a lot of problems. Fou need to ha!e patience with him." "I will talk with him and try to fi"ure out what to do." "@e is scared and takin" it out on you. >et=s talk to fi"ure out what to do." "I"nore him and "et the rest of your work done. (omeone else can take care of him for the rest of the day." &e!iew Information' The correct answer is #' "@e is scared and takin" it out on you. >et==s talk to fi"ure out what to do." This response e7plains the client==s beha!ior without belittlin" the *A?2s feelin"s. The *A? is encoura"ed to contribute to the plan of care to help sol!e the problem <. A client with a dia"nosis of bipolar disorder has been referred to a local boardin" home for consideration for placement. The social worker telephoned the hospital unit for information about the client2s mental status and ad3ustment. The appropriate response of the nurse should be which of these statements? I am sorry. &eferral information can only be pro!ided by the client2s health care pro!iders. EI can ne!er "i!e any information out by telephone. @ow do I know who you are?" (ince this is a referral+ I can "i!e you the this information. I need to "et the client2s written consent before I release any information to you. &e!iew Information' The correct answer is %' I need to "et the client2s written consent before I release any information to you. In order to release information about a client there must be a si"ned consent form with desi"nation of to whom information can be "i!en. -. A client is admitted with a dia"nosis of schi5ophrenia. The client refuses to take medication and states EI don2t think I need those medications. They make me too sleepy and drowsy. I insist that you e7plain their use and side effects.D The nurse should understand that A referral is needed to the psychiatrist who is to pro!ide the client A) with answers K ) The client has a ri"ht to know about the prescribed medications (uch education is an independent decision of the indi!idual nurse #) whether or not to teach clients about their medications #lients with schi5ophrenia are at a hi"her risk of psychosicial %) complications when they know about their medication side effects &e!iew Information' The correct answer is ' The client has a ri"ht to know about the prescribed medications #lients ha!e a ri"ht to informed consent which includes medications+ treatments+ or dia"nositic studies ,. .hich statement by the nurse is appropriate when askin" an unlicensed assisti!e personnel A*A?) to assist a <9 year-old sur"ical client to ambulate for the first time? "@a!e the client sit on the side of the bed for at least ) minutes before helpin" him stand." "If the client is di55y on standin"+ ask him to take some deep breaths." "Assist the client to the bathroom at least twice on this shift." "After you assist him to the chair+ let me know how he feels." &e!iew Information' The correct answer is A' "@a!e the client sit on the side of the bed for at least ) minutes before helpin" him stand." /i!e clear information to the *A? about what is e7pected for client safety. 9. The nurse recei!es a report on an older adult client with middle sta"e dementia. .hat information su""ests the nurse should do immediate follow up rather than dele"ate care to the nursin" assistant? The client @as had a chan"e in respiratory rate by an increase of ) breaths @as had a chan"e in heart rate by an increase of 18 beats .as minimally responsi!e to !oice and touch @as had a blood pressure chan"e by a drop in , mm@" systolic &e!iew Information' The correct answer is #' .as minimally responsi!e to !oice and touch A chan"e in le!el of consciousness indicates delirium related to acute illness. This would re1uire the assessment of a nurse. 18. A client tells the nurse+ "I ha!e somethin" !ery important to tell you if you promise not to tell." The best response by the nurse is "I must document and report any information."

"I can2t make such a promise." "That depends on what you tell me." "I must report e!erythin" to the treatment team." &e!iew Information' The correct answer is ' "I can2t make such a promise." (ecrets are inappropriate in therapeutic relationships and are counter producti!e to the therapeutic efforts of the interdisciplinary team. (ecrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand ri"hts+ limitations+ and boundaries re"ardin" confidentiality. 11. .hich task could be safely dele"ated by the nurse to an unlicensed assisti!e personnel A*A?)? A) e with a client who self-administers insulin ) #leanse and dress a small decubitus ulcer #) $onitor a client=s response to passi!e ran"e of motion e7cercises %) Apply and care for a client=s rectal pouch &e!iew Information' The correct answer is %' Apply and care for a client==s rectal pouch The &C may dele"ate the application and care of rectal pouches to a *A?. This is an uncomplicated+ routine type of task. 1). A client asks the nurse to call the police and states' EI need to report that I am bein" abused by a nurse.D The nurse should first 0ocus on reality orientation to place and person Assist with the report of the client2s complaint to the police ;btain more details of the client2s claim of abuse %ocument the statement on the client2s chart with a report to the mana"er &e!iew Information' The correct answer is #' ;btain more details of the client2s claim of abuse The ad!ocacy role of the professional nurse as well as the le"al duty of the reasonable prudent nurse re1uires the in!esti"ation of claims of abuse or !iolation of ri"hts. The nurse is le"ally accountable for actions dele"ated to others. The application of the nursin" process re1uires that the nurse "ather more information+ further assessment+ before documentation or the reportin" of the complaint. 14. A nurse from the maternity unit is floated to the critical care unit because of staff shorta"e on the e!enin" shift. .hich client would be appropriate to assi"n to this nurse? A client with A %opamine drip IB with !ital si"ns monitored e!ery 6 minutes A myocardial infarction that is free from pain and dysrhythmias A tracheotomy of )4 hours in some respiratory distress A pacemaker inserted this mornin" with intermittent capture &e!iew Information' The correct answer is ' A myocardial infarction that is free from pain and dysrhythmias This client is the most stable with minimal risk of complications or instability. The nurse can transfer basic nursin" skills to care for this client. 14. An unlicensed assisti!e personnel A*A?)+ who usually works on a sur"ical unit is assi"ned to float to a pediatric unit. .hich 1uestion by the char"e nurse would be most appropriate when makin" dele"ation decisions? "@ow lon" ha!e you been a *A? and what units you ha!e worked on?" ".hat type of care do you "i!e on the sur"ical unit and what a"es of clients?" ".hat is your comfort le!el in carin" for children and at what a"es?" "@a!e you re!iewed the list of e7pected skills you mi"ht need on this unit?" &e!iew Information' The correct answer is %' "@a!e you re!iewed the list of e7pected skills you mi"ht need on this unit?" The *A? must be competent to accept the dele"ated task. &e!iew of skills needed !ersus le!el of performance is the most efficient and effecti!e way to achie!e this in the least amount of time. 16. A client fre1uently admitted to the locked psychiatric unit repeatedly compliments and in!ites one of the nurses to "o out on a date. The nurse2s response should be to Ask to not be assi"ned to this client or to work on another unit Tell the client that such beha!ior is inappropriate Inform the client that hospital policy prohibits staff to date clients %iscuss the boundaries of the therapeutic relationship with the client &e!iew Information' The correct answer is %' %iscuss the boundaries of the relationship with the client The nurse-client relationship is one with professional not social boundaries. #onsistent adherence to the limits of the professional relationship builds trust. 1<. A client has a naso"astric tube after colon sur"ery. .hich one of these tasks can be safely dele"ated to an unlicensed assisti!e personnel A*A?)? To obser!e the type and amount of naso"astric tube draina"e $onitor the client for nausea or other complications Irri"ate the naso"astric tube with the ordered irri"ant

?erform nostril and mouth care &e!iew Information' The correct answer is %' ?erform nostril and mouth care (kin care around a naso"astric tube is a routine task that is appropriate for *A?s. The other tasks would be appropriate for a ?C or &C to do since they are ad!anced skills or re1uire e!aluation. 1-. The nurse is carin" for a <9 year-old client with a dia"nosis of hyper"lycemia. .hich tasks could the nurse dele"ate to the unlicensed assisti!e personnel A*A?)? A) Test blood su"ar e!ery ) hours by accucheck ) &e!iew with family and client si"ns of hyper"lycemia #) $onitor for mental status chan"es %) #heck skin condition of lower e7tremities &e!iew Information' The correct answer is A' Test blood su"ar e!ery ) hours by accucheck The *A? can do standard unchan"in" procedures 1,. A nurse is workin" with one licensed practical nurse A?C)+ a student nurse and an unlicensed assisti!e personnel A*A?). .hich newly admitted clients would be most appropriate to assi"n to the *A?? A) A -<-year-old client with se!ere depression ) A middle-a"ed client with an obsessi!e compulsi!e disorder #) A adolescent with dehydration and anore7ia A youn" adult who is a heroin addict in withdrawal with %) hallucinations &e!iew Information' The correct answer is ' A middle-a"ed client with an obsessi!e compulsi!e disorder The *A? can be assi"ned to care for a client with a chronic condition after an initial assessment by the nurse. This client has no risk of instability of condition. 19. The unlicensed assisti!e personnel A*A?) reports a sudden increase in temperature to 181 de"rees 0 for a post sur"ical client. The nurse checks on the client2s condition and obser!es a cup of steamin" coffee at the bedside. .hat instructions are appropriate to "i!e to the *A?? Hncoura"e oral fluids for the temperature ele!ation #heck temperature 16 minutes after hot li1uids are taken Ask the client to drink only cold water and 3uices #hart this temperature ele!ation on the flow sheet &e!iew Information' The correct answer is ' #heck temperature 16 minutes after hot li1uids are taken @ot li1uids+ smokin"+ eatin"+ chewin" "um+ and talkin" can all ele!ate temperature. .aitin" to take the temperature for 16 minutes will help the temperature return to its normal+ in order to "et an accurate readin". The other options are incorrect. )8. A client continuously calls out to the nursin" staff when anyone passes the client2s door and asks them to do somethin" in the room. The best response by the char"e nurse would be to Meep the client2s room door cracked to minimi5e the distractions Assi"n 1 of the nursin" staff to !isit the client re"ularly &eassure the client that 1 staff person will check fre1uently if the client needs anythin" Arran"e for each staff member to "o into the client2s room to check on needs e!ery hour on the hour &e!iew Information' The correct answer is ' Assi"n 1 of the nursin" staff to !isit the client re"ularly &e"ular+ fre1uent+ planned contact by 1 staff member pro!ides continuity of care and reduces the client2s need for attention. &esults for ?sychosocial Inte"rity 1. A client with a new dia"nosis of diabetes mellitus is referred for home care. A family member present e7presses concern that the client seems depressed. The nurse should initially focus assessment by usin" which approach? The results of a standardi5ed tool that measures depression ;bser!ation of affect and beha!ior In1uiry about use of alcohol 0amily history of emotional problems or mental illness &e!iew Information' The correct answer is ' ;bser!ation of affect and beha!ior Althou"h it is important to be"in an assessment for depression immediately+ the assessment should not be a""ressi!e unless the nurse has confirmed the obser!ation of the family member or if there are concerns about the risk of suicide. ). A mother with a &oman #atholic belief has "i!en birth in an ambulance on the way to the hospital. The neonate is in !ery critical condition with little e7pectation of sur!i!in" the trip to the hospital. .hich of these re1uests should the nurse in the ambulance anticipate and be prepared to do? The refusal of any treatment for self and the neonate until she talks to a reader The placement of a rosary necklace around the neonate=s neck and not to remo!e it unless absolutely necessary Arran"e for a church elder to be at the emer"ency department when the ambulance arri!es so a "layin" on hands" can be done ?our fluid o!er the forehead backwards towards the back of the head and say "I bapti5e you in the name of the father+ the son and the holy

spirit. Amen." &e!iew Information' The correct answer is %' ?our fluid o!er the forehead backwards towards the back of the head and say "I bapti5e you in the name of the father+ the son and the holy spirit. Amen." Infant baptism is madatory in the &oman #atholic belief especially if a neonate is not e7pected to li!e. Anyone may perform this if an infant or child is "ra!ely ill. ;ption A refers to the #hristian (cience belief. ;ption is a belief of &ussian ;rthodo7y. $ormons belie!e of de!ine healin" with the layin" on of hands+ as represented in option #. 4. An American Indian chief !isits his newborn son and performs a traditional ceremony that in!ol!es feathers and chantin". The attendin" nurse tells a collea"ue "I wonder if he has any idea how ridiculous he looks -- he=s a "rown manJ" The nurse=s response is an e7ample of A) %iscrimination ) (tereotypin" #) Hthnocentrism %) ?re3udice &e!iew Information' The correct answer is %' ?re3udice ?re3udice is a hostile attitude toward indi!iduals simply because they belon" to a particular "roup presumed to ha!e ob3ectionable 1ualities. ?re3udice refers to preconcei!ed ideas+ beliefs+ or opinions about an indi!idual+ "roup+ or culture that limit a full and accurate understandin" of the indi!idual+ culture+ "ender+ race+ e!ent+ or situation. 4. A client e7presses an"er when the call li"ht is not answered within 6 minutes. The client demanded a blanket. The best response for the nurse to make is A) "I apolo"i5e for the delay. I was in!ol!ed in an emer"ency." ) ">et=s talk. .hy are you upset about this?" "I am surprised that you are upset. The re1uest could ha!e waited #) a few more minutes." %) "I see this is frustratin" for you. I ha!e a few minutes so let=s talk." &e!iew Information' The correct answer is %' "I see this is frustratin" for you. I ha!e a few minutes so let==s talk." This is the best response because it "i!es credence to the client==s feelin"s and then concerns. ;ption does not acknowled"e or !alidate the client==s feelin"s. 6. An elderly client who li!es in a retirement community is admitted with these beha!iors as reported by the dau"hter' absence in the daily senior "roup acti!ity+ missin" the weekly card "ames+ a chan"e in callin" the dau"hter from daily to once a week+ and the client=s tomato "arden is o!er"rown with weeds. The nurse should assi"n this client to a room with which one of these clients? An adolescent who was admitted the day before with acute situational depression A middle a"ed person who has been on the unit for -) hours with a dysthymia An elderly person who was admitted 4 hours a"o with cycothymia A youn" adult who was admitted )4 hours a"o for deto7ification &e!iew Information' The correct answer is ' A middle a"ed person who has been on the unit for -) hours with a dysthymia The findin"s su""est a client who is depressed. The most therapeutic mileu or en!ironment for this client would be the client with a similar problem and a client that mi"ht be more stable. A secondary consideration is to match the a"e as close as possible. The client in option A has depression and would be more likely to be unstable since they ha!e been in the a"ency for )4 hours. %ysthymia is defined as a mild depression with findin"s of trouble fallin" asleep or no difficulty fallin" asleep but then wakes up in the middle of the ni"ht and with difficulty is able to fall back asleep. #ycothymia is the occurance of periods for beha!iors that do not meet the criteria for manic or ma3or depressi!e episodes. <. A client dia"nosed with anore7ia ner!osa states after lunch+ "I shouldn2t ha!e eaten all of that sandwich+ I don2t know why I ate it+ I wasn2t hun"ry." The client2s comments indicate that the client is likely e7periencin" A) /uilt ) loatin" #) An7iety %) 0ear &e!iew Information' The correct answer is A' /uilt If people with anore7ia lose control and eat more than they belie!e to be appropriate+ they e7perience "uilt. -. A <6-year-old #atholic @ispanic->atino client with prostate cancer adamantly refuses pain medication because the client belie!es that sufferin" is part of life. The client states Ee!eryone2s life is in /od=s hands.D The ne7t action for the nurse to take is to &eport the situation to the health care pro!ider %iscuss the situation with the client=s family Ask the client if talkin" with a priest would be desired %ocument the situation on the notes

&e!iew Information' The correct answer is #' Ask the client if talkin" with a priest would be desired eliefs re"ardin" pain are one of the oldest culturally related research areas in health care. Astute obser!ations and careful assessments must be completed to determine the le!el of pain a person can tolerate. @ealth-care practitioners must in!esti"ate the meanin" of pain to each person within a cultural e7planatory framework. ,. A teena"e female is admitted with the dia"nosis of anore7ia ner!osa. *pon admission+ the nurse finds a bottle of assorted pills in the client2s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A) "These pills aren2t antacids since they are all different." ) "(ome teena"ers use pills to lose wei"ht." K #) "Tell me about your week prior to bein" admitted." %) "Are you takin" pills to chan"e your wei"ht?" &e!iew Information' The correct answer is #' "Tell me about your week prior to bein" admitted." This is an open-ended 1uestion which is non3ud"emental and allows for further discussion. The topic is also nonthreatenin" yet will "i!e the nurse insi"ht into the client==s !iew of e!ents leadin" up to admission. It is the only option that is client centered. The other options focus on the pills. 9. A client who has a belief based in @induism is nearin" death. The nurse should plan for which action? After death a @indu priest will pour water into the mouth of the client and tie a thread around the client=s wrist The elders may be with the client durin" the process of the client dyin" and no last rites are "i!en The family must be with the client durin" the process of dyin" and be the only ones to wash the body after death The body is ritually cleansed and burial is to be as soon as possible after the death occurs &e!iew Information' The correct answer is A' After death a @indu priest will pour water into the mouth of the client and tie a thread around the client==s wirst This action indicates a blessin" in the practice of @induism. The family of a client who has the belief of @induism is particular about who touches the dead body and cremation is preferred. Also last rites are carefully prescribed. The actions in option are e7pected with persons from the #hurch of Sesus #hrist of >atter %ay (aints Aalso known as $ormon). Also with this belief cremation is discoura"ed. ;ption # lists practices of the Islam reli"ion. In addition only the family and friend may touch the body. ;ption % lists practices of Sudaism. In addition autopsy is prohibited and or"an donation or transplants are first appro!ed by a rabbi. 18. An e7plosion has occurred at a hi"h school for children with special needs and se!ere de!elopmental delays. ;ne of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. .hich of these inter!entions based on crisis inter!ention principles is appropriate to do ne7t? @elp the student to identify a specific problem Ask the parent to identify the ma3or problem Ask the student to think of different alternati!es H7amine with the parent a !aritey of options &e!iew Information' The correct answer is ' Ask the parent to identify the ma3or problem If a client is unable to participate in problem sol!in" because of de!elopmental delays or altered mental status+ then crisis inter!ention should not be attempted. @owe!er the family can be approached with the use of crisis inter!ention methods. The crisis inter!ention method includes 6 steps' identify the problem and then the alternati!es+ selection of an alternati!e+ implementation+ and e!aluation. 11. .hich statement made by a client to the admittin" nurse su""ests that the client is e7periencin" a manic episode? A) "I think all children should ha!e their heads sha!ed." ) "I ha!e been restricted in thou"ht and harmed." "I ha!e powers to "et you whate!er you wish+ no matter the K #) cost." "I think all of my contacts last week ha!e attempted to poison %) me." &e!iew Information' The correct answer is #' "I ha!e powers to "et you whate!er you wish+ no matter the cost." /randiosity is characteristic of a manic episode. 1). A client says+ "It=s rainin" outside and it=s rainin" in my heart. %id you know that (t. ?atrick dro!e the snakes out of Ireland? I=!e ne!er been to Ireland." The nurse would document this beha!ior as A) ?erse!eration ) #ircumstantiality #) Ceolo"isms %) 0li"ht of ideas &e!iew Information' The correct answer is %' 0li"ht of ideas 0li"ht of ideas is characteri5ed by o!er producti!ity of talk and !erbal skippin" from 1 idea to another. It is classic with clients dia"nosed as bipolar disorder and occurs in the manic state of this disease.

14. %urin" the chan"e-of-shift report the assi"ned nurse notes a #atholic client is scheduled to be admitted for the deli!ery of a ninth child. .hich comment stated an"rily to a collea"ue by this nurse indicates an attitude of pre3udice? A) "I wonder who is payin" for this trip to the hospital?" ) "I think she needs to "o to the city hospital." #) "All those people indul"e in lar"e familiesJ" K %) "%oesn=t she know there=s such a thin" as birth control?" &e!iew Information' The correct answer is %' "%oesn==t she know there==s such a thin" as birth control?" ?re3udice is a hostile attitude toward indi!iduals simply because they belon" to a particular "roup presumed to ha!e ob3ectionable 1ualities. ?re3udice refers to preconcei!ed ideas+ beliefs+ or opinions about an indi!idual+ "roup+ or culture that limit a full and accurate understandin" of the indi!idual+ culture+ "ender+ race+ e!ent+ or situation. 14. .hich of these statements by the nurse reflects the best use of therapeutic interaction techni1ues? "Fou look upset. .ould you like to talk about it?" "I=d like to know more about your family. Tell me about them." "I understand that you lost your partner. I don=t think I could "o on if that happened to me." "Fou look !ery sad. @ow lon" ha!e you been this way?" &e!iew Information' The correct answer is A' "Fou look upset. .ould you like to talk about it?" /i!in" broad openin" statements and makin" obser!ations are e7amples of therapeutic communication. The other options are too specific or focused to be therapeutic. 16. A nurse in the emer"ency department suspects domestic !iolence as the cause of a client=s in3uries. .hat action should the nurse take first? Ask client if there are any old in3uries also present Inter!iew the client without the persons who came with the client /ain client=s trust by not bein" hurried durin" the intake process ?hoto"raph the specific in3uries in 1uestion &e!iew Information' The correct answer is ' Inter!iew the client without the persons who came with the client It is critical to separate the client from their partner or si"nificant other. .ith the use of the nursin" process the nurse2s first action when a client is unstable or has potential problems is further assessment of the situation. 1<. .hich of these findin"s would indicate that the nurse-client relationship has passed from the orientation phase to the workin" phase? The client @as re!itali5ed a relationship with her family to help cope with the death of a dau"hter @ad reco"ni5ed re"ressi!e beha!ior as a defense mechanism H7presses a desire to be cared for and pampered &eco"ni5es feelin"s with appropriate e7pression of feelin"s &e!iew Information' The correct answer is %' &eco"ni5es feelin"s with appropriate e7pression of feelin"s %urin" the workin" phase+ the client is able to focus on pleasant or unpleasant feelin"s and e7press them appropriately. 1-. A client who is thou"ht to be homeless is brou"ht to the emer"ency department by police. The client is unkempt+ has difficulty concentratin"+ is unable to sit still and speaks in a loud tone of !oice. .hich of these actions is the appropriate nursin" inter!ention for the client at this time? Allow the client to randomly mo!e about the holdin" area until a hosptial room is a!ailable Hn"a"e the client in an acti!ity that re1uires focus and indi!idual effort Isolate the client in a secure room until control is re"ained by the client >ocate a room that has minimal stimulation outside of it for admission process &e!iew Information' The correct answer is %' >ocate a room that has minimal stimulation outside of it for admission process This inter!ention allows the client with moderate an7iety to ha!e human contact in an en!ironment with minimal stimulation. It also facilitates efficiency in the initial screenin" and admission process to the emer"ency department. 1,. A ) day-old child with spina bifida and menin"omyocele is in the intensi!e care unit after the initial sur"ery. As the nurse accompanies the "randparents for a first !isit+ which response should the nurse anticipate of the "randparents? A) %epression ) An"er #) 0rustration K %) %isbelief &e!iew Information' The correct answer is %' %isbelief The first phase of the "rie!in" process is shock+ denial or disbelief. Then follows an"er+ bar"ainin"+ depression and acceptance. Hach

sta"e can take any amount of time to work throu"h. #lients often "o back and forth the sta"es before acceptance occurs. (ome client "et stuck in 1 or ) of the sta"es. 19. .hich statement by the client durin" the initial assessment in the the emer"ency department is most indicati!e for suspected domestic !iolence? "I am determined to lea!e my house in a week." "Co one else in the family has been treated like this." "I ha!e only been married for ) months." "I ha!e tried lea!in"+ but ha!e always "one back." &e!iew Information' The correct answer is %' "I ha!e tried lea!in"+ but ha!e always "one back." Bictims de!elop a hi"h tolerance for abuse. They blame themsel!es for bein" !ictimi5ed. All members in the family suffer from the effects of abuse+ e!en if they are not the actual !ictims. 0or these reasons+ !ictims often ha!e an e7tensi!e history of abuse and stru""le for a lon" time before they can lea!e permanently. )8. A nurse states' "I dislike carin" for African-American clients because they are all so hostile." The nurse=s statement is an e7ample of A) ?re3udice ) %iscrimination #) (tereotypin" %) &acism &e!iew Information' The correct answer is #' (tereotypin" (tereotypin" refers to placin" people and institutions+ mentally or by attitudes+ into a narrow+ fi7ed trait+ ri"id pattern+ or within infle7ible "bo7like" characteristics. (tereotypin" is one of the most common concerns of nurses when they be"in to study different cultures and learn about transcultural nursin". &esults for @ealth ?romotion and $aintenance 1. A <4 year-old client scheduled for sur"ery with a "eneral anesthetic refuses to remo!e a set of dentures prior to lea!in" the unit for the operatin" room. .hat would be the most appropriate inter!ention by the nurse? H7plain to the client that the dentures must come out as they may A) "et lost or broken in the operatin" room Ask the client if there are second thou"hts about ha!in" the ) procedure Cotify the anesthesia department and the sur"eon of the client=s #) refusal Ask the client if the preference would be to remo!e the dentures in %) the operatin" room recei!in" area &e!iew Information' The correct answer is %' Ask the client if the preference would be to remo!e the dentures in the operatin" room recei!in" area #lients anticipatin" sur"ery may e7perience a !ariety of fears. This choice allows the client control o!er the situation and fosters the client==s sense of self-esteem and self-concept. ). The nurse has been teachin" adult clients about cardiac risks when they !isit the hypertension clinic. .hich form of e!aluation would best measure learnin"? A) ?erformance on written tests ) &esponses to !erbal 1uestions #) #ompletion of a mailed sur!ey %) &eported beha!ioral chan"es &e!iew Information' The correct answer is %' &eported beha!ioral chan"es If the client alters beha!iors such as smokin"+ drinkin" alcohol+ and stress mana"ement+ these su""est that learnin" has occurred. Additionally+ physical assessments and lab data may confirm risk reduction. 4. The nurse is plannin" care for an 1, month-old child. .hich action should be included in the child=s care? A) @old and cuddle the child fre1uently K ) Hncoura"e the child to feed himself fin"er food #) Allow the child to walk independently on the nursin" unit %) Hn"a"e the child in "ames with other children &e!iew Information' The correct answer is ' Hncoura"e the child to feed himself fin"er food Accordin" to Hrikson+ the toddler is in the sta"e of autonomy !ersus shame and doubt. The nurse should encoura"e increasin"ly independent acti!ities of daily li!in" that allow the toddler to assert his buddin" sense of control. 4. A partner is concerned because the client fre1uently daydreams about mo!in" to Ari5ona to "et away from the pollution and crowdin" in southern #alifornia. The nurse e7plains that (uch fantasies can "ratify unconscious wishes or prepare for K A) anticipated future e!ents ) %etachin" or dissociatin" in this way postpones painful feelin"s This con!ersion or transferrin" of a mental conflict to a physical #) symptom can lead to marital conflict To isolate the feelin"s in this way reduces conflict within the %) client and with others &e!iew Information' The correct answer is A' (uch fantasies can "ratify unconscious wishes or prepare for anticipated future e!ents 0antasy is ima"ined e!ents Adaydreamin") to e7press unconscious conflicts or "ratifyin" unconscious wishes.

6. An appropriate "oal for a client with an7iety would be to A) Bentilate an7ious feelin"s to the nurse ) Hstablish contact with reality #) >earn self-help techni1ues %) ecome desensiti5ed to past trauma &e!iew Information' The correct answer is #' >earn self-help techni1ues H7plorin" alternati!e copin" mechanisms will decrease present an7iety to a mana"eable le!el. Assistin" the client to learn self-help techni1ues will assist in learnin" to cope with an7iety. <. .hile the nurse is administerin" medications to a client+ the client states "I do not want to take that medicine today." .hich of the followin" responses by the nurse would be best? A) "That=s ;M+ its all ri"ht to skip your medication now and then." ) "I will ha!e to call your doctor and report this." K #) "Is there a reason why you don=t want to take your medicine?" "%o you understand the conse1uences of refusin" your %) prescribed treatment?" &e!iew Information' The correct answer is #' "Is there a reason why you don=t want to take your medicine?" .hen a new problem is identified+ it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are ade1uately identified in order to select the best nursin" care approaches. The nurse should try to disco!er the reason for the refusal which may be that the client has de!eloped untoward side effects. -. .hile carin" for a client+ the nurse notes a pulsatin" mass in the client=s periumbilical area. .hich of the followin" assessments is appropriate for the nurse to perform? A) $easure the len"th of the mass ) Auscultate the mass #) ?ercuss the mass %) ?alpate the mass &e!iew Information' The correct answer is ' Auscultate the mass Auscultation of the abdomen and findin" a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information "i!en to the health care pro!ider. The mass should not be palpated because of the risk of rupture. ,. A client is admitted to the hospital with a history of confusion. The client has difficulty rememberin" recent e!ents and becomes disoriented when away from home. .hich statement would pro!ide the bestreality orientation for this client? A) "/ood mornin". %o you remember where you are?" ) "@ello. $y name is Hlaine Sones and I am your nurse for today." #) "@ow are you today? &emember+ you=re in the hospital." "/ood mornin". Fou2re in the hospital. I am your nurse Hlaine %) Sones." &e!iew Information' The correct answer is %' "/ood mornin". Fou2re in the hospital. I am your nurse Hlaine Sones." As co"niti!e ability declines+ the nurse pro!ides a calm+ predictable en!ironment for the client. This response establishes time+ location and the care"i!ers name. 9. The nurse is teachin" the parents of a 4 month-old infant about nutrition. .hat is the main source of fluids for an infant until about 1) months of a"e? A) 0ormula or breast milk ) %ilute nonfat dry milk #) .armed fruit 3uice %) 0luoridated tap water &e!iew Information' The correct answer is A' 0ormula or breast milk 0ormula or breast milk are the perfect food and source of nutrients and li1uids up until 1 year. 18. The family of a < year-old with a fractured femur asks the nurse if the child=s hei"ht will be affected by the in3ury. .hich statement is true concernin" lon" bone fractures in children? A) /rowth problems will occur if the fracture in!ol!es the periosteum ) Hpiphyseal fractures often interrupt a child=s normal "rowth pattern #) #hildren usually heal !ery 1uickly+ so "rowth problems are rare Ade1uate blood supply to the bone pre!ents "rowth delay after %) fractures &e!iew Information' The correct answer is ' Hpiphyseal fractures often interrupt a child==s normal "rowth pattern The epiphyseal plate in children is where acti!e bone "rowth occurs. %ama"e to this area may cause "rowth arrest in either lon"itudinal "rowth of the limb or in pro"ressi!e deformity if the plate is in!ol!ed. An epiphyseal fracture is serious because it can interrupt and alter "rowth. 11. The nurse is assessin" a client who states her last menstrual period was $arch 1<+ and she has missed one period. (he reports

episodes of nausea and !omitin". ?re"ancy is confirmed by a urine test. .hat will the nurse calculate as the estimated date of deli!ery AH%%)? A) April , ) Sanuary 16 #) 0ebruary 11 %) %ecember )4 &e!iew Information' The correct answer is %' %ecember )4 Cae"ele==s rule' add - days and subtract 4 months from the first day of the last re"ular menstrual period to calculate the estimated date of deli!ery. 1). .hen screenin" children for scoliosis+ at what time of de!elopment would the nurse e7pect early si"ns to appear? A) ?renatally on ultrasound ) In early infancy #) .hen the child be"ins to bear wei"ht %) %urin" the preadolescent "rowth spurt &e!iew Information' The correct answer is %' %urin" the preadolescent "rowth spurt Idiopathic scoliosis is seldom apparent before 18 years of a"e and is most noticeable at the be"innin" of the preadolescent "rowth spurt. It is more common in females than in males. 14. A client with con"esti!e heart failure is newly admitted to home health care. The nurse disco!ers that the client has not been followin" the prescribed diet. .hat would be the most appropriate nursin" action? %ischar"e the client from home health care related to A) noncompliance Cotify the health care pro!ider of the client=s failure to follow ) prescribed diet %iscuss diet with the client to learn the reasons for not followin" K #) the diet %) $ake a referral to $eals-on-.heels &e!iew Information' The correct answer is #' %iscuss diet with client to learn the reasons for not followin" the diet .hen new problems are identified+ it is important for the nurse to collect accurate assessment data. efore reportin" findin"s to the health care pro!ider+ it is best to ha!e a complete understandin" of the client==s beha!ior and feelin"s as a basis for future teachin" and inter!ention. 14. A client states+ "?eople think I2m no "ood+ you know what I mean?" .hich of these responses would be most therapeutic? ".ell people often take their own feelin"s of inade1uacy out on A) others." "I think you2re "ood. (o you see+ there2s one person who likes ) you." K #) "I2m not sure what you mean. Tell me a bit more about that." ">et=s discuss this to see the reasons to create this impression on %) people?" &e!iew Information' The correct answer is #' "I2m not sure what you mean. Tell me a bit more about that." Therapeutic communication techni1ue that elicits more information is deli!ered in an open non-3ud"mental fashion. 16. A client bein" treated for hypertension returns to the community clinic for follow up. The client says+ "I know these pills are important+ but I 3ust can=t take these water pills anymore. I dri!e a truck for a li!in"+ and I can=t be stoppin" e!ery )8 minutes to "o to the bathroom." .hich of these is the best nursin" dia"nosis? A) Concompliance related to medication side effects ) Mnowled"e deficit related to misunderstandin" of disease state #) %efensi!e copin" related to chronic illness %) Altered health maintenance related to occupation &e!iew Information' The correct answer is A' Concompliance related to medication side effects The client kept his appointment+ and stated he knew the pills were important. @e is unable to comply with the re"imen from side effects+ not a lack of knowled"e about the disease process. 1<. .hen teachin" effecti!e stress mana"ement techni1ues to a client 1 hour before sur"ery+ which of the followin" should the nurse recommend? A) iofeedback ) %eep breathin" #) %istraction %) Ima"ery &e!iew Information' The correct answer is ' %eep breathin" %eep breathin" is a reliable and !alid method for reducin" stress+ and can be tau"ht and reinforced in a short period pre-operati!ely. 1-. .hen obser!in" 4 year-old children playin" in the hospital playroom+ what acti!ity would the nurse e7pect to see the children participatin" in? A) #ompetiti!e board "ames with older children ) ?layin" with their own toys alon" side with other children #) ?layin" alone with hand held computer "ames K %) ?layin" cooperati!ely with other preschoolers &e!iew Information' The correct answer is %' ?layin" cooperati!ely with other preschoolers

#ooperati!e play is typical of the preschool period. 1,. The nurse is assessin" a 4 month-old infant. .hich motor skill would the nurse anticipate findin"? A) @old a rattle ) an" two blocks #) %rink from a cup %) .a!e "bye-bye" &e!iew Information' The correct answer is A' @old a rattle The a"e at which a baby will de!elop the skill of "raspin" a toy with help is 4 to < months. 19. .hen teachin" a 18 year-old child about their impendin" heart sur"ery+ which form of e7plaination meets the de!elopmental needs of this a"e child? A) ?ro!ide a !erbal e7planation 3ust prior to the sur"ery ) ?ro!ide the child with a booklet to read about the sur"ery Introduce the child to another child who had heart sur"ery 4 days #) a"o K %) H7plain the sur"ery usin" a model of the heart &e!iew Information' The correct answer is %' H7plain the sur"ery usin" a model of the heart Accordin" to ?ia"et+ the school a"e child is in the concrete operations sta"e of co"niti!e de!elopment. *sin" somethin" concrete+ like a model will help the child understand the e7planation of the heart sur"ery. )8. The parents of a child who has suddenly been hospitali5ed for an acute illness state that they should ha!e taken the child to the pediatrician earlier. .hich approach by the nurse is best when dealin" with the parents= comments? A) 0ocus on the child=s needs and reco!ery ) H7plain the cause of the child=s illness #) Acknowled"e that early care would ha!e been better %) Accept their feelin"s without 3ud"ment &e!iew Information' The correct answer is %' Accept their feelin"s without 3ud"ment ?arents often blame themsel!es for their child==s illness. 0eelin" helpless and an"ry is normal and these feelin"s must be accepted. &esults for QYA - ?harmacolo"y ) 1. .hen carin" for a client with total parenteral nutrition AT?C)+ what is the most important action on the part of the nurse? A) &ecord the number of stools per day ) $aintain strict intake and output records #) (terile techni1ue for dressin" chan"e at IB site %) $onitor for cardiac arrhythmias &e!iew Information' The correct answer is #' (terile techni1ue for dressin" chan"e at IB site #lients recei!in" T?C are !ery susceptible to infection. The concentrated "lucose solutions are a "ood medium for bacterial "rowth. (trict sterile techni1ue is crucial in pre!entin" infection at IB infusion site. ). .hen carin" for a client who is recei!in" a thrombolytic a"ent to open a clot occluded coronary artery after a myocardial infarction+ which findin" would be of "reatest concern to the nurse? A) (ero san"inous draina"e from "ums ) @ematemesis #) ?ink frothy sputum %) (li"ht red color at urine &e!iew Information' The correct answer is ' @ematemesis 0rank bleedin" should be of the "reatest concern to the nurse. 4. A 6) year-old client is bein" transfused with one unit of packed cells. A half hour after the transfusion was initiated+ the client complains of chills and headache. .hich action should the nurse implement first? A) Cotify the health care pro!ider ) #heck the client=s temperature #) (top the transfusion %) ;btain a urine specimen &e!iew Information' The correct answer is #' (top the transfusion The first action when a client e7hibits si"ns of a potential transfusion reaction is to discontinue the transfusion immediately. 4. An adolescent client is hospitali5ed with menarthrosis from a @emophilia A bleedin" episode. .hich order should be 1uestioned by the nurse? A) ?assi!e ran"e of motion ) &eplacement of factor BIII K #) Aspirin for pain mana"ement %) Immobili5ation splint &e!iew Information' The correct answer is #' Aspirin for pain mana"ement

Aspirin is contraindicated in any client who is acti!ely bleedin". Ibuprofen is a more common pain medication. 6. The nurse is "i!in" instructions to the mother of a newborn infant with oral candidiasis. .hich statement by the mother would indicate the need for further teachin"? A) "Cystatin should be "i!en 4 times a day after my baby eats." ) "I will boil the nipples and pacifiers for twenty minutes." #) "I should be takin" the medication prescribed for this infection." K %) "The therapy can be discontinued when the spots disappear." &e!iew Information' The correct answer is %' "The therapy can be discontinued when the spots disappear." The therapy should be continued for a week+ e!en if lesions ha!e disappeared within a few days. <. The nurse is preparin" a client for dischar"e followin" in-patient treatment for pulmonary tuberculosis. .hich of these instructions should be "i!en to the client? A) #ontinue medication until findin"s are relie!ed K ) #ontinue medication use as prescribed A!oid contact with children+ pre"nant women or immuno #) depressed persons %) Take medication with Ampho"el if epi"astric distress occurs &e!iew Information' The correct answer is ' #ontinue medication use as prescribed Harly cessation of treatment may lead to de!elopment of dru" resistant bacteria. -. The nurse is administerin" an intra!enous pi""yback infusion of penicillin. .hich of the followin" client statements would re1uire the nurse=s immediate attention? A) "I ha!e a burnin" sensation when I urinate." ) "I ha!e soreness and achin" in my muscles." #) "I am itchin" all o!er." %) "I ha!e crampin" in my stomach." &e!iew Information' The correct answer is #' "I am itchin" all o!er." #omplaints of itchin"+ feelin" hot all o!er andGor the appearance of raised+ red welts on the skin are symptoms of an aller"ic reaction to the penicillin infusion. Therefore+ the dru" administration should be stopped immediately. ,. A woman dia"nosed with bipolar disorder is to take lithium A>ithane) as part of the treatment. .hat should the nurse discuss with the client as part of the teachin" plan? A) &isks of oral contracepti!es ) &eduction in e7ercise pro"ram #) A!oidance of alcohol %) #essation of smokin" &e!iew Information' The correct answer is #' A!oidance of alcohol Alcohol potentiates the effects of lithium+ and is to be a!oided. 9. The nurse prepares to administer eye drops to a < year-old child. .hich of these demonstrates the correct method for instillation of eye drops? A) %irectly on the anterior surface of the eyeball ) In the corner where the lids meet #) *nder the upper lid as it is pulled upward K %) In the con3uncti!al sac as the lower lid is pulled down &e!iew Information' The correct answer is %' In the con3uncti!al sac as the lower lid is pulled down Hye drops should be placed in the sac between the eye and the lower lid. This sac is formed by pullin" the lower lid down. 18. A depressed client is e7periencin" se!ere insomnia. The health care pro!ider orders tra5adone A%esyrel). The nurse tells the client to e7pect A) Impro!ement of acne K ) &elief of insomnia #) &educed arthritic pain %) >ess nasal stuffiness &e!iew Information' The correct answer is ' &elief of insomnia The sedati!e effects of the antidepressant are e7pected to relie!e insomnia. 11. A client with diabetes has a blood su"ar is 48< this mornin". After the nurse reports this lab result and the client=s symptoms of e7cessi!e hun"er and thirst+ what would the nurse e7pect the health care pro!ider to order? A) ;ran"e 3uice ) &e"ular insulin #) C?@ Insulin %) &epeat blood su"ar le!el &e!iew Information' The correct answer is ' &e"ular insulin &e"ular Insulin is a short-actin" insulin which will help reduce the client==s "lucose 1uickly. 1). The nurse is plannin" to administer otic drops to a < year-old child. .hich of the followin" is the correct procedure? A) @old the pinna up and back to instill the drops ) ?lace se!eral drops in the outer ear #) Insert cotton in the outer ear after "i!in" medication %) Assist the child to lie on the affected side afterwards

&e!iew Information' The correct answer is A' @old the pinna up and back to instill the drops The e7ternal auditory canal should be strai"htened by "ently pullin" the pinna up and back for otic drop administration. In children who are under 4 years of a"e+ the pinna should be pulled down and back. 14. A 1 year-old child is recei!in" temporary total parental nutrition AT?C) throu"h a central !enous line. This is the first day of T?C therapy. Althou"h all of the followin" nursin" actions must be included in the plan of care of this child+ which one would be a priority at this time? A) *se aseptic techni1ue durin" dressin" chan"es ) $aintain central line catheter inte"rity #) $onitor serum "lucose le!els %) #heck results of li!er function tests &e!iew Information' The correct answer is #' $onitor serum "lucose le!els @yper"lycemia may occur durin" the first day or ) as the child adapts to the hi"h-"lucose load of the T?C solution. Thus+ a chief nursin" responsibility is blood "lucose testin". 14. Today=s prothrombin time for a client recei!in" #oumadin is )8 Anormal ran"e listed by the lab is 18-14). .hat is the appropriate nursin" action? A) Cotify the health care pro!ider immediately K ) &eco"ni5e that this is a therapeutic le!el #) ;bser!e the client for hematoma de!elopment %) Assess for bleedin" at "ums or IB sites &e!iew Information' The correct answer is ' &eco"ni5e that this is a therapeutic le!el 0or the client on #oumadin therapy+ this prothrombin le!el is within the therapeutic ran"e. 16. The nurse administered intra!enous "amma "lobulin to an 1, month-old child with AI%(. The parent asks why this medication is bein" "i!en. .hat is the nurse2s best response? A) "It will slow down the replication of the !irus." ) "This medication will impro!e your child=s o!erall health status." K #) "This medication is used to pre!ent bacterial infections." "It will increase the effecti!eness of the other medications your %) child recei!es." &e!iew Information' The correct answer is #' "This medication is used to pre!ent bacterial infections." Intra!enous "amma "lobulin is "i!en to help pre!ent as well as to fi"ht bacterial infections in youn" children with AI%(. 1<. The nurse is administerin" the initial total parenteral nutrition solution to a client. .hich of the followin" assessments re1uires the nurse=s immediate attention? A) Temperature of 4-.6 de"rees #elsius ) *rine output of 488 cc in 4 hours #) ?oor skin tur"or %) lood "lucose of 468 m"Gdl &e!iew Information' The correct answer is %' lood "lucose of 468 m"Gdl Total parenteral nutrition formulas contain de7trose in concentrations of 18: or "reater to supply )8: to 68: of the total calories. lood "lucose le!els should be checked e!ery 4 to < hours. A slidin" scale dose of insulin may be ordered to maintain the blood "lucose le!el below )88m"Gdl. 1-. The nurse is teachin" a client with asthma about the correct use of the A5macort Atriamcinolone) inhaler. .hich of the followin" statements+ if made by the client+ would indicate that the teachin" was effecti!e? A) "The inhaler can be used whene!er I feel short of breath." K ) "I should rinse my mouth after usin" the inhaler." #) "If I for"et a dose+ I can double up on the ne7t dose." %) I should not use a spacer with my A5macort. &e!iew Information' The correct answer is ' "I should rinse my mouth after usin" the inhaler." A5macort Atriamcinolone) is an inhaled corticosteroid+ used to pre!ent asthma attacks. It is often used in con3unction with a bronchodilator. The client should be instructed to rinse his mouth after usin" the inhaler to wash away any steroid residue so as to reduce the risk of oral fun"al infections.

A client takin" a non-potassium sparin" diuretic such as furosemide will likely need a potassium supplement to pre!ent hypokalemia. This client did not take supplemental potassium. (i"ns and symptoms of hypokalemia include weakness and muscle cramps. @ypokalemic clients are more sensiti!e to di"o7in to7icity. 19. The nurse admits a client with hypertension who complains of di55iness after takin" diltia5em A#ardi5em). .hich of the followin" is the most important information for the nurse to assess? A) (chedule for takin" medicine ) %aily intake of potassium #) Acti!ity and rest patterns %) aseline heart rate &e!iew Information' The correct answer is A' (chedule for takin" medicine A critical assessment is compliance with the prescribed medication schedule and dose. )8. .hich of the followin" classifications of medications would be most often used for clients with schi5ophrenia? A) Anti-depressants ) $ood stabili5ers #) An7iolytics %) Ceuroleptics &e!iew Information' The correct answer is %' Ceuroleptics Ceuroleptics are antipsychotic dru"s which are most beneficial in treatin" the si"ns and symptoms of schi5ophreniaI any of the other meds mi"ht also be used+ but neuroleptics are the most widely used. )1. A hospitali5ed , month-old infant is recei!in" di"o7in for the treatment of Tetralo"y of 0allot. ?rior to administerin" the ne7t dose of medication+ the parent reports that the baby has !omited one time+ 3ust after breakfast. The heart rate is -). .hat is the initial response of the nurse? A) /i!e the dose after lunch ) &educe the ne7t dose by half #) %ouble the ne7t dose K %) @old the medication &e!iew Information' The correct answer is %' @old the medication To7ic side effects of di"o7in include bradycardia+ dysrhythmia+ nausea+ !omitin"+ anore7ia+ di55iness+ headache+ weakness and fati"ue. In infants and youn" children+ only 1 episode of !omitin"+ associated with mealtime+ does not usually warrant withholdin" the medication. @owe!er+ bradycardia Anormal rate in this a"e child is ,8-188 in the awake sta"e) is sufficient reason to hold the medication and notify the appropriate practitioner. )). A child is treated with edetate calcium disodium A#alcium H%TA) for lead poisonin". .hich of these should the nurse assess first ? A) (erum potassium le!el ) lood calcium le!el #) *rinary output %) %eep tendon refle7es &e!iew Information' The correct answer is #' *rinary output #alcium H%TA is to7ic to the kidneys. *rine output must be measured to monitor renal function. #alcium H%TA should not be "i!en to a child that cannot maintain ade1uate intake of fluids and ade1uate kidney function. )4. The nurse is assessin" a client who has taken haldol A@aloperidol) for se!eral months. .hich of the followin" is a side effect of this medication and must be reported immediately to the health care pro!ider? A) $uscle flaccidity ) %ystonic reaction #) $ood swin"s %) %ry+ harsh cou"h &e!iew Information' The correct answer is ' %ystonic reaction @aldol is a neuroleptic antipsychotic dru" that may cause distonic reaction. %osa"e may ha!e to be ad3usted. )4. The nurse is carin" for a client with renal calculi. .hich health care pro!ider order would be a priority? A) $orphine sulfate as client controlled anal"esia ) ?ush oral fluids and keep !ein open #) #ontinuous warm compresses to the flank area %) Intra!enous antibiotics &e!iew Information' The correct answer is A' $orphine sulfate as client controlled anal"esia Administerin" narcotic anal"esics pro!ide prompt relief of the se!ere pain caused by kidney stones.

)6. A client with an"ina has been instructed about the use of sublin"ual nitro"lycerin. .hich of the followin" statements made to the nurse indicates a 1,. A client is admitted to the hospital because of heart failure and need for further teachin"? di"o7in to7icity. At home+ the client was takin" di"o7in A>ano7in) and A) "I will rest briefly ri"ht after takin" 1 tablet." furosemide A>asi7). .hich symptom would the nurse anticipate findin" ) "I can take )-4 tablets at once if I ha!e se!ere pain." on the initial assessment? #) "I=ll call the doctor if pain continues after 4 tablets 6 minutes apart." K A) $uscle weakness and crampin" "I understand that the medication should be kept in the dark ) #onfusion %) bottle." #) lood in the urine &e!iew Information' The correct answer is ' "I can take )-4 tablets at once if I ha!e %) Tinnitis se!ere pain." &e!iew Information' The correct answer is A' $uscle weakness and crampin"

#lients must understand that 3ust 1 sublin"ual tablet should be taken at a time. After rest and a 6 minute inter!al+ a second and then a third tablet may be necessary. )<. The nurse is teachin" administration of albuterol inhalation to an adult with asthma. .hich of the followin" demonstrates proper teachin"? A) "*se this medication at bedtime to promote rest." ) "%iscontinue the inhalation if you are di55y." #) "Inhale this medication after other asthma sprays." %) "Cotify the health care pro!ider if you need the dru" more often." &e!iew Information' The correct answer is %' "Cotify the health care pro!ider if you need the dru" more often." If the client notices that the albuterol inhalation is used more fre1uently+ the health care pro!ider should be notified so that a chan"e in dose or medication can be ordered. )-. A hospitali5ed , month-old is recei!in" "entamicin A#idomycin). In monitorin" the infant for dru" to7icity+ the nurse should re!iew which laboratory results first? A) lood urea nitro"en ) Thyro7in le!els #) /rowth hormone le!els %) ?latelet counts &e!iew Information' The correct answer is A' lood urea nitro"en To7icity to the amino"lycoside antibiotic+ "entamicin+ is seen in increased *C and serum creatinine le!els. Midney dama"e may be re!ersible if the dru" is stopped at the first si"n of to7icity. ),. A client who is recei!in" chemotherapy throu"h a central line is admitted to the hospital with a dia"nosis of sepsis. .hich of the followin" nursin" inter!entions should recei!e priority? A) Inspect all sites that may ser!e as entry ports for bacteria ) ?lace the client in re!erse isolation #) #han"e the dressin" o!er the site of the central line %) &estrict contact with persons ha!in" known+ or recent+ infections &e!iew Information' The correct answer is A' Inspect all sites that may ser!e as entry ports for bacteria ?rompt reco"nition of source of infection and subse1uent initiation of therapy will reduce morbidity and mortality. )9. The nurse is carin" for a client with ?arkinson=s disease who has de!eloped hallucinations. .hich of the followin" medications that the client is recei!in" may ha!e been a contributin" factor? A) >-%opa ) #o"entin #) aclofen %) enadryl &e!iew Information' The correct answer is A' >-%opa .hile it is unclear whether some 1G4 of clients with ?arkinson==s disease ha!e a dementia+ the nurse should ask about hallucinations because the ?arkinson==s disease medications will cause hallucinations when they are at too hi"h a dose. This should be asked at each client !isit in home care or clinic !isits. 48. The nurse is carin" for a child recei!in" albuterol A?ro!entil) for asthma. The parents ask the nurse why their child is recei!in" this medication. .hich e7planation is correct? A) decrease the swellin" in the airways." K ) rela7 the smooth muscles in the airways." #) reduce the secretions blockin" the airways." stimulate the respiratory center in the brain that control %) respirations." &e!iew Information' The correct answer is ' rela7 the smooth muscles in the airways." Albuterol Abeta-adrener"ic a"onist) is the dru" of choice in treatin" asthma because it allows the smooth muscle in the airway to rela7. The airway can then dilate to increase airflow. 41. The nurse prepares to "i!e a one year-old child an intramuscular in3ection. .here is the best site for this in3ection? A) %eltoid muscle ) Bentro"luteal muscle #) %orso"luteal muscle %) Bastus lateralis muscle &e!iew Information' The correct answer is %' Bastus lateralis muscle The preferred site for an in3ection for an infant is the !astus lateralis muscle which lies alon" the lateral aspect of the thi"h. This site is able to tolerate lar"er !olumes+ and it is not located near any ner!es or blood !essels. 4). The nurse is administerin" albuterol A?ro!entil) to a child with asthma. .hich of the followin" assessments by the nurse indicate the need for an ad3ustment of the medication? A) >ethar"y and fati"ue

) Hdema is the lower e7tremities #) Apical ?ulse of 11) %) Temperature of 181 de"rees 0ahrenheit &e!iew Information' The correct answer is #' Apical ?ulse of 11) ;ne of the most common ad!erse effects of beta adrener"ic medications is an increase in heart rate. 44. To which of the followin" nursin" home residents could the nurse safely administer tricyclic antidepressants without 1uestionin" the health care pro!ider=s order? A) An ,6 year-old male with narrow-an"le "laucoma ) An African-American with beni"n prostatic hypertrophy #) A <6 year-old female with mild hypertension %) A @ispanic female with coronary artery disease &e!iew Information' The correct answer is #' A <6 year-old female with mild hypertension Tricyclics can be safely administered to the hypertensi!e client. 44. The nurse is teachin" a client about precautions with #oumadin. The nurse should instruct the client to a!oid foods with e7cessi!e amounts of which nutrient A) #alcium ) Bitamin M #) Iron %) Bitamin H &e!iew Information' The correct answer is ' Bitamin M Hatin" foods with e7cessi!e amounts of Bitamin M contained in "reen leafy !e"etables may alter anticoa"ulant effects. 46. The nurse is carin" for a 16 month-old child with a first episode of otitis media. .hich of the followin" inter!entions should the nurse include in instructions to the child=s parents? A) H7plain that the child should complete the full 6 days of antibiotics ) ?ro!ide them with handout describin" care of myrin"otomy tubes #) %escribe the tympanocentesis to detect persistent infections Hmphasi5e the importance of a return !isit after completion of %) antibiotics &e!iew Information' The correct answer is %' Hmphasi5e the importance of a return !isit after completion of antibiotics The usual treatment for otitis media is oral antibiotics for 18-14 days. The child should be e7amined a"ain after completion of the full course of antibiotics to assess for persistent infection or middle ear effusion. 4<. The nurse is carin" for an ,1 year-old client with colorectal cancer. The client=s pain has been mana"ed until now with acetaminophen with codeine. ecause of increased pain+ intra!enous morphine is added. .hat should the nurse reco"ni5e about the !alidity of this order? A) Inappropriate because of potential respiratory depression ) Appropriate despite the e7pected effect of mental confusion #) Inappropriate and demonstrates poor knowled"e of pain control %) Appropriate pain mana"ement around-the-clock &e!iew Information' The correct answer is %' Appropriate pain mana"ement around-the-clock Hlderly clients with cancer pain are fre1uently under medicated. This mana"ement is appropriate+ and should be offered throu"hout the day and ni"ht. 4-. efore administerin" di"o7in A>ano7in) to a client+ which of the followin" nursin" assessments is a priority? A) Auscultate breath sounds ) #heck for bowel sounds #) $onitor the heart rate %) $easure the blood pressure &e!iew Information' The correct answer is #' $onitor the heart rate >ano7in+ a cardiac "lycoside used in con"esti!e heart failure+ helps the heart beat more effecti!ely AZ inotrope)+ and decreases the heart rate A- chronotrope). ecause di"o7in slows the heart rate+ the medication should be held if the heart rate is below <8. 4,. .hen teachin" a client about the use of sublin"ual nitro"lycerin+ the nurse should emphasi5e that which of these is the most common side effect? A) @eadache ) %ry mouth #) %epression %) Anore7ia &e!iew Information' The correct answer is A' @eadache The most common side effect is headache+ related to the "enerali5ed !asodilatation. 49. .hat would the nurse e7pect to see in a client who is e7periencin" symptoms of tardi!e dyskinesia? A) &apid ton"ue mo!ements ) *ncontrolled hand tremors durin" meals #) eha!ioral chan"es %) &epetiti!e slappin" mo!ements &e!iew Information' The correct answer is A' &apid ton"ue mo!ements Tardi!e dyskinesia is a syndrome of in!oluntary mo!ements of the face+ mouth+ ton"ue+ trunk+ and limbs that may occur after years of treatment with neuroleptic

a"ents. ?redisposin" factors include older a"e+ many years of treatment ci"arette smokin"+ and diabetes mellitus. 48. The nurse is teachin" a client who has a new prescription for sublin"ual nitro"lycerin. .hich of the followin" must be emphasi5ed? A) &est in bed for an hour after takin" medication ) Take the medication at the same time each day #) Meep the medication bottle in the refri"erator %) #arry the nitro"lycerine with you at all times &e!iew Information' The correct answer is %' #arry the nitro"lycerine with you at all times Citro"lycerin should be carried with the client in and out of the home+ so it can be used when an"ina pain occurs. &esults for QYA-%ele"ation 1. The home care nurse has been mana"in" a client for < weeks. .hat is the best method to determine the 1uality of care pro!ided by a home health care aide assi"ned to assist with the care of this client? A) Ask the client and family if they are satisfied with the care "i!en %etermine if the home health aide=s care is consistent with the plan ) of care In!esti"ate if the home health aide is prompt and stays an #) appropriate len"th of time for care #heck the documentation of the aide for appropriateness and %) comprehensi!eness &e!iew Information' The correct answer is ' %etermine if the home health aide is followin" the plan of care Althou"h the nurse must complete all of the abo!e responsibilities+ e!aluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral+ health care pro!iders2 orders+ the initial nursin" assessment+ the client2s responses to the planned inter!entions+ and the client==s and family==s feedback or in1uires. ). The nurse in the same day sur"ery unit assi"ns the unlicensed assisti!e personnel A*A?) to "i!e a 1888 ml soap solution enema A((H) to a client scheduled for an abdominal hysterectomy. .hich statement by the nurse is most appropriate? A) "Administer enemas until the results are clear." ) "/i!e 4 enemas before sur"ery." #) ">et me know the results of the enema." %) "(low the flow of the solution if crampin" occurs." &e!iew Information' The correct answer is %' "(low the flow of the solution if crampin" occurs." The professional nurse can dele"ate tasks with an e7pected outcome. The *A? is "i!en ade1uate information about the procedure. 4. An &C from the women2s health clinic is temporarily reassi"ned to a medical-sur"ical unit. .hich of these client assi"nments would be most appropriate for this nurse? A newly dia"nosed client with type ) diabetes mellitus who is A) learnin" foot care A client from a motor !ehicle accident with an e7ternal fi7ation K ) de!ice on the le" A client admitted for a barium swallow after a transient ischemic #) attack %) A newly admitted client with a dia"nosis of pancreatic cancer &e!iew Information' The correct answer is ' A motor !ehicle accident A$BA) client with an e7ternal fi7ation de!ice on the le" This client is the most stable+ re1uires basic safety measures and has a predictable outcome. 4. .hich client data should the nurse act upon when a home health aide calls the nurse from the client=s home to report these items? A) The client has complaints of not sleepin" well for the past week. The family wants to discontinue the home meal ser!ice+ meals on ) wheels. The urine in the urinary catheter ba" is of a deeper amber+ almost #) brown color. %) The partner says the client has slower days e!ery other day. &e!iew Information' The correct answer is #' The urine in the urinary catheter ba" is of a deeper amber almost brown color. @ome health aides need to report di!erse information to nurses throu"h phone calls and documentation. The nurse who de!elops the plan of care for a specific client+ and super!ises the aide+ must identify potential dan"er si"ns which re1uire immediate action and follow-up. The color of the urine re1uires follow-up e!aluation. 6. A client is recei!in" an intra!enous AIB) infusion for pain control. .hen carin" for this client+ which one of these actions can the &C safely assi"n to an unlicensed assisti!e personnel A*A?)? Ask the client the de"ree of relief and document the client2s A) response ) %ecrease the set rate on the pump by ) mlGminute #) #heck the IB site for draina"e and loose tape K %) Assist the client with ambulation and a "own chan"e

&e!iew Information' The correct answer is %' Assist the client with ambulation and a "own chan"e .hen directin" the *A?+ communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be dele"ated since they do not re1uire independent 3ud"ment. <. A practical nurse A?C) from the pediatric unit is assi"ned to work in a critical care unit. .hich client assi"nment would be appropriate? A client admitted with multiple trauma with a history of a newly A) implanted pacemaker A new admission with left-sided weakness from a stroke and mild ) confusion A 64 year-old client dia"nosed with cardiac arrest from a #) suspected myocardial infarction A 46 year-old client in balanced traction admitted < days a"o K %) after a motor !ehicle accident &e!iew Information' The correct answer is %' A 46 year-old client in balanced traction admitted < days a"o after a motor !ehicle accident This client is the most stable with a predictable outcome. -. A )6 year-old client+ unresponsi!e after a motor !ehicle accident+ is bein" transferred from the hospital to a lon" term care facility. To which o staff members should the char"e nurse assi"n the client? A) *nlicensed assisti!e personnel A*A?) ) (enior nursin" student #) ?C %) &C &e!iew Information' The correct answer is %' An &C The &C is responsible for teachin" and assessment associated with dischar"e and these acti!ities can not be dele"ated to the other listed persons. ,. .hich statement by the nurse is appropriate when "i!in" an assi"nment to an unlicensed assisti!e personnel A*A?) to ambulate a client for the first time after a colon resection? "@a!e the client sit on the side of the bed before helpin" the client A) to walk." "If the client is di55y ask the client to take some slow+ deep ) breaths." #) "@elp the client to walk in the room as often as the client wishes." %) ".hen you help the client to walk+ ask if any pain occurs." &e!iew Information' The correct answer is A' "@a!e the client sit on the side of the bed before helpin" himGher to walk." This statement "i!es clear directions to the *A? about the task and is most closely associated with the information in the stem that this is an initial "ettin" out of bed after sur"ery. 9. A char"e nurse workin" in a lon" term care facility is makin" out assi"nments. .hich assi"nment to an unlicensed assisti!e personnel A*A?)+ if made by the nurse+ re1uires inter!ention by the super!isor? A) ?ro!ide decubitus ulcer care and apply a dry dressin" ) athe and feed a client on bed rest #) ;ral suctionin" of an unresponsi!e elderly client Teachin" a family intermittent Abolus) feedin"s !ia /-tube before K %) dischar"e &e!iew Information' The correct answer is %' Teachin" a family intermittent Abolus) feedin"s !ia /-tube before dischar"e Initial teachin" can not be dele"ated to a *A? or a ?C and must be done by &Cs. 18. .hich task for a client with anemia and confusion could the nurse dele"ate to the unlicensed assisti!e personnel A*A?)? A) %ocument skin tur"or and color chan"es ) Test stool for occult blood and urine for "lucose #) (u""est foods hi"h in iron and those easily consumed %) &eport mental status chan"es and the de"ree of mental clarity &e!iew Information' The correct answer is ' Test stool for occult blood and urine for "lucose The *A? can do standard+ unchan"in" procedures that re1uire no decision makin". 11. .hich one of these tasks can be safely dele"ated to a ?C? A) Assess the function of a newly created ileoostomy ) #are for a client with a recent complicated double barrel colostomy #) ?ro!ide stoma care for a client with a well functionin" ostomy %) Teach ostomy care to a client and their family members &e!iew Information' The correct answer is #' ?ro!ide stoma care for a client with a well functionin" ostomy. The care of a mature stoma and the application of an ostomy appliance may be dele"ated to a ?C. This client has minimal risk of instability of the situation. 1). The nurse assi"ns an unlicensed assisti!e personnel A*A?) to care for a client with a musculoskeletal disorder. The client ambulates with a le" splint. .hich task re1uires super!ision of the *A?? A) &eport si"ns of redness o!erlyin" a 3oint K ) $onitor the client=s response to ambulatory acti!ity #) Hncoura"ement for the independence in self-care %) Assist the client to transfer from a bed to a chair

&e!iew Information' The correct answer is ' $onitor the client==s response to ambulatory acti!ity $onitorin" the client2s response to inter!entions re1uires assessment+ a task to be performed by an &C. 14. .hich of these clients would be most appropriate to assi"n to a ?C? A trauma !ictim with 1uadriple"ia and a client 1 day post-op radical A) neck dissection A client with newly dia"nosed type ) diabetes mellitus and a client ) with a history of AI%( admitted for pneumonia A client with hemiple"ia is fed by a naso"astric tube and client with #) a left le" amputation in rehabilitation A client with a history of schi5ophrenia in alcohol withdrawal and a %) client with chronic renal failure &e!iew Information' The correct answer is #' A client with hemiple"ia is fed by a naso"astric tube and client with a left le" amputation in rehabilitation This client re1uires supporti!e care and inter!entions within the scope of practice of a ?C. This client is stable with little risk of complications or instability. 14. A client has had a tracheostomy for ) weeks after a motor !ehicle accident. .hich task could the &C safely dele"ate to unlicensed assisti!e personnel A*A?)? A) Teach the client how to cou"h up secretions ) #han"es the tracheostomy trach ties #) $onitor if client has shortness of breath K %) ?erform routine tracheostomy dressin" care &e!iew Information' The correct answer is %' ?erform routine tracheostomy dressin" care *nlicensed assisti!e personnel should be able to perform routine tracheostomy care. 16. .hich of these clients would be appropriate to assi"n to a ?C? A trauma !ictim with multiple lacerations and re1uires comple7 A) dressin"s. K ) An elderly client with cystitis and an indwellin" urethral catheter. A confused client whose family complains about the nursin" care #) ) days after sur"ery. A client admitted for possible transient ischemic attack with %) unstable neuro si"ns. &e!iew Information' The correct answer is ' An elderly client with cystitis and an indwellin" urethral catheter. This is a stable client+ with predictable outcome and care and minimal risk for complications. 1<. Two people call in sick on the medical-sur"ical unit and no additional help is a!ailable. The team consists of an &C+ an >?C and an unlicensed assisti!e personnel A*A?). .hich of these acti!ities should the nurse assi"n to the *A?? A) Assist with plans for any clients dischar"ed ) ?ro!ide basic hy"iene care to all clients on the unit #) Assess a client after an acute myocardial infarction %) /ather the !ital si"ns of all clients on the unit &e!iew Information' The correct answer is ' ?ro!ide basic hy"iene care to all clients on the unit asic client care+ which is routine+ should be dele"ated to a *A? since the unit is short on help. The !ital si"ns would be done by the &C and ?C as they made rounds since this data is more critical to make decisions about the care of the clients. 1-. %urin" the inter!iew of a prospecti!e employee who 3ust completed the a"ency orientation+ which approach would be the best for the nurse mana"er to use to assess competence? A) .hat de"ree of super!ision for basic care do you think you need? K ) >et2s re!iew your skills check-list for type and le!el of skill. #) Are you comfortable workin" independently? %) .hat client care tasks or assi"nments do you prefer? &e!iew Information' The correct answer is ' >et2s re!iew your skills check-list for type and le!el of skill. The nurse needs to know that the employee has competence in certain tasks. ;ne way to do this is to do mutual re!iew of documented skills. 1,. An unlicensed assisti!e personnel A*A?)+ who usually works in pediatrics is assi"ned to work on a medical-sur"ical unit. .hich one of the 1uestions by the char"e nurse would be most appropriate prior to makin" dele"ation decisions? A) "@ow lon" ha!e you been a *A??D ) ".hat type of care did you "i!e in pediatrics?D #) "%o you ha!e your competency checklist that we can re!iew?D %) "@ow comfortable are you to care for adult clients?D &e!iew Information' The correct answer is #' "%o you ha!e your competency checklist that we can re!iew?D The *A? must be competent to accept the dele"ated task. 0urther assessment of the 1ualifications of the *A? is important in order to assi"n the ri"ht task.

19. The measurement and documentation of !ital si"ns is e7pected for clients in a lon" term facility. .hich staff type would it be a priority to dele"ate these tasks to? A) ?ractical nurse A?C) ) &e"istered Curse A&C) #) *nlicensed assisti!e personnel A*A?) %) Bolunteer &e!iew Information' The correct answer is #' *nlicensed assisti!e personnel A*A?) The measurement and recordin" of !ital si"ns may be dele"ated to *A?. this falls under the umbrella of routine task with stable clients. ;ther considerations for dele"ation of care to *A? would be' who is capable and is the least e7pensi!e worker to do each task? )8. The &C dele"ates the task of takin" !ital si"ns of all the clients on the medical-sur"ical unit to an unlicensed assisti!e personnel A*A?). (pecific written and !erbal instructions are "i!en to not take a post-mastectomy client2s blood pressure on the left arm. >ater as the &C is makin" rounds+ the nurse finds the blood pressure cuff on that client2s left arm. .hich of these statements is most accurate? A) The &C is accountable for this situation. ) The &C did not dele"ate appropriately. #) The *A? is co!ered by the &C2s license. %) The *A? is responsible for followin" instructions. &e!iew Information' The correct answer is %' The *A? is responsible for followin" instructions. The *A? is responsible for carryin" out the acti!ity correctly once directions ha!e been clearly communicated especially if "i!en !erbally and in writin". )1. As the &C responsible for a client in isolation+ which can be dele"ated to the ?C? K A) &einforcement of isolation precautions ) Assessment of the client=s attitude about infection control #) H!aluation of staffs= compliance with control measures %) ;bser!ation of the client=s total en!ironment for risks &e!iew Information' The correct answer is A' &einforcement of isolation precautions ?Cs and *A?s can reinforce information that was ori"inally "i!en by the &C. )). The care of which of the followin" clients can the nurse safely dele"ate to an unlicensed assisti!e personnel A*A?)? A client with peripheral !ascular disease and an ulceration of the K A) lower le". A pre-operati!e client awaitin" adrenalectomy with a history of ) asthma An elderly client with hypertension and self-reported non#) compliance A new admission with a history of transient ischemic attacks and %) di55iness &e!iew Information' The correct answer is A' A client with peripheral !ascular disease and an ulceration of the lower le". This client is stable with no risk of instability as compared to the other clients. And this client has a chronic condition+ with needs of supporti!e care. )4. The char"e nurse on a cardiac step-down unit makes assi"nments for the team consistin" of an &C+ a ?C+ and an unlicensed assisti!e person. .hich client should be assi"ned to the ?C? A 49 year-old with new onset atrial fibrillation with a rapid A) !entricular response K ) A 6, year-old hypertensi!e with possible an"ina. #) A 46 year-old scheduled for cardiac catheteri5ation. A <6 year-old for dischar"e after an"ioplasty and stent %) placement. &e!iew Information' The correct answer is ' A 6, year-old hypertensi!e with possible an"ina. This is the most stable client. The clients in options # and % re1uire initial teachin". The client in option A is considered unstable since the dysrhythmia is a new onset. )4. .hen walkin" past a client2s room+ the nurse hears 1 unlicensed assisti!e personnel A*A?) talkin" to another *A?. .hich statement re1uires follow-up inter!ention? A) "If we work to"ether we can "et all of the client care completed." "(ince I am late for lunch+ would you do this one client=s "lucose K ) test?" #) "This client seems confused+ we need to watch monitor closely." %) "I2ll come back and make the bed after I "o to the lab." &e!iew Information' The correct answer is ' "(ince I am late for lunch+ would you do this one client==s "lucose test?" ;nly the &C and ?C can dele"ate to *A?s. ;ne *A? can not dele"ate a task to another *A?. The &C or ?C is le"ally accountable for the nursin" care. )6. A staff nurse complains to the nurse mana"er that an unlicensed assisti!e personnel A*A?) consistently lea!es the work area untidy and does not restock supplies. The best initial response by the nurse mana"er is which of these statements?

I will arran"e for a conference with you and the *A? within the ne7t week. ) I can assure you that I will look into the matter. I would like for you to approach the *A? about the problem the #) ne7t time it occurs. %) I will add this concern to the a"enda for the ne7t unit meetin". &e!iew Information' The correct answer is #' (u""est that the nurse approach the assistant about the problem @elpin" staff mana"e conflict is part of the mana"er==s role. It is appropriate to ur"e the nurse to confront the other staff member to work out problems without a mana"er==s inter!ention when possible. A)

notes that pulse o7imetry has been ordered. .hich statement by the nurse is appropriate? "In order to measure your o7y"en le!el+ please remo!e the polish A) from at least ) nails." "If you do not remo!e all your polish+ I will re1uest a needlestick to ) test o7y"en le!els." #) "I am sorry. All your nail polish must "o off." %) "I will ask your pro!ider if we must ruin those beautiful nails." &e!iew Information' The correct answer is A' "In order to measure your o7y"en le!el+ please remo!e the polish from at least ) nails." In order to effecti!ely measure pulse o7imetry+ there can be no nail polish on the fin"er with the readin" de!ice. The client should be approached usin" therapeutic communication skills. The other options are not appropriate. <. The nurse is remo!in" a fecal impaction on a -6 year-old client. It is most important that the nurse remember that A) the procedure be done prior to the bath ) family members should be tau"ht the procedure K #) cardiac dysrhythmias can result durin" the process %) increased dietary fiber can minimi5e such problems &e!iew Information' The correct answer is #' cardiac dysrhythmias can result durin" the process #ardiac dysrhythmias such as se!ere bradycardia can result from !a"al ner!e stimulation durin" fecal impaction remo!al in the elderly or in cardiac patients. ;ptions 1+ ) and 4 are appropriate thou"h are not the most important considerations. -. .hen takin" the client2s blood pressure A ?)+ the nurse cannot hear the sounds throu"h the stethoscope. .hich action should the nurse take first? A) take the ? a"ain in ) minutes in the same arm ) retake the ? a"ain immediately in the same arm #) use an electronic ? cuff on the other arm %) check to see if the stethoscope is plu""ed &e!iew Information' The correct answer is A' take the ? a"ain in ) minutes in the same arm It is best to wait ) minutes between readin"s of a ? in the same arm to allow the !essels to reco!er from bein" s1uee5ed. The electronic cuff would also re1uire a ) minute wait and may not read a !ery low pressure. ,. The client with multiple sclerosis has an order to chan"e the naso"astric tube. To promote safety when remo!in" the tube+ the nurse should A) ask the client to hold a breath ) offer sips of water #) brin" the code cart to the bedside %) empty the tube of all draina"e &e!iew Information' The correct answer is A' ask the client to hold a breath @oldin" the breath closes the epi"lottis to help pre!ent aspiration. ;ccasionally passin" a C/ tube is easier if the client swallows durin" the process. Hmptyin" the tube does not pre!ent aspiration. There should be no need for the code cart. 9. A client is bein" dischar"ed home today+ and will be takin" M-dur )8mH1 per day by mouth. The nurse should reinforce that potassium le!els will be decreased by A) foods seasoned with salt substitute ) fre1uent daily snacks of black licorice #) prescribed potassium-sparin" diuretics %) occasional use of a nonsteroidal anti-inflammatory dru" AC(AI%) &e!iew Information' The correct answer is ' fre1uent daily snacks of black licorice H7cessi!e intake of black licorice can lead to decreased MZ le!els due to the effect of "lyceric acid Aaldosterone effect). The e7cessi!e intake of salt substitutes+ MZ sparin" diuretics and C(AI%s all ha!e the potential for raisin" the MZ le!el. 18. A client has 3ust returned from the ?ost-Anesthesia #are *nit A?A#*) to the sur"ical unit after a cholecystectomy. .hen initial !ital si"ns are taken the nurse notes a temperature of 94., de"rees 0ahrenheit. .hich first nursin" action is appropriate? A) #ontinue to monitor the !ital si"ns as indicated K ) Apply a warm blanket and check the temperature in 18 minutes #) Ask the ?A#* nurse more details of what happened in ?A#* #all the health care pro!ider and obtain further orders for %) warmin" &e!iew Information' The correct answer is ' Apply a warm blanket and check the temperature in ten minutes A client2s post-operati!e temperature should be at least 96 de"rees. If the temperature does not increase+ the nurse should call the pro!ider for orders for an electric warmin" blanket or other measures. It is not sufficient to continue monitorin" without takin" action. 11. The client with amyotrophic lateral sclerosis is scheduled for 1<8 ml of enteral feedin" as a bolus e!ery 4 hours. efore flushin" with water the nurse aspirates the feedin" tube contents and "ets back 1,8 ml of feedin". .hat is the ne7t appropriate nursin" action? A) Administer the feedin" as ordered ) @old the ne7t feedin" #) 0lush with sterile water

&esults for QYA-&andom W11. A client e7periences intense an7iety after the home was destroyed by a fire. The client escaped from the fire with only minor in3uries. The nurse knows that the most important initial inter!ention would be to' A) (u""est the client rent an apartment with a sprinkler system ) ?ro!ide a brochure on methods to promote rela7ation. K #) %etermine a!ailable community and personal resources %) H7plore the feelin"s of "rief associated with the loss &e!iew Information' The correct answer is #' %etermine a!ailable community and personal resources The client has e7perienced a sudden e!ent that has resulted in dise1uilibrium. The most important initial inter!ention focuses on identifyin" resources and obtainin" assistance for housin" and other immediate needs. Information on home safety+ rela7ation e7ercises+ and "rief counselin" are of !alue after meetin" initial needs for shelter. ). An elderly client with tuberculosis has difficulty cou"hin" up secretions for a sputum specimen. .hich nursin" action is appropriate? A) (pray the oropharyn7 with saline ) Ask the client to drink a warm li1uid #) 0orce fluids for the ne7t , hours K %) &aise the head of the bed to at least 46 de"rees &e!iew Information' The correct answer is %' &aise the head of the bed to at least 46 de"rees ?lacin" the client in semi or hi"h fowler2s position will promote lun" e7pansion and effecti!e cou"hin". .hile drinkin" li1uids helps to loosen secretions o!er time+ they should not be "i!en when collectin" a specimen. (prayin" the throat with saline may cause irritation and cou"hin" and reduce o7y"enation. 4. The nurse is carin" for a 1< year-old client with femur fracture14 hours after sur"ery. Assessment findin"s include tachycardia+ increased shortness of breath+ a temperature of 188.) de"rees 0ahrenheit+ complaints of feelin" an7ious+ and o7y"en saturation le!el of ,,:. In immediately notifyin" the pro!ider of these findin"s+ the nurse reco"ni5es the client is at risk for A) compartment syndrome ) atelectasis #) myocardial infarction %) fatty embolism &e!iew Information' The correct answer is %' fatty embolism The findin"s are cardinal si"ns of a fatty embolism. #ompartment syndrome does not cause increased shortness of breath or feelin"s of an7iousness. Atelectasis occurs when !entilation is decreased and secretions accumulate. $yocardial infarction is characteri5ed with chest pain and "enerally does not occur in 1< year olds unless there is a cardiac history. 4. The client referred for a mammo"raphy 1uestions the nurses about the cancer risks from radiation e7posure. .hat is the appropriate response by the nurse? The radiation from a mammo"raphy is e1ui!alent to 1 hour of K A) sun e7posure. Fou ha!e nothin" to worry aboutI it is less than tannin" in the ) nude. #) A chest 7-ray "i!es you more radiation e7posure. %) H7posure to mammo"raphy e!ery ) years is not dan"erous. &e!iew Information' The correct answer is A' The radiation from a mammo"raphy is e1ui!alent to one hour of sun e7posure. The e7posure of radiation from a mammo"raphy is e1ui!alent to 1 hour of sun e7posureI a client would ha!e to ha!e se!eral in a year2s time to be at risk for cancer. This answer is concise and "i!es the client a point of reference. ;ption ) is 3ud"mental and nontherapeutic. ;ption 4 is not accurate and can cause further concern about radiation e7posure. ;ption 4 does not clearly address the client2s 1uestion. 6. ;n admission to the ambulatory sur"ery unit+ the nurse notices the client=s painted fin"er nails. ;n re!iewin" the pre-op orders+ the nurse

%) %iscard the undi"ested feedin" &e!iew Information' The correct answer is ' @old the ne7t feedin" If residual is "reater than 168 ml+ then the ne7t feedin" should be held. Administerin" water or the ne7t feedin" does not help with the di"estion of this feedin". %iscardin" the feedin" that was aspirated depletes the body of en5ymes and electrolytes that ha!e been mi7ed with the feedin". 1). The nurse is insertin" a 0oley catheter into the bladder of a female adult client. The nurse slips the catheter into an openin" for four-6 inches and no urine is obtained. The most probable reason for this is that A) there is no urine present in the bladder ) the catheter is in the !a"ina #) the catheter is not inserted in far enou"h %) the bladder is o!er distended &e!iew Information' The correct answer is ' the catheter is in the !a"ina The urinary catheter is inserted about ) to 4 inches in the urinary meatus until the urine flow is !isuali5ed. If urine does not flow+ the catheter is rotated "ently and carefully inserted another inch farther. A catheter inserted 4 to 6 inches with no urine return is probably in the !a"ina. 14. After the death of a client+ the family approaches the nurse and re1uests that a family member be allowed to perform a ritual bath on the deceased prior to mo!in" the body. The appropriate response by the nurse is A) I will ha!e to check on hospital re"ulations and policies. ) These procedures ha!e to be carried out by our staff. #) Is there anythin" you need from me to perform the ritual bath? %) A ritual bath will ha!e to wait until after post-mortem care &e!iew Information' The correct answer is #' Is there anythin" you need from me to perform the ritual bath? &ationale' In some reli"ious traditions+ a ritual bath is performed by a family member or a ritual burial society. Curses should in1uire about rituals or obser!ances followin" death and respect these. ;ptions 1+ ) and 4 are inappropriate and insensiti!e. &esults for QYA-&andom W16 1. The nurse detects blood-tin"ed fluid leakin" from the nose and ears of a head trauma client. .hat is the appropriate nursin" action? A) ?ack the nose and ears with sterile "au5e ) Apply pressure to the in3ury site K #) Apply bulky+ loose dressin" to nose and ears %) Apply an ice pack to the back of the neck &e!iew Information' The correct answer is #' Apply bulky+ loose dressin" to nose and ears Applyin" a bulky+ loose dressin" to the nose and ears permits the fluid to drain and pro!ides a !isual reference for the amount of draina"e. ). A nurse mana"er considers chan"in" staff assi"nments from , hour shifts to 1) hour shifts. A staff-selected plannin" committee has appro!ed the chan"e+ yet the staff are complainin". As a chan"e a"ent+ the nurse mana"er should first A) (upport the plannin" committee and post the new schedule ) H7plore how the plannin" committee e!aluated barriers to the plan #) %esi"n a different approach to deli!er care with fewer staff %) &etain the pre!ious staffin" pattern for another < months &e!iew Information' The correct answer is ' H7plore how the plannin" committee e!aluated barriers to the plan The mana"er is ultimately responsible for deli!ery of care and yet has "i!en a committee chosen by staff the ri"ht to appro!e or disappro!e the chan"e. ?lanned chan"e in!ol!es e7plorin" barriers and restrainin" forces before implementin" chan"e. To smooth acceptance of the chan"e+ restrainin" factors need to be e!aluated. The mana"er wants to build the staff==s skills at implementin" chan"e. @elpin" the committee e!aluate its decision-makin" is a useful step before re3ectin" or implementin" the chan"e. .hen possible all affected by the chan"e should be in!ol!ed in the plannin". The 1uestion is whether staff input has been thorou"hly taken into consideration. 4. The nurse is carin" for a depressed client with a new prescription for an ((&I antidepressant. In re!iewin" the admission history and physical+ which of the followin" should prompt 1uestions about the safety of this medication? A) @istory of obesity K ) ?rescribed use of an $A; inhibitor #) %ia"nosis of !ascular disease %) Takes antacids fre1uently &e!iew Information' The correct answer is ' ?rescribed use of an $A; inhibitor

((&Is should not be taken concurrently with $A; inhibitors because serious+ lifethreatenin" reactions may occur with this combination of dru"s. 4. In preparin" medications for a client with a "astrostomy tube+ the nurse should contact the health care pro!ider before administerin" which of the followin" dru"s throu"h the tube? A) #ardi5em (& tablet Adiltia5em) ) >ano7in li1uid #) ;s-cal tablet Acalcium carbonate) %) Tylenol li1uid Aacetaminophen &e!iew Information' The correct answer is A' #ardi5em (& tablet Adiltia5em) #ardi5em (& is a "sustained-release" dru" form. (ustained release AcontrolledreleaseI lon"-actin") dru" formulations are desi"ned to release the dru" o!er an e7tended period of time. If crushed+ as would be re1uired for "astrostomy tube administration+ sustained-release properties and blood le!els of the dru" will be altered. The health care pro!ider must substitute another medication. 6. The most common reason for an Ap"ar score of , and 9 in a newborn is an abnormality of what parameter? A) @eart rate ) $uscle tone #) #ry K %) #olor &e!iew Information' The correct answer is %' #olor Acrocyanosis Ablue hands and feet) is the most common Ap"ar score deduction+ and is a normal adaptation in the newborn. <. A nurse has asked a second staff nurse to si"n for a wasted narcotic+ which was not witnessed by another person. This seems to be a recent pattern of beha!ior. .hat is the appropriate initial action? K A) &eport this immediately to the nurse mana"er ) #onfront the nurse about the suspected dru" use (i"n the narcotic sheet and document the e!ent in an incident #) report %) #ounsel the collea"ue about the risky beha!iors &e!iew Information' The correct answer is A' &eport this immediately to the nurse mana"er The incident must be reported to the appropriate super!isor+ for both ethical and le"al reasons. This is not an incident that a co-worker can resol!e without referral to a mana"er. -. To obtain data for the nursin" assessment+ the nurse should' A) ;bser!e carefully the client2s non!erbal beha!iors ) Adhere to pre-planned inter!iew "oals and structure #) Allow clients to talk about whate!er they want K %)

Elicit clients' description of their experiences, thoughts and behaviors

&e!iew Information' The correct answer is %' Hlicit clients== description of their e7periences+ thou"hts and beha!iors The nurse2s understandin" of the client rests the comprehensi!eness of assessment data obtained by listenin" to the client2s self re!elation. ,. The nurse will administer li1uid medicine to a 9 month-old child. .hich of the followin" methods is appropriate? A) Allow the infant to drink the li1uid from a medicine cup K ) Administer the medication with a syrin"e ne7t to the ton"ue #) $i7 the medication with the infant=s formula in the bottle %) @old the child upri"ht and administer the medicine by spoon &e!iew Information' The correct answer is ' Administer the medication with a syrin"e ne7t to the ton"ue *sin" a needle-less syrin"e to "i!e li1uid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth+ "a""in" will be reduced. 9. A client calls the nurse with a complaint of sudden deep throbbin" le" pain. .hat is the appropriate first action by the nurse? A) (u""est isometric e7ercises ) $aintain the client on bed rest #) Ambulate for se!eral minutes %) Apply ice to the e7tremity &e!iew Information' The correct answer is ' $aintain the client on bed rest The findin" su""ests deep !ein thrombosis. The client must be maintained on bed rest and the pro!ider notified immediately. 18. The nurse is teachin" diet restrictions for a client with Addison=s disease. The client would indicate an understandin" of the diet by statin" K A) "I will increase sodium and fluids and restrict potassium." ) "I will increase potassium and sodium and restrict fluids." #) "I will increase sodium+ potassium and fluids." %) "I will increase fluids and restrict sodium and potassium." &e!iew Information' The correct answer is A' "I will increase sodium and fluids and restrict potassium." The manifestation of Addison==s disease due to mineralocorticoid deficiency resultin" from renal sodium wastin" and potassium retention include dehydration+ hypotension+ hyponatremia+ hyperkalemia and acidosis.

11. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. .hat is the initial action the nurse should take? A) &eport the beha!ior to the char"e nurse Talk with the client to find out about the preferred herbal ) preparation #) #ontact the client=s health care pro!ider %) H7plain the importance of the medication to the client &e!iew Information' The correct answer is ' Talk with the client to find out about the preferred herbal preparation &espect for differences is demonstrated by incorporatin" traditional cultural practices for stayin" healthy into professional prescriptions and inter!entions. The challen"e for the health-care pro!ider is to understand the client==s perspecti!e. "#ulture care preser!ation or maintenance refers to those assisti!e+ supportin"+ facilitati!e or enablin" professional actions and decisions that help people of a particular culture to retain andGor preser!e rele!ant care !alues to that they can maintain their well-bein"+ reco!er from illness or face handicaps andGor death". 1). %urin" the initial physical assessment on a client who is a Bietnamese immi"rant+ the nurse notices small+ circular+ ecchymotic areas on the client=s knees. The best action for the nurse to take is to A) Ask the client for more information about the nature of the bruises ) Ask the client and then the family about the findin"s #) &eport the bruisin" to social ser!ices to follow-up %) %ocument the findin"s on the admission sheet &e!iew Information' The correct answer is A' Ask the client for more information about the nature of the bruises "#uppin"" is practiced by Bietnamese. The principle is to create a !acuum inside a special cup by i"nitin" alcohol-soaked cotton inside the cup. .hen the flame e7tin"uishes+ the cup is immediately applied to the skin of the painful site. The belief' the suction e7udes the no7ious element. The "reater the bruise+ the "reater the seriousness of the illness. There is no need to ask the family members. 14. A client with considerable pain asks' E.hat is your opinion re"ardin" acupuncture as a dru"-free method for alle!iatin" pain?D The nurse responds+ "I=d for"et about it as those weird non-.estern treatments can be scary." The nurse=s response is an e7ample of A) ?re3udice ) %iscrimination #) Hthnocentrism %) #ultural insensiti!ity &e!iew Information' The correct answer is #' Hthnocentrism Hthnocentrism+ the uni!ersal tendency of human bein"s to think that their ways of thinkin"+ actin"+ and belie!in" are the only ri"ht+ proper+ and natural ways+ can be a ma3or barrier to pro!idin" culturally conscious care. Hthnocentrism perpetuates an attitude that beliefs that differ "reatly from one==s own are stran"e+ bi5arre+ or unenli"htened+ and therefore wron". Hthnocentrism refers to the unconscious tendency to look at others throu"h the lens of one==s own cultural norms and customs and to take for "ranted that one==s own !alues are the only ob3ecti!e reality. At a more comple7 le!el+ the ethnocentrist re"ards others as inferior or immoral and belie!es his or her own ideas are intrinsically "ood+ ri"ht+ necessary+ and desirable+ while remainin" unaware of his or her own !alue 3ud"ments. 14. A 9 year-old is taken to the emer"ency room with ri"ht lower 1uadrant pain and !omitin". .hen preparin" the child for an emer"ency appendectomy+ what must the nurse e7pect to be the child=s "reatest fear? A) #han"e in body ima"e ) An unfamiliar en!ironment #) ?ercei!ed loss of control %) /uilt o!er bein" hospitali5ed &e!iew Information' The correct answer is #' ?ercei!ed loss of control 0or school a"e children+ ma3or fears are loss of control and separation from friendsGpeers. 16. A nurse arran"es for a interpreter to facilitate communication between the health care team and a non-Hn"lish speakin" client. To promote therapeutic communication+ the appropriate action for the nurse to remember when workin" with an interpreter is to ?romote !erbal and non!erbal communication with both the client K A) and the interpreter (peak only a few sentences at a time and then pause for a few ) moments ?lan that the encounter will take more time than if the client #) spoke Hn"lish %) Ask the client to speak slowly and to look at the person spoken to &e!iew Information' The correct answer is A' ?romote !erbal and non!erbal communication with both the client and the interpreter The nurse should communicate with the client and the family+ not with the interpreter. #ulturally appropriate eye contact+ "estures+ and body lan"ua"e toward the client and family are important factors to

enhance rapport and understandin". $aintain eye contact with both the client and interpreter to elicit feedback and read non!erbal cues. 1<. The nurse is plannin" care for a ) year-old hospitali5ed child. .hich of the followin" will produces the most stress at this a"e? A) (eparation an7iety ) 0ear of pain #) >oss of control %) odily in3ury &e!iew Information' The correct answer is A' (eparation an7iety .hile a toddler will e7perience all of the stresses+ separation from parents is the ma3or stressor. 1-. .hich statement describes strate"ies that help build personal power in an or"ani5ation? >on"e!ity in an or"ani5ation+ social ties to people in power+ and a A) history as someone who does not back down in conflict ends with success /oals are met with the use of networkin"+ mentorin"+ and K ) coalition buildin" @i"h !isibility and formal power are maintained with a #) confrontational style #redibility to one=s position is enhanced when professional dress %) and demeanor are employed &e!iew Information' The correct answer is ' /oals are meet with the use of networkin"+ mentorin"+ and coalition buildin" Cetworkin"+ mentorin"+ and coalition buildin" are positi!e uses of personal power to meet "oals. 1,. A )4 year-old male is admitted with a dia"nosis of testicular cancer. The nurse would e7pect the client to ha!e A) (crotal discoloration ) (ustained painful erection #) Inability to achie!e erection %) @ea!iness in the affected testicle &e!iew Information' The correct answer is %' @ea!iness in the affected testicle The feelin" of hea!iness in the scrotum is related to testicular cancer and not epididymitis. (e7ual performance and related issues are not affected at this time. 19. A mother telephones the clinic and says EI am worried because my breast-fed 1 month-old infant has soft+ yellow stools after each feedin".D The nurse=s best response would be which of these? This type of stool is normal for breast fed infants. Meep doin" as A) you ha!e. The stool should ha!e turned to li"ht brown by now. .e need to ) test the stool 0ormula supplements mi"ht need to be added to increase the bulk #) of the stools. .ater should be offered se!eral times each day in addition to the %) breast feedin". &e!iew Information' The correct answer is A'This type of stool is normal for breast fed infants. Meep doin" as you ha!e. In breast-fed infants+ stools are fre1uent and yellow to "olden and !ary from soft to thick li1uid in consistency. Co chan"e in feedin"s is indicated. )8. @ospital staff re1uests that the parents with a /reek herita"e of a hospitali5ed infant remo!e the amulet from around the child=s neck. The parents refuse. The nurse understands that the parents may be concerned about A) $ental de!elopment delays K ) H!il eye or en!y of others #) 0ri"ht from spiritual bein"s %) alance in body systems &e!iew Information' The correct answer is ' H!il eye or en!y of others $atiasma+ " A% eye or e!il eye " results from the en!y or admiration of others. .hile the eye is able to harm a wide !ariety of thin"s includin" inanimate ob3ects+ children are particularly susceptible to attack. ?ersons of /reek herita"e employ a !ariety of pre!enti!e mechanisms to thwart the effects of en!y+ includin" protecti!e charms in the form of amulets consistin" of blessed wood or incense. )1. .hich statement describes the use of a decision "rid for decision makin"? A) It is both a !isual and a 1uantitati!e method of decision makin" ) It is the fastest way for "roup decision makin" #) It allows the data to be "raphed for easy interpretation %) It is the only truly ob3ecti!e way to make a decision in a "roup &e!iew Information' The correct answer is A' It is both a !isual and a 1uantitati!e method of decision makin" A decision "rid allows the "roup to !isually e7amine alternati!es and e!aluate them 1uantitati!ely with wei"htin". )). The nurse is carin" for se!eral -8 to ,8 year-old clients on bed rest. .hat is the most important measure to pre!ent skin breakdown? A) $assa"e le"s fre1uently ) 0re1uent turnin" #) $oisten skin with lotions %) Apply moist heat to reddened areas &e!iew Information' The correct answer is ' 0re1uent turnin"

0re1uent turnin" will pre!ent skin breakdown. )4. %ual dia"nosis indicates that there is a substance abuse problem as well as a A) #ross addiction K ) $ental disorder #) %isorder of any type %) $edical problem &e!iew Information' The correct answer is ' $ental disorder %ual dia"nosis is the concurrent presence of a ma3or psychiatric disorder and chemical dependence. )4. .hich of the followin" should the nurse obtain from a client prior to ha!in" electrocon!ulsi!e therapy? A) ?ermission to !ideotape ) (ali!ary p@ #) $ini-mental status e7am %) ?re-anesthesia work-up &e!iew Information' The correct answer is %' ?re-anesthesia workup H#T is deli!ered under "eneral anesthesia and the client should be prepared as for any procedure in!ol!e anesthesia. )6. The nurse is carin" for se!eral hospitali5ed children with the followin" dia"noses. .hich disorder is likely to result in metabolic acidosis? A) (e!ere diarrhea for )4 hours ) Causea with anore7ia #) Alternatin" constipation and diarrhea %) Bomitin" for o!er 4, hours &e!iew Information' The correct answer is A' (e!ere diarrhea (e!ere diarrhea is the only problem listed that can lead to metabolic acidosis if untreated. )<. The nurse is assi"ned to care for a client newly dia"nosed with an"ina. As part of dischar"e teachin"+ it is important to remind the client to remo!e the nitro"lycerine patch after 1) hours in order to pre!ent what condition? A) (kin irritation ) %ru" tolerance #) (e!ere headaches %) ?ostural hypotension &e!iew Information' The correct answer is ' %ru" tolerance &emo!in" a nitro"lycerine patch for a period of 18-1) hours daily pre!ents tolerance to the dru"+ which can occur with continuous patch use. )-. .hat is the ma3or de!elopmental task that the mother must accomplish durin" the first trimester of pre"nancy? A) Acceptance of the pre"nancy ) Acceptance of the termination of the pre"nancy #) Acceptance of the fetus as a separate and uni1ue bein" %) (atisfactory resolution of fears related to "i!in" birth &e!iew Information' The correct answer is A' Acceptance of the pre"nancy %urin" the first trimester the maternal focus is directed toward acceptance of the pre"nancy and ad3ustment to the minor discomforts. ),. %urin" the two-month well-baby !isit+ the mother complains that formula seems to stick to her baby=s mouth and ton"ue. .hich of the followin" would pro!ide the most !aluable nursin" assessment? A) Inspect the baby=s mouth and throat ) ;btain cultures of the mucous membranes #) 0lush both sides of the mouth with normal saline K %) *se a soft cloth to attempt to remo!e the patches &e!iew Information' The correct answer is %' *se a soft cloth to attempt to remo!e the patches #andidiasis can be distin"uished from coa"ulated milk when attempts to remo!e the patches with a soft cloth are unsuccessful. )9. After successful alcohol deto7ification+ a client remarked to a friend+ "I2!e tried to stop drinkin" but I 3ust can2t+ I can2t e!en work without ha!in" a drink." The client2s belief that he needs alcohol indicates his dependence is primarily A) ?sycholo"ical ) ?hysical #) iolo"ical %) (ocial-cultural &e!iew Information' The correct answer is A' ?sycholo"ical .ith psycholo"ical dependence+ it is the client Ts thou"hts and attitude toward alcohol that produces cra!in" and compulsi!e use. 48. A nurse is carin" for a client with peripheral arterial insufficiency of the lower e7tremities. .hich inter!ention should be included in the plan of care to reduce le" pain?

A) Hle!ate the le"s abo!e the heart ) Increase in"estion of caffeine products #) Apply cold compresses %) >ower the le"s to a dependent position &e!iew Information' The correct answer is %' >ower the le"s to a dependent position Ischemic pain is relie!ed by placin" feet in a dependent position. This position impro!es peripheral perfusion. 41. A diabetic client asks the nurse why the health care pro!ider ordered a "lycolsylated hemo"lobin A@bA) measurement+ since a blood "lucose readin" was 3ust performed. Fou will e7plain to the client that the @bA test' A) ?ro!ides a more precise blood "lucose !alue than self-monitorin" ) Is performed to detect complications of diabetes #) $easures circulatin" le!els of insulin %) &eflects an a!era"e blood su"ar for se!eral months &e!iew Information' The correct answer is %' &eflects an a!era"e blood su"ar for se!eral months /lycosolated hemo"lobin !alues reflect the a!era"e blood "lucose Ahemo"lobinbound) for the pre!ious 4-4 months and is used to monitor client adherence to the therapeutic re"imen 4). The nurse is speakin" to a "roup of parents and school teachers of children about care for children with rheumatic fe!er. It is a priority to emphasi5e that A) @ome schoolin" is preferred to classroom instruction ) #hildren may remain strep carriers for years #) $ost play acti!ities will be restricted indefinitely %) #lumsiness and beha!ior chan"es should be reported &e!iew Information' The correct answer is %' #lumsiness and beha!ior chan"es should be reported A ma3or manifestation of rheumatic fe!er that reflects central ner!ous system in!ol!ement is chorea. Harly symptoms of chorea include beha!ior chan"es and clumsiness. #horea is characteri5ed by sudden+ aimless+ irre"ular mo!ements of the e7tremities+ in!oluntary facial "rimaces+ speech disturbances+ emotional lability+ and muscle weakness. #horea is transitory and all manifestations e!entually disappear. 44. A client admits to ben5odia5epine dependence for se!eral years. (he is now in an outpatient deto7ification pro"ram. The nurse must understand that a priority durin" withdrawal is A) A!oid alcohol use durin" this time ) ;bser!e the client for hypotension #) Abrupt discontinuation of the dru" %) Assess for mild physical symptoms &e!iew Information' The correct answer is A' A!oid alcohol use durin" this time #entral ner!ous system depressants interact with alcohol. The client will "radually reduce the dosa"e+ under the health care pro!ider==s direction. %urin" this time+ alcohol must be a!oided. 44. A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the followin" to pre!ent aspirin to7icity? A) (erum potassium ) ?rotein intake #) >actose tolerance K %) (erum albumin &e!iew Information' The correct answer is %' (erum albumin .hen hi"hly protein-bound dru"s are administered to patients with low serum albumin Aprotein) le!els+ e7cess free Aunbound) dru" can cause e7a""erated and dan"erous effects. 46. A mother calls the clinic+ concerned that her 6 week-old infant is "sleepin" more than her brother did." .hat is the best initial response? A) "%o you remember his sleep patterns?" ) "@ow old is your other child?" K #) ".hy do you think this a concern?" %) "%oes the baby sleep after feedin"?" &e!iew Information' The correct answer is #' ".hy do you think this a concern?" ;pen ended 1uestions encoura"e further discussion and con!ersation+ thereby elicitin" further information. 4<. The nurse is carin" for a client with #;?% who becomes dyspneic. The nurse should A) Instruct the client to breathe into a paper ba" ) ?lace the client in a hi"h 0owler=s position #) Assist the client with pursed lip breathin" %) Administer o7y"en at <>Gminute !ia nasal cannula &e!iew Information' The correct answer is #' Assist the client with pursed lip breathin" *se pursed-lip breathin" durin" periods of dyspnea to control rate and depth of respiration and impro!e respiratory muscle coordination. 4-. The nurse is carin" for a client with a deep !ein thrombosis. .hich findin" would re1uire the nurse=s immediate attention? A) Temperature of 18) de"rees 0ahrenheit

) ?ulse rate of 9, beats per minute #) &espiratory rate of 4) %) lood pressure of 98G68 &e!iew Information' The correct answer is #' &espiratory rate of 4) #lients with deep !ein thrombosis are at risk for the de!elopment of pulmonary embolism. The most common symptoms are tachypnea+ dyspnea+ and chest pain. 4,. A < year-old child dia"nosed with acute "lomerulonephritis AA/C) is e7periencin" anore7ia+ moderate edema and ele!ated blood urea nitro"en A *C) le!els. The child re1uests a peanut butter sandwich for lunch. .hat would the nurse=s best response to this re1uest? "That=s a "ood choice+ and I know it is your fa!orite. Fou can ha!e A) it today." ) "I=m sorry+ that is not a "ood choice+ but you could ha!e pasta." "I know that is your fa!orite+ but let me help you pick another #) lunch." %) "Fou cannot ha!e the peanut butter until you are feelin" better." &e!iew Information' The correct answer is #' "I know that is your fa!orite+ but let me help you pick another lunch." #hildren with A/C who ha!e edema+ hypertension oli"uria and a5otemia may ha!e dietary restrictions limitin" sodium+ fluids+ protein and potassium. /i!in" the child a short e7planation and offerin" to talk about an alternati!e is appropriate for this a"e. 49. .hich type of traction can the nurse e7pect to be used on a year-old with a fractured femur and e7tensi!e skin dama"e? A) Cinety-ninety ) uck=s #) ryant %) &ussell &e!iew Information' The correct answer is A' Cinety-ninety Cinety de"ree-ninety de"ree traction is used for fractures of the femur or tibia. A skeletal pin or wire is sur"ically placed throu"h the distal part of the femur+ while the lower part of the e7tremity is in a boot cast. Traction ropes and pulleys are applied. 48. A nurse aide is takin" care of a ) year-old child with .ilm=s tumor. The nurse aide asks the nurse why there is a si"n abo!e the bed that says %; C;T ?A>?ATH T@H A %;$HC? The best response by the nurse would be which of these statements? K A) "Touchin" the abdomen could cause cancer cells to spread." ) "H7aminin" the area would cause difficulty to the child." #) "?ushin" on the stomach mi"ht lead to the spread of infection." "?lacin" any pressure on the abdomen may cause an abnormal %) e7perience." &e!iew Information' The correct answer is A' "Touchin" the abdomen could cause cancer cells to spread." $anipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. athin" and turnin" the child should be done carefully. The other options are similar but not the most specific. &esults for QYA-&andom W14 1. A nurse admits a 4 week-old infant to the special care nursery with a dia"nosis of bronchopulmonary dysplasia. As the nurse re!iews the birth history+ which data would be most consistent with this dia"nosis? A) /estational a"e assessment su""ested "rowth retardation ) $econium was cleared from the airway at deli!ery #) ?hototherapy was used to treat &h incompatibility K %) The infant recei!ed mechanical !entilation for ) weeks &e!iew Information' The correct answer is %' The infant recei!ed mechanical !entilation for ) weeks ronchopulmonary dysplasia is an iatro"enic disease caused by therapies such as use of positi!e-pressure !entilation used to treat lun" disease. ). A client with bipolar disorder is reluctant to take lithium A>ithane) as prescribed. The most therapeutic response by the nurse to his refusal is A) "Fou need to take your medicine+ this is how you "et well." ) "If you refuse your medicine+ we2ll 3ust ha!e to "i!e you a shot." K #) ".hat is it about the medicine that you don2t like?" "I can see that you are uncomfortable ri"ht now+ I2ll wait until %) tomorrow." &e!iew Information' The correct answer is #' ".hat is it about the medicine that you don2t like?" Cursin" inter!entions for clients with psychotic disorders are aimed at establishin" a trustin" relationship+ establishin" clear communications+ presentin" reality and reinforcin" appropriate beha!ior. 4. The nurse sees a substance abusin" client occasionally in the outpatient clinic. In e!aluatin" the client=s pro"ress+ the nurse reco"ni5es that the most re!ealin" resistant beha!ior is A) &ecurrin" crises

) #ontinuin" dru" use #) &ationali5in" comments %) $issin" appointments &e!iew Information' The correct answer is ' #ontinuin" dru" use #ontinuin" to use the dru" demonstrates lack of commitment to the treatment pro"ram. This fact must be understood by the nurse as part of the disease of addiction.

4. A new nurse mana"er is seekin" a mentor in the administrati!e realm. .hich of these characteristics is a priority for the outcome of a positi!e e7perience with a mentor? A) Information is clarified as needed K ) A teacher-coach role is taken by the mentor #) The mentee accepts feedback ob3ecti!ely %) The mentor is randomly assi"ned by administration &e!iew Information' The correct answer is ' A teacher-coach role is taken by the mentor oth the mentor and mentee+ the nurse mana"er+ initially need to be open to a positi!e learnin" e7perience. The teacher-coach is the priority for the outcome of an ideal relationship. 6. ?arents of a < month-old breast fed baby ask the nurse about increasin" the baby=s diet. .hich of the followin" should be added first? K A) #ereal ) H""s #) $eat %) Suice &e!iew Information' The correct answer is A' #ereal The "uidelines of the American Academy of ?ediatrics recommend that one new food be introduced at a time+ be"innin" with strained cereal. . <. A nurse is eatin" in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears sli"htly blue. The appropriate initial action should be to A) e"in mouth to mouth resuscitation ) /i!e the child water to help in swallowin" K #) ?erform 6 abdominal thrusts %) #all for the emer"ency response team &e!iew Information' The correct answer is #' ?erform 6 abdominal thrusts At this a"e+ the most effecti!e way to clear the airway of food is to perform abdominal thrusts. - A !ictim of domestic !iolence states+ "If I were better+ I would not ha!e been beat." .hich feelin" best describes what the !ictim may be e7periencin"? A) 0ear ) @elplessness K #) (elf-blame %) &e3ection &e!iew Information' The correct answer is #' (elf-blame %omestic !iolence !ictims may be immobili5ed by a !ariety of affecti!e responses+ one bein" self-blame. The !ictim belie!es that a chan"e in their beha!ior will cause the abuser to become non!iolent+ which is a myth. ,. A client has been admitted with complaints of lower abdominal pain+ difficulty swallowin"+ nausea+ di55iness+ headache and fati"ue. The client is a"itated+ fearful+ tachycardic and complains of bein" "too sick to return to work." The client is dia"nosed as ha!in" somatoform disorder. In formulatin" a plan of care+ the nurse must consider that the client=s beha!ior K A) Is controlled by their subconscious mind ) Is manipulati!e to a!oid work responsibilities #) .ould respond to psychoeducational strate"ies %) #ould be modified throu"h reality therapy &e!iew Information' The correct answer is A' Is controlled by their subconscious mind ?ersons with somatoform disorder do not intend to fei"n illnessI their complaints are not under their conscious control. To intend so is called "malin"erin"" or a factitious disorder. 9. .hich statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child? A) "I know there is a problem since my baby is always constipated." "$y child doesn=t like many fruits and !e"etables+ but she really K ) lo!es her milk." "I can=t understand why my child is not eatin" as much as she did #) 4 months a"o." %) "$y child doesn=t drink a whole "lass of 3uice or water at 1 time." &e!iew Information' The correct answer is ' "$y child doesn==t like many fruits and !e"etables+ but she really lo!es her milk." About ) to 4 cups of milk a day are sufficient for the youn" child==s needs. (ometimes e7cess milk intake+ a habit carried o!er from infancy+ may e7clude many solid foods from the diet. As a result+ the child may lack iron and de!elop a so-called milk anemia. Althou"h the ma3ority of infants with iron deficiency are underwei"ht+ many are o!erwei"ht because of e7cessi!e milk in"estion. 18. The nurse is plannin" care for a client durin" the acute phase of a sickle cell !aso-occlusi!e crisis. .hich of the followin" actions would be most appropriate?

A) 0luid restriction 1888cc per day ) Ambulate in hallway 4 times a day K #) Administer anal"esic therapy as ordered %) Hncoura"e increased caloric intake &e!iew Information' The correct answer is #' Administer anal"esic therapy as ordered The main "eneral ob3ecti!es in the treatment of a sickle cell crisis is bed rest+ hydration+ electrolyte replacement+ anal"esics for pain+ blood replacement and antibiotics to treat any e7istin" infection. 11. 0ollowin" sur"ery for placement of a !entriculoperitoneal AB?) shunt as treatment for hydrocephalus+ the parents 1uestion why the infant has a small abdominal incision. The best response by the nurse would be to e7plain that the incision was made in order to K A) ?ass the catheter into the abdominal ca!ity ) ?lace the tubin" into the urinary bladder #) Bisuali5e abdominal or"ans for catheter placement %) Insert the catheter into the stomach &e!iew Information' The correct answer is A' ?ass the catheter into the abdominal ca!ity The preferred procedure in the sur"ical treatment of hydrocephalus is placement of a !entriculoperitoneal shunt. This shunt procedure pro!ides primary draina"e of the cerebrospinal fluid from the !entricles to an e7tracranial compartment+ usually the peritoneum. A small incision is made in the upper 1uadrant of the abdomen so the shunt can be "uided into the peritoneal ca!ity. 1). The nurse is teachin" a client with metastatic bone disease about measures to pre!ent hypercalcemia. It would be important for the nurse to emphasi5e A) The need for at least 6 ser!in"s of dairy products daily ) &estriction of fluid intake to less than 1 liter per day K #) The importance of walkin" as much as possible %)

1<. An ambulatory client reports edema durin" the day in his feet and ankles that disappears while sleepin" at ni"ht. .hat is the most appropriate follow-up 1uestion for the nurse to ask? A) "@a!e you had a recent heart attack?" "%o you become short of breath durin" your normal daily ) acti!ities?" #) "@ow many pillows do you use at ni"ht to sleep comfortably?" %) "%o you smoke?" &e!iew Information' The correct answer is ' "%o you become short of breath durin" your normal daily acti!ities?" These are the symptoms of ri"ht-sided heart failure+ which causes increased pressure in the systemic !enous system. To e1uali5e this pressure+ the fluid shifts into the interstitial spaces causin" edema. ecause of "ra!ity+ the lower e7tremities are first affected in an ambulatory patient. This 1uestion would elicit information to confirm the nursin" dia"nosis of acti!ity intolerance and fluid !olume e7cess both associated with ri"ht-sided heart failure. 1-. The nursin" care plan for a toddler dia"nosed with Mawasaki %isease Amucocutaneous lymph node syndrome) should be based on the hi"h risk for de!elopment of which problem? A) #hronic !essel pla1ue formation ) ?ulmonary embolism #) ;cclusions at the !essel bifurcations K %) #oronary artery aneurysms &e!iew Information' The correct answer is %' #oronary artery aneurysms Mawasaki %isease in!ol!es all the small and medium-si5ed blood !essels. There is pro"ressi!e inflammation of the small !essels which pro"resses to the mediumsi5ed muscular arteries+ potentially dama"in" the walls and leadin" to coronary artery aneurysms. 1,. The nurse auscultates bibasilar inspiratory crackles in a newly admitted <, year-old client with a dia"nosis of con"esti!e heart disease. .hich findin" is most likely to occur? A) #hest pain ) ?eripheral edema #) Cail clubbin" %) >ethar"y &e!iew Information' The correct answer is ' ?eripheral edema .hen crackles are heard bibasilarly+ con"esti!e heart failure is suspected. This is often accompanied by peripheral edema secondary to fluid o!erload caused by ineffecti!e cardiac pumpin". 19. .hile workin" with an obese adolescent+ it is important for the nurse to reco"ni5e that obesity in adolescents is most often associated with what other beha!ior? A) (e7ual promiscuity ) ?oor body ima"e #) %roppin" out of school %) %ru" e7perimentation &e!iew Information' The correct answer is ' ?oor body ima"e As the adolescent "ains wei"ht+ there is a lessenin" sense of self esteem and poor body ima"e. )8. The nurse should initiate dischar"e plannin" for a client .hen the client or family demonstrate readiness to learn self care A) modalities ) .hen informed that a date for dischar"e has been determined #) *pon admission to the emer"ency room %) .hen the client=s condition is stabili5ed on the assi"ned unit &e!iew Information' The correct answer is #' *pon admission to the emer"ency room .ith decreased len"ths of stay+ dischar"e plans must be incorporated into the initial plan of care upon admission to an emer"ency room or hospital unit. )1. The nurse is carin" for a client with a pressure ulcer on the heel that is co!ered with black hard tissue. .hich would be an appropriate "oal in plannin" care for this client? A) ?rotection for the "ranulation tissue ) @eal infection #) %ebride eschar %) Meep the tissue intact &e!iew Information' The correct answer is %' Meep the tissue intact If the black tissue+ Aeschar) is dry and intact no treatment is necessary. If the area chan"es Acellulitis+ pain) this is a si"n of infection+ re1uirin" debridement. )). .hen pro!idin" nursin" measures to relie!e a 18)-de"ree 0ahrenheit fe!er in a toddler with an infection+ what is the most effecti!e inter!ention? A) *se medications to lower the temperature set point ) Apply e7tra layers of clothin" to pre!ent shi!erin" #) Immerse the child in a tub containin" cool water %) /i!e a tepid spon"e bath prior to "i!in" an antipyretic &e!iew Information' The correct answer is A' *se medications to lower the temperature set point #onditions such as infection+ mali"nancy+ aller"y+ central ner!ous system lesion and radiation cause the temperature set-point to be raised. ecause the

Early recognition of findings associated with tetany

&e!iew Information' The correct answer is #' The importance of walkin" as much as possible $obility must be emphasi5ed to pre!ent deminerali5ation and breakdown of bones. 14. A nurse and client are talkin" about the client2s pro"ress toward understandin" his beha!ior under stress. This is typical of which phase in the therapeutic relationship? A) ?re-interaction ) ;rientation #) .orkin" %) Termination &e!iew Information' The correct answer is #' .orkin" %urin" the workin" phase alternati!e beha!iors and techni1ues are e7plored. The nurse and the client discuss the meanin" behind the beha!ior. 14. A child is sent to the school nurse by a teacher who has a written note that 0ifth2s disease is suspected. .hich characteristic would the nurse e7pect to find? A) $acule that rapidly pro"resses to papule and then !esicles Hrythema on the face+ primarily on cheeks "i!in" a "slapped face" ) appearance %iscrete rose pink macules will appear first on the trunk and fade #) when pressure is applied Moplick spots appear first followed by a rash that appears first on %) the face and spreads downward &e!iew Information' The correct answer is ' Hrythema on the face+ primarily on cheeks "i!in" a "slapped face" appearance 0ifth disease is also refered to it as par!o!irus infection or erythema infectiosum. (ome people may call it slapped-cheek disease because of the face rash that de!elops resemblin" slap marks. It is also commonly called fifth disease because it was fifth of a "roup of oncecommon childhood diseases that all ha!e similar rashes. The other 4 diseases are measles+ rubella+ scarlet fe!er and %ukes== disease. ?ersons won2t know that a child has par!o!irus infection until the rash appears+ and by that time+ the child is no lon"er conta"ious. 16. %elirium tremens could best be described as %isor"ani5ed thinkin"+ feelin"s of terror and non-purposeful A) beha!ior A "enerali5ed shakin" of the body accompanied by repetiti!e ) thou"hts An e7cited state accompanied by disorientation+ hallucination and #) tachycardia %) (in"le or multiple 3erks caused by rapid contractin" muscles &e!iew Information' The correct answer is #' An e7cited state accompanied by disorientation+ hallucination and tachycardia %urin" %T(+ the person e7periences confusion+ disorientation+ hallucinations+ tachycardia+ hypertension+ e7treme tremors+ a"itation+ diaphoresis and fe!er.

temperature set point is normal in hyperthermia and ele!ated in fe!er+ different measures must be taken in order to be effecti!e. The most effecti!e inter!ention in the mana"ement of fe!er is the administration of antipyretics which lower the set point. )4. The nurse is carin" for a pre-adolescent client in skeletal %unlop traction. .hich nursin" inter!ention is appropriate for this child? K A) $ake certain the child is maintained in correct body ali"nment. ) e sure the traction wei"hts touch the end of the bed. #) Ad3ust the head and foot of the bed for the child=s comfort %) &elease the traction for 16-)8 minutes e!ery < hours prn. &e!iew Information' The correct answer is A' $ake certain the child is maintained in correct body ali"nment. ;bser!e for correct body ali"nment with emphasis on ali"nment of shoulders+ hips and le"s. )4. The nurse is assessin" a healthy child at the ) year check up. .hich of the followin" should the nurse report immediately to the health care pro!ider? A) @ei"ht and wei"ht percentiles !ary widely ) /rowth pattern appears to ha!e slowed #) &ecumbent and standin" hei"ht are different %) (hort term wei"ht chan"es are une!en &e!iew Information' The correct answer is A' @ei"ht and wei"ht percentiles !ary widely ;n the "rowth cur!e+ hei"ht and wei"ht should be close in percentiles at this a"e. The wide difference may indicate a problem. )6. The parents of a ) year-old child report that he has been holdin" his breath whene!er he has temper tantrums. .hat is the best action by the nurse? A) Teach the parents how to perform cardiopulmonary resuscitation &ecommend that the parents "i!e in when he holds his breath to ) pre!ent ano7ia Ad!ise the parents to i"nore breath holdin" because breathin" will #) be"in as a refle7 Instruct the parents on how to reason with the child about possible %) harmful effects &e!iew Information' The correct answer is #' Ad!ise the parents to i"nore breath holdin" because breathin" will be"in as a refle7 If temper tantrums are accompanied by breath holdin"+ the parents need to know that this beha!ior will not result in harm to the child. I"norin" the breath holdin" is best+ knowin" that breathin" will be"in a"ain by refle7. )<. The nurse is assessin" a client in the emer"ency room. .hich statement su""ests that the problem is acute an"ina? A) "$y pain is deep in my chest behind my sternum." ) ".hen I sit up the pain "ets worse." #) "As I take a deep breath the pain "ets worse." %) "The pain is ri"ht here in my stomach area." &e!iew Information' The correct answer is A' "$y pain is deep in my chest behind my sternum." The pain of an"ina is usually locali5ed chest pain. )-. The nurse is assessin" the mental status of a client admitted with possible or"anic brain disorder. .hich of these 1uestions will best assess the function of the client=s recent memory? "Came the year." ".hat season is this?" Apause for answer after A) each 1uestion) "(ubtract - from 188 and then subtract - from that." Apause for ) answer) "Cow continue to subtract - from the new number." "I am "oin" to say the names of three thin"s and I want you to #) repeat them after me' blue+ ball+ pen." ".hat is this on my wrist?" Apoint to your watch) Then ask+ ".hat %) is the purpose of it?" &e!iew Information' The correct answer is #' "I am "oin" to say the names of three thin"s and I want you to repeat them after me' blue+ ball+ pen." &ecent memory is the ability to recall e!ents in the immediate past and up to ) weeks pre!iously. ),. In plannin" care for a < month-old infant+ what must the nurse pro!ide to assist in the de!elopment of trust? A) 0ood ) .armth K #) (ecurity %)

".ould you please clarify what you ha!e written so I am sure I am readin" it correctly?" "I am ha!in" difficulty readin" your handwritin". It would sa!e me #) time if you would be more careful." "?lease print in the future so I do not ha!e to spend e7tra time %) attemptin" to read your writin"." &e!iew Information' The correct answer is ' ".ould you please clarify what you ha!e written so I am sure I am readin" it correctly?" Asserti!e communication respects the ri"hts and responsibilities of both parties. This statement is an honest e7pression of concern for safe practice and a re1uest for clarification without self-depreciation. It reflects the ri"ht of the professional to "i!e and recei!e information. ) 48. .hat is the most important consideration when teachin" parents how to reduce risks in the home? A) A"e and knowled"e le!el of the parents ) ?ro7imity to emer"ency ser!ices #) Cumber of children in the home %) A"e of children in the home &e!iew Information' The correct answer is %' A"e of children in the home A"e and de!elopmental le!el of the child are most important in pro!idin" a framework for anticipatory "uidance. 41. A 46 year-old client with sickle cell crisis is talkin" on the telephone but stops as the nurse enters the room to re1uest somethin" for pain. The nurse should A) Administer a placebo ) Hncoura"e increased fluid intake #) Administer the prescribed anal"esia %) &ecommend rela7ation e7ercises for pain control &e!iew Information' The correct answer is #' Administer the prescribed anal"esia &elief of pain is the e7pected outcome for treatment of sickle cell crisis. ?ain may be present e!en without o!ert si"ns. 4). .hile carin" for a toddler with croup+ which initial si"n of croup re1uires the nurse=s immediate attention? A) &espiratory rate of 4) ) >ethar"y for the past hour #) Apical pulse of 64 %) #ou"hin" up copious secretions &e!iew Information' The correct answer is A' &espiratory rate of 48 (i"ns of impendin" airway obstruction include increased respiratory rate and pulseI substernal+ suprasternal and intercostal retractionsI flarin" naresI and increased restlessness or a""itation. 44. A client is admitted with low T4 and T4 le!els and an ele!ated T(@ le!el. ;n initial assessment+ the nurse would anticipate which of the followin" assessment findin"s? A) >ethar"y ) @eat intolerance #) %iarrhea %) (kin eruptions &e!iew Information' The correct answer is A' >ethar"y In hypothyroidism the metabolic acti!ity of all cells of the body decreases+ reducin" o7y"en consumption+ decreasin" o7idation of nutrients for ener"y+ and producin" less body heat. Therefore+ the nurse can e7pect the client to complain of constipation+ lethar"y and inability to "et warm. 44. The emer"ency room nurse admits a child who e7perienced a sei5ure at school. The father comments that this is the first occurrence+ and denies any family history of epilepsy. .hat is the best response by the nurse? A) "%o not worry. Hpilepsy can be treated with medications." ) "The sei5ure may or may not mean your child has epilepsy." #) "(ince this was the first con!ulsion+ it may not happen a"ain." %) ">on" term treatment will pre!ent future sei5ures." &e!iew Information' The correct answer is ' "The sei5ure may or may not mean your child has epilepsy." There are many possible causes for a childhood sei5ure. These include fe!er+ central ner!ous system conditions+ trauma+ metabolic alterations and idiopathic Aunknown). 46. Alcohol and dru" abuse impairs 3ud"ment and increases risk takin" beha!ior. .hat nursin" dia"nosis best applies? A) &isk for in3ury ) &isk for knowled"e deficit #) Altered thou"ht process %) %isturbance in self-esteem &e!iew Information' The correct answer is A' &isk for in3ury Accidents increase as a result of into7ication. (tudies indicate alcohol as a factor in 68: of motor !ehicle fatalities+ 64: of all deaths from accidental falls+ <4: of fatal fires+ and ,8: of suicides. 4<. The nurse is carin" for a 18 month-old infant who is has o7y"en !ia mask. It is important for the nurse to maintain patency of which of these areas? A) $outh ) Casal passa"es

Comfort

&e!iew Information' The correct answer is #' (ecurity .hile the infant has many physical needs+ it must be touched+ lo!ed+ and stimulated to de!elop security and trust. )9. A nurse has 3ust recei!ed a medication order which is not le"ible. .hich statement best reflects asserti!e communication? "I cannot "i!e this medication as it is written. I ha!e no idea of A) what you mean."

#) ack of throat %) ronchials &e!iew Information' The correct answer is ' Casal passa"es Infants+ from birth to 1 year of a"e+ are obli"atory nose breathers. 4-. The nurse is pro!idin" instructions for a client with pneumonia. .hat is the most important information to con!ey to the client? A) "Take at least ) weeks off from work." ) "Fou will need another chest 7-ray in < weeks." #) "Take your temperature e!ery day." %) "#omplete all of the antibiotic e!en if your findin"s decrease." &e!iew Information' The correct answer is %' "#omplete all of the antibiotic e!en if your findin"s decrease." To a!oid a recurrence of the pneumonia the client must complete the prescribed doses at the prescribed dosin" inter!als. 4,. .hen counselin" a < year old who is e7periencin" enuresis+ what must the nurse understand about the pathophysiolo"ical basis of this disorder? K A) @as no clear etiolo"y ) $ay be associated with sleep phobia #) @as a definite "enetic link %) Is a si"n of willful misbeha!ior &e!iew Information' The correct answer is A' @as no clear etiolo"y Althou"h predicti!e factors associated with enuresis ha!e been identified+ no clear etiolo"y has been determined. 49. The nurse is discussin" ne"ati!ism with the parents of a 48 month-old child. @ow should the nurse tell the parents to best respond to this beha!ior? A) &eprimand the child and "i!e a 16 minute "time out" ) $aintain a permissi!e attitude for this beha!ior K #) *se patience and a sense of humor to deal with this beha!ior %) Assert authority o!er the child throu"h limit settin" &e!iew Information' The correct answer is #' *se patience and a sense of humor to deal with this beha!ior The nurse should help the parents see the ne"ati!ism as a normal "rowth of autonomy in the toddler. They can best handle the ne"ati!e toddler by usin" patience and humor. 48. The nurse is talkin" by telephone with a parent of a 4 year-old child who has chickenpo7. .hich of the followin" demonstrates appropriate teachin" by the nurse? A) #hewable aspirin is the preferred anal"esic ) Topical cortisone ointment relie!es itchin" K #) ?apules+ !esicles+ and crusts will be present at one time %) The illness is only conta"ious prior to lesion eruption &e!iew Information' The correct answer is #' ?apules+ !esicles+ and crusts will be present at one time All 4 sta"es of the chicken po7 lesions will be present on the child==s body at one time. &esults for QYA-&andom W14 1. The nurse is assi"ned to a client who has heart failure . %urin" the mornin" rounds the nurse sees the client de!elop sudden an7iety+ diaphoresis and dyspnea. The nurse auscultates+ crackles bilaterally. .hich nursin" inter!ention should be performed first? A) Take the client=s !ital si"ns ) ?lace the client in a sittin" position with le"s dan"lin" #) #ontact the health care pro!ider %) Administer the ?&C antian7iety a"ent &e!iew Information' The correct answer is ' ?lace the client in a sittin" position with le"s dan"lin" ?lace the client in a sittin" position with le"s dan"lin" to pool the blood in the le"s. This helps to diminish !enous return to the heart and minimi5e the pulmonary edema. The result will enhance the client2s ability to breathe. The ne7t actions would be to contact the heath care pro!ider+ then take the !ital si"ns and then the administration of the antian7iety a"ent. ). The nurse is carin" for a toddler with atopic dermatitis. The nurse should instruct the parents to A) %ress the child warmly to a!oid chillin" ) Meep the child away from other children for the duration of the rash #) #lean the affected areas with tepid water and deter"ent %) .rap the child=s hand in mittens or socks to pre!ent scratchin" &e!iew Information' The correct answer is %' .rap the child==s hand in mittens or socks to pre!ent scratchin" A toddler with atopic dermatitis need to ha!e fin"ernails cut short and co!ered so the child will not be able to scratch the skin lesions+ thereby causin" new lesions and possible a secondary infection. 4. A reco!erin" alcoholic asked the nurse+ ".ill it be ok for me to 3ust drink at special family "atherin"s?" .hich initial response by the nurse would be best? A) "A reco!erin" person has to be !ery careful not to lose control+

therefore+ confine your drinkin" 3ust at family "atherin"s." "At your ne7t AA meetin" discuss the possibility of limited ) drinkin" with your sponsor." "A reco!erin" person needs to "et in touch with their feelin"s. %o #) you want a drink?" "A reco!erin" person cannot return to drinkin" without startin" K %) the addiction process o!er." &e!iew Information' The correct answer is %' "The reco!erin" person cannot return to drinkin" without startin" the addiction process o!er." &eco!ery is total abstinence from all dru"s. 4. In takin" the history of a pre"nant woman+ which of the followin" would the nurse reco"ni5e as the primary contraindication for breast feedin"? A) A"e 48 years ) >actose intolerance #) 0amily history of breast cancer %) *ses cocaine on weekends &e!iew Information' The correct answer is %' *ses cocaine on weekends in"e use of cocaine can be 3ust as harmful to the breast fed newborn as re"ular use. 6. A client is recei!in" nitroprusside IB for the treatment of acute heart failure with pulmonary edema. .hat dia"nostic lab !alue should the nurse monitor in relation to this medication? A) ?otassium ) Arterial blood "asses #) lood urea nitro"en %) Thiocyanate &e!iew Information' The correct answer is %' Thiocyanate Thiocyanate le!els rise with the metabolism if nitroprusside and can cause cyanide to7icity. <. A !ictim of domestic !iolence tells the batterer she needs a little time away. @ow would the nurse e7pect that the batterer mi"ht respond? .ith acceptance and !iews the !ictim2s comment as an indication A) that their marria"e is in trouble K ) .ith fear of re3ection causin" increased ra"e toward the !ictim .ith a new commitment to seek counselin" to assist with their #) marital problems .ith relief+ and welcomes the separation as a means to ha!e %) some personal time &e!iew Information' The correct answer is ' .ith fear of re3ection causin" increased ra"e toward the !ictim The fear of re3ection and loss only ser!e to increase the batterer2s ra"e at his partner. -. A postpartum mother is unwillin" to allow the father to participate in the newborn=s care+ althou"h he is interested in doin" so. (he states+ "I am afraid the baby will be confused about who the mother is. aby raisin" is for mothers+ not fathers." The nurse=s initial inter!ention should be what focus? A) %iscuss with the mother sharin" parentin" responsibilities (et time aside to "et the mother to e7press her feelin"s and ) concerns #) Arran"e for the parents to attend infant care classes %) Talk with the father and help him accept the wife=s decision &e!iew Information' The correct answer is ' (et time aside to "et the mother to e7press her feelin"s and concerns Con-3ud"mental support for e7pressed feelin"s may lead to resolution of competiti!e feelin"s in a new family. #ultural influences may also be re!ealed. ,. A client with emphysema !isits the clinic. .hile teachin" about proper nutrition+ the nurse should emphasi5e that the client A) Hat foods hi"h in sodium increases sputum li1uefaction ) *se o7y"en durin" meals impro!es "as e7chan"e #) ?erform e7ercise after respiratory therapy enhances appetite %) #leanse the mouth of dried secretions reduces risk of infection &e!iew Information' The correct answer is ' *se o7y"en durin" meals impro!es "as e7chan"e #lients with emphysema breathe easier when usin" o7y"en while eatin". 9. .hich of these parents2 comment for a newborn would most likely re!eal an initial findin" of a suspected pyloric stenosis? A) I noticed a little lump a little abo!e the belly button. ) The baby seems hun"ry all the time. $ild !omitin" that pro"ressed to !omitin" shootin" across the #) room. %) Irritation and spittin" up immediately after feedin"s. &e!iew Information' The correct answer is #' $ild emesis pro"ressin" to pro3ectile !omitin" $ild re"ur"itation or emesis that pro"resses to pro3ectile !omitin" is a pattern of !omitin" associated with pyloric stenosis as an initial findin". The other findin"s are present+ thou"h not initial findin"s. 18. The nurse is assessin" a child for clinical manifestations of iron deficiency anemia. .hich factor would the nurse reco"ni5e as cause for the findin"s? A) %ecreased cardiac output

) Tissue hypo7ia #) #erebral edema %) &educed o7y"en saturation &e!iew Information' The correct answer is ' Tissue hypo7ia .hen the hemo"lobin falls sufficiently to produce clinical manifestations+ the findin"s are directly attributable to tissue hypo7ia+ a decrease in the o7y"en carryin" capacity of the blood. 11. The nurse would e7pect the cystic fibrosis client to recei!e supplemental pancreatic en5ymes alon" with a diet K A) @i"h in carbohydrates and proteins ) >ow in carbohydrates and proteins #) @i"h in carbohydrates+ low in proteins %) >ow in carbohydrates+ hi"h in proteins &e!iew Information' The correct answer is A' @i"h in carbohydrates and proteins ?ro!ide a hi"h-ener"y diet by increasin" carbohydrates+ protein and fat Apossibly as hi"h as 48:). A fa!orable response to the supplemental pancreatic en5ymes is based on tolerance of fatty foods+ decreased stool fre1uency+ absence of steatorrhea+ impro!ed appetite and lack of abdominal pain. 1). In e!aluatin" the "rowth of a 1) month-old child+ which of these findin"s would the nurse e7pect to be present in the infant? A) Increased 18: in hei"ht ) ) deciduous teeth #) Tripled the birth wei"ht %) @ead [ chest circumference &e!iew Information' The correct answer is #' Tripled the birth wei"ht The infant usually triples his birth wei"ht by the end of the first year of life. @ei"ht usually increases by 68: from birth len"th. A 1) month- old child should ha!e appro7imately < teeth. A estimate number of teeth by subtractin" < from a"e in months+ ie 1) V < \ <). y 1) months of a"e+ head and chest circumferences are appro7imately e1ual. 14. A @ispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to @a!e the unlicensed assisti!e personnel A*A?) reheat the food if A) the client wishes ) Ask the client what foods are acceptable or bad #) Hncoura"e her to eat for healin" and stren"th %) (chedule the dietitian to meet with the client as soon as possible &e!iew Information' The correct answer is ' Ask the client what foods are acceptable $any @ispanic women subscribe to the balance of hot and cold foods in the post partum period. .hat defines "cold" can best be e7plained by the client or family. 14. The father of an , month-old infant asks the nurse if his infant=s !ocali5ations are normal for his a"e. .hich of the followin" would the nurse e7pect at this a"e? A) #ooin" ) Imitation of sounds #) Throaty sounds %) >au"hter &e!iew Information' The correct answer is ' Imitation of (ounds Imitation of sounds such as "da-da" is e7pected at this time. 16. The nurse should reco"ni5e that physical dependence is accompanied by what findin"s when alcohol consumption is first reduced or ended? A) (ei5ures ) .ithdrawal #) #ra!in" %) $arked tolerance &e!iew Information' The correct answer is ' .ithdrawal The early si"ns of alcohol withdrawal de!elop within a few hours after cessation or reduction of alchohol intake. 1<. Immediately followin" an acute batterin" incident in a !iolent relationship+ the batterer may respond to the partner2s in3uries by A) (eekin" medical help for the !ictim=s in3uries ) $inimi5in" the episode and underestimatin" the !ictim2s in3uries #) #ontactin" a close friend and askin" for help %) ein" !ery remorseful and assistin" the !ictim with medical care &e!iew Information' The correct answer is ' $inimi5in" the episode and underestimatin" the !ictim2s in3uries $any abusers lack an understandin" of the effect of their beha!ior on the !ictim and use e7cessi!e minimi5ation and denial. 1-. The nurse is plannin" to "i!e a 4 year-old child oral di"o7in. .hich of the followin" is the best approach by the nurse? A) "%o you want to take this pretty red medicine?" ) "Fou will feel better if you take your medicine."

#) "This is your medicine+ and you must take it all ri"ht now." %) ".ould you like to take your medicine from a spoon or a cup?" &e!iew Information' The correct answer is %' ".ould you like to take your medicine from a spoon or a cup?" At 4 years of a"e+ a child often feels a loss of control when hospitali5ed. /i!in" a choice about how to take the medicine will allow the child to e7press an opinion and ha!e some control. 1,. In plannin" care for a child dia"nosed with minimal chan"e nephrotic syndrome+ the nurse should understand the relationship between edema formation and A) Increased retention of albumin in the !ascular system K ) %ecreased colloidal osmotic pressure in the capillaries #) 0luid shift from interstitial spaces into the !ascular space %) &educed tubular reabsorption of sodium and water &e!iew Information' The correct answer is ' %ecreased colloidal osmotic pressure in the capillaries The increased "lomerular permeability to protein causes a decrease in serum albumin which results in decreased colloidal osmotic pressure. 19. An ei"hteen month-old has been brou"ht to the emer"ency room with irritability+ lethar"y o!er ) days+ dry skin and increased pulse. ased upon the e!aluation of these initial findin"s+ the nurse would assess the child for additional findin"s of A) (epticemia ) %ehydration #) @ypokalemia %) @ypercalcemia &e!iew Information' The correct answer is ' %ehydration #linical findin"s dehydration include lethar"y+ irritability+ dry skin+ and increased pulse. )8. A client who has been drinkin" for fi!e years states that he drinks when he "ets upset about "thin"s" such as bein" unemployed or feelin" like life is not leadin" anywhere. The nurse understands that the client is usin" alcohol as a way to deal with A) &ecreational and social needs ) 0eelin"s of an"er K #) >ife2s stressors %) Issues of "uilt and disappointment &e!iew Information' The correct answer is #' >ife2s stressors Alcohol is used by some people to mana"e an7iety and stress. The o!erall intent is to decrease ne"ati!e feelin"s and increase positi!e feelin"s. )1. The nurse is monitorin" the contractions of a woman in labor. A contraction is recorded as be"innin" at 18'88 A.$. and endin" at 18'81 A.$. Another be"ins at 18'16 A.$. .hat is the fre1uency of the contractions? A) 14 minutes ) 18 minutes #) 16 minutes %) Cine minutes &e!iew Information' The correct answer is #' 16 minutes 0re1uency is the time from the be"innin" of one contraction to the be"innin" of the ne7t contraction. )). The nurse is performin" an assessment on a child with se!ere airway obstruction. .hich findin" would the nurse anticipate findin"? A) &etractions in the intercostal tissues of the thora7 ) #hest pain a""ra!ated by respiratory mo!ement #) #yanosis and mottlin" of the skin %) &apid+ shallow respirations &e!iew Information' The correct answer is A' &etractions in the soft tissues of the thora7 (li"ht intercostal retractions are normal. @owe!er in disease states+ especially in se!ere airway obstruction+ retractions becomes e7treme. )4. %urin" the e!aluation phase for a client+ the nurse should focus on All findin" of physical and psychosocial stressors of the client and in A) the family The client=s status+ pro"ress toward "oal achie!ement+ and on"oin" ) re-e!aluation (ettin" short and lon"-term "oals to insure continuity of care from #) hospital to home (elect inter!entions that are measurable and achie!able within %) selected timeframes &e!iew Information' The correct answer is ' The client==s status+ pro"ress toward "oal achie!ement+ and on"oin" re-e!aluation H!aluation process of the nursin" process focuses on the client==s status+ pro"ress toward "oal achie!ement and on"oin" re-e!aluation of the plan of care. )4. The school nurse suspects that a third "rade child mi"ht ha!e Attention %eficit @yperacti!ity %isorder. ?rior to referrin" the child for further e!aluation+ the nurse should A) ;bser!e the child=s beha!ior on at least ) occasions ) #onsult with the teacher about how to control impulsi!ity #ompile a history of beha!ior patterns and de!elopmental K #) accomplishments

%) #ompare the child=s beha!ior with classic si"ns and symptoms &e!iew Information' The correct answer is #' #ompile a history of beha!ior patterns and de!elopmental accomplishments A complete beha!ioral+ and de!elopmental history plays an important role in determinin" the dia"nosis. )6. .hich of the actions su""ested to the &C by the ?C durin" a plannin" conference for a 18 month-old infant admitted ) hours a"o with bacterial menin"itis would be acceptable to add to the plan of care? A) $easure head circumference ) ?lace in airborne isolation #) ?ro!ide passi!e ran"e of motion %) ?ro!ide an o!er-the-crib protecti!e top &e!iew Information' The correct answer is A' $easure head circumference In menin"itis+ assessment of neurolo"ical si"ns should be done fre1uently. @ead circumference is measured because subdural effusions and obstructi!e hydrocephalus can de!elop as a complication of menin"itis. The client will ha!e already been on airborne precautions and crib top applied to bed on admission to the unit. )<. A client is admitted with a dia"nosis of hepatitis . In re!iewin" the initial laboratory results+ the nurse would e7pect to find ele!ation in which of the followin" !alues? A) lood urea nitro"en ) Acid phosphatase K #) ilirubin %) (edimentation rate &e!iew Information' The correct answer is #' ilirubin In the laboratory data pro!ided+ the only ele!ated le!el e7pected is bilirubin. Additional li!er function tests will confirm the dia"nosis. )-. The nurse is discussin" nutritional re1uirements with the parents of an 1, month-old child. .hich of these statements about milk consumption is correct? A) $ay drink as much milk as desired ) #an ha!e milk mi7ed with other foods #) .ill benefit from fat-free cow=s milk K %) (hould be limited to 4-4 cups of milk daily &e!iew Information' The correct answer is %' (hould be limited to three to four cups of milk daily $ore than 4) ounces of milk a day considerably limits the intake of solid foods+ resultin" in a deficiency of dietary iron+ as well as other nutrients. ),. The nurse is talkin" with a client. The client abruptly says to the nurse+ "The moon is full. Astronauts walk on the moon. .alkin" is a "ood health habit." The client2s beha!ior most likely indicates A) Ceolo"isms ) %issociation K #) 0li"ht of ideas %) .ord salad &e!iew Information' The correct answer is #' 0li"ht of ideas 0li"ht of ideas - defines nearly continuous flow of speech+ 3umpin" from 1 topic to another. )9. A mother asks about e7pected motor skills for a 4 year-old child. .hich of the followin" would the nurse emphasi5e as normal at this a"e? A) Sumpin" rope ) Tyin" shoelaces K #) &idin" a tricycle %) ?layin" hopscotch &e!iew Information' The correct answer is #' &idin" a tricycle #oordination is "ained throu"h lar"e muscle use. A child of 4 has the ability to ride a tricycle. 48. A home health nurse is carin" for a client with a pressure sore that is red+ with serous draina"e+ is ) inches in diameter with loss of subcutaneous tissue. The appropriate dressin" for this wound is A) A transparent film dressin" ) .et dressin" with debridement "ranules #) .et to dry with hydro"en pero7ide K %) $oist saline dressin" &e!iew Information' The correct answer is %' $oist saline dressin" This wound is a sta"e III pressure ulcer. The wound is red A"ranulation tissue) and does not re1uire debridement. The wound must be protected for "ranulation tissue to proliferate. A moist dressin" allows epithelial tissues to mi"rate more rapidly. 41. The nurse enters a ) year-old child=s hospital room in order to administer an oral medication. .hen the child is asked if he is ready to take his medicine+ he immediately says+ "CoJ". .hat would be the most appropriate ne7t action? K A) >ea!e the room and return fi!e minutes later and "i!e the

medicine ) H7plain to the child that the medicine must be taken now #) /i!e the medication to the father and ask him to "i!e it %) $i7 the medication with ice cream or applesauce &e!iew Information' The correct answer is A' >ea!e the room and return fi!e minutes later and "i!e the medicine (ince the nurse "a!e the child a choice about takin" the medication+ the nurse must comply with the child==s response in order to build or maintain trust. (ince toddlers do not ha!e an accurate sense of time+ lea!in" the room and comin" back later is another episode to the toddler. 4). A nurse is doin" preconceptual counselin" with a woman who is plannin" a pre"nancy. .hich of the followin" statements su""ests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A) "I understand that a "lass of wine with dinner is healthy." ) " eer is not really hard alcohol+ so I "uess I can drink some." "If I drink+ my baby may be harmed before I know I am K #) pre"nant." %) "%rinkin" with meals reduces the effects of alcohol." &e!iew Information' The correct answer is #' "If I drink+ my baby may be harmed before I know I am pre"nant." Alcohol has the "reatest terato"enic effect durin" or"ano"enesis+ in the first weeks of pre"nancy. Therefore women considerin" a pre"nancy should not drink. 44. The client who is recei!in" enteral nutrition throu"h a "astrostomy tube has had 4 diarrhea stools in the past )4 hours. The nurse should K A) &e!iew the medications the client is recei!in" ) Increase the formula infusion rate #) Increase the amount of water used to flush the tube %) Attach a rectal ba" to protect the skin &e!iew Information' The correct answer is A' &e!iew the medications the client is recei!in" Antibiotics and medications containin" sorbital may induce diarrhea. 44. A nurse is assi"ned to a client who is a new admission for the treatment of a frontal lobe brain tumor. .hich history offered by the family members would be anticipated by the nurse as associated with the dia"nosis and communicated? A) "$y partner=s breathin" rate is usually below 1)." "I find the mood swin"s and the chan"e from a calm person to K ) bein" an"ry all the time hard to deal with." #) "It seems our se7 life is none7istant o!er the past < months." "In the mornin" and e!enin" I hear complaints that readin" is %) ne7t to impossible from blurred print." &e!iew Information' The correct answer is ' "I find the mood swin"s and the chan"e from a calm person to bein" an"ry all the time hard to deal with." The frontal lobe of the brain controls affect+ 3ud"ment and emotions. %ysfunction in this area results in findin"s such as emotional lability+ chan"es in personality+ inattenti!eness+ flat affect and inappropriate beha!ior. 46. The nurse prepares for a %en!er (creenin" test with a 4 year-old child in the clinic. The mother asks the nurse to e7plain the purpose of the test. .hat is the nurse2s best response about the purpose of the %en!er? A) It measures a child2s intelli"ence. K ) It assesses a child=s de!elopment. #) It e!aluates psycholo"ical responses. %) It helps to determine problems. &e!iew Information' The correct answer is ' It assesses a child==s de!elopment. The %en!er %e!elopmental Test II is a screenin" test to assess children from birth throu"h < years in personalGsocial+ fine motor adapti!e+ lan"ua"e and "ross motor de!elopment. A child e7periences the fun of play durin" the test. 4<. The nurse is preparin" a 6 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are an7ious and concerned about the child=s reaction to impendin" sur"ery. .hich nursin" inter!ention would be best to prepare the child? A) Introduce the child to all staff the day before sur"ery K ) H7plain the sur"ery 1 week prior to the procedure #) Arran"e a tour of the operatin" and reco!ery rooms %) Hncoura"e the child to brin" a fa!orite toy to the hospital &e!iew Information' The correct answer is ' H7plain the sur"ery 1 week prior to the procedure A 6 year-old can understand the sur"ery+ and should be prepared well before the procedure. $ost of these procedures are "same day" sur"eries and do not re1uire an o!erni"ht stay. 4-. The nurse+ assistin" in applyin" a cast to a client with a broken arm+ knows that The cast material should be dipped se!eral times into the warm A) water ) The cast should be co!ered until it dries K #) The wet cast should be handled with the palms of hands %) The casted e7tremity should be placed on a cloth-co!ered surface

&e!iew Information' The correct answer is #' The wet cast should be handled with the palms of hands @andle cast with palms of the hands and lift at ) points of the e7tremity. This will pre!ent stress at the in3ury site and pressure areas on the cast. 4,. ased on principles of teachin" and learnin"+ what is the best initial approach to pre-op teachin" for a client scheduled for coronary artery bypass? A) Tourin" the coronary intensi!e unit ) $ailin" a !ideo tape to the home K #) Assessin" the client=s learnin" style %) Administerin" a written pre-test &e!iew Information' The correct answer is #' Assessin" the client==s learnin" style As with any anticipatory teachin"+ assess the client==s le!el of knowled"e and learnin" style first. 49. A 4 year-old child is reco!erin" from chicken po7 A!aricella). The parents would like to ha!e the child return to day care as soon as possible. In order to ensure that the illness is no lon"er communicable+ what should the nurse assess for in this child? K A) All lesions crusted ) Hle!ated temperature #) &hinorrhea and cory5a %) ?resence of !esicles &e!iew Information' The correct answer is A' All lesions crusted The rash be"ins as a macule+ with fe!er+ and pro"resses to a !esicle that breaks open and then crusts o!er. .hen all lesions are crusted+ the child is no lon"er in a communicable sta"e. 48. The nurse is pro!idin" instructions to a new mother on the proper techni1ues for breast feedin" her infant. .hich statement by the mother indicates the need for additional instruction? "I should position my baby completely facin" me with my baby=s A) mouth in front of my nipple." ) "The baby should latch onto the nipple and areola areas." #) "There may be times that I will need to manually e7press milk." I can switch to a bottle if I need to take a break from breast K %) feedin". &e!iew Information' The correct answer is %' I can switch to a bottle if I need to take a break from breast feedin". abies adapt more 1uickly to the breast when they aren==t confused about what is put into their mouths and its purpose. Artificial nipples do not len"then and compress the way the human nipples Aareola) do. The use of an artificial nipple weakens the baby==s suck as the baby decreases the suckin" pressure to slow fluid flow. abies should not be "i!en a bottle durin" the learnin" sta"e of breast feedin". &esults for QYA-&andom W1) 1. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schi5ophrenia. @is symptoms ha!e been mana"ed for se!eral months with fluphena5ine A?roli7in). .hich should be a focus of the first assessment? A) (tressors in the home K ) $edication compliance #) H7posure to hot temperatures %) Alcohol use &e!iew Information' The correct answer is ' $edication compliance ?roli7in is an antipsychotic G neuroleptic medication useful in mana"in" the symptoms of (chi5ophrenia. #ompliance with daily doses is a critical assessment. ). The nurse is carin" for a client with an unstable spinal cord in3ury at the T- le!el. .hich inter!ention should take priority in plannin" care? A) Increase fluid intake to pre!ent dehydration K ) ?lace client on a pressure reducin" support surface #) *se skin care products desi"ned for use with incontinence %) Increase caloric intake to aid healin" &e!iew Information' The correct answer is ' ?lace client on a pressure reducin" support surface This client is at "reatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relie!e pressure+ shear and friction forces. 4. A nurse is conductin" a community wide seminar on childhood safety issues. .hich of these children is at the hi"hest risk for poisonin"? A) 9 month-old who stays with a sitter 6 days a week K ) )8 month-old who has 3ust learned to climb stairs #) 18 year-old who occasionally stays at home unattended %) 16 year-old who likes to repair bicycles

&e!iew Information' The correct answer is ' Twenty month-old who has 3ust learned to climb stairs Toddlers are at most risk for poisonin" because they are increasin"ly mobile+ need to e7plore and en"a"e in autonomous beha!ior. 4. %urin" an e7amination of a ) year-old child with a tentati!e dia"nosis of .ilm=s tumor+ the nurse would be most concerned about which statement by the mother? A) $y child has lost 4 pounds in the last month. ) *rinary output seemed to be less o!er the past ) days. K #) All the pants ha!e become ti"ht around the waist. %) The child prefers some salty foods more than others. &e!iew Information' The correct answer is #' #lothin" has become ti"ht around the waist ?arents often reco"ni5e the increasin" abdominal "irth first. This is an early si"n of .ilm==s tumor+ a mali"nant tumor of the kidney. 6. .hat is the most important aspect to include when de!elopin" a home care plan for a client with se!ere arthritis? K A) $aintainin" and preser!in" function ) Anticipatin" side effects of therapy #) (upportin" copin" with limitations %) Hnsurin" compliance with medications &e!iew Information' The correct answer is A' $aintainin" and preser!in" function To maintain 1uality of life+ the plan for care must emphasi5e preser!in" function. ?roper body positionin" and posture and acti!e and passi!e ran"e of motion e7ercises important inter!entions for maintainin" function of affected 3oints. <. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. .hat assessment data will be most useful in counselin" the parent? K A) A"e of the child ) (iblin" position in family #) (tressful family e!ents %) ?arental discipline strate"ies &e!iew Information' The correct answer is A' A"e of the child %urin" the preschool period children are usin" their rapidly "rowin" !ocabulary faster than they can produce their words. This failure to master sensorimotor inte"rations results in stutterin". This dysfluency in speech pattern is a normal characteristic of lan"ua"e de!elopment. Therefore+ knowin" the child==s a"e is most important in determinin" if any true dysfunction mi"ht be occurrin". -. A pre-term newborn is to be fed breast milk throu"h naso"astric tube. .hy is breast milk preferred o!er formula for premature infants? A) #ontains less lactose ) Is hi"her in caloriesGounce K #) ?ro!ides antibodies %) @as less fatty acid &e!iew Information' The correct answer is #' ?ro!ides antibodies reast milk is ideal for the preterm baby who needs additional protection a"ainst infection throu"h maternal antibodies. It is also much easier to di"est+ therefore less residual is left in the infant==s stomach. ,. .hich of the followin" nursin" assessments in an infant is most !aluable in identifyin" serious !isual defects? K A) &ed refle7 test ) Bisual acuity #) ?upil response to li"ht %) #o!er test &e!iew Information' The correct answer is A' &ed refle7 test A brilliant+ uniform red refle7 is an important si"n because it !irtually rules out almost all serious defects of the cornea+ a1ueous chamber+ lens+ and !itreous chamber. 9. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by -cm+ the wound base is red and moist with no e7udate and the surroundin" skin is intact. .hich of the followin" co!erin"s is most appropriate for this wound? A) Transparent dressin" ) %ry sterile dressin" with antibiotic ointment #) .et to dry dressin" K %) ;cclusi!e moist dressin" &e!iew Information' The correct answer is %' ;cclusi!e moist dressin" This wound has "ranulation tissue present and must be protected. The use of a moisture retenti!e dressin" is the best choice because moisture supports wound healin". 18. A 48 month-old child is admitted to the hospital unit. .hich of the followin" toys would be appropriate for the nurse to select from the toy room for this child? A) #artoon stickers K ) >ar"e wooden pu55le #) lunt scissors and paper %) each ball &e!iew Information' The correct answer is ' >ar"e wooden pu55le

Appropriate toys for this child==s a"e include items such as push-pull toys+ blocks+ poundin" board+ toy telephone+ puppets+ wooden pu55les+ fin"er paint+ and thick crayons. 11. A nurse is to present information about #hinese folk medicine to a "roup of student nurses. ased on this cultural belief+ the nurse would e7plain that illness is attributed to the Fan"+ the positi!e force that represents li"ht+ warmth+ and A) fullness Fin+ the ne"ati!e force that represents darkness+ cold+ and K ) emptiness #) *se of improper hot foods+ herbs and plants %) A failure to keep life in balance with nature and others &e!iew Information' The correct answer is ' Fin+ the ne"ati!e force that represents darkness+ cold+ and emptiness #hinese folk medicine proposes that health is re"ulated by the opposin" forces of yin and yan". Fin is the ne"ati!e female force characteri5ed by darkness+ cold and emptiness. H7cessi!e yin predisposes one to ner!ousness. 1). A ) year-old child has 3ust been dia"nosed with cystic fibrosis. The child=s father asks the nurse ".hat is our ma3or concern now+ and what will we ha!e to deal with in the future?" .hich of the followin" is the best response? A) "There is a probability of life-lon" complications." "#ystic fibrosis results in nutritional concerns that can be dealt ) with." "Thin+ tenacious secretions from the lun"s are a constant stru""le K #) in cystic fibrosis." "Fou will work with a team of e7perts and also ha!e access to a %) support "roup that the family can attend." &e!iew Information' The correct answer is #' "Thin+ tenacious secretions from the lun"s are a constant stru""le in cystic fibrosis." All of the options will be concerns with cystic fibrosis+ howe!er the respiratory threats are the ma3or concern in these clients. ;ther information of interest is that cystic fibrosis is an autosomal recessi!e disease. There is a )6: chance that each of these parent==s pre"nancies will result in a child with systic fibrosis. 14. .hich type of accidental poisonin" would the nurse e7pect to occur in children under a"e <? K A) ;ral in"estion ) Topical contact #) Inhalation %) Hye splashes &e!iew Information' The correct answer is A' ;ral in"estion The "reatest risk for youn" children is from oral in"estion. .hile children under a"e < may come in contact with other poisons or inhale to7ic fumes+ these are not common. 14. A client was admitted to the psychiatric unit with a dia"nosis of bipolar disorder. @e constantly bothers other clients+ tries to help the housekeepin" staff+ demonstrates pressured speech and demands constant attention from the staff. .hich acti!ity would be best for the client? A) &eadin" ) #heckers #) #ards K %) ?in"-pon" &e!iew Information' The correct answer is %' ?in"-pon" This pro!ides an outlet for physical ener"y and re1uires limited attention. 16. The nurse is carin" for a client who has de!eloped cardiac tamponade. .hich findin" would the nurse anticipate? A) .idenin" pulse pressure ) ?leural friction rub K #) %istended neck !eins %) radycardia &e!iew Information' The correct answer is #' %istended neck !eins In cardiac tamponade+ intrapericardial pressures rise to a point at which !enous blood cannot flow into the heart. As a result+ !enous pressure rises and the neck !eins become distended. 1<. .hich nursin" action is a priority as the plan of care is de!eloped for a - year-old child hospitali5ed for acute "lomerulonephritis? A) Assess for "enerali5ed edema ) $onitor for increased urinary output #) Hncoura"e rest durin" hyperacti!e periods K %) Cote patterns of increased blood pressure &e!iew Information' The correct answer is %' Cote patterns of increased blood pressure @ypertension is a key assessment in the course of the disease. 1-. The nurse is carin" for a child recei!in" chest physiotherapy A#?T). .hich of the followin" actions by the nurse would be appropriate?

A) (chedule the therapy thirty minutes after meals ) Teach the child not to cou"h durin" the treatment K #) #onfine the percussion to the rib ca"e area %) ?lace the child in a prone position for the therapy &e!iew Information' The correct answer is #' #onfine the percussion to the rib ca"e area ?ercussion Aclappin") should be only done in the area of the rib ca"e. 1,. A polydru" user has been in reco!ery for , months. The client has be"an skippin" breakfast and not eatin" re"ular dinners. The client has also started fre1uentin" bars to "see old buddies." The nurse understands that the client2s beha!ior is a warnin" si"n to indicate that the client may be K A) headed for relapse ) feelin" hopeless #) approachin" reco!ery %) in need of increased sociali5ation &e!iew Information' The correct answer is A' headed for relapse It takes 9 to 16 months to ad3ust to a lifestyle free of chemical use+ thus it is important for clients to acknowled"e that relapse is a possibility and to identify early si"ns of relapse. 19. A client was admitted to the psychiatric unit with ma3or depression after a suicide attempt. In addition to feelin" sad and hopeless+ the nurse would assess for A) An7iety+ unconscious an"er+ and hostility ) /uilt+ indecisi!eness+ poor self-concept K #) ?sychomotor retardation or a"itation %) $eticulous attention to "roomin" and hy"iene &e!iew Information' The correct answer is #' ?sychomotor retardation or a"itation (omatic or physiolo"ic symptoms of depression include' fati"ue+ psychomotor retardation or psychomotor a"itation+ chronic "enerali5ed or local pain+ sleep disturbances+ disturbances in appetite+ "astrointestinal complaints and impaired libido. )8. A client is e7periencin" hallucinations that are markedly increased at ni"ht. The client is !ery fri"htened by the hallucinations. The client2s partner asked to stay a few hours beyond the !isitin" time+ in the client2s pri!ate room. .hat would be the best response by the nurse demonstratin" emotional support for the client? "Co+ it would be best if you brou"ht the client some readin" A) material that she could read at ni"ht." "Co+ your presence may cause the client to become more ) an7ious." "Fes+ stayin" with the client and orientin" her to her surroundin"s K #) may decrease her an7iety." "Fes+ would you like to spend the ni"ht when the client2s beha!ior %) indicates that she is fri"htened?" &e!iew Information' The correct answer is #' "Fes+ stayin" with the client and orientin" her to her surroundin"s may decrease her an7iety." Hncoura"in" the family or a close friend to stay with the client in a 1uiet surroundin" can help increase orientation and minimi5e confusion and an7iety. )1. At a well baby clinic the nurse is assi"ned to assess an , month-old child. .hich of these de!elopmental achie!ements would the nurse anticipate that the child would be able to perform? A) (ay ) words ) ?ull up to stand K #) (it without support %) %rink from a cup &e!iew Information' The correct answer is #' (it without support The a"e at which the normal child de!elops the ability to sit steadily without support is , months. )). The nurse is talkin" to parents about nutrition in school a"ed children. .hich of the followin" is the most common nutritional disorder in this a"e "roup? A) ulimia ) Anore7ia K #) ;besity %) $alnutrition &e!iew Information' The correct answer is #' ;besity $any factors contribute to the hi"h rate of obesity in school a"ed children. These include heredity+ sedentary lifestyle+ social and cultural factors and poor knowled"e of balanced nutrition. )4. At the "eriatric day care pro"ram a client is cryin" and repeatin" "I want to "o home. #all my daddy to come for me." The nurse should A) In!ite the client to 3oin the e7ercise "roup ) Tell the client you will call someone to come for her K #) /i!e the client simple information about what she will be doin" %) 0irmly direct the client to her assi"ned "roup acti!ity &e!iew Information' The correct answer is #' /i!e the client simple information about what she will be doin" The distressed disoriented client should be "ently oriented to reduce fear and increase the sense of safety and security. Hn!ironmental chan"es pro!oke stress and fear.

)4. A !ictim of domestic !iolence states to the nurse+ "If only I could chan"e and be how my companion wants me to be+ I know thin"s would be different." .hich would be the best response by the nurse? "The !iolence is temporarily caused by unusual circumstances+ A) don2t stop hopin" for a chan"e." "?erhaps+ if you understood the need to abuse+ you could stop ) the !iolence." "Co one deser!es to be beaten. Are you doin" anythin" to #) pro!oke your spouse into beatin" you?" " atterers lose self-control because of their own internal reasons+ K %) not because of what their partner did or did not do." &e!iew Information' The correct answer is %' " atterers lose selfcontrol because of their own internal reasons+ not because of what their partner did or did not do." ;nly the perpetrator has the ability to stop the !iolence. A chan"e in the !ictim2s beha!ior will not cause the abuser to become non!iolent. )6. A 4, year-old female client is admitted to the hospital with an acute e7acerbation of asthma. This is her third admission for asthma in - months. (he describes how she doesn=t really like ha!in" to use her medications all the time. .hich e7planation by the nurse best describes the lon"-term conse1uence of uncontrolled airway inflammation? A) %e"eneration of the al!eoli ) #hronic bronchoconstriction of the lar"e airways K #) >un" remodelin" and permanent chan"es in lun" function %) 0re1uent pneumonia &e!iew Information' The correct answer is #' >un" remodelin" and permanent chan"es in lun" function .hile an asthma attack is an acute e!ent from which lun" function essentially returns to normal+ chronic under-treated asthma can lead to lun" remodelin" and permanent chan"es in lun" function. Increased bronchial !ascular permeability leads to chronic airway edema which leads to mucosal thickenin" and swellin" of the airway. Increased mucous secretion and !iscosity may plu" airways+ leadin" to airway obstruction. #han"es in the e7tracellular matri7 in the airway wall may also lead to airway obstruction. These lon"-term conse1uences should help you to reinforce the need for daily mana"ement of the disease whether or not the patient "feels better". )<. A mother wants to switch her 9 month-old infant from an ironfortified formula to whole milk because of the e7pense. *pon further assessment+ the nurse finds that the baby eats table foods well+ but drinks less milk than before. .hat is the best ad!ice by the nurse? A) #han"e the baby to whole milk ) Add chocolate syrup to the bottle K #) #ontinue with the present formula %) ;ffer fruit 3uice fre1uently &e!iew Information' The correct answer is #' #ontinue with the present formula The recommended a"e for switchin" from formula to whole milk is 1) months. (witchin" to cow==s milk before the a"e of 1 can predispose an infant to aller"ies and lactose intolerance. )-. ?ri!acy and confidentiality of all client information is le"ally protected. In which of these situations would the nurse make an e7ception to this practice? A) .hen a family member offers information about their lo!ed one K ) .hen the client threatens self-harm and harm to others .hen the health care pro!ider decides the family has a ri"ht to #) know the client=s dia"nosis .hen a !isitor insists that the !isitor has been "i!en permission %) by the client &e!iew Information' The correct answer is ' .hen the client threatens self-harm and harm to others ?ri!acy and confidentiality of all client information is protected with the e7ception of the client who threatens self harm or endan"erin" the public. ),. The nurse is carin" for a client who is in the late sta"e of multiple myeloma. .hich of the followin" should be included in the plan of care? A) $onitor for hyperkalemia ) ?lace in protecti!e isolation K #) ?recautions with position chan"es %) Administer diuretics as ordered &e!iew Information' The correct answer is #' ?recautions with position chan"es ecause multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resultin" in osteoporosis+ client2s are at hi"h risk for patholo"ical fractures. )9. The nurse is makin" a home !isit to a client with chronic obstructi!e pulmonary disease A#;?%). The client tells the nurse that he used to be able to walk from the house to the mailbo7 without difficulty. Cow+ he has to pause to catch his breath halfway throu"h

the trip. .hich dia"nosis would be most appropriate for this client based on this assessment? Acti!ity intolerance caused by fati"ue related to chronic tissue K A) hypo7ia Impaired mobility related to chronic obstructi!e pulmonary ) disease #) (elf care deficit caused by fati"ue related to dyspnea Ineffecti!e airway clearance related to increased bronchial %) secretions &e!iew Information' The correct answer is A' Acti!ity intolerance caused by fati"ue related to chronic tissue hypo7ia Acti!ity intolerance describes a condition in which the client==s physiolo"ical capacity for acti!ities is compromised. 48. The nurse admits a client newly dia"nosed with hypertension. .hat is the best method for assessin" the blood pressure? A) (tandin" and sittin" K ) In both arms #) After e7ercisin" %) (upine position &e!iew Information' The correct answer is ' In both arms lood pressure should be taken in both arms due to the fact that one subcla!ian artery may be stenosed+ causin" a false hi"h in that arm. 41. The nurse is carin" for residents in a lon" term care settin" for the elderly. .hich of the followin" acti!ities will be most effecti!e in meetin" the "rowth and de!elopment needs for persons in this a"e "roup? A) Aerobic e7ercise classes ) Transportation for shoppin" trips K #) &eminiscence "roups %) &e"ularly scheduled social acti!ities &e!iew Information' The correct answer is #' &eminiscence "roups Accordin" to Hrikson==s theory+ older adults need to find and accept the meanin"fulness of their li!es+ or they may become depressed+ an"ry+ and fear death. &eminiscin" contributes to successful adaptation by maintainin" selfesteem+ reaffirmin" identity+ and workin" throu"h loss. 4). ?ost-procedure nursin" inter!entions for electrocon!ulsi!e therapy include A) Applyin" hard restraints if sei5ure occurs ) H7pectin" client to sleep for 4 to < hours K #) &emainin" with client until oriented %) H7pectin" lon"-term memory loss &e!iew Information' The correct answer is #' &emainin" with client until oriented #lient awakens post-procedure )8-48 minutes after treatment and appears "ro""y and confused. The nurse remains with the client until the client is oriented and able to en"a"e in self care. 44. The nurse assesses delayed "ross motor de!elopment in a 4 year-old child. The inability of the child to do which action confirms this findin"? K A) (tand on 1 foot ) #atch a ball #) (kip on alternate feet %) &ide a bicycle &e!iew Information' The correct answer is A' (tand on 1 foot At this a"e+ "ross motor de!elopment allows a child to balance on 1 foot. 44. The mother of a 16 month-old child asks the nurse to e7plain her child=s lab results and how they show her child has iron deficiency anemia. The nurse=s best response is "Althou"h the results are here+ your doctor will e7plain them A) later." K ) "Four child has less red blood cells that carry o7y"en." #) "The blood cells that carry nutrients to the cells are too lar"e." %) "There are not enou"h blood cells in your child=s circulation." &e!iew Information' The correct answer is ' "Four child has less red blood cells that carry o7y"en." The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell le!els+ low hemo"lobin le!els and microcytic+ hypochromic red blood cells. A simple but clear e7planation is appropriate. 46. In a child with suspected coarctation of the aorta+ the nurse would e7pect to find A) (tron" pedal pulses ) %iminishin" cartoid pulses #) Cormal femoral pulses K %) oundin" pulses in the arms &e!iew Information' The correct answer is %' oundin" pulses in the arms #oarctation of the aorta+ a narrowin" or constriction of the descendin" aorta+ causes increased flow to the upper e7tremities Aincreased pressure and pulses). 4<. At the day treatment center a client dia"nosed with (chi5ophrenia - ?aranoid Type sits alone alertly watchin" the acti!ities of clients and staff. The client is hostile when approached and asserts that the doctor "i!es her medication to control her mind. The client=s beha!ior most likely indicates A) 0eelin"s of increasin" an7iety related to paranoia

) (ocial isolation related to altered thou"ht processes (ensory perceptual alteration related to withdrawal from #) en!ironment %) Impaired !erbal communication related to impaired 3ud"ment &e!iew Information' The correct answer is ' (ocial isolation related to altered thou"ht processes @ostility and absence of in!ol!ement are data supportin" a dia"nosis of social isolation. @er psychiatric dia"nosis and her idea about the purpose of medication su""ests altered thinkin" processes.

#) Insert a padded ton"ue blade in client=s mouth %) Hle!ate the head of the bed &e!iew Information' The correct answer is ' ?lace the client on their side The cprrect answer is . This position keeps the airway patent and pre!ents aspiration 4. After talkin" with her partner+ a client !oluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse+ "$y husband told me to "et treatment or he would di!orce me. I don2t belie!e I really need treatment but I don2t want my husband to lea!e me." .hich response by the nurse would assist the client? "In early reco!ery+ it=s 1uite common to ha!e mi7ed feelin"s+ but A) unmoti!ated people can2t "et well." "In early reco!ery+ it2s 1uite common to ha!e mi7ed feelin"s+ but ) I didn2t know you had been pressured to come." "In early reco!ery it2s 1uite common to ha!e mi7ed feelin"s+ #) perhaps it would be best to seek treatment on an outclient bases." "In early reco!ery+ it2s 1uite common to ha!e mi7ed feelin"s. K %) >et2s discuss the benefits of sobriety for you." &e!iew Information' The correct answer is %' "In early reco!ery+ it2s 1uite common to ha!e mi7ed feelin"s. >et2s discuss the benefits of sobriety for you." This response "i!es the client the opportunity to decrease ambi!alent feelin"s by focusin" on the benefits of sobriety. %ependence issues are "reat for the client fosterin" ambi!alence. 4. A neonate born 1) hours a"o to a methadone maintained woman is e7hibitin" a hyperacti!e $;&; refle7 and sli"ht tremors. The newborn passedone loose+ watery stool. .hich of these is a nursin" priority? A) @old the infant at fre1uent inter!als. K ) Assess for neonatal withdrawl syndrome #) ;ffer fluids to pre!ent dehydration %) Administer pare"oric to stop diarrhea &e!iew Information' The correct answer is ' Assess for neonatal withdrawl syndrome Ceonatal withdrawl syndrome is a cluster of findin"s that si"nal the withdrawal of the infant from the opiates. The findin"s seen in methadone withdrawal are often more se!ere than for other substances. Initial si"ns are central ner!ous system hyper irritability and "astro-intestinal symptoms. If withdrawal si"ns are se!ere+ there is an increased mortality risk. (corin" the infant ensures proper treatment durin" the period of withdrawal. 6. The nurse is carin" for a post myocardial infarction client in an intensi!e care unit. It is noted that urinary output has dropped from <8 --8 ml per hour to 48 ml per hour. This chan"e is most likely due to A) %ehydration ) %iminished blood !olume K #) %ecreased cardiac output %) &enal failure &e!iew Information' The correct answer is #' %ecreased cardiac output #ardiac output and urinary output are directly correlated. The nurse should suspect a drop in cardiac output if the urinary output drops. <. The primary nursin" dia"nosis for a client with con"esti!e heart failure with pulmonary edema is A) ?ain ) Impaired "as e7chan"e K #) #ardiac output altered' decreased %) 0luid !olume e7cess &e!iew Information' The correct answer is #' #ardiac output altered' decreased All nursin" inter!entions should be focused on impro!in" cardiac output. Increasin" cardiac output is the primary "oal of therapy. #omfort will impro!e as the client impro!es and the respiratory status will impro!e as cardiac output increases. -. The nurse is performin" a de!elopmental assessment on an , month-old. .hich findin" should be reported to the health care pro!ider? A) >ifts head from the prone position ) &olls from abdomen to back #) &esponds to parents= !oices K %) 0alls forward when sittin" &e!iew Information' The correct answer is %' 0alls forward when sittin" (ittin" without support is e7pected at this a"e. ,. A client has recei!ed her first dose of fluphena5ine A?roli7in) ) hours a"o. (he suddenly e7periences torticollis and in!oluntary spastic muscle mo!ement. In addition to administerin" the ordered anticholiner"ic dru"+ what other measure should the nurse implement? K A) @a!e respiratory support e1uipment a!ailable ) Immediately place her in the seclusion room #) Assess the client for an7iety and a"itation %) Administer prn dose of I$ antipsychotic medication &e!iew Information' The correct answer is A' @a!e respiratory support e1uipment a!ailable

4-. A <6-year-old @ispanic->atino client with prostate cancer rates his pain as a < on a 8-to-18 scale. The client refuses all pain medication other than $otrin+ which does not relie!e his pain. The ne7t action for the nurse to take is to K A) Ask the client about the refusal of certain pain medications ) Talk with the client=s family about the situation #) &eport the situation to the health care pro!ider %) %ocument the situation in the notes &e!iew Information' The correct answer is A' Ask the client about the refusal of certain pain medications eliefs re"ardin" pain are one of the oldest culturally related research areas in health care. Astute obser!ations and careful assessments must be completed to determine the le!el of pain a person can tolerate. @ealth care practitioners must in!esti"ate the meanin" of pain to each person within a cultural e7planatory framework. 4,. .hen teachin" adolescents about se7ually transmitted diseases+ what should the nurse emphasi5e that is the most common infection? A) /onorrhea K ) #hlamydia #) @erpes %) @IB &e!iew Information' The correct answer is ' #hlamydia #hlamydia has the hi"hest incidence of any se7ually transmitted disease in this country. ?re!ention is similar to safe se7 practices tau"ht to pre!ent any (T%' use of a condom and spermicide for protection durin" intercourse. 49. 0irst-time parents brin" their 6 day-old infant to the pediatrician=s office because they are e7tremely concerned about its breathin" pattern. The nurse assesses the baby and finds that the breath sounds are clear with e1ual chest e7pansion. The respiratory rate is 4,-4) breaths per minute with occasional periods of apnea lastin" 18 seconds in len"th. .hat is the correct analysis of these findin"s? A) The pediatrician must e7amine the baby ) Hmer"ency e1uipment should be a!ailable K #) This breathin" pattern is normal %) A future referral may be indicated &e!iew Information' The correct answer is #' This breathin" pattern is normal &espiratory rate in a newborn is 48-<8 breathsGminute and periods of apnea often occur+ lastin" up to 16 seconds. The nurse should reassure the parents that this is normal to allay their an7iety. 48. A client is admitted with the dia"nosis of menin"itis. .hich findin" would the nurse e7pect in assessin" this client? A) @ypere7tension of the neck with passi!e shoulder fle7ion K ) 0le7ion of the hip and knees with passi!e fle7ion of the neck #) 0le7ion of the le"s with rebound tenderness %) @yperfle7ion of the neck with rebound fle7ion of the le"s &e!iew Information' The correct answer is ' 0le7ion of the hip and knees with passi!e fle7ion of the neck A positi!e rud5inski2s si"nUfle7ion of hip and knees with passi!e fle7ion of the neckI a positi!e Merni"2s si"nUinability to e7tend the knee to more than 146 de"rees+ without pain behind the knee+ while the hip is fle7ed usually establishes the dia"nosis of menin"itis. &esults for QYA-&andom W11 1. #lients takin" which of the followin" dru"s are at risk for depression? K A) (teroids ) %iuretics #) 0olic acid %) Aspirin &e!iew Information' The correct answer is A' (teroids Ad!erse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. H7amples include' phenothia5ines+ steroids+ and reserpine. ). .hen a client is ha!in" a "eneral tonic clonic sei5ure+ the nurse should A) @old the client=s arms at their side K ) ?lace the client on their side

?ersons recei!in" neuroleptic medication e7periencin" torticollis and in!oluntary muscle mo!ement are demonstratin" side effects that could lead to respiratory failure. 9. The nurse walks into a client=s room and finds the client lyin" still and silent on the floor. The nurse should first A) Assess the client=s airway ) #all for help K #) Hstablish that the client is unresponsi!e %) (ee if anyone saw the client fall &e!iew Information' The correct answer is #' Hstablish that the client is unresponsi!e The first step in #?& is to establish unresponsi!eness. (econd is to call for help. Third is openin" the airway. 18. The nurse is carin" for a client ) hours after a ri"ht lower lobectomy. %urin" the e!aluation of the water-seal chest draina"e system+ it is noted that the fluid le!el bubbles constantly in the water seal chamber. ;n inspection of the chest dressin" and tubin"+ the nurse does not find any air leaks in the system. The ne7t best action for the nurse is to K A) #heck for subcutaneous emphysema in the upper torso ) &eposition the client to a position of comfort #) #all the health care pro!ider as soon as possible %) #heck for any increase in the amount of thoracic draina"e &e!iew Information' The correct answer is A' #heck for subcutaneous emphysema in the upper torso #ontinuous bubblin" in the water seal chamber is an abnormal findin" ) hours after a lobectomy. 0urther assessment of appropriate factors was done by the nurse to rule out an air leak in the sytem. Thus the conclusion is that the problem is one of an air leak in the lun". This client may need to be returned to sur"ery to deal with the sustained air leak. Action by the health care pro!ider is re1uired to pre!ent further complications. 11. The nurse is teachin" a client with dysrhythmia about the electrical pathway of an impulse as it tra!els throu"h the heart. .hich of these demonstrates the normal pathway? A) AB node+ (A node+ undle of @is+ ?urkin3e fibers ) ?urkin3e fibers+ (A node+ AB node+ undle of @is #) undle of @is+ ?urkin3e fibers+ (A node + AB node K %) (A node+ AB node+ undle of @is+ ?urkin3e fibers &e!iew Information' The correct answer is %' (A node+ AB node+ undle of @is+ ?urkin3e fibers The pathway of a normal electrical impulse throu"h the heart is' (A node+ AB node+ undle of @is+ ?urkin3e fibers. 1). .hen assessin" a client who has 3ust under"one a cardio!ersion+ the nurse finds the respirations are 1). .hich action should the nurse take first? A) Try to !i"orously stimulate normal breathin" ) Ask the &C to assess the !ital si"ns #) $easure the pulse o7imetry K %) #ontinue to monitor respirations &e!iew Information' The correct answer is %' 4. #ontinue to monitor respirations 1) respirations per minute is tolerated post-operati!ely. A ran"e from , to 18 "i!es cause for concern. At that point pulse o7imetry is taken+ as that rate could be tolerated. Bi"orous stimulation is not indicated beyond deep breathin" and cou"hin". It is not necessary to ask the &C to check findin"s. 14. A new nurse on the unit notes that the nurse mana"er seems to be hi"hly respected by the nursin" staff. The new nurse is surprised when one of the nurses states' "The mana"er makes all decisions and rarely asks for our input." The best description of the nurse mana"er=s mana"ement style is A) ?articipati!e or democratic ) *ltraliberal or communicati!e K #) Autocratic or authoritarian %) >aisse5 faire or permissi!e &e!iew Information' The correct answer is #' Autocratic or authoritarian Autocratic leadership style is su""ested in this situation. It is appropriate for "roups with little education and e7perience and who need stron" direction+ while participati!e or democratic style is usually more successful on nursin" units. 14. A depressed client who has recently been actin" suicidal is now more social and ener"etic than usual. (milin"ly he tells the nurse "I2!e made some decisions about my life." .hat should be the nurse2s initial response? A) "Fou2!e made some decisions." K ) "Are you thinkin" about killin" yourself?" #) "I2m so "lad to hear that you2!e made some decisions." %) "Fou need to discuss your decisions with your therapist."

&e!iew Information' The correct answer is ' "Are you thinkin" about killin" yourself?" (udden mood ele!ation and ener"y may si"nal increased risk of suicide. The nurse must !alidate suicide ideation as a be"innin" step in e!aluatin" seriousness of risk. 16. The nurse carin" for a 14 year-old boy with se!ere @emophilia A+ who was admitted after a fall while playin" basketball. In understandin" his beha!ior and in plannin" care for this client+ what must the nurse understand about adolescents with hemophilia? A) $ust ha!e structured acti!ities K ) ;ften take part in acti!e sports #) H7plain limitations to peer "roups %) A!oid risks after bleedin" episodes &e!iew Information' The correct answer is ' ;ften take part in acti!e sports Hstablish an a"e-appropriate safe en!ironment. Adolescent hemophiliacs should be aware that contact sports may tri""er bleedin". @owe!er+ de!elopmental characteristics of this a"e "roup such as impulsi!ity+ ine7perience and peer pressure+ place adolescents in unsafe en!ironments. 1<. .hen an autistic client be"ins to eat with her hands+ the nurse can best handle the problem by ?lacin" the spoon in the client2s hand and statin"+ "*se the spoon K A) to eat your food." #ommentin" "I belie!e you know better than to eat with your ) hand." Sokin"ly statin"+ ".ell I "uess fin"ers sometimes work better #) than spoons." &emo!in" the food and statin" "Fou can2t ha!e anymore food %) until you use the spoon." &e!iew Information' The correct answer is A' ?lacin" the spoon in the client2s hand and statin" "*se the spoon to eat your food." This response identifies adapti!e beha!ior with instruction and !erbal e7pectation. 1-. In assessin" the healin" of a client=s wound durin" a home !isit+ which of the followin" is the best indicator of "ood healin"? A) .hite patches ) /reen draina"e K #) &eddened tissue %) Hschar de!elopment &e!iew Information' The correct answer is #' &eddened tissue As the wound "ranulates+ redness indicates healin". 1,. .hich therapeutic communication skill is most likely to encoura"e a depressed client to !ent feelin"s? A) %irect confrontation ) &eality orientation #) ?ro3ecti!e identification K %) Acti!e listenin" &e!iew Information' The correct answer is %' Acti!e listenin" *se of therapeutic communication skills such as silence and acti!e listenin" encoura"es !erbali5ation of feelin"s. 19. In order to enhance a client=s response to medication for chest pain from acute an"ina+ the nurse should emphasi5e K A) >earnin" rela7ation techni1ues ) >imitin" alcohol use #) Hatin" smaller meals %) A!oidin" passi!e smoke &e!iew Information' The correct answer is A' >earnin" rela7ation techni1ues The only factor that can enhance the client==s response to pain medication for an"ina is reducin" an7iety throu"h rela7ation methods. An7iety can be "reat enou"h to make the pain medication totally ineffecti!e. )8. The nurse is carin" for ) children who ha!e had sur"ical repair of con"enital heart defects. 0or which defect is it a priority to assess for findin"s of heart conduction disturbance? A) Artrial septal defect ) ?atent ductus arteriosus #) Aortic stenosis K %) Bentricular septal defect &e!iew Information' The correct answer is %' Bentricular septal defect .hile assessments for conduction disturbance should be included followin" repair of any defect+ it is a priority for this condition. A !entricular septal defect is an abnormal openin" between the ri"ht and left !entricles. The atrio!entricular bundle Abundle of @is)+ a part of the electrical conduction system of the heart+ e7tends from the atrio!entricular node alon" each side of the inter!entricular septum and then di!ides into ri"ht and left bundle branches. (ur"ical repair of a !entricular septal defect consists of a purse-strin" approach or a patch sewn o!er the openin". Hither method in!ol!es manipulation of the !entricular septum+ thereby increasin" risk of interruptin" the conduction pathway. #onse1uently+ postoperati!e complications include conduction disturbances. )1. #lients with mitral stenosis would likely manifest findin"s associated with con"estion in the K A) ?ulmonary circulation ) %escendin" aorta

#) (uperior !ena ca!a %) undle of @is &e!iew Information' The correct answer is A' ?ulmonary circulation #on"estion occurs in the pulmonary circulation due to the inefficient emptyin" of the left !entricle and the lack of a competent !al!e to pre!ent back flow into the pulmonary !ein. )). The nurse is teachin" a smokin" cessation class and notices there are ) pre"nant women in the "roup. .hich information is a priority for these women? A) >ow tar ci"arettes are less harmful durin" pre"nancy K ) There is a relationship between smokin" and low birth wei"ht #) The placenta ser!es as a barrier to nicotine %) $oderate smokin" is effecti!e in wei"ht control &e!iew Information' The correct answer is ' There is a relationship between smokin" and low birth wei"ht Cicotine reduces placental blood flow+ and may contribute to fetal hypo7ia or placenta pre!ia+ decreasin" the "rowth potential of the fetus. )4. .hat is the best way for the nurse to accomplish a health history on a 14 year-old client? A) @a!e the mother present to !erify information K ) Allow an opportunity for the teen to e7press feelin"s #) *se the same type of lan"ua"e as the adolescent %) 0ocus the discussion of risk factors in the peer "roup &e!iew Information' The correct answer is ' Allow an opportunity for the teen to e7press feelin"s Adolescents need to e7press their feelin"s. /enerally+ they talk freely when "i!en an opportunity and some pri!acy to do so. )4. .hat principle of @IB disease should the nurse keep in mind when plannin" care for a newborn who was infected in utero? The disease will incubate lon"er and pro"ress more slowly in this A) infant K ) The infant is !ery susceptible to infections #) /rowth and de!elopment patterns will proceed at a normal rate %) #areful monitorin" of renal function is indicated &e!iew Information' The correct answer is ' The infant is !ery susceptible to infections @IB infected children are susceptible to opportunistic infections due to a compromised immune system. )6. .hile plannin" care for a preschool a"ed child+ the nurse understands de!elopmental needs. .hich of the followin" would be of the most concern to the nurse? A) ?layin" ima"inati!ely K ) H7pressin" shame #) Identifyin" with family %) H7plorin" the playroom &e!iew Information' The correct answer is ' H7pressin" shame Hrikson describes the sta"e of the preschool child as bein" the time when there is normally an increase in initiati!e. The child should ha!e resol!ed the sense of shame and doubt in the toddler sta"e. )<. A client has been recei!in" lithium A>ithane) for the past two weeks for the treatment of bipolar illness. .hen plannin" client teachin"+ what is most important to emphasi5e to the client? A) $aintain a low sodium diet ) Take a diuretic with lithium #) #ome in for e!aluation of serum lithium le!els e!ery 1-4 months K %) @a!e blood lithium le!els drawn durin" the summer months &e!iew Information' The correct answer is %' @a!e blood lithium le!els drawn durin" the summer months #lients takin" lithium therapy need to be aware that hot weather may cause e7cessi!e perspiration+ a loss of sodium and conse1uently an increase in serum lithium concentration. )-. .hile teachin" a client about their medications+ the client asks how lon" it will take before the effects of lithium take place. .hat is the best response of the nurse? A) Immediately ) (e!eral days K #) ) weeks %) 1 month &e!iew Information' The correct answer is #' ) weeks >ithium is started immediately to treat bipolar disorder because it is 1uite effecti!e in controllin" mania. >ithium takes appro7imately ) weeks to effect chan"e in a client2s symptoms. ),. The nursin" inter!ention that best describes treatment to deal with the beha!iors of clients with personality disorders include ?ointin" out inconsistencies in speech patterns to correct thou"ht A) disorders ) Acceptin" client and the client=s beha!ior unconditionally

#) Hncoura"in" dependency in order to de!elop e"o controls K %) #onsistent limit-settin" enforced )4 hours per day &e!iew Information' The correct answer is %' #onsistent limit-settin" enforced )4 hours per day Treatment approaches that include restructurin" the personality+ assistin" the person with de!elopmental le!el and settin" limits for maladapti!e beha!ior such as actin" out. )9. 0ollowin" a cocaine hi"h+ the user commonly e7periences an e7tremely unpleasant feelin" called A) #ra!in" K ) #rashin" #) ;utward bound %) Coddin" out &e!iew Information' The correct answer is ' #rashin" 0ollowin" cocaine use+ the intense pleasure is replaced by an e1ually unpleasant feelin" referred to as crashin". 48. The nurse asks a client with a history of alcoholism about the client2s drinkin" beha!ior. The client states "I didn2t hurt anyone. I 3ust like to ha!e a "ood time+ and drinkin" helps me to rela7." The client is usin" which defense mechanism? A) %enial ) ?ro3ection #) Intellectuali5ation K %) &ationali5ation &e!iew Information' The correct answer is %' &ationali5ation &ationali5ation is 3ustifyin" illo"ical or unreasonable ideas+ actions+ or feelin"s by de!elopin" acceptable e7planations that satisfies the teller as well as the listener. 41. ;ne reason that domestic !iolence remains e7tensi!ely undetected is A) 0ew battered !ictims seek medical care K ) There is typically a series of minor+ !a"ue complaints #) H7penses due to police and court costs are prohibiti!e Bery little knowled"e is currently known about batterers and %) batterin" relationships &e!iew Information' The correct answer is ' There is typically a series of minor+ !a"ue complaints (i"ns of abuse may not be clearly manifested and a series a minor complaints such as headache+ abdominal pain+ insomnia+ back pain+ and di55iness may be co!ert indications of abuse undetected. #omplaints may be !a"ue. 4). A client de!elops !olume o!erload from an IB that has infused too rapidly. .hat assessment would the nurse e7pect to find? K A) (4 heart sound ) Thready pulse #) 0lattened neck !eins %) @ypo!entilation &e!iew Information' The correct answer is A' Auscultation of an Auscultation of an (4 heart sound. This is an early si"n of !olume o!erload Aor #@0) because durin" the first phase of diastole+ when blood enters the !entricles+ an e7tra sound is produced due to the presence of fluid left in the !entricles. 44. The nurse is carin" for a client with end sta"e renal disease. .hat action should the nurse take to assess for patency in a fistula used for hemodialysis? A) ;bser!e for edema pro7imal to the site ) Irri"ate with 6 mls of 8.9: Cormal (aline K #) ?alpate for a thrill o!er the fistula %) #heck color and warmth in the e7tremity &e!iew Information' The correct answer is #' ?alpate for a thrill o!er the fistula To assess for patency in a fistula or "raft+ the nurse auscultates for a bruit and palpates for a thrill. ;ther options are not related to e!aluation for patency. 44. A ) year-old child is bein" treated with Amo7icillin suspension+ )88 milli"rams per dose+ for acute otitis media. The child wei"hs 48 lb. A16 k") and the daily dose ran"e is )8-48 m"Gk" of body wei"ht+ in three di!ided doses e!ery , hours. *sin" principles of safe dru" administration+ what should the nurse do ne7t? K A) /i!e the medication as ordered ) #all the health care pro!ider to clarify the dose #) &eco"ni5e that antibiotics are o!er-prescribed %) @old the medication as the dosa"e is too low &e!iew Information' The correct answer is A' /i!e the medication as ordered Amo7icillin continues to be the dru" of choice in the treatment of acute otitis media. The dose ran"e is )8-48 m"Gk"Gday di!ided e!ery , hours. 16k" 7 48m" \ <88m"+ di!ided by 4 \ )88 m" per dose. The prescribed dose is correct and should be "i!en as ordered. 46. The nurse is participatin" in a community health fair. As part of the assessments+ the nurse should conduct a mental status e7amination when A) An indi!idual displays restlessness ) There are ob!ious si"ns of depression K #) #onductin" any health assessment %) The resident reports memory lapses &e!iew Information' The correct answer is #' #onductin" any health assessment

A mental status assessment is a critical part of baseline information+ and should be a part of e!ery e7amination. 4<. The nurse is carin" for a 1) year-old with an acute illness. .hich of the followin" indicates the nurse understands common siblin" reactions to hospitali5ation? A) Foun"er siblin"s adapt !ery well K ) Bisitation is helpful for both #) The siblin"s may en3oy pri!acy %) Those cared for at home cope better &e!iew Information' The correct answer is ' Bisitation is helpful for both #ontact with the ill child helps siblin"s understand the reasons for hospitali5ation and maintains the relationship. 4-. ?arents of a - year-old child call the clinic nurse because their dau"hter was sent home from school because of a rash. The child had been seen the day before by the health care pro!ider and dia"nosed with 0ifth %isease Aerythema infectiosum). .hat is the most appropriate action by the nurse? Tell the parents to brin" the child to the clinic for further A) e!aluation &efer the school officials to printed materials about this !iral ) illness Inform the teacher that the child is recei!in" antibiotics for the #) rash H7plain that this rash is not conta"ious and does not re1uire K %) isolation &e!iew Information' The correct answer is %' H7plain that this rash is not conta"ious and does not re1uire isolation 0ifth %isease is a !iral illness with an uncertain period of communicability Aperhaps 1 week prior to and 1 week after onset). Isolation of the child with 0ifth %isease is not necessary e7cept in cases of hospitali5ed children who are immunosuppressed or ha!in" aplastic crises. The parents may need written confirmation of this from the health care pro!ider. 4,. .hen makin" a home !isit to a client with chronic pyelonephritis+ which nursin" action has the hi"hest priority? A) 0ollow-up on lab !alues before the !isit ) ;bser!e client findin"s for the effecti!eness of antibiotics K #) Ask for a lo" of urinary output %) As for the lo" of the oral intake &e!iew Information' The correct answer is #' Ask for a lo" of urinary output The nurse must monitor the urine output as a priority because it is the best indictor of renal function. The other options would be done after an e!aluation of the urine output. 49. The nurse is carin" for a newborn who has 3ust been dia"nosed with hypospadias. After discussin" the defect with the parents+ the nurse should e7pect that A) #ircumcision can be performed at any time ) Initial repair is delayed until a"es <-, #) ?ost-operati!e appearance will be normal K %) (ur"ery will be performed in sta"es &e!iew Information' The correct answer is %' (ur"ery will be performed in sta"es @ypospadias+ a condition in which the urethral openin" is located on the !entral surface or below the penis+ is corrected in sta"es as soon as the infant can tolerate sur"ery. 48. The nurse is assessin" a client on admission to a community mental health center. The client discloses that she has been thinkin" about endin" her life. The nurse=s best response would be A) "%o you want to discuss this with your pastor?" ) ".e will help you deal with those thou"hts." #) "Is your life so terrible that you want to end it?" K %) "@a!e you thou"ht about how you would do it?" &e!iew Information' The correct answer is %' "@a!e you thou"ht about how you would do it?" This response pro!ides an openin" to discuss intent and means of committin" suicide. &esults for QYA-&andom W9 1. The nursin" care plan for a client with decreased adrenal function should include A) Hncoura"in" acti!ity ) ?lacin" client in re!erse isolation K #) >imitin" !isitors %) $easures to pre!ent constipation &e!iew Information' The correct answer is #' >imitin" !isitors Any e7ertion+ either physical or emotional+ places additional stress on the adrenal "lands which could precipitate an addisonian crisis. The plan of care should protect this client from the physical and emotional e7ertion of !isitors.

). The nurse is carin" for a client with acute pancreatitis. After pain mana"ement+ which inter!ention should be included in the plan of care? K A) #ou"h and deep breathe e!ery ) hours ) ?lace the client in contact isolation #) ?ro!ide a diet hi"h in protein %) Institute sei5ure precautions &e!iew Information' The correct answer is A' #ou"h and deep breathe e!ery ) hours &espiratory infections are common because of fluid in the retro peritoneum pushin" up a"ainst the diaphra"m causin" shallow respirations. Hncoura"in" the client to cou"h and deep breathe e!ery ) hours will diminish the occurrence of this complication. 4. .hich of the followin" conditions assessed by the nurse would contraindicate the use of ben5tropine A#o"entin)? A) Ceuromali"nant syndrome ) Acute e7trapyramidal syndrome K #) /laucoma+ prostatic hypertrophy %) ?arkinson=s disease+ atypical tremors &e!iew Information' The correct answer is #' /laucoma+ prostatic hypertrophy /laucoma and prostatic hypertrophy are contraindications to the use of ben5tropine A#o"entin) as the dru" is an anticholiner"ic a"ent. 4. The nurse is carin" for a client in the coronary care unit. The display on the cardiac monitor indicates !entricular fibrillation. .hat should the nurse do first? A) ?erform defibrillation ) Administer epinephrine as ordered K #) Assess for presence of pulse %) Institute #?& &e!iew Information' The correct answer is #' Assess for presence of pulse Artifact can mimic !entricular fibrillation on a cardiac monitor. If the client is truly in !entricular fibrillation+ no pulse will be present. The standard of care is to !erify the monitor display with an assessment of the client2s pulse. 6. %urin" the use of an interpreter to teach a client about a procedure to do in the home the nurse should take which approach? (peak directly to the interpreter while presentin" information and A) use pauses for 1uestions Talk to the interpreter in ad!ance and lea!e the client and ) interpreter alone Include a family member and direct communications to that #) person 0ace the client while presentin" the information as the interpreter K %) talks in the nati!e lan"ua"e &e!iew Information' The correct answer is %' 0ace the client while presentin" the information as the interpreter talks in the nati!e lan"ua"e . #ommunication is the cornerstone of an effecti!e teachin" plan+ especially when the nurse and client do not share the same cultural herita"e. H!en if the nurse uses an interpreter+ it is critical that the nurse use con!ersational style and spacin"+ personal space+ eye contact+ touch+ and orientation to time strate"ies that are acceptable to the client. Therefore+ face the client and present the information to the client+ allow the interpreter to translate the content. 0acin" the client allows non-!erbal communication to take place between the client and nurse. <. A client is in her third month of her first pre"nancy. %urin" the inter!iew+ she tells the nurse that she has se!eral se7 partners and is unsure of the identity of the baby=s father. .hich of the followin" nursin" inter!entions is a priority? K A) #ounsel the woman to consent to @IB screenin" ) ?erform tests for se7ually transmitted diseases #) %iscuss her hi"h risk for cer!ical cancer %) &efer the client to a family plannin" clinic &e!iew Information' The correct answer is A' #ounsel the woman to consent to @IB screenin" The client==s beha!ior places her at hi"h risk for @IB. Testin" is the first step. If the woman is @IB positi!e+ the earlier treatment be"ins+ the better the outcome. -. A client is dischar"ed followin" hospitali5ation for con"esti!e heart failure. The nurse teachin" the family su""ests they encoura"e the client to rest fre1uently in which of the followin" positions? K A) @i"h 0owler=s ) (upine #) >eft lateral %) >ow 0owler=s &e!iew Information' The correct answer is A' @i"h 0owler==s (ittin" in a chair or restin" in a bed in hi"h 0owler==s position decreases the cardiac workload and facilitates breathin". ,. A nurse who is e!aluatin" a mentally retarded ) year-old in a clinic should stress which "oal when talkin" to the child=s mother? A) Teachin" the child self care skills ) ?reparin" for independent toiletin" K #) ?romotin" the child=s optimal de!elopment %) @elpin" the family decide on lon" term care

&e!iew Information' The correct answer is #' ?romotin" the child==s optimal de!elopment The primary "oal of nursin" care for a mentally retarded child is to promote the child==s optimum de!elopment. 9. The nurse is carin" for a client with tri"eminal neural"ia Atic douloureau7). To assist the client with nutrition needs+ the nurse should K A) ;ffer small meals of hi"h calorie soft food ) Assist the client to sit in a chair for meals #) ?ro!ide additional ser!in"s of fruits and raw !e"etables %) Hncoura"e the client to eat fish+ li!er and chicken &e!iew Information' The correct answer is A' ;ffer small meals of hi"h calorie soft food If the client is losin" wei"ht because of poor appetite due to the pain+ assist in selectin" foods that are hi"h in calories and nutrients+ to pro!ide more nourishment with less chewin". (u""est that fre1uent+ small meals be eaten instead of three lar"e ones. To minimi5e 3aw mo!ements when eatin"+ su""est that foods be pureed. 18. The nurse is assessin" a ) year-old client with a possible dia"nosis of con"enital heart disease. .hich of these is most likely to be seen with this dia"nosis? A) (e!eral otitis media episodes in the last year ) .ei"ht and hei"ht in 18th percentile since birth K #) Takes fre1uent rest periods while playin" %) #han"in" food preferences and dislikes &e!iew Information' The correct answer is #' Takes fre1uent rest periods while playin" #hildren with heart disease tend to ha!e e7ercise intolerance. The child self-limits acti!ity+ which is consistent with manifestations of con"enital heart disease in children. 11. The nurse is carin" for a 18 year-old on admission to the burn unit. ;ne assessment parameter that will indicate that the child has ade1uate fluid replacement is K A) *rinary output of 48 ml per hour ) Co complaints of thirst #) Increased hematocrit %) /ood skin tur"or around burn &e!iew Information' The correct answer is A' *rinary output of 48 ml per hour 0or a child of this a"e+ this is ade1uate output+ yet does not su""est o!erload. 1). *pon e7aminin" the mouth of a 4 year-old child+ the nurse disco!ers that the teeth ha!e chalky white-to-yellowish stainin" with pittin" of the enamel. .hich of the followin" conditions would most likely e7plain these findin"s? A) In"estion of tetracycline K ) H7cessi!e fluoride intake #) ;ral iron therapy %) ?oor dental hy"iene &e!iew Information' The correct answer is ' H7cessi!e fluoride intake The described findin"s are indicati!e of fluorosis+ a condition characteri5ed by an increase in the e7tent and de"ree of the enamel==s porosity. This problem can be associated with repeated swallowin" of toothpaste with fluoride or drinkin" water with hi"h le!els of fluoride. 14. The nurse is reassi"ned to work at the ?oison #ontrol #enter telephone hotline. In which of these cases of childhood poisonin" would the nurse su""est that parents ha!e the child drink oran"e 3uice? An 1, month-old who ate an undetermined amount of crystal K A) drain cleaner ) A 14 month-old who chewed ) lea!es of a philodendron plant A )8 month-old who is found sittin" on the bathroom floor beside #) an empty bottle of dia5epam ABalium) A 48 month-old who has swallowed a mouthful of charcoal li"hter %) fluid &e!iew Information' The correct answer is A' An 1, month-old who ate an undetermined amount of crystal drain cleaner %rain cleaner is !ery alkaline. The oran"e 3uice is acidic and will help to neutrali5e this substance. 14. .hich of these is an e7ample of a !ariation in the newborn resultin" from the presence of maternal hormones? K A) Hn"or"ement of the breasts ) $on"olian spots #) Hdema of the scrotum %) >anu"o &e!iew Information' The correct answer is A' Hn"or"ement of the breasts reast en"or"ement occurs in both se7es as a result of the withdrawal of maternal hormones.

16. A ) month-old child has had a cleft lip repair. The selection of which restraint would re1uire no further action by the char"e nurse? K A) Hlbow ) $ummy #) Sacket %) #lo!e hitch &e!iew Information' The correct answer is A' Hlbow The elbow restraint will pre!ent the child from touchin" the sur"ical site without hinderin" mo!ement of other parts of the body. 1<. A client treated for depression tells the nurse at the mental health clinic that he recently purchased a hand"un because he is thinkin" about suicide. The first nursin" action should be to K A) Cotify the health care pro!ider immediately ) (u""est in-patient psychiatric care #) &espect the client=s confidential disclosure %) ?hone the family to warn them of the risk &e!iew Information' The correct answer is A' Cotify the health care pro!ider immediately The health care pro!ider must be contacted immediately as the client is a dan"er to self and others. @ospitali5ation is indicated. 1-. A client has 3ust been admitted with portal hypertension. .hich nursin" dia"nosis would be a priority in plannin" care? A) Altered nutrition' less than body re1uirements K ) ?otential complication hemorrha"e #) Ineffecti!e indi!idual copin" %) 0luid !olume e7cess &e!iew Information' The correct answer is ' ?otential complication hemorrha"e Hsopha"eal !arices are dilated and tortuous !essels of the esopha"us that are at hi"h risk for rupture if portal circulation pressures rise. 1,. .hile plannin" care for a ) year-old hospitali5ed child+ which situation would the nurse e7pect to most likely affect the beha!ior? A) (tran"e bed and surroundin"s K ) (eparation from parents #) ?resence of other toddlers %) *nfamiliar toys and "ames &e!iew Information' The correct answer is ' (eparation from parents (eparation an7iety if most e!ident from < months to 48 months of a"e. It is the "reatest stress imposed on a toddler by hospitali5ation. If separation is a!oided+ youn" children ha!e a tremendous capacity to withstand other stress. 19. .hich of the followin" should the nurse teach the client to a!oid when takin" chlorproma5ine @#> AThora5ine)? K A) %irect sunli"ht ) 0oods containin" tyramine #) 0oods fermented with yeast %) #anned citrus fruit drinks &e!iew Information' The correct answer is A' A!oid direct sunli"ht ?henothia5ine increases sensiti!ity to the sun+ makin" clients especially susceptible to sunburn. )8. The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is K A) "Fou think that someone wants to poison you?" ) ".hy do you think the food is poisoned?" #) "These feelin"s are a symptom of your illness." %) "Fou2re safe here. I won2t let anyone poison you." &e!iew Information' The correct answer is A' "Fou think that someone wants to poison you?" This response acknowled"es perception throu"h a reflecti!e 1uestion which presents opportunity for discussion+ clarification of meanin"+ and e7pressin" doubt. )1. The nurse is carin" for a client with cirrhosis of the li!er with ascites. .hen instructin" nursin" assistants in the care of the client+ the nurse should emphasi5e that A) The client should remain on bed rest in a semi-0owler=s position The client should alternate ambulation with bed rest with le"s K ) ele!ated #) The client may ambulate and sit in chair as tolerated The client may ambulate as tolerated and remain in semi-0owlers %) position in bed &e!iew Information' The correct answer is ' The client should alternate ambulation with bed rest with le"s ele!ated Hncoura"e alternatin" periods ambulation and bed rest with le"s ele!ated to mobili5e edema and ascites. Hncoura"e and assist the client with "radually increasin" periods of ambulation. )). The nurse is performin" physical assessments on adolescents. .hen would the nurse anticipate that females e7perience "rowth spurts? K A) About ) years earlier than males ) About the same time as males

#) Sust prior to the onset of puberty %) That increase hei"ht by 4 inches each year &e!iew Information' The correct answer is A' About ) years earlier than males Cormally+ females in their teen a"e years e7perience a "rowth spurt about ) years earlier than their male peers. )4. The nurse is has 3ust admitted a client with se!ere depression. 0rom which focus should the nurse identify a prioriy nursin" dia"nosis? A) Cutrition ) Hlimination #) Acti!ity K %) (afety &e!iew Information' The correct answer is %' (afety (afety is a priority of care for the depressed client. ?recautions to pre!ent suicide must be a part of the plan. )4. .hile e7plainin" an illness to a 18 year-old+ what should the nurse keep in mind about the co"niti!e de!elopment at this a"e? A) They are able to make simple association of ideas K ) They are able to think lo"ically in or"ani5in" facts #) Interpretation of e!ents ori"inate from their own perspecti!e %) #onclusions are based on pre!ious e7periences &e!iew Information' The correct answer is ' Think lo"ically in or"ani5in" facts The child in the concrete operations sta"e+ accordin" to ?ia"et+ is capable of mature thou"ht when allowed to manipulate and or"ani5e ob3ects. )6. The nurse enters the room as a 4 year-old is ha!in" a "enerali5ed sei5ure. .hich inter!ention should the nurse do first? A) #lear the area of any ha5ards K ) ?lace the child on the side #) &estrain the child %) /i!e the prescribed anticon!ulsant &e!iew Information' The correct answer is ' ?lace the child on the side ?rotectin" the airway is the top priority in a sei5ure. If a child is acti!ely con!usin"+ a patent airway and o7y"enation must be assured. )<. The nurse is re!iewin" a depressed client=s history from an earlier admission. %ocumentation of anhedonia is noted. The nurse understands that this findin" refers to A) &eports of difficulty fallin" and stayin" asleep ) H7pression of persistent suicidal thou"hts K #) >ack of en3oyment in usual pleasures %) &educed senses of taste and smell &e!iew Information' The correct answer is #' >ack of en3oyment in usual pleasures >ack of en3oyment in usual pleasures defines this term. )-. A client has 3ust returned to the medical-sur"ical unit followin" a se"mental lun" resection. After assessin" the client+ the first nursin" action would be to A) Administer pain medication K ) (uction e7cessi!e tracheobronchial secretions #) Assist client to turn+ deep breathe and cou"ht %) $onitor o7y"en saturation &e!iew Information' The correct answer is ' (uction e7cessi!e tracheobronchial secretions (uctionin" the copious tracheobronchial secretions present in postthoracic sur"ery clients maintains an open airway which is always the priority nursin" inter!ention. ),. .hile assessin" a client in an outpatient facility with a panic disorder+ the nurse completes a thorou"h health history and physical e7am. .hich findin" is most si"nificant for this client? A) #ompulsi!e beha!ior K ) (ense of impendin" doom #) 0ear of flyin" %) ?redictable episodes &e!iew Information' The correct answer is ' (ense of impendin" doom The feelin" of o!erwhelmin" and uncontrollable doom is characteristic of a panic attack. )9. A 1< month-old child has 3ust been admitted to the hospital. As the nurse assi"ned to this child enters the hospital room for the first time+ the toddler runs to the mother+ clin"s to her and be"ins to cry. .hat would be the initial action by the nurse? A) Arran"e to chan"e client care assi"nments K ) H7plain that this beha!ior is e7pected #) %iscuss the appropriate use of "time-out" %) H7plain that the child needs e7tra attention

&e!iew Information' The correct answer is ' H7plain that this beha!ior is e7pected %urin" normal de!elopment+ fear of stran"ers becomes prominent be"innin" around a"e <-, months. (uch beha!iors include clin"in" to parent+ cryin"+ and turnin" away from the stran"er. These fearsGbeha!iors e7tend into the toddler period and may persist into preschool. 48. A 16 year-old client with a len"thy confinin" illness is at risk for altered "rowth and de!elopment of which task? A) >oss of control ) Insecurity K #) %ependence %) >ack of trust &e!iew Information' The correct answer is #' %ependence The client role fosters dependency. Adolescents may react to dependency with re3ection+ uncooperati!eness+ or withdrawal. 41. .hich playroom acti!ities should the nurse or"ani5e for a small "roup of year-old hospitali5ed children? K A) (ports and "ames with rules ) 0in"er paints and water play #) "%ress-up" clothes and props %) #hess and tele!ision pro"rams &e!iew Information' The correct answer is A' (ports and "ames with rules The purpose of play for the - year-old is cooperation. &ules are !ery important. >o"ical reasonin" and social skills are de!eloped throu"h play. 4). The nurse is discussin" dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is K A) "Hat a balanced diet for your a"e." ) "Increase your intake of protein and Bitamin A." #) "%ecrease fatty foods from your diet." %) "%o not use caffeine in any form+ includin" chocolate." &e!iew Information' The correct answer is A' "Hat a balanced diet for your a"e." A diet for a teena"er with acne should be a well balanced diet for their a"e. There are no recommended additions and subtractions from the diet. 44. The nurse is assi"ned to a newly deli!ered woman with @IBGAI%(. The student asks the nurse about how it is determined that a person has AI%( other than a positi!e @IB test. The nurse responds A) "The complaints of at least 4 common findin"s." ) "The absence of any opportunistic infection." K #) "#%4 lymphocyte count is less than )88." %) "%e!elopmental delays in children." &e!iew Information' The correct answer is #' "#%4 lymphocyte count is less than )88." #%4 lymphocyte counts are normally <88 to 1888. In 1994 the #enter for %isease #ontrol defined AI%( as ha!in" a positi!e @IB plus one of these V the presence of an opportunistic infection or a #%4 lymphocyte count of less than )88. 44. The nurse is carin" for a child who has 3ust returned from sur"ery followin" a tonsillectomy and adenoidectomy. .hich action by the nurse is appropriate? A) ;ffer ice cream e!ery ) hours ) ?lace the child in a supine position #) Allow the child to drink throu"h a straw K %) ;bser!e swallowin" patterns &e!iew Information' The correct answer is %' ;bser!e swallowin" patterns The nurse should obser!e for increased swallowin" fre1uency to check for hemorrha"e. 46. A )4 year-old sin"le client is in the 44rd week of her first pre"nancy. (he tells the nurse that she has e!erythin" ready for the baby and has made plans for the first weeks to"ether at home. .hich normal emotional reaction does the nurse reco"ni5e? A) Acceptance of the pre"nancy ) 0ocus on fetal de!elopment K #) Anticipation of the birth %) Ambi!alence about pre"nancy &e!iew Information' The correct answer is #' Anticipation of the birth %irectin" acti!ities toward preparation for the newborn==s needs and personal ad3ustment are indicators of appropriate emotional response in the third trimester. 4<. The nurse is plannin" care for a client with pneumococcal pneumonia. .hich of the followin" would be most effecti!e in remo!in" respiratory secretions? A) Administration of cou"h suppressants K ) Increasin" oral fluid intake to 4888 cc per day #) $aintainin" bed rest with bathroom pri!ile"es %) ?erformin" chest physiotherapy twice a day &e!iew Information' The correct answer is ' Increasin" oral fluid intake to 4888 cc per day (ecretion remo!al is enhanced with ade1uate hydration which thins and li1uefies secretions. 4-. The nurse in a well-child clinic e7amines many children on a daily basis. .hich of the followin" toddlers re1uires further follow up?

A) A 14 month-old unable to walk ) A )8 month-old only usin" ) and 4 word sentences #) A )4 month-old who cries durin" e7amination K %) A 48 month-old only drinkin" from a sippy cup &e!iew Information' The correct answer is %' A 48 month-old only drinkin" from a sippy cup A 48 month-old should be able to drink from a cup without a co!er. 4,. .hich of the followin" would be the best strate"y for the nurse to use when teachin" insulin in3ection techni1ues to a newly dia"nosed client with diabetes? A) /i!e written pre and post tests ) Ask 1uestions durin" practice #) Allow another diabetic to assist K %) ;bser!e a return demonstration &e!iew Information' The correct answer is %' ;bser!e a return demonstration (ince this is a psychomotor skill+ this is the best way to know if the client has learned the proper techni1ue. 49. A client has de!eloped thrombophlebitis of the left le". .hich nursin" inter!ention should be "i!en the hi"hest priority? K A) Hle!ate le" on ) pillows ) Apply support stockin"s #) Apply warm compresses %) $aintain complete bed rest &e!iew Information' The correct answer is A' Hle!ate le" on ) pillows The first "oal of non-pharmacolo"ic inter!entions is to minimi5e edema of the affected e7tremity by le" ele!ation. 48. A nurse from the sur"ical department is reassi"ned to the pediatric unit. The char"e nurse should reco"ni5e that the child at hi"hest risk for cardiac arrest and is the least likely to be assi"ed to this nurse is which child? A) #on"enital cardiac defects ) An acute febrile illness K #) ?rolon"ed hypo7emia %) (e!ere multiple trauma &e!iew Information' The correct answer is #' ?rolon"ed hypo7emia $ost often+ the cause of cardiac arrest in the pediatric population is prolon"ed hypo7emia. #hildren usually ha!e both cardiac and respiratory arrest. &esults for QYA-&andom W, 1. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawin" up insulin. It would be most appropriate for the nurse to refer the client to A) A social worker from the local hospital K ) An occupational therapist from the community center #) A physical therapist from the rehabilitation a"ency %) Another client with diabetes mellitus and takes insulin &e!iew Information' The correct answer is ' An occupational therapist from the community center An occupational therapist can assist a client to impro!e the fine motor skills needed to prepare an insulin in3ection. ). A priority "oal of in!oluntary hospitali5ation of the se!erely mentally ill client is A) &e-orientation to reality ) Hlimination of symptoms K #) ?rotection from harm to self or others %)

4. The nurse is teachin" parents about the treatment plan for a ) weeks-old infant with Tetralo"y of 0allot. .hile awaitin" future sur"ery+ the nurse instructs the parents to immediately report K A) >oss of consciousness ) 0eedin" problems #) ?oor wei"ht "ain %) 0ati"ue with cryin" &e!iew Information' The correct answer is A' >oss of consciousness .hile parents should report any of the obser!ations+ they need to call the health care pro!ider immediately if the le!el of alertness chan"es. This indicates ano7ia+ which may lead to death. The structural defects associated with Tetralo"y of 0allot include pulmonic stenosis+ !entricular septal defect+ ri"ht !entricular hypertrophy and o!erridin" of the aorta. (ur"ery is often delayed+ or may be performed in sta"es. 6. A client is scheduled for an Intra!enous ?yelo"ram AIB?). In order to prepare the client for this test+ the nurse would Instruct the client to maintain a re"ular diet the day prior to the A) e7amination ) &estrict the client=s fluid intake 4 hours prior to the e7amination Administer a la7ati!e to the client the e!enin" before the K #) e7amination %) Inform the client that only 1 7-ray of his abdomen is necessary &e!iew Information' The correct answer is #' Administer a la7ati!e to the client the e!enin" before the e7amination owel prep is important because it will allow "reater !isuali5ation of the bladder and ureters. <. The nurse is carin" for a woman ) hours after a !a"inal deli!ery. %ocumentation indicates that the membranes were ruptured for 4< hours prior to deli!ery. .hat is the priority nursin" dia"noses at this time? A) Altered tissue perfusion ) &isk for fluid !olume deficit #) @i"h risk for hemorrha"e K %) &isk for infection &e!iew Information' The correct answer is %' &isk for infection $embranes ruptured o!er )4 hours prior to birth "reatly increases the risk of infection to both mother and the newborn. -. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that #ircumcision is delayed so the foreskin can be used for the K A) sur"ical repair This procedure is contraindicated because of the permanent ) defect There is no medical indication for performin" a circumcision on #) any child The procedure should be performed as soon as the infant is %) stable &e!iew Information' The correct answer is A' #ircumcision is delayed so the foreskin can be used for the sur"ical repair H!en if mild hypospadias is suspected+ circumcision is not done in order to sa!e the foreskin for sur"ical repair+ if needed. ,. The nurse is carin" for a client in the late sta"es of Amyotrophic >ateral (clerosis AA.>.(.). .hich findin" would the nurse e7pect? A) #onfusion ) >oss of half of !isual field K #) (hallow respirations %) Tonic-clonic sei5ures &e!iew Information' The correct answer is #' (hallow respirations A.>.(. is a chronic pro"ressi!e disease that in!ol!es de"eneration of the anterior horn of the spinal cord as well as the corticospinal tracts. .hen the intercostal muscles and diaphra"m become in!ol!ed+ the respirations become shallow and cou"hin" is ineffecti!e. 9. A client complained of nausea+ a metallic taste in her mouth+ and fine hand tremors ) hours after her first dose of lithium carbonate A>ithane). .hat is the nurse2s best e7planation of these findin"s? K A) These side effects are common and should subside in a few days The client is probably ha!in" an aller"ic reaction and should ) discontinue the dru" Takin" the lithium on an empty stomach should decrease these #) symptoms %ecreasin" dietary intake of sodium and fluids should minimi5e %) the side effects &e!iew Information' The correct answer is A' These side effects are common and should subside in a few days Causea+ metallic taste and fine hand tremors are common side effects that usually subside within days. 18. A 6- year-old male client has a hemo"lobin of 18 m"Gdl and a hematocrit of 4):. .hat would be the most appropriate follow-up by the home care nurse? K A) Ask the client if he has noticed any bleedin" or dark stools ) Tell the client to call 911 and "o to the emer"ency department

eturn to independent functioning

&e!iew Information' The correct answer is #' ?rotection from selfharm and harm to others In!oluntary hospitali5ation may be re1uired for persons considered dan"erous to self or others or for indi!iduals who are considered "ra!ely disabled. 4. The nurse is carin" for a client with a lon" le" cast. %urin" dischar"e teachin" about appropriate e7ercises for the affected e7tremity+ the nurse should recommend K A) Isometric ) &an"e of motion #) Aerobic %) Isotonic &e!iew Information' The correct answer is A' Isometric The nurse should instruct the client on isometric e7ercises for the muscles of the casted e7tremity+ i.e.+ instruct the client to alternately contract and rela7 muscles without mo!in" the affected part. The client should also be instructed to do acti!e ran"e of motion e7ercises for e!ery 3oint that is not immobili5ed at re"ular and fre1uent inter!als.

immediately #) (chedule a repeat @emo"lobin and @ematocrit in 1 month %) Tell the client to schedule an appointment with a hematolo"ist &e!iew Information' The correct answer is A' Ask the client if he has noticed any bleedin" or dark stools Cormal hemo"lobin for males is 14.8 - 1, "G188 ml. Cormal hemotocrit for males is 4) - 6):. These !alues are below normal and indicate mild anemia. The first thin" the nurse should do is ask the client if he==s noticed any bleedin" or chan"e in stools that could indicate bleedin" from the /I tract. 11. A client is scheduled for a percutaneous transluminal coronary an"ioplasty A?T#A). The nurse knows that a ?T#A is the A) (ur"ical repair of a diseased coronary artery ) ?lacement of an automatic internal cardiac defibrillator ?rocedure that compresses pla1ue a"ainst the wall of the K #) diseased coronary artery to impro!e blood flow %) Con-in!asi!e radio"raphic e7amination of the heart &e!iew Information' The correct answer is #' ?rocedure that compresses pla1ue a"ainst the wall of the diseased coronary artery to impro!e blood flow ?T#A is performed to impro!e coronary artery blood flow in a diseased artery. It is performed durin" a cardiac catheteri5ation. Aorta coronary bypass /"aft is the sur"ical procedure to repair a diseased coronary artery. 1). 0or a < year-old child hospitali5ed with moderate edema and mild hypertension associated with acute "lomerulonephritis AA/C)+ which one of the followin" nursin" inter!entions would be appropriate? K A) Institute sei5ure precautions ) .ei"h the child twice per shift #) Hncoura"e the child to eat protein-rich foods %) &elie!e boredom throu"h physical acti!ity &e!iew Information' The correct answer is A' Institute sei5ure precautions The se!erity of the acute phase of A/C is !ariable and unpredictableI therefore+ a child with edema+ hypertension+ and "ross hematuria may be sub3ect to complications+ and anticipatory preparation such as sei5ure precautions are needed. 14. 0ollowin" mitral !al!e replacement sur"ery a client de!elops ?B#2s. The health care pro!ider orders a bolus of >idocaine followed by a continuous >idocaine infusion at a rate of ) m"mGminute. The IB solution contains ) "rams of >idocaine in 688 cc2s of %6.. The infusion pump deli!ers <8 microdropsGcc. .hat rate would deli!er 4 m"m of >idocaineGminute? K A) <8 microdropsGminute ) )8 microdropsGminute #) 48 microdropsGminute %) 48 microdropsGminute &e!iew Information' The correct answer is A' <8 microdropsGminute ) "m\)888 m"m )888 m"mG688 cc \ 4 m"mG7 cc )8887 \ )888 7\ )888G)888 \ 1 cc of IB solutionGminute ## 7 <8 microdrops \ <8 microdropsGminute 14. An adolescent client comes to the clinic 4 weeks after the birth of her first baby. (he tells the nurse she is concerned because she has not returned to her pre-pre"nant wei"ht. .hich action should the nurse perform first? A) &e!iew the client=s wei"ht pattern o!er the year ) Ask the mother to record her diet for the last )4 hours K #) Hncoura"e her to talk about her !iew of herself %) /i!e her se!eral pamphlets on postpartum nutrition &e!iew Information' The correct answer is #' Hncoura"e her to talk about her !iew of herself To an adolescent+ body ima"e is !ery important. The nurse must acknowled"e this before assessment and teachin". 16. To pre!ent a !alsal!a maneu!er in a client reco!erin" from an acute myocardial infarction+ the nurse would A) Assist the client to use the bedside commode K ) Administer stool softeners e!ery day as ordered #) Administer antidysrhythmics prn as ordered %) $aintain the client on strict bed rest &e!iew Information' The correct answer is ' Administer stool softeners e!ery day as ordered Administerin" stool softeners e!ery day will pre!ent strainin" on defecation which causes the Balsal!a maneu!er. If constipation occurs then la7ati!es would be necessary to pre!ent strainin". If strainin" on defecation produced the !alsal!a maneu!er and rhythm disturbances resulted then antidysrhythmics would be appropriate. 1<. A 4 year-old had a hip spica cast applied ) hours a"o. In order to facilitate dryin"+ the nurse should

K A) H7pose the cast to air and turn the child fre1uently ) *se a heat lamp to reduce the dryin" time #) @andle the cast with the abductor bar %) Turn the child as little as possible &e!iew Information' The correct answer is A' H7pose the cast to air and turn the child fre1uently The child should be turned e!ery ) hours+ with surface e7posed to the air. 1-. The nurse is carin" for a 14 year-old followin" spinal fusion for scoliosis. .hich of the followin" inter!entions is appropriate in the immediate postoperati!e period? A) &aise the head of the bed at least 48 de"rees ) Hncoura"e ambulation within )4 hours K #) $aintain in a flat position+ lo"rollin" as needed %) Hncoura"e le" contraction and rela7ation after 4, hours &e!iew Information' The correct answer is #' $aintain in a flat position+ lo"rollin" as needed The bed should remain flat for at least the first )4 hours to pre!ent in3ury. >o"rollin" is the best way to turn for the client while on bed rest. 1,. A client was admitted to the psychiatric unit after complainin" to her friends and family that nei"hbors ha!e bu""ed her home in order to hear all of her business. (he remains aloof from other clients+ paces the floor and belie!es that the hospital is a house of torture. Cursin" inter!entions for the client should appropriately focus on efforts to A) #on!ince the client that the hospital staff is tryin" to help ) @elp the client to enter into "roup recreational acti!ities K #) ?ro!ide interactions to help the client learn to trust staff Arran"e the en!ironment to limit the client2s contact with other %) clients &e!iew Information' The correct answer is #' ?ro!ide interactions to help the client learn to trust staff This establishes trust+ facilitates a therapeutic alliance between staff and client. 19. The nurse is assessin" an infant with de!elopmental dysplasia of the hip. .hich findin" would the nurse anticipate? K A) *ne1ual le" len"th ) >imited adduction #) %iminished femoral pulses %) (ymmetrical "luteal folds &e!iew Information' The correct answer is A' *ne1ual le" len"th (hortenin" of a le" is a si"n of de!elopmental dysplasia of the hip. )8. A nurse is carin" for a ) year-old child after correcti!e sur"ery for Tetralo"y of 0allot. The mother reports that the child has suddenly be"un sei5in". The nurse reco"ni5es this problem is probably due to K A) A cerebral !ascular accident ) ?ostoperati!e menin"itis #) $edication reaction %) $etabolic alkalosis &e!iew Information' The correct answer is A' A cerebral !ascular accident ?olycythemia occurs as a physiolo"ical reaction to chronic hypo7emia which commonly occurs in clients with Tetralo"y of 0allot. ?olycythemia and the resultant increased !iscosity of the blood increase the risk of thromboembolic e!ents. #erebro!ascular accidents may occur. (i"ns and symptoms include sudden paralysis+ altered speech+ e7treme irritability or fati"ue+ and sei5ures. )1. 0ollowin" a dia"nosis of acute "lomerulonephritis AA/C) in their < year-old child+ the parents remark' E.e 3ust don2t know how he cau"ht the diseaseJD The nurse=s response is based on an understandin" that A) A/C is a streptococcal infection that in!ol!es the kidney tubules ) The disease is easily transmissible in schools and camps #) The illness is usually associated with chronic respiratory infections It is not "cau"ht" but is a response to a pre!ious -hemolytic K %) strep infection &e!iew Information' The correct answer is %' It is not "cau"ht" but is a response to a pre!ious -hemolytic strep infection A/C is "enerally accepted as an immune-comple7 disease in relation to an antecedent streptococcal infection of 4 to <t weeks prior+ and is considered as a noninfectious renal disease. )). A couple asks the nurse about risks of se!eral birth control methods. .hat is the most appropriate response by the nurse? A) Corplant is safe and may be remo!ed easily K ) ;ral contracepti!es should not be used by smokers #) %epo-?ro!era is con!enient with few side effects %) The I*% "i!es protection from pre"nancy and infection &e!iew Information' The correct answer is ' ;ral contracepti!es should not be used by smokers The use of oral contracepti!es in a pre"nant woman who smokes increases her risk of cardio!ascular problems+ such as thromboembolic disorders. )4. A client e7periences post partum hemorrha"e ei"ht hours after the birth of twins. 0ollowin" administration of IB fluids and 688 ml of whole blood+ her hemo"lobin and hematocrit are within normal limits. (he asks the nurse whether

she should continue to breast feed the infants. .hich of the followin" is based on sound rationale? "Cursin" will help contract the uterus and reduce your risk of K A) bleedin"." " reastfeedin" twins will take too much ener"y after the ) hemorrha"e." "The blood transfusion may increase the risks to you and the #) babies." %) ">actation should be delayed until the "real milk" is secreted." &e!iew Information' The correct answer is A' "Cursin" will help contract the uterus and reduce your risk of bleedin"." (timulation of the breast durin" nursin" releases o7ytocin+ which contracts the uterus. This contraction is especially important followin" hemorrha"e. )4. The nurse is carin" for a post-sur"ical client at risk for de!elopin" deep !ein thrombosis. .hich inter!ention is an effecti!e pre!enti!e measure? A) ?lace pillows under the knees ) *se elastic stockin"s continuously K #) Hncoura"e ran"e of motion and ambulation %) $assa"e the le"s twice daily &e!iew Information' The correct answer is #' Hncoura"e ran"e of motion and ambulation $obility reduces the risk of deep !ein thrombosis in the post-sur"ical client and the adult at risk. )6. The nurse is carin" for a )8 lbs A9 k") < month-old with a 4 day history of diarrhea+ occasional !omitin" and fe!er. ?eripheral intra!enous therapy has been initiated+ with 6: de7trose in 8.44: normal saline with )8 mH1 of potassium per liter infusin" at 46 mlGhr. .hich findin" should be reported to the health care pro!ider immediately? A) 4 episodes of !omitin" in 1 hour ) ?eriodic cryin" and irritability #) Bi"orous suckin" on a pacifier K %) Co measurable !oidin" in 4 hours &e!iew Information' The correct answer is %' Co measurable !oidin" in 4 hours The concern is possible hyperkalemia+ which could occur with continued potassium administration and a decrease in urinary output since potassium is e7creted !ia the kidneys. )<. .hich response by the nurse would best assist the chemically impaired client to deal with issues of "uilt? "Addiction usually causes people to feel "uilty. %on2t worry+ it is a A) typical response due to your drinkin" beha!ior." ".hat ha!e you done that you feel most "uilty about and what K ) steps can you be"in to take to help you lessen this "uilt?" "%on2t focus on your "uilty feelin"s. These feelin"s will only lead #) you to drinkin" and takin" dru"s." "Fou2!e caused a "reat deal of pain to your family and close %) friends+ so it will take time to undo all the thin"s you2!e done." &e!iew Information' The correct answer is ' ".hat ha!e you done that you feel most "uilty about and what steps can you be"in to take to help you lessen this "uilt?" This response encoura"es the client to "et in touch with their feelin"s and utili5e problem sol!in" steps to reduce "uilt feelin"s. )-. A client with schi5ophrenia is recei!in" @aloperidol A@aldol) 6 m" t.i.d.. The client2s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse reco"ni5es this as what type of side effect? K A) ;culo"yric crisis ) Tardi!e dyskinesia #) Cysta"mus %) %yspha"ia &e!iew Information' The correct answer is A' ;culo"yric crisis This refers to in!oluntary muscles spasm of the eye. ),. .hich of the followin" measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis? A) *se only cloth diapers that are rinsed in bleach ) %o not use occlusi!e ointments on the rash #) *se commercial baby wipes with each diaper chan"e %iscontinue a new food that was added to the infant=s diet 3ust K %) prior to the rash &e!iew Information' The correct answer is %' %iscontinue a new food that was added to the infant==s diet 3ust prior to the rash The addition of new foods to the infant==s diet may be a cause of diaper dermatitis. )9. A mother brin"s her )< month-old to the well-child clinic. (he e7presses frustration and an"er due to her child=s constantly sayin" "no" and his refusal to follow her directions. The nurse e7plains this is normal for his a"e+ as ne"ati!ism is attemptin" to meet which de!elopmental need?

A) Trust ) Initiati!e K #) Independence %) (elf-esteem &e!iew Information' The correct answer is #' Independence In Hrikson2s theory of de!elopment+ toddlers stru""le to assert independence. They often use the word EnoD e!en when they mean yes. This sta"e is called autonomy !ersus shame and doubt 48. .hich beha!ioral characteristic describes the domestic abuser? A) Alcoholic ) ;!er confident #) @i"h tolerance for frustrations K %) >ow self-esteem &e!iew Information' The correct answer is %' >ow self-esteem atterers are usually physically or psycholo"ically abused as children or ha!e had e7periences of parental !iolence. atterers are also manipulati!e+ ha!e a low selfesteem+ and ha!e a "reat need to e7ercise control or power-o!er partner. 41. .hich statement by the client with chronic obstructi!e lun" disease indicates an understandin" of the ma3or reason for the use of occasional pursed-lip breathin" A) "This action of my lips helps to keep my airway open." ) "I can e7pel more when I pucker up my lips to breathe out." #) "$y mouth doesn=t "et as dry when I breathe with pursed lips." " y prolon"in" breathin" out with pursed lips the little areas in K %) my lun"s don=t collapse." &e!iew Information' The correct answer is %' " y prolon"in" breathin" out with pursed lips my little areas in my lun"s don==t collapse." #lients with chronic obstructi!e pulmonary disease ha!e difficulty e7halin" fully as a result of the weak al!eolar walls from the disease process . Al!eolar collapse can be a!oided with the use of pursed-lip breathin". This is the ma3or reason to use it. The other options are secondary effects of purse-lip breathin". 4). %urin" the admission assessment on a client with chronic bilateral "laucoma+ which statement by the client would the nurse anticipate since it is associated with this problem? A) "I ha!e constant blurred !ision." ) "I can=t see on my left side." K #) "I ha!e to turn my head to see my room." %) "I ha!e specks floatin" in my eyes." &e!iew Information' The correct answer is #' "I ha!e to turn my head to see my room." Intraocular pressure becomes ele!ated which slowly produces a pro"ressi!e loss of the peripheral !isual field in the affected eye alon" with rainbow halos around li"hts. Intraocular pressure becomes ele!ated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye. 44. A 19 year-old client is paraly5ed in a car accident. .hich statement used by the client would indicate to the nurse that the client was usin" the mechanism of "suppression"? K A) "I don=t remember anythin" about what happened to me." ) "I=d rather not talk about it ri"ht now." #) "It=s all the other "uy=s faultJ @e was "oin" too fast." %) "$y mother is heartbroken about this." &e!iew Information' The correct answer is A' "I don==t remember anythin" about what happened to me." (uppression is willfully puttin" an unacceptable thou"ht or feelin" out of one2s mind. A deliberate e7clusion "!oluntary for"ettin"" is "enerally used to protect one2s own self esteem. 44. .hile carin" for the client durin" the first hour after deli!ery+ the nurse determines that the uterus is bo""y and there is !a"inal bleedin". .hat should be the nurse=s first action? A) #heck !ital si"ns K ) $assa"e the fundus #) ;ffer a bedpan %) #heck for perineal lacerations &e!iew Information' The correct answer is ' $assa"e the fundus The nurse2s first action should be to massa"e the fundus until it is firm as uterine atony is the primary cause of bleedin" in the first hour after deli!ery. 46. An infant wei"hed - pounds , ounces at birth. If "rowth occurs at a normal rate+ what would be the e7pected wie"ht at < months of a"e? K A) %ouble the birth wei"ht ) Triple the birth wei"ht #) /ain < ounces each week %) Add ) pounds each month &e!iew Information' The correct answer is A' %ouble the birth wei"ht Althou"h "rowth rates !ary+ infants normally double their birth wei"ht by < months. 4<. ;n admission to the psychiatric unit+ the client is tremblin" and appears fearful. The nurse2s initial response should be to A) /i!e the client orientation materials and re!iew the unit rules and

re"ulations Introduce himGherself and accompany the client to the client2s K ) room Take the client to the day room and introduce her to the other #) clients Ask the nursin" assistant to "et the client2s !ital si"ns and %) complete the admission search &e!iew Information' The correct answer is ' Introduce himGherself and accompany the client to the client2s room An7iety is tri""ered by chan"e that threatens the indi!idual2s sense of security. In response to an7iety in clients+ the nurse should remain calm+ minimi5e stimuli+ and mo!e the client to a calmer+ more secureGsafe settin". 4-. A client with asthma has low pitched whee5es present on the final half of e7halation. ;ne hour later the client has hi"h pitched whee5es e7tendin" throu"hout e7halation. This chan"e in assessment indicates to the nurse that the client K A) @as increased airway obstruction ) @as impro!ed airway obstruction #) Ceeds to be suctioned %) H7hibits hyper!entilation &e!iew Information' The correct answer is A' @as increased airway obstruction The hi"her pitched a sound is+ the more narrow the airway. Therefore+ the obstruction has increased or worsened. .ith no e!idence of secretions no support e7ists to indicate the need for suctionin". 4,. A client asks the nurse about includin" her ) and 1) year-old sons in the care of their newborn sister. .hich of the followin" is an appropriate initial statement by the nurse? K A) "0ocus on your sons= needs durin" the first days at home." ) "Tell each child what he can do to help with the baby." #) "(u""est that your husband spend more time with the boys." %) "Ask the children what they would like to do for the newborn." &e!iew Information' The correct answer is A' "0ocus on your sons== needs durin" the first days at home." In an e7panded family+ it is important for parents to reassure older children that they are lo!ed and as important as the newborn. 49. A 1< year-old client is admitted to a psychiatric unit with a dia"nosis of attempted suicide. The nurse is aware that the most fre1uent cause for suicide in adolescents is A) ?ro"ressi!e failure to adapt ) 0eelin"s of an"er or hostility #) &eunion wish or fantasy %) 0eelin"s of alienation or isolation &e!iew Information' The correct answer is %' 0eelin"s of alienation or isolation The isolation may occur "radually resultin" in a loss of all meanin"ful social contacts. Isolation can be self imposed or can occur as a result of the inability to e7press feelin"s. At this sta"e of de!elopment it is important to achie!e a sense of identity and peer acceptance. 48. A newborn has been dia"nosed with hypothyroidism. In discussin" the condition and treatment with the family+ the nurse should emphasi5e A) They can e7pect the child will be mentally retarded K ) Administration of thyroid hormone will pre!ent problems #) This rare problem is always hereditary %) ?hysical "rowthGde!elopment will be delayed &e!iew Information' The correct answer is ' Administration of thyroid hormone will pre!ent problems Harly identification and continued treatment with hormone replacement corrects this condition. &esults for QYA-&andom W1. A @ispanic client refuses emer"ency room treatment until a curandero is called. The nurse understands that this person brin"s what to situations of illness? K A) @olistic healin" ) (piritual ad!isin" #) @erbal preparations %) .itchcraft potions &e!iew Information' The correct answer is A' @olistic healin" This traditional folk practitioner uses holistic methods for illnesses not related to witchcraft. $any times+ the curandero works with traditional health care pro!iders to restore health. ). In addition to disturbances in mental awareness and orientation+ a client with co"niti!e impairment is also likely to show loss of ability in A) @earin"+ speech+ and si"ht ) Hndurance+ stren"th+ and mobility K #) >earnin"+ creati!ity+ and 3ud"ment

%) alance+ fle7ibility+ and coordination &e!iew Information' The correct answer is #' >earnin"+ creati!ity and 3ud"ment #o"niti!e impairments are due to physiolo"ical processes that affect memory and other co"niti!e processes. 4. In a lon" term rehabilitation care unit a client with spinal cord in3ury complains of a poundin" headache. The client is sittin" in a wheelchair watchin" tele!ision in the assi"ned room. 0urther assessment by the nurse re!eals e7cessi!e sweatin"+ a splotchy rash+ pilomotor erection+ facial flushin"+ con"ested nasal passa"es and a heart rate of 68. The nurse should do which action ne7t? Take the client=s respirations+ blood pressure A ?)+ temperature A) and then pupillary responses ?lace the client into the bed and administer the ordered ?&C ) anal"esic #heck the client for bladder distention and the client=s urinary K #) catheter for kinks Turn the tele!ision off and then assist client to use rela7ation %) techni1ues &e!iew Information' The correct answer is #' #heck the client for bladder distention and the client==s urinary catheter for kinks These are findin"s of autonomic dysrefle7ia+ also called hyperrefle7ia. This response occurs in clients with a spinal cord in3ury abo!e the T-< le!el. It is typically initiated by any no7ious stimulus below the le!el of in3ury such as a full bladder+ an enema or bowel mo!ement+ fecal impaction+ uterine contractions+ chan"in" of the catheter+ and !a"inal or rectal e7aminations. The stimulus creates an e7a""erated response of the sympathetic ner!ous system and can be a lifethreatenin" e!ent. The ? is typically e7tremely hi"h. The priority action of the nurse is to identify and relie!e the cause of the stimulus. 4. The nurse is performin" a physical assessment on a client with insulin dependent diabetes mellitus. .hich client complaint calls for immediate nursin" action? K A) %iaphoresis and shakiness ) &educed lower le" sensation #) Intense thirst and hun"er %) ?ainful hematoma on thi"h &e!iew Information' The correct answer is A' %iaphoresis and shakiness %iaphoresis is a si"n of hypo"lycemia which warrants immediate attention. 6. The nurse is teachin" a client about the healthy use of e"o defense mechanisms. An appropriate "oal for this client would be K A) &educe fear and protect self-esteem ) $inimi5e an7iety and delay apprehension #) A!oid conflict and lea!e unpleasant situations %) Increase independence and communicate more often &e!iew Information' The correct answer is A' &educe fear and protect selfesteem H"o defense mechanisms are unconscious proacti!e barriers that are used to mana"e instinct and affect the presence of stressful situations. @ealthy reactions are those in which the client admits that they are feelin" !arious emotions. <. In re!iewin" the assessment data of a client suspected of ha!in" diabetes insipidus+ the nurse e7pects which of the followin" after a water depri!ation test? A) Increased edema and wei"ht "ain K ) *nchan"ed urine specific "ra!ity #) &apid protein e7cretion %) %ecreased blood potassium &e!iew Information' The correct answer is ' *nchan"ed urine specific "ra!ity .hen fluids are restricted+ the client continues to e7crete lar"e amounts of dilute urine. This findin" supports the dia"nosis. Cormally+ urine is more concentrated with reduced fluid intake. -. The nurse is e!aluatin" the "rowth and de!elopment of a toddler with AI%(. The nurse would anticipate findin" that the child has A) Achie!ed de!elopmental milestones at an erratic rate ) %elay in musculoskeletal de!elopment #) %isplayed difficulty with speech de!elopment K %) %elay in achie!ement of most de!elopmental milestones &e!iew Information' The correct answer is %' %elayed in achie!in" all de!elopmental milestones The ma3ority of children with AI%( ha!e neurolo"ical in!ol!ement. There is decreased brain "rowth as e!idenced by microcephaly and abnormal neurolo"ic findin"s. %e!elopmental delays are common+ or after achie!in" normal de!elopment+ there may be loss of milestones. The other options are correct but are too specific to be the best response. ,. A client was admitted with a dia"nosis of pneumonia. .hen auscultatin" the client=s breath sounds+ the nurse hears inspiratory crackles in the ri"ht base. Temperature is 18).4 de"rees 0arenheit orally. .hat findin" would the nurse e7pect? A) 0lushed skin ) radycardia K #) $ental confusion %) @ypotension &e!iew Information' The correct answer is #' $ental confusion

#rackles su""est pneumonia+ which is likely to be accompanied by mental confusion related to hypo7ia. 9. ?ostoperati!e orders for a client under"oin" a mitral !al!e replacement include monitorin" pulmonary artery pressure to"ether with pulmonary capillary wed"e pressure with a pulmonary artery catheter. This action by the nurse will assess A) &i"ht !entricular pressure K ) >eft !entricular end-diastolic pressure #) Acid- ase balance %) #oronary artery stability &e!iew Information' The correct answer is ' >eft !entricular enddiastolic pressure The pulmonary capillary wed"e pressure is reflecti!e of left !entricular end-diastolic pressure. ?ulmonary artery pressures are an assessment tool used to determine the ability of the heart to recei!e and pump blood effecti!ely. 18. The nurse is pro!idin" instructions for a client with asthma who is sensiti!e to house dust-mites. .hich information about pre!ention of asthma episodes would be the most helpful to include durin" the teachin"? A) #han"e the pillow co!ers e!ery month ) .ash bed linens in warm water with a cold rinse K #) .ash and rinse the bed linens in hot water %) *se air filters in the furnace system &e!iew Information' The correct answer is #' .ash and rinse the bed linens in hot water 0or asthma clients who are sensiti!e to house dust-mites it is essential the mattresses and pillows are encased in aller"en-impermeable co!ers. All bed linens such as pillow cases+ sheets and blankets should be washed and rinsed weekly in hot water at temperatures abo!e 148 de"rees 0ahrenheit+ the temperature necessary to kill the dust-mites. 11. A client is recei!in" o7y"en therapy !ia a nasal cannula. .hen pro!idin" nursin" care+ which of the followin" inter!entions would be appropriate? A) %etermine that ade1uate mist is supplied K ) Inspect the nares and ears for skin breakdown #) >ubricate the tips of the cannula before insertion %) $aintain sterile techni1ue when handlin" cannula &e!iew Information' The correct answer is ' Inspect the nares and ears for skin breakdown ;7y"en therapy can cause dryin" of the nasal mucosa. ?ressure from the tubin" can cause skin irritation. 1). The nurse is carin" for a client with ?arkinson=s disease. The client spends o!er 1 hour to dress for scheduled therapies. .hat is the most appropriate action for the nurse to take in this situation? A) Ask family members to dress the client ) Hncoura"e the client to dress more 1uickly K #) Allow the client the time needed to dress %) %emonstrate methods on how to dress more 1uickly &e!iew Information' The correct answer is #' Allow the client the time needed to dress #lients with ?arkinson==s disease often wish to take care of themsel!es but become !ery upset when hurried and then are unable to mana"e at all. Any form of hurryin" the client will result in a !ery upset and nonfunctionin" client. 14. The nurse is assessin" a 1) year-old who has @emophilia A. .hich findin" would the nurse anticipate? A) An e7cess of red blood cells ) An e7cess of white blood cells K #) A deficiency of clottin" factor BIII %) A deficiency of clottin" factors BIII and IP &e!iew Information' The correct answer is #' A deficiency of clottin" factor BIII @emophilia A is characteri5ed by an absence or deficiency of 0actor BIII. 14. The nurse is assessin" a newborn infant and obser!es low set ears+ short palpebral fissures+ flat nasal brid"e and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about K A) Alcohol use durin" pre"nancy ) *sual nutritional intake #) 0amily "enetic disorders %) $aternal and paternal a"es &e!iew Information' The correct answer is A' Alcohol use durin" pre"nancy The identification of this cluster of facial characteristics is often linked to fetal alcohol syndrome. 16. A ) month-old infant has both a cleft lip and palate which will be repaired in sta"es. In the immediate postoperati!e period for a cleft lip repair+ which nursin" approach should be the priority? K A) &emo!e protecti!e arm de!ices one at a time for short periods

with super!ision Initiate by mouth feedin"s when alert+ with the return of the "a" ) refle7 Introduce to the parents how to cleanse the suture line with the #) prescribed protocol %) ?osition the infant on the back after feedin"s throu"hout the day &e!iew Information' The correct answer is A' &emo!e protecti!e arm de!ices one at a time for short periods with super!ision The ma3or efforts in the postoperati!e period are directed toward protectin" the operati!e site. Hlbow restraints should be used and only 1 arm released at a time with close super!ision by the nurse andGor parents. 1<. The new "raduate nurse inter!iews for a position in a nursin" department of a lar"e health care a"ency+ described by the inter!iewer as ha!in" shared "o!ernance. .hich of these statements best illustrates the shared "o!ernance model? A) An appointed board o!ersees any administrati!e decisions K ) Cursin" departments share responsibility for client outcomes (taff "roups are appointed to discuss nursin" practice and client #) education issues %) Con-nurse mana"ers super!ise nursin" staff in "roups of units &e!iew Information' The correct answer is ' Cursin" departments share responsibility for client outcomes (hared "o!ernance or self-"o!ernance is a method of or"ani5ational desi"n that promotes empowerment of nurses to "i!e them responsibility for client care issues. 1-. The nurse is teachin" childbirth preparation classes. ;ne woman asks about her ri"hts to de!elop a birthin" plan. .hich response made by the nurse would be best? A) ".hat is your reason for wantin" such a plan?" ) "@a!e you talked with your health care pro!ider about this?" K #) ">et us discuss your ri"hts as a couple." %) ".rite your ideal plan for the ne7t class." &e!iew Information' The correct answer is #' ">et us discuss your ri"hts as a couple." %iscussion of the health care pro!ider==s role and the couple==s ri"hts and limitations in selectin" birth options must precede de!elopment of a plan. 1,. A client is admitted with the dia"nosis of myocardial infarction A$I). .hich of the followin" lab !alues would be consistent with this dia"nosis A) >ow serum albumin ) @i"h serum cholesterol #) Abnormally low white blood cell count K %) Hle!ated creatinine phosphokinase A#?M ) &e!iew Information' The correct answer is %' Hle!ated #?M Acreatinine phosphokinase) An ele!ated #?M is a common findin" in the client with an $I. #M le!els be"in to rise appro7imately 4 to 1) hours after an acute $I+ peak in )4 hours+ and return to normal within ) to 4 days. Troponin le!els rise as well. 19. A client tells the nurse he is fearful of planned sur"ery because of e!il thou"hts about a family member. .hat is the best initial response by the nurse? A) #all a chaplain ) %eny the feelin"s #) #ite reco!ery statistics K %) >isten to the client &e!iew Information' The correct answer is %' >isten to the client Therapeutic communications are based on attenti!e listenin" to e7pressed feelin"s. If the nurse is not familiar with the cultural beliefs of a client+ acceptance of feelin"s is followed by 1uestions about the beliefs. )8. A 14 month-old had cleft palate sur"ical repair se!eral days a"o. The parents ask the nurse about feedin"s after dischar"e. .hich lunch is the best e7ample of an appropriate meal? A) @ot do"+ carrot sticks+ "elatin+ milk K ) (oup+ blenderi5ed soft foods+ ice cream+ milk #) ?eanut butter and 3elly sandwich+ chips+ puddin"+ milk %) aked chicken+ applesauce+ cookie+ milk &e!iew Information' The correct answer is ' (oup+ blenderi5ed soft foods+ ice cream+ milk In a child with cleft palate repair+ parents should prepare soft foods and a!oid those foods with particles that mi"ht traumati5e the sur"ical site. )1. The &C is plannin" care at a team meetin" for a ) month-old child in bilateral le" casts for con"enital clubfoot. .hich of these su""estions by the ?C should be considered the priority nursin" "oal followin" cast application? A) Infant will e7perience minimal pain ) $uscle spasms will be relie!ed #) $obility will be mana"ed as tolerated K %) Tissue perfusion will be maintained &e!iew Information' The correct answer is %' Tissue perfusion will be maintained Immediately followin" cast application+ the chief "oal is to maintain circulation and tissue perfusion around the cast. ?ermanent tissue dama"e can occur within a few hours if perfusion is not maintained.

)). The nurse would e7pect which eatin" disorder to ha!e the "reatest fluctuations in potassium? A) in"e eatin" disorder ) Anore7ia ner!osa K #) ulemia %) ?ur"e syndrome &e!iew Information' The correct answer is #' ulemia .ith bulemia the pur"in" process tends to make your body dehydrated and to lower the le!el of potassium in your blood. >ow potassium le!els can cause weakness+ abdominal crampin" and irre"ular heart rhythms. )4. .hen plannin" the care for a youn" adult client dia"nosed with anore7ia ner!osa which of these concerns should the nurse determine to be the priority for lon" term mobility? A) %i"esti!e problems K ) Amenorrhea #) Hlectrolyte imbalance %) lood disorders &e!iew Information' The correct answer is ' Amenorrhea #han"es in reproducti!e hormones and in thyroid hormones can cause absence of mestruation called amenorrhea which contributes to osteoporosis and bone fractures. )4. The nurse is plannin" care for a client with increased intracranial pressure. The best position for this client is A) Trendelenber" ) ?rone K #) (emi-0owlers %) (ide-lyin" with head flat &e!iew Information' The correct answer is #' (emi-0owlers $aintainin" the head of the bed at 16-48 de"rees reduces cerebral !enous con"estion )6. .hile performin" an initial assessment on a newborn followin" a breech deli!ery+ the nurse suspects hip dislocation. .hich of the followin" is most su""esti!e of the abnormality? A) 0le7ion of lower e7tremities ) Ce"ati!e ;rtlani response #) >en"thened le" of affected side K %) Irre"ular hip symmetry &e!iew Information' The correct answer is %' Irre"ular hip symmetry Harly assessment of irre"ular hip symmetry alerts the nurse and the health care pro!ider to a correctable con"enital hip dislocation. )<. The nurse is carin" for a client admitted to the hospital with ri"ht lower lobe A&>>) pneumonia. ;n assessment+ the nurse notes crackles o!er the &>>. The client has si"nificant pleuritic pain and is unable to take in a deep breath in order to cou"h effecti!ely. .hich nursin" dia"nosis would be most appropriate for this client based on this assessment data? Impaired "as e7chan"e related to acute infection and sputum A) production Ineffecti!e airway clearance related to sputum production and K ) ineffecti!e cou"h #) Ineffecti!e breathin" pattern related to acute infection %) An7iety related to hospitali5ation and role conflict &e!iew Information' The correct answer is ' Ineffecti!e airway clearance related to sputum production and ineffecti!e cou"h Ineffecti!e airway clearance is defined as the inability to cou"h effecti!ely. .hile the other dia"noses may be appropriate for this client+ this is the only one supported directly by the assessment data "i!en. )-. A youn" child is admitted for treatment of lead poisonin". The nurse reco"ni5es that the most serious effect of chronic lead poisonin" is K A) #entral ner!ous system dama"e ) $oderate anemia #) &enal tubule dama"e %) /rowth impairment &e!iew Information' The correct answer is A' #entral ner!ous system dama"e The most serious conse1uences of chronic lead poisonin" occur in the central ner!ous system. Ceural cells are destroyed by the to7ic effects of the lead resultin" in many problems with the intellect ran"in" from mild deficits to mental retardation and e!en death. ),. At a nursin" staff meetin"+ there is discussion of percei!ed ine1uities in weekend staff assi"nments. As a follow-up+ the nurse mana"er should initially A) Allow the staff to chan"e assi"nments ) #larify reasons for current assi"nments #) @elp staff see the comple7ity of issues

K %) 0acilitate creati!e thinkin" on staffin" &e!iew Information' The correct answer is %' 0acilitate creati!e thinkin" on staffin" The "mo!in" phase" of chan"e in!ol!es !iewin" the problem from a new perspecti!e+ incorporatin" new and different approaches to the problem. The mana"er can facilitate staff==s sol!in" the problem. )9. A client is admitted with a dia"nosis of myocardial infarction A$I). The client is complainin" of chest pain. The nurse knows that pain related to an $I is due to K A) Insufficient o7y"enation of the cardiac muscle ) ?otential circulatory o!erload #) >eft !entricular o!erload %) Hlectrolyte imbalance &e!iew Information' The correct answer is A' Insufficient o7y"enation of the cardiac muscle %ue to ischemia to the heart muscle+ the client e7periences pain. This happens because an $I can block or interfere with the normal cardiac circulation. 48. A client was re-admitted to the hospital followin" a recent skull fracture. .hich findin" re1uires the nurse=s immediate attention? K A) >ethar"y ) A"itation #) Ata7ia %) @earin" loss &e!iew Information' The correct answer is A' >ethar"y The le!el of consciousness or responsi!eness is the most important measure of the client==s risin" intracranial pressure. >ook for lethar"y+ delay in response to !erbal su""estions and slowin" of speech. Assess for risin" blood pressure or widenin" pulse pressure and for respiratory irre"ularities. There may be !omitin" but it is usually pro3ectile without the presence of nausea. 41. Fou are teachin" a client about the patient controlled anal"esia A?#A) planned for post-operati!e care. .hich indicates further teachin" may be needed by the client? A) "I will be recei!in" continuous doses of medication." K ) "I should call the nurse before I take additional doses." #) "I will call for assistance if my pain is not relie!ed." %) "The machine will pre!ent an o!erdose." &e!iew Information' The correct answer is ' "I should call the nurse before I take additional doses." ?atient controlled anal"esia offers the client more control. The client should be instructed to initiate additional doses as needed without askin" for assistance unless there is insufficient control of the pain. 4). .hen carin" for a client with ad!anced cirrhosis of the li!er+ which nursin" dia"nosis should take priority? K A) &isk for in3ury' hemorrha"e ) &isk for in3ury related to peripheral neuropathy #) Altered nutrition' less than body re1uirements %) 0luid !olume e7cess' ascites &e!iew Information' The correct answer is A' &isk for in3ury' hemorrha"e >i!er disease interferes with the production of prothrombin and other factors essential for blood clottin". @emorrha"e+ especially from esopha"eal !arices can be life threatenin". This takes priority o!er the other nursin" dia"nosis. 44. The nurse is carin" for a client with left !entricular heart failure. .hich one of the followin" assessments is an early indication of inade1uate o7y"en transport? A) #rackles in the lun"s K ) #onfusion and restlessness #) %istended neck !eins %) *se of accessory muscles &e!iew Information' The correct answer is ' #onfusion and restlessness Ceurolo"ical chan"es are early si"ns of inade1uate o7y"enation. 44. ;n initial e7amination of a 16 month-old child with suspected otitis media+ which "roup of findin"s would the &C anticipate findin"? ?eriorbital edema+ absent li"ht refle7 and translucent tympanic A) membrane K ) Irritability+ rhinorrhea+ and bul"in" tympanic membrane %iarrhea+ retracted tympanic membrane and enlar"ed parotid #) "land %) Bomitin"+ pullin" at ears and pearly white tympanic membrane &e!iew Information' The correct answer is ' Irritability+ rinorrhea+ and bul"in" tympanic membrane #linical manifestations of otitis media include irritability+ rinorrhea+ bul"in" tympanic membrane+ and pullin" at ears. 46. A child with Tetralo"y of 0allot !isits the clinic se!eral weeks before planned sur"ery. The nurse should "i!e priority attention to K A) Assessment of o7y"enation ) ;bser!ation for de!elopmental delays #) ?re!ention of infection %) $aintenance of ade1uate nutrition &e!iew Information' The correct answer is A' Assessment of o7y"enation All of the abo!e would be important in a child dia"nosed with Tetralo"y of 0allot. @owe!er+ persistent hypo7emia causes acidosis which further decreases

pulmonary blood flow. Additionally+ low o7y"enation leads to de!elopment of polycythemia and resultant neurolo"ic complications. 4<. .hen teachin" new parents to pre!ent (udden Infant %eath (yndrome A(I%() what is the most important practice the nurse should instruct them to do? K A) ?lace the infant in a supine or side lyin" position for sleep ) %o not allow anyone to smoke in the home #) 0ollow recommended immuni5ation schedule %) e sure to check infant e!ery one hour &e!iew Information' The correct answer is A' ?lace the infant in a supine or side lyin" position for sleep #urrent thinkin" is that infants become hypo7ic when they sleep because of positional narrowin" of the airway and respiratory inflammation. The most compellin" data comes from studies that link sleep habits with an increased risk of (I%(. (leepin" in the prone position may cause oropharyn"eal obstruction or affect the thermal balance or arousal state. (leep apnea is not the cause of (I%(. ecause of research findin"s and the " ack to (leep" campai"n+ that number and the number of (I%( deaths has dropped dramatically. 4-. A client is admitted with a distended bladder due to the inability to !oid. The nurse obtains an order to catheteri5e the client knowin" that "radual emptyin" is preferred o!er complete emptyin" because it A) &educes the potential for renal collapse K ) &educes the potential for shock #) &educes the intensity of bladder spasms %) ?re!ents bladder atrophy &e!iew Information' The correct answer is ' &educes the potential for shock #omplete+ rapid emptyin" can cause shock and hypotension due to sudden chan"es in the abdominal ca!ity. 4,. The nurse is assessin" a client with a deep !ein thrombosis. .hich of the followin" si"ns andGor symptoms would the nurse anticipate findin"? A) &apid respirations ) %iaphoresis K #) (wellin" of lower e7tremity %) ?ositi!e abinski=s si"n &e!iew Information' The correct answer is #' (wellin" of lower e7tremity The most common si"ns of deep !ein thrombosis are pain in the re"ion of the thrombus and unilateral swellin" distal to the site. 49. A < year-old female is dia"nosed with recurrent urinary tract infections A*TI). .hich one of the followin" instructions would be best for the nurse to tell the care"i!er? A) Increase bladder tone by delayin" !oidin" ) .hen launderin" clothin"+ rinse se!eral times K #) *se plain water for the bath+ shampooin" hair last %) @a!e the child use antibacterial soaps while bathin" &e!iew Information' The correct answer is #' *se plain water for the bath+ shampooin" hair last @air should be shampooed last with a rinsin" of plain water o!er the "enital area. The oils in soaps and bubble bath can cause irritation+ which may lead to *TI==s in youn" "irls. 48. A woman comes to the antepartum clinic for a routine prenatal e7amination. (he is 1) weeks pre"nant with her second child. .hich of the followin" shows proper documentation of the client=s obstetric history by the nurse? A) ?ara )+ /ra!ida 1 ) Culli"ra!ida )+ ?ara 1 #) ?rima"ra!ida 1+ ?ara 1 K %) /ra!ida )+ ?ara 1 &e!iew Information' The correct answer is %' /ra!ida )+ ?ara 1 /ra!ida describes a woman who is or has been pre"nant+ re"ardless of pre"nancy outcome. ?ara describes the number of babies born past a point of !iability. Therefore a woman pre"nant with her second child would be described as /ra!ida )+ ?ara 1. ?rimipara refers to a woman who has completed one pre"nancy to the period of !iability. $ultipara refers to a woman who has completed ) or more pre"nancies to the sta"e of !iability. &esults for QYA-&andom W< 1. ;n admission to the hospital a client with an acute asthma episode has intermittent nonproducti!e cou"hin" and a pulse o7imeter readin" of ,,:. The client states+ EI feel like this is "oin" to be a bad time this admission. I wish I would not ha!e "one into that bar with all those people who smoke last ni"ht.D .hich nursin" dia"noses would be most important for this client? A) An7iety related to hospitali5ation ) Ineffecti!e airway clearance related to potential thick secretions #) Altered health maintenance related to pre!entati!e beha!iors

associated with asthma Impaired "as e7chan"e related to bronchoconstriction and K %) mucosal edema &e!iew Information' The correct answer is %' Impaired "as e7chan"e related to bronchoconstriction and mucosal edema ?ulse o7imetry reflects o7y"enation of arterial blood. .hile the other dia"noses may be appropriate for this client they are not the most appropriate or priority. ). A client returned from sur"ery for a perforated appendi7 with locali5ed peritonitis. In !iew of this dia"nosis+ how would the nurse position the client? A) ?rone ) %orsal recumbent K #) (emi-0owler %) (upine &e!iew Information' The correct answer is #' (emi-0owler The semi-0owler position assists draina"e and pre!ents spread of infection throu"hout the abdominal ca!ity. 4. .hile carin" for a client with infecti!e endocarditis+ the nurse must be alert for si"ns of pulmonary embolism. .hich of the followin" assessment findin"s su""ests this complication? A) ?ositi!e @oman=s si"n ) 0e!er and chills K #) %yspnea and cou"h %) (ensory impairment &e!iew Information' The correct answer is #' %yspnea and cou"h Be"etation from the infected heart !al!es often leads to pulmonary embolism in the client with infecti!e endocarditis. #ou"h+ pleuritic chest pain and dyspnea are early symptoms. 4. .hile assessin" an &h positi!e newborn whose mother is &h ne"ati!e+ the nurse reco"ni5es the risk for hyperbilirubinemia. .hich of the followin" should be reported immediately? A) Saundice e!ident at )< hours ) @ematocrit of 66: K #) (erum bilirubin of 1)m" %) ?ositi!e #oomb=s test &e!iew Information' The correct answer is #' (erum bilirubin of 1)m" The ele!ated bilirubin is in the ran"e that re1uires immediate inter!ention+ such as phototherapy. At a serum bilirubin of 1) m".+ the neonate is at risk for the de!elopment of kerniterus+ or bilirubin encephalopathy. The health care pro!ider determines the therapy appropriate after re!iewin" all laboratory findin"s. 6. The school nurse is called to the play"round for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been a!ulsed A"knocked out"). After reco!erin" the tooth+ the initial response should be to K A) &inse the tooth in water before placin" it in the socket ) ?lace the tooth in a clean plastic ba" for transport to the dentist #) @old the tooth by the roots until reachin" the emer"ency room %) Ask the child to replace the tooth e!en if the bleedin" continues &e!iew Information' The correct answer is A' &inse the tooth in water before placin" it in the socket 0ollowin" a!ulsion of a permanent tooth+ it is important to rinse the dirty tooth in water+ saline solution or milk before re-implantation. If possible+ replace the tooth in its socket within 48 minutes+ a!oidin" contact with the root. The child should be taken to the dentist as soon as possible. <. The nurse is carin" for a 4 year-old child with a "reenstick fracture. In e7plainin" this type of fracture to the parents+ the best response by the nurse should be that A child=s bone is more fle7ible and can be bent 46 de"rees before A) breakin" ones of children are more porous than adults and often ha!e K ) incomplete breaks #ompression of porous bones produces a buckle or torus type #) break %) one fra"ments often remain attached by a periosteal hin"e &e!iew Information' The correct answer is ' ones of children are more porous than adults and often ha!e incomplete breaks The pliable bones of "rowin" children are more porous than those of the adult+ which allows them to bend+ buckle+ and break in a ""reenstick" manner. A "reenstick fracture occurs when a bone is an"ulated beyond the limits of bendin". The compressed side bends and the tension side fails+ causin" an incomplete fracture. -. %urin" the be"innin" shift assessment of a client with asthma and is recei!in" o7y"en per nasal cannula at ) liters per minute+ the nurse would be most concerned about which unreported findin"? A) ?ulse o7imetry readin" of ,9: ) #rackles at the base of the lun"s on auscultation K #) &apid shallow respirations with intermittent whee5es %) H7cessi!e thirst with a dry cracked ton"ue &e!iew Information' The correct answer is #' &apid shallow respirations with intermittent whee5es ;f the "i!en findin"s this has the "reatest risk for potential complications. (hallow and rapid respirations may indicate that the client is loosin" muscle stren"th

re1uired to breath. The intermittent whee5es could be an indication of more narrowed small airways and a worsenin" condition. ,. %urin" the care of a client with >e"ionnaire=s disease+ which findin" would re1uire the nurse=s immediate attention? A) ?leuritic pain on inspiration ) %ry mucus membranes in the mouth #) A decrease in respiratory rate from 44 to )4 K %) %ecrease in chest wall e7pansion &e!iew Information' The correct answer is %' %ecrease in chest wall e7pansion The respiratory status of a client with this acute bacterial pneumonia known as >e"ionnaires== disease is critical. Cote that all of these findin"s would be of a concern. The task is to select the priority concern. #hest wall e7pansion reflects a possible decrease in the depth and effort of respirations. 0urther findin"s of restlessness may indicate hypo7emia. If these occurred the client may then need mechanical !entilation. ;ption A is e7pected with such infections of the lun". ;ption indicates dehydration which may result in thick sputum which is most difficult to cou"h up. ;ption # is a desired effect of therapy. 9. A child and his family were e7posed to $ycobacterium tuberculosis about ) months a"o+ to confirm the presence or absence of an infection+ it is most important for all family members to ha!e a A) #hest 7-ray ) lood culture #) (putum culture K %) ??% intradermal test &e!iew Information' The correct answer is %' ??% intradermal test The administration of the ??% intradermal test determines the presence of the infection with the $ycobacterium tuberculosis or"anism. It is effecti!e at 4 to < weeks after the initial infection. 18. The nurse is assi"ned to a client with ?arkinson=s disease. .hich findin"s would the nurse anticipate? A) Conintention tremors and ur"ency with !oidin" K ) Hcholalia and a shufflin" "ait #) $uscle spasm and a bent o!er posture %) Intention tremor and 3erky mo!ement of the elbows &e!iew Information' The correct answer is ' Hcholalia and a shufflin" "ait #lients with ?arkinson==s disease ha!e a !ery distincti!e "ait with 1uick short steps Ashufflin") which may increase in speed so that they are unable to stop. They also ha!e echolalia which means the repeatin" of phrases or words that are directed to them durin" con!ersation. In the other options only part of the option is associated with ?arkinson2s disease' nonintention tremors+ bent o!er posture+ and the co"wheel or 3erky mo!ement of the elbows. 11. .hich of these statements by the nurse is incorrect to use to reinforce information about cancers to a "roup of youn" adults? Fou can reduce your risk of this serious type of stomach cancer K A) by eatin" lots of fruits and !e"etables+ limitin" all meat+ and a!oidin" nitrate-containin" foods. ?rostate cancer is the most common cancer in American men ) with results to threaten se7uality and life. #olorectal cancer is the second-leadin" cause of cancer-related #) deaths in the *nited (tates. >un" cancer is the leadin" cause of cancer deaths in the *nited %) (tates. Fet it=s the most pre!entable of all cancers. &e!iew Information' The correct answer is A. It is recommended that only red meat limited for the pre!ention of stomach cancer. All of the other statements are correct information. 1). A <- year-old client is admitted with substernal chest pain with radiation to the 3aw. @is admittin" dia"nosis is Acute $yocardial Infraction A$I). The priority nursin" dia"nosis for this client durin" the immediate )4 hours is A) #onstipation related to immobility ) @i"h risk for infection K #) Impaired "as e7chan"e %) 0luid !olume deficit &e!iew Information' The correct answer is #' Impaired "as e7chan"e In the immediate post $I period impaired "as e7chan"e related to o7y"en supply and demand is a ma3or problem. 14. .ith an alert of an internal disaster and the need for beds+ the char"e nurse is asked to list clients who are potential dischar"es within the ne7t hour. .hich client should the char"e nurse select? An elderly client who has had type ) diabetes for o!er )8 years+ K A) admitted with diabetic ketoacidosis )4 hours a"o ) An adolescent admitted the prior ni"ht with Tylenol into7ication A middle a"ed client with an internal automatic defibrilator and #) complaints of Epassin" out at unknown timesD admitted yesterday

A school a"e child dia"nosed with suspected bacterial menni"itis and was admitted at the chan"e of shifts &e!iew Information' The correct answer is A' An elderly client who has had type ) diabetes for o!er )8 years+ admitted with diabetic ketoacidosis )4 hours a"o This client is the most stable and has a chronic condition. Tylenol into7ication re1uires at least 4 to 4 days of intensi!e obser!ation for the risk of hepatic failure. The other clients are considered unstable. %) 14. The nurse is assessin" a newborn the day after birth. A hi"h pitched cry+ irritability and lack of interest in feedin" are noted. The mother si"ned her own dischar"e a"ainst medical ad!ice. .hat inter!ention is appropriate nursin" care? K A) &educe the en!ironmental stimuli ) ;ffer formula e!ery ) hours #) Talk to the newborn while feedin" %) &ock the baby fre1uently &e!iew Information' The correct answer is A' &educe the en!ironmental stimuli This newborn appears to be withdrawin" from substances taken by the mother before its birth. &educin" noise and li"ht will reduce the central ner!ous system responses to stimuli. 16. A hospitali5ed child suddenly has a sei5ure while his family is !isitin". The nurse notes whole body ri"idity followed by "eneral 3erkin" mo!ements. The child !omits immediately after the sei5ure. A priority nursin" dia"nosis for the child is A) @i"h risk for infection related to !omitin" ) Altered family processes related to chronic illness #) 0luid !olume deficit related to !omitin" K %) &isk for aspiration related to loss of consciousness &e!iew Information' The correct answer is %' &isk for aspiration related to loss of consciousness The tonic-clonic sei5ure appears suddenly and often leads to brief loss of consciousness. The "reatest risk for the child is from airway blocka"e+ as mi"ht follow aspiration. 1<. A 4 month-old child takin" di"o7in A>ano7in) has a blood pressure of 9)G-,I restin" pulse of -,I respirations ), and a potassium le!el of 4., mH1G>. The client is irritable and has !omited twice since the mornin" dose of di"o7in. .hich findin" is most indicati!e of di"o7in to7icity? K A) radycardia ) >ethar"y #) Irritability %) Bomitin" &e!iew Information' The correct answer is A' radycardia The most common si"n of di"o7in to7icity in children is bradycardia Aheart rate below 188 in an infant). 1-. A @ispanic client confides in the nurse that she is concerned that staff may "i!e her newborn the "e!il eye." The nurse should communicate to other personnel that the appropriate approach is to K A) Touch the baby after lookin" at him ) Talk !ery slowly while speakin" to him #) A!oid touchin" the child %) >ook only at the parents &e!iew Information' The correct answer is A' Touch the baby after lookin" at him In many cultures+ an "e!il eye" is cast when lookin" at a person without touchin" him. Thus+ the spell is broken by touchin" while lookin" or assessin". 1,. A client is admitted for #;?%. .hich findin would re1uire the nurse=s immediate attention? A) Causea and !omitin" K ) &estlessness and confusion #) >ow-"rade fe!er and cou"h %) Irritatin" cou"h and li1uefied sputum &e!iew Information' The correct answer is ' &estlessness and confusion &espiratory failure may be si"naled by e7cessi!e somnolence+ restless+ a""ressi!eness+ confusion+ central cyanosis and shortness of breath. .hen these symptoms occur+ A /s should be obtained. 19. A youn" adult male has been dia"nosed with testicular cancer. .hich of these statements by this client would need to be e7plored by the nurse to clarify information? This sur"ical procedure in!ol!es remo!in" one or both testicles A) throu"h a cut in the "roin. $y lymph nodes in my lower belly also may be remo!ed. I ha!e a "ood chance to re"ain my fertility later. @owe!er if I am ) concerned+ I can ha!e my sperm fro5en and preser!ed Acryopreser!ed) before chemotherapy. If I ha!e cancer at sta"e 4 it means I ha!e less in!ol!ement of K #) the cancer. After the sur"ical remo!al of a testicle+ I can ha!e an artificial %) testicle Aprosthesis) placed inside my scrotum. This artificial implant has the wei"ht and feel of a normal testicle. &e!iew Information' The correct answer is #' If I ha!e cancer at sta"e 4 it means I ha!e less in!ol!ement of the cancer. (ta"e 4 is the most e7tensi!e in!ol!ement of cancer with any type.

)8. A newly appointed nurse mana"er is ha!in" difficulties with time mana"ement. .hich ad!ice from an e7perienced mana"er should the new mana"er do initially? (et daily "oals and establish priorities for each hour and each A) day. ) Ask for additional assistance when you feel o!erwhelmed. K #) Meep a time lo" of your day in hourly blocks for at least 1 week. #omplete each task before be"innin" another acti!ity in selected %) instances. &e!iew Information' The correct answer is #' Meep a time lo" of your day in hourly blocks for at least 1 week. Apply the nursin" process to time mana"ement in that assessment of the current acti!ities is the initial step. A baseline is established for acti!ities and time use so that needed chan"es can be pinpointed. )1. The nurse and a student nurse are discussin" the specific points about infants born to @ sA"-positi!e mothers. .hich of these comments by the student indicates a need for clarification of information? "The infant will "et the hepititis !accine A@ep ) and the A) hepatitis immune "lobulin within 1) hours at birth at separate in3ection sites." ) "The second dose can be "i!en at 1 to ) months of a"e." "The third dose should be "i!en at least 1< weeks from the K #) second dose." "The last dose in the series is not to be "i!en before a"e )4 %) weeks." &e!iew Information' The correct answer is #' "The third dose should be "i!en at least 1< weeks from the second dose." The third dose is to be "i!en 1< weeks from the first dose and , weeks from the second dose. All of the other options are correct information. These infants will also need to ha!e the blood tested for hepatitis titers and antibodies between 9 and 16 months. )). A -4 year-old male is admitted due to inability to !oid. @e has a history of an enlar"ed prostate and has not !oided in 14 hours. .hen assessin" for bladder distention+ the best method for the nurse to use is to assess for A) &ebound tenderness ) >eft lower 1uadrant dullness K #) &ounded swellin" abo!e the pubis %) *rinary dischar"e &e!iew Information' The correct answer is #' &ounded swellin" abo!e the pubis (wellin" abo!e the pubis is representati!e of a distended bladder in the male client. )4. .hich one of the followin" statements+ if made by the client+ indicates teachin" about Inderal Apropranolol) has been effecti!e? A) "I may e7perience sei5ures if I stop the medication apruptly." ) " I may e7perience an increase in my heart rate for a few weeks." #) D I can e7pect to feel ner!ousness the first few weeks." K %) E I can ha!e a heart attack if I stop this medication suddenly." &e!iew Information' The correct answer is %' E I can ha!e a heart attack if I stop this medication suddenly." %iscontinuin" beta blockers suddenly can cause an"ina+ hypertension+ dysrhythmias+ or an $I. )4. A < month-old infant who is bein" treated for de!elopmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to A) /ently rub the skin with a cotton swab to relie!e itchin" ) ?lace the fa!orite books and push-pull toys in the crib To check e!ery few hours for the ne7t day or ) for swellin" in the K #) baby=s feet %) Turn the baby with the abduction stabili5er bar e!ery ) hours &e!iew Information' The correct answer is #' To check fre1uently for swellin" in the baby==s feet A child in a hip spica cast must be checked for circulatory impairment. ;bser!e e7tremities for swellin"+ discoloration+ mo!ement and sensation. 0or children beyond the neonatal period+ traction andGor sur"ery followed by hip spica castin" is usually needed. )6. The nurse is teachin" a client with cardiac disease about the anatomy and physiolo"y of the heart. .hich is the correct pathway of blood flow throu"h the heart? A) &i"ht !entricle+ left !entricle+ ri"ht atrium+ left atrium ) >eft !entricle+ ri"ht !entricle+ left atrium+ ri"ht atrium K #) &i"ht atrium+ ri"ht !entricle+ left atrium+ left !entricle %) &i"ht atrium+ left atrium+ ri"ht !entricle+ left !entricle &e!iew Information' The correct answer is #' &i"ht atrium+ ri"ht !entricle+ left atrium+ left !entricle The pathway of blood flow throu"h the heart is ri"ht atrium+ ri"ht !entricle+ left atrium+ left !entricle.

)<. The nurse mana"er has a nurse employee who is suspected of a problem with chemical dependency. .hich inter!ention would be the best approach by the nurse mana"er? A) #onfront the nurse about the suspicions in a pri!ate meetin" (chedule a staff conference+ without the nurse present+ to collect ) information #onsult the human resources department about the issue and K #) needed actions %) #ounsel the employee to resi"n to a!oid in!esti"ation &e!iew Information' The correct answer is #' #onsult the human resources department about the issue and needed actions To a!oid le"al repercussions+ the nurse needs to consult with the human resources department for proper procedure for documentation and counselin". The employee may be protected under the Americans with %isabilities Act. )-. The nurse would teach a client with &aynaud=s phenomenon that it is most important to K A) (top smokin" ) Meep feet dry #) &educe stress %) A!oid caffeine &e!iew Information' The correct answer is A' (top smokin" The most important teachin" for this client is to stop smokin". The 1uestion is askin" what is the most important teachin". The others tend to be done less fre1uently than smokin" and are less of a threat. ),. The nurse is carin" for a client with status epilepticus. The most important nursin" assessment of this client is A) Intra!enous drip rate K ) >e!el of consciousness #) ?ulse and respiration %) In3uries to the e7tremities &e!iew Information' The correct answer is ' >e!el of consciousness #erebral blood flow under"oes a )68: increase durin" sei5ure acti!ity depletin" o7y"en at the neuronal le!el. #erebral ano7ia may result in pro"ressi!e brain tissue in3ury and destruction. The nurse should monitor the client2s le!el of consciousness continuously. H!en when sei5ures are controlled+ the client may be unconscious for a while. )9. A client has been admitted for menin"itis. In re!iewin" the laboratory analysis of cerebrospinal fluid A#(0)+ the nurse would e7pect to note K A) @i"h protein ) #lear color #) Hle!ated sed rate %) Increased "lucose &e!iew Information' The correct answer is A' @i"h protein A positi!e #(0 for menin"itis would include presence of protein+ a positi!e blood culture+ decreased "lucose+ cloudy color with an increased openin" pressure+ and an ele!ated white blood cell count. 48. The hospital is plannin" to downsi5e and eliminate a number of staff positions as a cost-sa!in" measure. To assist staff in this chan"e process+ the nurse mana"er is preparin" for the "unfree5in"" phase of chan"e. .ith this approach and phase the nurse mana"er should A) %iscuss with the staff how to deal with any defensi!e beha!ior K ) H7plain to the unit staff why chan"e is necessary #) Assist the staff durin" the acceptance of the new chan"es %) #larify what the chan"es mean to the community and hospital &e!iew Information' The correct answer is ' H7plain to the unit staff why the chan"e is necessary The first phase of chan"e+ unfree5in"+ be"ins with awareness of the need for chan"e. This can be facilitated by the mana"er who clearly understands the need and stands behind it. The phase is completed when staff comprehend the need for chan"e. 41. .hich of these tests with fre1uency would the nurse e7pect to monitor for the e!aluation of clients with poor "lycemic control in persons a"ed 1, and older? A "lycosylated hemo"lobin AA1c) should be performed durin" an K A) initial assessment and durin" follow-up assessments+ which should occur at no lon"er than 4-month inter!als ) A "lycosylated hemo"lobin is to be obtained at least twice a year A fastin" "lucose and a "lycosylated hemo"lobin is to be obtained #) at 4 months inter!als after the initial assessment A "lucose tolerance test+ a fastin" "lucose and a "lycosylated %) hemo"lobin should be obtained at <-month inter!als after the initial assessment &e!iew Information' The correct answer is A' A "lycosylated hemo"lobin AA1c) should be performed durin" an initial assessment and durin" follow-up assessments+ which should occur at no lon"er than three-month inter!als American %iabetes Association AA%A) recommends obtainin" a "lycosylated hemo"lobin durin" an initial assessment and then routinely as part of continuin" care. In the absence of well-controlled studies that su""est a definite testin" protocol+ e7pert opinion recommends "lycosylated hemo"lobin be obtained at least twice a year in patients who are meetin" treatment "oals and who ha!e stable "lycemic control and more fre1uently A1uarterly assessment) in patients whose therapy was chan"ed or who are not meetin" "lycemic "oals. The "oals for persons with diabetes define the tar"et A1c le!el as less than or e1ual to <.6: or

less than -.8:. American Association of #linical Hndocrinolo"istsGAmerican #olle"e of Hndocrinolo"y AAA#HGA#H) recommends that a "lycosylated hemo"lobin be performed durin" an initial assessment and durin" follow-up assessments+ which should occur at no lon"er than three-month inter!als. $ost would a"ree+ howe!er+ that an A1c le!el "reater than 9.8: is poor control for all patient types. 4). At a routine health assessment+ a client tells the nurse that she is plannin" a pre"nancy in the near future. (he asks about preconception diet chan"es. .hich of the statements made by the nurse is best? A) "Include fibers in your daily diet." K ) "Increase "reen leafy !e"etable intake." #) "%rink a "lass of milk with each meal." %) "Hat at least 1 ser!in" of fish weekly." &e!iew Information' The correct answer is ' "Increase "reen leafy !e"etable intake." 0olic acid sources should be included in the diet and are critical in the pre-conceptual and early "estational periods to foster neural tube de!elopment and pre!ent birth defects such as spina bifida. 44. A client comes into the community health center upset and cryin" statin" EI will die of cancer now that I ha!e this disease.D And then the client hands the nurse a paper with one word written on it' "?heochromocytoma." .hich response should the nurse state initally? ?heochromocytomas usually aren=t cancerous Amali"nant). ut K A) they may be associated with cancerous tumors in other endocrine "lands such as the thyroid Amedullary carcinoma of the thyroid). This problem is dia"nosed by blood and urine tests that re!eal ) ele!ated le!els of adrenaline and noradrenaline. #omputeri5ed tomo"raphy A#T) or ma"netic resonance ima"in" #) A$&I) are used to detect an adrenal tumor. Fou probably ha!e had episodes of sweatin"+ heart poundin" and %) headaches. &e!iew Information' The correct answer is A' ?heochromocytomas usually aren==t cancerous Amali"nant). ut they may be associated with cancerous tumors in other endocrine "lands such as the thyroid Amedullary carcinoma of the thyroid). All of the options are correct information. The best response of the nurse is to address the issue presented by the client Efear of cancer.D ?heochromocytomas may release lar"e amounts of adrenaline into the bloodstream after an in3ury or durin" sur"ery. 0or this reason+ they can be life-threatenin" if unreco"ni5ed or untreated. 44. A client with chronic con"esti!e heart failure should be instructed to contact the home health nurse if which findin" occurs? K A) .ei"ht "ain of ) pounds or more in a 4, hour period ) *rinatin" 4 to 6 times each day #) A si"nificant decrease in appetite %) Appearance of non-pittin" ankle edema &e!iew Information' The correct answer is A' .ei"ht "ain of ) pounds or more in a 4, hour period It is critical for clients to report and be treated for rapid wei"ht "ain+ decreased urinary output+ worsenin" nocturnal orthopnea+ pittin" ankle edema+ and other symptoms of chronic heart failure to decrease their risk of hospitali5ation. 46. The nurse is carin" for a client on mechanical !entilation. .hen performin" endotrachial suctionin"+ the nurse will a!oid hypo7ia by A) Insertin" a fenestrated catheter with a whistle tip without suction #ompletin" suction pass in 48 seconds with pressure of 168 mm ) @" @ypero7y"enatin" with 188: ;) for 1 to ) minutes before and K #) after each suction pass $inimi5in" suction pass to <8 seconds while slowly rotatin" the %) lubricated catheter &e!iew Information' The correct answer is #' @ypero7y"enatin" with 188: ;) for 1-) minutes before and after each suction pass Administer supplemental 188: o7y"en throu"h the mechanical !entilator or manual resuscitation ba" for 1 to ) minutes before+ after and between suctionin" passes to pre!ent hypo7emia. 4<. A female client dia"nosed with "enital herpes simple7 !irus ) A@(B )) complains of dysuria+ dyspareunia+ leukorrhea and lesions on the labia and perianal skin. A primary nursin" action with the focus of comfort should be to K A) (u""est 4 to 4 warm sit5 baths per day ) #leanse the "enitalia twice a day with soap and water #) (pray warm water o!er "enitalia after urination %) Apply heat or cold to lesions as desired &e!iew Information' The correct answer is A' Hncoura"e 4 to 4 warm sit5 baths per day 0re1uent sit5 baths may sooth the area and reduce inflammation. The other actions are correct actions. @owe!er+ they would not address the entire "roup of problems.

4-. .hich findin" would be the most characteristic of an acute episode of reacti!e airway disease? A) Auditory "ur"lin" ) Inspiratory laryn"eal stridor K #) Auditory e7piratory whee5in" %) 0re1uent dry cou"hin" &e!iew Information' The correct answer is #' .hee5in" on e7piration In an acute episode of reacti!e airway disease+ breathin" is likely to be characteri5ed by whee5in" on e7piration. This sound is made as air is forced throu"h the narrowed passa"es and often is heard by the naked ear without a stethoscope. 4,. .hich tasks+ if dele"ated by the new char"e nurse to a unlicensed assisti!e personnel A*A?)+ would re1uire inter!ention by the nurse mana"er? A) To help an elderly client to the bathroom. ) To empty a foley catheter ba". K #) To bathe a woman with internal radon seeds. %) To feed a ) year-old with a broken arm. &e!iew Information' The correct answer is #' To bathe a woman with internal radon seeds. A client with internal radiation is comple7 care and not suitable to be assi"ned to a *A?. Additionally+ the client would not recei!e a complete bath because of the radiation risks. 49. An ,) year-old client is prescribed eye drops for treatment of "laucoma. .hat assessment is needed before the nurse be"ins teachin" proper administration of the medication? A) %etermine third party payment plan for this treatment K ) The client2s manual de7terity #) ?ro7imity to health care ser!ices %) Ability to use !isual assisti!e de!ices &e!iew Information' The correct answer is ' The client2s manual de7terity Inability to self administer eye drops is a common problem amon" the elderly due to decreased fin"er de7terity. 48. The nurse uses the %&/ A%ia"nosis &elated /roup) manual to A) #lassify nursin" dia"noses from the client=s health history ) Identify findin"s related to a medical dia"nosis K #) %etermine reimbursement for a medical dia"nosis %) Implement nursin" care based on case mana"ement protocol &e!iew Information' The correct answer is #' %etermine reimbursement for a medical dia"nosis %&/==s are the basis of prospecti!e payment plan for reimbursement for $edicare clients. &esults for QYA-&andom W6 1. The community health nurse has been followin" the care for an adolescent with a history of morbid obesity+ asthma+ hypertension and is )) weeks in to a pre"nancy. .hich of these lab reports sent to the clinic need to be called to the teens health care pro!ider within the ne7t hour? A) @emoblobin 11 "G> and calcium < m"Gdl K ) $a"nesium 8., mH1G> and creatinine 4 m"Gdl #) lood urea nitro"en ), and "lucose ))6 m"Gdl %) @ematocrit 44: and platelets )88+888 &e!iew Information' The correct answer is ' $a"nesium 8., mH1G> and creatinine 4 m"Gdl The client2s lab !alues are all abnormal e7cept for the platelets. The ma"nesium is low and the creatinine is hi"h which indicates renal failure. .ith the history of hypertension the findin"s e7hibit the risk of preeclampsia. The client needs to be referred for immediate follow up with a health care pro!ider. ). The nurse has identified what appears to be !entricular tachycardia on the cardiac monitor of a client bein" e!aluated for possible myocardial infarction. The first action the nurse would perform is to A) e"in cardiopulmonary resuscitation ) ?repare for immediate defibrillation #) Cotify the "#ode" team and health care pro!ider K %) Assess airway breathin" and circulation &e!iew Information' The correct answer is %' Assess airway breathin" and circulation The nurse must first assess the client to determine the appropriate ne7t step. In this case the first step the nurse must take is to e!aluate the A+ + #==s. 4. To pre!ent keratitis in an unconscious client+ the nurse should apply moisturi5in" ointment to the A) 0in"er and toenail 1uicks K ) Hyes #) ?erianal area %) H7ternal ear canals &e!iew Information' The correct answer is ' Hyes Meratitis is a corneal ulcer or abrasion. Meratitis is caused by e7posure and re1uires application of moisturi5in" ointment to the e7posed cornea and a plastic bubble shield or eye patch. 4. The nurse is carin" for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which !itamins?

A) + %+ and M ) A+ %+ and M #) A+ #+ and % %) A+ + and # &e!iew Information' The correct answer is ' A+ %+ and M The uptake of fat soluble !itamins is decreased in children with #ystic 0ibrosis. Bitamins A+ %+ and M are fat soluble and are likely to be deficient in clients with #ystic 0ibrosis.

&e!iew Information' The correct answer is #' #ontinue the same anal"esic dosa"e %yin" patients who ha!e been in chronic pain will probably continue to e7perience pain e!en thou"h unresponsi!e. ?ain medication should be continued at the same dose+ if effecti!e 11. .hich of these clients would the tria"e nurse re1uest for the health care pro!ider to e7amine immediately? K A) A 6 month-old infant who has audible whee5in" and "runtin" ) An adolescent who has soot o!er the face and shirt #) A middle-a"ed man with second de"ree burns o!er the ri"ht hand %) A toddler with sin"ed ends of lon" hair that e7tends to the waist &e!iew Information' The correct answer is A' A 6 month-old infant who has audible whee5in" and "runtin" The a"e and the findin"s puts this client at immediate risk for respiratory complications. 1). An infant has 3ust returned from sur"ery for placement of a "astrostomy tube as an initial treatment for tracheoesopha"eal fistula. The mother asks'D.hen can the tube can be used for feedin"?D The nurse=s best response would be which of these comments? A) 0eedin"s can be"in in 6 to - days. ) The use of the feedin" tube can be"in immediately. K #) The stomach contents and air must be drained first. %) The incision healin" must be complete before feedin". &e!iew Information' The correct answer is #' (tomach contents and air must be drained first After sur"ery for "astrostomy tube placement+ the catheter is left open and attached to "ra!ity draina"e for )4 hours or more. 14. A pre-term baby de!elops nasal flarin"+ cyanosis and diminished breath sounds on one side. The pro!ider=s dia"nosis is spontaneous pneumothora7. .hich procedure should the nurse prepare for first? A) #ardiopulmonary resuscitation K ) Insertion of a chest tube #) ;7y"en therapy %) Assisted !entilation &e!iew Information' The correct answer is ' Insertion of a chest tube ecause a portion of the lun" has collapsed+ a chest tube will be inserted to restore ne"ati!e pressure in the chest ca!ity. 14. The nurse is carin" for a -6 year old client in con"esti!e heart failure. .hich findin" su""ests that di"italis le!els should be re!iewed? K A) H7treme fati"ue ) Increased appetite #) Intense itchin" %) #onstipation &e!iew Information' The correct answer is A' H7treme fati"ue H7treme fati"ue and weakness are common+ early si"ns of di"italis to7icity+ which would be e!ident in lab data 16. The nurse is teachin" a client with atrial fibrillation about the use of #oumadin Awarfarin) at home. .hich of these should be emphasi5ed to the client to a!oid? A) >ar"e indoor "atherin"s ) H7posure to sunli"ht #) Acti!e physical e7ercise K %) 0oods rich in !itamin M &e!iew Information' The correct answer is %' 0oods rich in !itamin M Bitamin M acts as an antidote to the pharmacolo"ic action of #oumadin therapy+ decreasin" #oumadin==s effecti!eness. 0oods hi"h in !itamin M include dark "reens+ tomatoes+ bananas+ cheese+ and fish. 1<. A nurse carin" for premature newborns in an intensi!e care settin" carefully monitors o7y"en concentration. .hat is the most common complication of this therapy? A) Intra!entricular hemorrha"e K ) &etinopathy of prematurity #) ronchial pulmonary dysplasia %) Cecroti5in" enterocolitis &e!iew Information' The correct answer is ' &etinopathy of prematurity .hile there are other causes for retinal dama"e in the premature infant+ maintainin" the o7y"en concentration below 48: reduces one risk factor. 1-. A nurse mana"er is usin" the techni1ue of brainstormin" to help sol!e a problem. ;ne nurse critici5es another nurse2s contribution and be"ins to find ob3ections to the su""estion. The nurse mana"er=s best response is to A) >et2s mo!e on to a new action that deals with the problem. I think you need to reser!e 3ud"ment until after all su""estions ) are offered. Bery well thou"ht out. Four analytic skills and interest are #) incredible. >et2s mo!e to the Twhat ifL2 as related to these ob3ections for an K %) e7ploration of spin off ideas. &e!iew Information' The correct answer is %' >et2s mo!e to the Twhat ifL2 as related to these ob3ections for an e7ploration of spin off ideas. The "oal of brainstormin" is to "ather as many ideas as possible without 3ud"ment that slows

6. The nurse is teachin" a )- year-old client with asthma about mana"ement of their therapeutic re"ime. .hich statement would indicate the need for additional instruction? A) "I should monitor my peak flow e!ery day." "I should contact the clinic if I am usin" my medication more ) often." "I need to limit my e7ercise+ especially acti!ities such as walkin" K #) and runnin"." %) "I should learn stress reduction and rela7ation techni1ues." &e!iew Information' The correct answer is #' "I need to limit my e7ercise+ especially acti!ities such as walkin" and runnin"." >imitin" physical acti!ity in an otherwise healthy+ youn" client should not be necessary. If e7ercise intolerance e7ists+ the asthma mana"ement plan should include specific medications to treat the problem such as usin" an inhaled beta-a"onist 6 minutes before e7ercise. The "oal is always to return to a normal lifestyle. <. .hile carin" for a child with &eye=s (yndrome+ the nurse should "i!e which action the hi"hest priority? A) $onitor intake and output ) ?ro!id "ood skin care K #) Assess le!el of consciousness %) Assis with ran"e of motion &e!iew Information' The correct answer is #' Assess le!el of consciousness Altered le!el of consciousness su""ests increasin" intercranial pressure related to cerebral edema. -. A newborn presents with a pronounced cephalhematoma followin" a birth in the posterior position. .hich nursin" dia"nosis should "uide the plan of care? A) ?ain related to periosteal in3ury ) Impaired mobility related to bleedin" K #) ?arental an7iety related to knowled"e deficit %) In3ury related to intercranial hemorrha"e &e!iew Information' The correct answer is #' ?arental an7iety related to knowled"e deficit This hematoma is related to pressure at the time of labor and birth. The condition resol!es o!er a period of weeks to months. ?arental an7iety must be addressed by listenin" to their fears and e7plainin" the nature of this alteration. #aput (uccinidanium which is edema typically will "o away within a few days. ,. A confused client has been placed in physical restraints by order of the health care pro!ider. .hich task could be assi"ned to an unlicensed assisti!e personnel A*A?)? K A) Assist the client with acti!ities of daily li!in" ) $onitor the clients physical safety #) H!aluate for basic comfort needs %) %ocument mental status and muscle stren"th &e!iew Information' The correct answer is A' Assist with acti!ities of daily li!in" The person to whom the acti!ity is dele"ated must be capable of performin" it . The *A? is capable of assistin" clients with basic needs. 9. A client is scheduled to ha!e a blood test for cholesterol and tri"lycerides the ne7t day. The nurse would tell the client A) " e sure and eat a fat-free diet until the test." "%o not eat or drink anythin" but water for 1) hours before the K ) blood test." #) "@a!e the blood drawn within ) hours of eatin" breakfast." "(tay at the laboratory so ) blood samples can be drawn an hour %) apart." &e!iew Information' The correct answer is ' "%o not eat or drink anythin" but water for 1) hours before the blood test." lood lipid le!els should be measured on a fastin" sample. 18. A client who is terminally ill has been recei!in" hi"h doses of an opiod anal"esic for the past month. As death approaches and the client becomes unresponsi!e to !erbal stimuli+what orders would the nurse e7pect from the health care pro!ider? A) %ecrease the anal"esic dosa"e by half ) %iscontinue the anal"esic K #) #ontinue the same anal"esic dosa"e %) ?rescribe a less potent dru"

the creati!e process and may discoura"e inno!ati!e ideas. H7ploration of the nurses ob3ections would encoura"e the "eneration of new ideas. 1,. The nurse is carin" for an acutely ill 18 year-old client. .hich of the followin" assessments would re1uire the nurses immediate attention? A) &apid boundin" pulse ) Temperature of 4,.6 de"rees #elsius #) ?rofuse %iaphoresis K %) (low+ irre"ular respirations &e!iew Information' The correct answer is %' (low+ irre"ular respirations A slow and irre"ular respiratory rate is a si"n of fati"ue in an acutely ill child. 0ati"ue can rapidly lead to respiratory arrest. 19. A child is dia"nosed with poison i!y. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playin" in wooded areas. As the nurse asks 1uestions about possible contact+ which of the followin" would the nurse reco"ni5e as hi"hest risk for e7posure? A) ?layin" with toys in a back yard flower "arden ) Hatin" small amounts of "rass while playin" "farm" K #) ?layin" with cars on the pa!ement near burnin" lea!es %) Throwin" a ball to a nei"hborhood child who has poison i!y &e!iew Information' The correct answer is #' ?layin" with cars on the pa!ement near burnin" lea!es (moke from burnin" lea!es or stems of the poison i!y plant can produce a reaction. %irect contact with the to7ic oil+ urushiol+ is the most common cause for this dermatitis. )8. The nurse is teachin" a "roup of adults about modifiable cardiac risk factors. .hich of the followin" should the nurse focus on first? A) .ei"ht reduction ) (tress mana"ement #) ?hysical e7ercise K %) (mokin" cessation &e!iew Information' The correct answer is %' (mokin" cessation (toppin" smokin" is the priority for clients at risk for cardiac disease+ because of the effect to reduce o7y"enation and constrict blood !essels. )1. The nurse is carin" for a 6 year-old child who has the left le" in skeletal traction. .hich of the followin" acti!ities would be an appropriate di!ersional acti!ity? A) Mickin" balloons with ri"ht le" ) ?layin" "(imon (ays" K #) ?layin" hand held "ames %) Throw bean ba"s &e!iew Information' The correct answer is #' ?layin" hand held "ames Immobili5ation with traction must be maintained until bone ends are in satisfactory ali"nment. Acti!ities that increase mobility interfere with the "oals of treatment. )). The nurse is assessin" a client with portal hypertension. .hich of the followin" findin"s would the nurse e7pect? A) H7piratory whee5es ) lurred !ision #) Acites %) %ilated pupils &e!iew Information' The correct answer is #' Acites ?ortal hypertension can occur in a client with ri"ht-sided heart failure or cirrhosis of the li!er. ?ortal hypertension can lead to acites due to the increased protal pressure as well as a lowered osmotic pressure. )4. A parent tells the nurse that their < year-old child who normally en3oys school+ has not been doin" well since the "randmother died ) months a"o. .hich statement most accurately describes thou"hts on death and dyin" at this a"e? K A) %eath is personified as the bo"eyman or de!il ) %eath is percei!ed as bein" irre!ersible #) The child feels "uilty for the "randmother=s death %) The child is worried that he+ too+ mi"ht die &e!iew Information' The correct answer is A' %eath is personified as the bo"eyman or de!il ?ersonification of death is typical of this de!elopmental le!el. )4. A <- year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the followin" findin"s are present A) Temperature of 4-.6 de"rees #elsius with painful urination K ) An open wound on their heel #) Insomnia and daytime fati"ue %) Causea with ) episodes of !omitin"

&e!iew Information' The correct answer is ' An open wound on their heel .hen si"ns of infection occur in their feet+ elderly clients who ha!e diabetes andGor !ascular disease should seek health care 1uickly and continue treatment until the infection is resol!ed. .ithout treatment+ serious infection+ "an"rene+ limb loss+ and death may result. )6. The nurse admits an elderly $e7ican-American mi"rant worker after an accident that occurred durin" work. To facilitate communication the nurse should initially A) &e1uest a (panish interpreter ) (peak throu"h the family or co-workers #) *se pictures+ letter boards+ or monitorin" K %) Assess the client=s ability to speak Hn"lish &e!iew Information' The correct answer is %' Assess the client==s ability to speak Hn"lish %espite the cultural herita"e+ the nurse cannot make assumptions. (tereotypin" is to be a!oided. The nurse should assess the client==s comfort and ability in speakin" Hn"lish. )<. In assessin" a post partum client+ the nurse palpates a firm fundus and obser!es a constant trickle of bri"ht red blood from the !a"ina. .hat is the most likely cause of these findin"s? A) *terine atony K ) /enital lacerations #) &etained placenta %) #lottin" disorder &e!iew Information' The correct answer is ' /enital lacerations #ontinuous bleedin" in the absence of a bo""y fundus indicates undetected "enital tract lacerations. )-. The nurse notes an abrupt onset of confusion in an elderly patient. .hich of the followin" recently-ordered medications would most likely contribute to this chan"e? A) Anticoa"ulant ) >i1uid antacid K #) Antihistamine %) #ardiac "lycoside &e!iew Information' The correct answer is #' Antihistamine Hlderly people are susceptible to the side effect of anticholiner"ic dru"s+ such as antihistamines. Hspecially at hi"h doses+ antihistamines often cause confusion in the elderly. ),. The nurse is carin" for a client with acti!e tuberculosis who has a history of noncompliance. .hich of the followin" actions by the nurse would represent appropriate care for this client? Instruct the client to wear a hi"h efficiency particulate air mask in A) public places. K ) Ask a family member to super!ise daily compliance #) (chedule weekly clinic !isits for the client Ask the health care pro!ider to chan"e the re"imen to fewer %) medications &e!iew Information' The correct answer is ' Ask a family member to super!ise daily compliance %irect-obser!ed therapy A%;T) is a reco"ni5ed method for ensurin" client compliance to the dru" re"imen. The pro"ram can be set up to directly obser!e the client takin" the medication in the clinic+ home+ workplace or other con!enient location. )9. The nurse mana"er identifies that time spent by staff in chartin" is e7cessi!e+ re1uirin" o!ertime for completion. The nurse mana"er states that "staff will form a task force to in!esti"ate and de!elop potential solutions to the problem+ and report on this at the ne7t staff meetin"." The nurse mana"er=s leadership style is best described as A) >aisse5-faire ) Autocratic K #) ?articipati!e %) /roup &e!iew Information' The correct answer is #' ?articipati!e ?articipati!e style of mana"ement in!ol!es staff in decision-makin" processes. (taffGmana"er interactions are open and trustin". $ost work efforts are 3oint. 48. A nursin" student asks the nurse mana"er to e7plain the forces that dri!e health care reform. The appropriate response by the nurse mana"er should include The escalation of fees with a decreased reimbursement K A) percenta"e ) @i"h costs of dia"nostic and end-of-life treatment procedures #) Increased numbers of elderly and of the chronically ill of all a"es A steep rise in health care pro!ider fees and in insurance %) premiums &e!iew Information' The correct answer is A' The escalation of fees with a decreased reimbursement percenta"e The percenta"e of the "ross national product representin" health care costs rose dramatically with reimbursement based on fee for ser!ice. &eimbursement for $edicare and $edicaid recipients based on fee for ser!ice also escalates health care costs.

41. A client with hepatitis A A@AB) is newly admitted to the unit. .hich action would be the priority to include in the plan of care within the initial )4 hours for this client? A) .ear masks with shields if potential splash ) *se disposable utensils and plates for meals K #) .ear "own and "lo!es durin" client contact %) ?ro!ide soft easily di"ested food with fre1uent snacks &e!iew Information' The correct answer is #' .ear "own and "lo!es durin" client contact @AB is usually transmitted !ia the fecal-oral route. That means that someone with the !irus handles food without washin" his or her hands after usin" the bathroom. The !irus can also be contracted by drinkin" contaminated water+ eatin" raw shellfish from water polluted with sewa"e or bein" in close contact with a person who==s infected U e!en if that person has no si"ns and symptoms. In fact+ the disease is most conta"ious before si"ns and symptoms e!er appear. The nurse should reco"ni5e the importance of isolation precautions from the initial contact with the client on admission until the nonconta"ious con!alescence period. 4). A client has been takin" alpra5olam APana7) for 4 days. Cursin" assessment should re!eal which e7pected effect of the dru"? K A) Tran1uili5ation+ numbin" of emotions ) (edation+ anal"esia #) &elief of insomnia and phobias %) %iminished tachycardia and tremors associated with an7iety &e!iew Information' The correct answer is A' Tran1uili5ation+ numbin" of emotions The anti-an7iety dru"s produce tran1uili5in" effects and may numb the emotions. 44. The nurse obser!es a staff member carin" for a client with a left unilateral mastectomy. The nurse would inter!ene if she notices the staff member is A) Ad!isin" client to restrict sodium intake K ) Takin" the blood pressure in the left arm #) Hle!atin" her left arm abo!e heart le!el %) #ompressin" the draina"e de!ice &e!iew Information' The correct answer is ' Takin" the blood pressure in the left arm 0or those clients who ha!e had a unilateral mastectomy+ blood pressure should not be measured on the affected side to a!oid the possibility of lymphedema. 44. A -8 year-old post-operati!e client has ele!ated serum *C+ @ct+ #l+ and CaZ. #reatinine and MZ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is' A) Impaired "as e7chan"e ) $etabolic acidosis #) &enal insufficiency K %) 0luid !olume deficit &e!iew Information' The correct answer is %' 0luid !olume deficit In fluid !olume deficit+ serum *C+ CaZ and hematocrit may be ele!ated secondary to hemoconcentration. 46. The nurse is pro!idin" foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teachin" if the client stated A) "I can only wear cotton socks." ) "I cannot "o barefoot around my house." K #) "I will trim corns and calluses re"ularly." %) "I should ask a family member to inspect my feet daily." &e!iew Information' The correct answer is #' "I will trim corns and calluses re"ularly." #lients who are elderly+ ha!e diabetes+ andGor ha!e !ascular disease often ha!e decreased circulation and sensation in one or both feet. Their !ision may also be impaired. Therefore+ they need to be tau"ht to e7amine their feet daily or ha!e someone else do so. They should wear cotton socks which ha!e not been mended+ and always wear shoes when out of bed. They should not cut their nails+ corns+ and calluses+ but should ha!e them trimmed by their health care pro!ider+ nurse+ or other pro!ider who speciali5es in foot care. 4<. A woman who deli!ered 6 days a"o and had been dia"nosed with preeclampsia calls the hospital tria"e nurse hotline to ask for ad!ice. (he states E I ha!e had the worst headache for the past ) days. It pounds and by the middle of the afternoon e!erythin" I look at looks wa!y. Cothin" I ha!e taken helps.D .hat should the nurse do ne7t? Ad!ise the client that the swin"s in her hormones may ha!e that A) effect. @owe!er+ su""est for her to call her health care pro!ider within the ne7t day. Ad!ise the client to ha!e someone brin" her to the emer"ency ) room as soon as possible Ask the client to stay on the line+ "et the address and send an K #) ambulance to the home %) Ask what the client has taken? @ow often? Ask about other

specific complaints. &e!iew Information' The correct answer is #' Ask the client to stay on the line+ "et the address and send an ambulance to the home The correct response is #. The woman is at risk for sei5ure acti!ity. The ambulance needs to brin" the woman to the hospital. 0or at risk clients+ preeclampsia and eclampsia may occur prior to+ durin" or after deli!ery. After deli!ery the window of time can be up to ten days. 4-. The primary teachin" for a client followin" an e7tracorporeal shock-wa!e lithotripsy AH(.>) procedure is K A) %rink 4888 to 4888 cc of fluid each day for one month ) >imit fluid intake to 1888 cc each day for one month #) Increase intake of citrus fruits to three ser!in"s per day %) &estrict milk and dairy products for one month &e!iew Information' The correct answer is A' %rink 4888 to 4888 cc of fluid each day for 1 month %rinkin" three to four 1uarts A4888 to 4888 cc) of fluid each day will aid passa"e of fra"ments and help pre!ent formation of new calculi. 4,. A client on warfarin therapy followin" coronary artery stent placement calls the clinic to ask if he can take Alka-(elt5er for an upset stomach. .hat is the best reponse by the nurse? K A) A!oid Alka-(elt5er because it contains aspirin ) Take Alka-(elt5er at a different time of day than the warfarin #) (elect another antacid that does not inacti!ate warfarin %) *se on-half the recommended dose of Alka-(elt5er &e!iew Information' The correct answer is A' A!oid Alka-(elt5er because it contains aspirin Alka-(elt5er is an o!er-the-counter aspirin-antacid combination. Aspirin+ an antiplatelet dru"+ will potentiate the anticoa"ulant effect of warfarin and may result in e7cess bleedin" 49. The nurse is workin" with parents to plan home care for a ) year-old with a heart problem. A priority nursin" inter!ention would be to Hncoura"e the parents to enroll in cardiopulmonary resuscitation K A) class ) Assist the parents to plan 1uiet play acti!ities at home #) (tress to the parents that they will need relief care "i!ers %) Instruct the parents to a!oid contact with persons with infection &e!iew Information' The correct answer is A' Hncoura"e the parents to enroll in cardiopulmonary resuscitation class .hile all su""estions are appropriate+ the education of the parentsGcare"i!ers should include techni1ues of cardiopulmonary resuscitation in order to pro!ide for emer"ency care of their child. 48. The nurse is carin" for a client with &heumatoid Arthritis. .hich nursin" dia"nosis should recei!e priority in the plan of care? A) &isk for in3ury ) (elf care deficit K #) Alteration in comfort %) Alteration in mobility &e!iew Information' The correct answer is #' Alteration in comfort &elie!in" pain is the number one ob3ecti!e of this client==s plan of care. &esults for QYA-&andom W4 1. An unlicensed assisti!e staff member asks the nurse mana"er to e7plain the beliefs of a #hristian (cientist who refuses admission to the hospital after a motor !ehicle accident. The best response of the nurse would be which of these statements? "(piritual healin" is emphasi5ed and the mind contributes to the K A) cure." "The primary belief is that dietary practices result in health or ) illness." #) "0astin" and prayer are initial actions to take in physical in3ury." "$editation is intensi!e in the initial 4, hours and daily %) thereafter." &e!iew Information' The correct answer is A' "(piritual healin" is emphasi5ed and the mind contributes to the cure." 0or the #hristian (cientist+ a mind cure uses spiritual healin" methods. 0or the belie!er+ medical treatments may interfere with drawin" closer to /od. ). In order to be effecti!e in administerin" cardiopulmonary resuscitation to a 6 year-old+ the nurse must A) Assess the brachial pulses K ) reathe once e!ery 6 compressions #) *se both hands to apply chest pressure %) #ompress ,8-98 times per minute &e!iew Information' The correct answer is ' reathe once e!ery 6 compressions 0or a 6 year-old+ the nurse should "i!e 1 breath for e!ery 6 compressions. 4. The nurse is pro!idin" home care for a client with heart failure and pulmonary edema. .hich nursin" dia"nosis should ha!e priority in plannin" care? A) Impaired skin inte"rity related to dependent edema

Acti!ity intolerance related to o7y"en supply and demand imbalance #) #onstipation related to immobility %) &isk for infection related to ineffecti!e mobili5ation of secretions &e!iew Information' The correct answer is ' Acti!ity Intolerance related to o7y"en supply and demand imbalance This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of o7y"en and complaints of dyspnea and fati"ue. )

) @ib #) I?B %) %ta? &e!iew Information' The correct answer is A' $$& $edical mana"ement of Mawasaki in!ol!es administration of immuno"lobulins. $easles+ mumps+ rubella A$$&) is a li!e !irus !accine. 0ollowin" administration of immuno"lobulins+ li!e !accines should be held due to possible interference with the body==s ability to form antibodies. 18. The nurse is assessin" a pre"nant client in her third trimester. The parents are informed that the ultrasound su""ests that the baby is small for "estational a"e A(/A). An earlier ultrasound indicated normal "rowth. The nurse understands that this chan"e is most likely due to what factor? A) (e7ually transmitted infection ) H7posure to terato"ens K #) $aternal hypertension %) #hromosomal abnormalities &e!iew Information' The correct answer is #' $aternal hypertension ?re"nancy induced hypertension is a common cause of late pre"nancy fetal "rowth retardation. Basoconstriction reduces placental e7chan"e of o7y"en and nutrients. 11. After the shift report in a labor and deli!ery unit which of these clients would the nurse check first? A middle a"ed woman with asthma and diabetes mellitus Type 1 A) has a ? of 168G94 A middle a"ed woman with a history of two prior !a"inal term ) births is ) cm dilated A youn" woman wo is a "rand multipara has cer!ical dilation of 4 #) cm and 68: effaced An adolescent who is 1, weeks pre"nant has a report of no fetal K %) heart tones and cou"hin" up frothy sputum &e!iew Information' The correct answer is %' An adolescent who is 1, weeks pre"nant has a report of no fetal heart tones and cou"hin" up frothy sputum This client has an actual complication. The others present with findin"s of potential complications. 1). The nurse is carin" for an ,- year-old client with urinary retention. .hich findin" should be reported immediately? K A) 0ecal impaction ) Infre1uent !oidin" #) (tress incontinence %) urnin" with urination &e!iew Information' The correct answer is A' 0ecal impaction The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. ladder outlet obstruction is a common cause of urine retention in the elderly. 14. The naso"astric tube of a post-op "astrectomy client has stopped drainin" "reenish li1uid. The nurse should A) Irri"ate it as ordered with distilled water K ) Irri"ate it as ordered with normal saline #) ?lace the end of the tube in water to see if the water bubbles %) .ithdraw the tube se!eral inches and reposition it &e!iew Information' The correct answer is ' Irri"ate it as ordered with normal saline Caso"astric tubes are only irri"ated with normal saline to maintain patency. 14. The parents of a child who has recently been dia"nosed with asthma ask the nurse to e7plain the condition to them. The best response is "Asthma causesL K A) the airway to become narrow and obstructs airflow." ) air to be trapped in the lun"s because the airways are dilated." #) the ner!es that control respiration to become hyperacti!e." a decrease in the stress hormones which pre!ents the airways %) from openin"." &e!iew Information' The correct answer is A' the airway to become narrow and obstructs airflow." Asthma is defined as airway obstruction or a narrowin" that is characteri5ed by bronchial irritability after e7posure to !arious stimuli. 16. The nurse is assessin" a child with suspected lead poisonin". .hich of the followin" assessments is the nurse most likely to find? K A) #omplaints of numbness and tin"lin" in feet ) .hee5in" noted when lun" sound auscultated #) H7cessi!e perspiration %) %ifficulty sleepin" &e!iew Information' The correct answer is A' #omplaints of numbness and tin"lin" in feet A child who has unusual neurolo"ic si"ns or symptoms+ neuropathy+ footdrop+ or anemia that cannot be attributed to other causes may be sufferin" from lead poisonin". This most often occurs when a child in"ests or inhales paint chips from lead-based paint or dust from remodelin" in older buildin"s. 1<. The nurse is carin" for a client with end-sta"e heart failure. The family members are distressed about the client=s impendin" death. .hat action should the nurse do first?

4. 0or which of the followin" mother-baby pairs should the nurse re!iew the #oomb=s test in preparation for administerin" &h; A%) immune "lobulin within -) hours of birth? K A) &h ne"ati!e mother with &h positi!e baby ) &h ne"ati!e mother with &h ne"ati!e baby #) &h positi!e mother with &h positi!e baby %) &h positi!e mother with &h ne"ati!e baby &e!iew Information' The correct answer is A' &h ne"ati!e mother with &h positi!e baby An &h- mother who deli!ers an &hZ baby may de!elop antibodies to the fetal red cells to which she may be e7posed durin" pre"nancy or at placental separation. If the #oombs test is ne"ati!e+ no sensiti5ation has occurred. The &h;A%) immune "lobulin is "i!en to block antibody formation in the mother. 6. An ,8 year-old nursin" home resident has a temperature of 181.< de"rees 0ahrenheit rectally. This is a sudden chan"e in an otherwise healthy client. .hich should the nurse assess first? A) >un" sounds ) *rine output K #) >e!el of alertness %) Appetite &e!iew Information' The correct answer is #' >e!el of alertness Assessin" le!el of consciousness Aalert !s. lethar"ic !s. unresponsi!e) will help the health care pro!ider determine the se!erity of the acute episode. If the client is alert+ responses to 1uestions about complaints can be followed-up 1uickly. <. .hich of these women in the labor and deli!ery unit would the nurse check first when the water breaks for all of them within a ) minute period? A multi"ra!ida with station at Z)+ contractions at 16 minutes A) apart with duration of 48 seconds+ cer!i7 dilated at - cm+ and 68: effacement A multi"ra!ida with station at -1+ contractions at 16 minutes apart K ) with duration of 48 seconds+ cer!i7 dilated at 4 cm+ and 18: effacement A primapara with station at 8+ contractions at )8 minutes apart #) with duration of )8 seconds+ cer!i7 dilated at ) cm and 18: effacement A primapara with station at 1+ contractions at 16 minutes apart %) with duration of 46 seconds+ cer!i7 dilated at 6 cm and 68: effacement &e!iew Information' The correct answer is ' A multi"ra!ida with station at -1+ contractions at 16 minutes apart with duration of 48 seconds+ cer!i7 dilated at 4 cm+ and 18: effacement .hen the station of -1 or -) is present and the water breaks+ the risk is "reater for a prolapsed cord. -. .hat is the ma3or purpose of community health research? K A) %escribe the health conditions of populations ) H!aluate illness in the community #) H7plain the health conditions of families %) Identify the health conditions of the en!ironment &e!iew Information' The correct answer is A' %escribe the health conditions of populations #ommunity health focuses upon a""re"ate population care. ,. The recent increase in the reported cases of acti!e tuberculosis AT ) in the *nited (tates is attributed to which factor? A) The increased homeless population in ma3or cities K ) The rise in reported cases of positi!e @IB infections #) The mi"ration patterns of people from forei"n countries %) The a"in" of the population located in "roup homes &e!iew Information' The correct answer is ' The rise in reported cases of positi!e @IB infections etween 19,6 and )88) there has been a si"nificant increase in the reported cases of T . The increase was most e!ident in cities with a hi"h incidence of positi!e @IB infection. ?ositi!e @IB infection currently is the "reatest known risk factor for reacti!atin" latent T infections as well. 9. A 16 month-old child comes to the clinic for a follow-up !isit after hospitali5ation for treatment of Mawasaki %isease. The nurse reco"ni5es that which of the followin" scheduled immuni5ations will be delayed? K A) $$&

A) H7plain the sta"es of death and dyin" to the family ) &ecommend an easy-to-read book on "rief K #) Assess the family=s patterns for dealin" with death %) Ask about their reli"ious affiliations &e!iew Information' The correct answer is #' Assess the family==s patterns for dealin" with death .hen a new problem is identified+ it is important for the nurse to collect accurate assessment data. This is crucial to ensure that the client and their family==s needs are ade1uately identified in order to select the best nursin" care approaches. 1-. The nurse is carin" for a client with $eniere=s disease. .hen teachin" the client about the disease+ the nurse should e7plain that the client should a!oid foods hi"h in A) #alcium ) 0iber K #) (odium %) #arbohydrate &e!iew Information' The correct answer is #' (odium The client with $eniere==s disease has an e7cess accumulation of fluid in the inner ear. A low sodium diet will aid in reducin" the fluid. (odium restriction is also ordered as ad3unct to diuretic therapy. 1,. The nurse is teachin" a mother who will breast feed for the first time. .hich of the followin" is a priority? A) (how her films on the physiolo"y of lactation ) /i!e the client se!eral illustrated pamphlets K #) Assist her to position the newborn at the breast %) /i!e her pri!acy for the initial feedin" &e!iew Information' The correct answer is #' Assist her to position the newborn at the breast .hile all of the responses are helpful in teachin"+ the priority is placin" the infant to breast as soon after birth as possible to establish contact and allow the newborn to be"in to suck. 19. The nurse is takin" a health history from parents of a child admitted with possible &eye=s (yndrome. .hich recent illness would the nurse reco"ni5e as increasin" the risk to de!elop &eye=s (yndrome? A) &ubeola ) $enin"itis K #) Baricella %) @epatitis &e!iew Information' The correct answer is #' Baricella Baricella Achicken po7) and influen5a are !iral illnesses that ha!e been identified as increasin" the risk for &eye==s (yndrome. *se of aspirin is contraindicated for children with these infections. )8. .hile "i!in" care to a ) year-old client+ the nurse should remember that the toddler=s tendency to say "no" to almost e!erythin" is an indication of what pyschosocial skill? A) (tubborn beha!ior ) &e3ection of parents #) 0rustration with adults K %) Assertion of control &e!iew Information' The correct answer is %' Assertion of control Ce"ati!ism is a normal beha!ior in toddlers. The nurse must be aware that this beha!ior is an important si"n of the child==s pro"ress from dependency to autonomy and independence. )1. A postpartum client admits to alcohol use throu"hout the pre"nancy. .hich of the followin" newborn assessments su""ests to the nurse that the infant has fetal alcohol syndrome? A) /rowth retardation is e!ident ) $ultiple anomalies are identified K #) #ranial facial abnormalities are noted %) ?rune belly syndrome is suspected &e!iew Information' The correct answer is #' #ranial facial abnormalities are noted #haracteristic facial abnormalities are seen in the newborn with fetal alcohol syndrome. )). The nurse is attendin" a workshop about carin" for persons infected with @epatitis. .hich statement is correct when referrin" to the incidence rate for @epatitis? The number of persons in a population who de!elop @epatitis K A) durin" a specific period of time The total number of persons in a population who ha!e @epatitis ) at a particular time The percenta"e of deaths resultin" from @epatitis durin" a #) specific time The occurrence of @epatitis in the population at a particular %) time &e!iew Information' The correct answer is A' The number of persons in a population who de!elop @epatitis durin" a specific period of time

This is the correct definition of incidence of the disease. )4. A 4< year-old female client has a hemo"lobin le!el of 14 "Gdl and a hematocrit of 4): followin" a %Y#. .hich of the followin" would the nurse e7pect to find when assessin" this client? K A) #apillary refill less than 4 seconds ) ?ale mucous membranes #) &espirations 4< breaths per minute %) #omplaints of fati"ue when ambulatin" &e!iew Information' The correct answer is A' #apillary refill less than 4 seconds (ince the hemo"lobin and hematocrit are normal for an adult female+ addition assessments should be normal. #apillary refill is "normal" assessment data. )4. The nurse is carin" for a client suspected to ha!e Tuberculosis AT ). .hich of the followin" dia"nostic tests is essential for determinin" the presence of acti!e T ? The nurse is carin" for a client suspected to ha!e Tuberculosis AT ). .hich of the followin" dia"nostic tests is essential for determinin" the presence of acti!e T ? A) Tuberculin skin testin" K ) (putum culture #) .hite blood cell count %) #hest 7-ray &e!iew Information' The correct answer is ' (putum culture The sputum culture is the most accurate method for determinin" the presence of acti!e T . )6. The nurse has been teachin" an apprehensi!e primipara who has difficulty in initial nursin" of the newborn. .hat obser!ation at the time of dischar"e su""ests that initial breast feedin" is effecti!e? K A) The mother feels calmer and talks to the baby while nursin" The mother awakens the newborn to feed whene!er it falls ) asleep #) The newborn falls asleep after 4 minutes at the breast %) The newborn refuses the supplemental bottle of "lucose water &e!iew Information' The correct answer is A' The mother feels calmer and talks to the baby while nursin" Harly e!aluation of successful breastfeedin" can be measured by the client==s !oiced confidence and satisfaction with the infant. )<. The mother of a burned child asks the nurse to clarify what is meant by a third de"ree burn. The best response by the nurse is A) "The top layer of the skin is destroyed." ) "The skin layers are swollen and reddened." K #) "All layers of the skin were destroyed in the burn." %) "$uscle+ tissue and bone ha!e been in3ured." &e!iew Information' The correct answer is #' "All layers of the skin were destroyed in the burn." A third de"ree burn is a full thickness in3ury to dermis+ epidermis and subcutaneous tissue. )-. The nurse is takin" a health history from a Cati!e American client. It is critical that the nurse must remember that eye contact with such clients is considered A) H7pected K ) &ude #) ?rofessional %) Hn3oyable &e!iew Information' The correct answer is ' &ude Cati!e Americans consider direct eye contact to be impolite or a""ressi!e amon" stran"ers. ),. A nurse is instructin" a class for new parents at a local community center. The nurse would stress that which acti!ity is most ha5ardous for an , month-old child? A) &idin" in a car ) 0allin" off a bed #) Hlectrical outlets K %) Hatin" peanuts &e!iew Information' The correct answer is %' Hatin" peanuts Asphy7iation by forei"n materials in the respiratory tract is the leadin" cause of death in children less than < years of a"e. )9. .hen teachin" parents about sickle cell disease+ the nurse should tell them that their child=s anemia is caused by A) &educed o7y"en capacity of cells due to lack of iron K ) An imbalance between red cell destruction and production #) %epression of red and white cells and platelets %) Inability of sickle shaped cells to re"enerate &e!iew Information' The correct answer is ' An imbalance between red cell destruction and production Anemia results when the rate of red cell destruction e7ceeds the rate of production throu"h stimulated erythropoiesis in bone marrow Alife span shortened from 1)8 days to 1)-)8 days). 48. The nurse is assessin" a newborn deli!ered at home by an admitted heroin addict. .hich of the followin" would the nurse e7pect to obser!e?

A) @ypertonic neuro refle7 ) Immediate #C( depression #) >ethar"y and sleepiness K %) Sitteriness at )4-4, hours &e!iew Information' The correct answer is %' Sitteriness at )4-4, hours .ithdrawal si"ns may not be e!ident for 1-) days after birth. Irritability and poor feedin" also are e!ident. 41. The nurse is carin" for a client with con"esti!e heart failure. .hich findin" re1uires the nurse=s immediate attention? K A) ?ulse o7imetry of ,6: ) Cocturia #) #rackles in lun"s %) %iaphoresis &e!iew Information' The correct answer is A' ?ulse o7imetry of ,6: An o7y"en saturation of ,,: or less indicates hypo7emia and re1uires the nurse==s immediate attention. 4). The nurse is assessin" a youn" child at a clinic !isit for a mild respiratory infection. Moplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? K A) Inspect the skin ) Auscultate breath sounds #) H!aluate muscle stren"th %) In!esti"ate elimination patterns &e!iew Information' The correct answer is A' Inspect the skin A characteristic si"n of rubeola is Moplik spots Asmall red spots with a bluish white center). These are found on the buccal mucosa about ) days before and after the onset of the measles rash. 44. .hich action is most likely to ensure the safety of the nurse while makin" a home !isit? ;bser!ation durin" the !isit of no e!idence of weapons in the A) home ?rior to the !isit+ re!iew client=s record for any pre!ious entries ) about !iolence &emain alert at all times and lea!e if cues su""est the home is K #) not safe #arry a cell phone+ pa"er andGor hand held alarm for %) emer"encies &e!iew Information' The correct answer is #' (tayin" alert at all times and lea!in" if cues su""est the home is not safe Co person or e1uipment can "uarantee nurses== safety+ althou"h the risk of !iolence can be minimi5ed. efore makin" initial !isits+ re!iew referral information carefully and ha!e a plan to communicate with a"ency staff. (chedule appointments with clients. .hen dri!in" into an area for the first time+ note potential ha5ards and sources of assistance. ecome ac1uainted with nei"hbors. e alert and confident while parkin" the car+ walkin" to the client==s door+ makin" the !isit+ walkin" back to the car+ and dri!in" away. >I(THC to clients. If they tell you to lea!e+ do so. 44. An adolescent client is admitted in respiratory alkalosis followin" aspirin o!erdose. The nurse reco"ni5es that this imbalance was caused by K A) Tachypnea ) Acidic byproducts #) Bomitin" and dehydration %) @yperpyre7ia &e!iew Information' The correct answer is A' Tachypnea (timulation of respiratory center leads to hyper!entilation+ thus decreasin" #;) le!els which causes respiratory alkalosis. 46. The nurse disco!ers that the parents of a ) year-old child continue to use an apnea monitor each ni"ht. The parents state' E.e are concerned about the possible occurrence of sudden infant death syndrome A(I%().D In order to take appropriate action+ the nurse must understand that A) The child is within the a"e "roup most susceptible to (I%( ) The peak a"e for occurrence of (I%( is , to 1) months of a"e #) The apnea monitor is not effecti!e on a child in this a"e "roup K %) 96: of (I%( cases occur before < months of a"e &e!iew Information' The correct answer is %' 96: percent of all (I%( cases occur before < months ?eak a"e of (I%( occurrence is ) to 4 months and 96: of cases occur by < months of a"e. It is the leadin" cause of death in infants 1 month to 1 year of a"e. 4<. As a client is bein" dischar"ed followin" resolution of a spontaneous pneumothora7+ he tells the nurse that he is now "oin" to @awaii for a !acation. The nurse would warn him to a!oid A) (urfin" K ) (cuba di!in" #) ?arasailin"

%) (wimmin" &e!iew Information' The correct answer is ' (cuba di!in" The nurse would stron"ly emphasi5e the need for clients with history of spontaneous pneumothora7 problems to a!oid hi"h altitudes+ flyin" in unpressuri5ed aircraft and scuba di!in". The ne"ati!e pressures could cause the lun" to collapse a"ain. 4-. The nurse is pro!idin" diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasi5e that the diet should be A) @i"h calorie+ low fat+ low sodium ) @i"h protein+ low fat+ low carbohydrate K #) @i"h protein+ hi"h calorie+ unrestricted fat %) @i"h carbohydrate+ low protein+ moderate fat &e!iew Information' The correct answer is #' @i"h protein+ hi"h calorie+ unrestricted fat The child with #ystic 0ibrosis needs a well balanced diet that is hi"h in protein and calories. 0at does not need to be restricted. 4,. A client had arri!ed in the *(A from a de!elopin" country 1 week prior. The client is to be admitted to the medical sur"ical unit with a dia"nosis of AI%( with a history of unintended wei"ht loss+ dru" abuse+ ni"ht sweats+ producti!e cou"h and a "feelin" of bein" hot all the time." The nurse should assi"n the client to share a room with a client with the dia"nosis of Acute tuberculosis with a producti!e cou"h of discolored sputum K A) for o!er three months >upus and !esicles on one side of the middle trunk from the back ) to the abdomen #) ?seudomembranous colitis and #. difficile. %) H7acerbation of polyarthritis with se!ere pain &e!iew Information' The correct answer is A' Acute tuberculosis with a producti!e cou"h of discolored sputum for o!er three months The client for admission has classic findin"s of pulmonary tuberculosis. ;f the choices the client in option A has the similar dia"nosis and it is acceptable to put these types of clients in the same room when no other alternati!e e7ists. #lients are considered conta"ious until the cou"h is eliminated with medications which initially is a combination of 4 dru"s simultaneously. 49. A client=s admission urinalysis shows the specific "ra!ity !alue of 1.849. .hich of the followin" assessment data would the nurse e7pect to find when assessin" this client? A) $oist mucous membranes ) *rinary fre1uency K #) ?oor skin tur"or %) Increased blood pressure &e!iew Information' The correct answer is #' ?oor skin tur"or The specific "ra!ity !alue is hi"h+ indicatin" dehydration. ?oor skin tur"or Atentin" of the skin) is consistent with this problem. 48. ?arents are concerned that their 11 year-old child is a !ery picky eater. The nurse su""ests which of the followin" as the best initial approach? A) #onsider a li1uid supplement to increase calories K ) %iscuss conse1uences of an unbalanced diet with the child #) ?ro!ide fruit+ !e"etable and protein snacks %) Hncoura"e the child to keep a daily lo" of foods eaten &e!iew Information' The correct answer is ' %iscuss conse1uences of an unbalanced diet with the child It is important to educate the preadolescent as to appropriate diet+ and the problems that mi"ht arise if diet is not ade1uate. &esults for QYA-&andom W4 1. At a community health fair the blood pressure of a <) year-old client is 1<8G9<. The client states E$y blood pressure is usually much lower.D The nurse should tell the client to K A) "o "et a blood pressure check within the ne7t 4, to -) hours ) check blood pressure a"ain in ) months #) see the health care pro!ider immediately %) !isit the health care pro!ider within 1 week for a ? check &e!iew Information' The correct answer is A' "o "et a blood pressure check within the ne7t 4, to -) hours The blood pressure readin" is moderately hi"h with the need to ha!e it rechecked in a few days. The client states it is Tusually much lower.2 Thus a concern e7ists for complications such as stroke. @owe!er immediate check by the pro!ider of care is not warranted. .aitin" ) months or a week for follow-up is too lon". ). A client is admitted to the emer"ency room with renal calculi and is complainin" of moderate to se!ere flank pain and nausea. The client2s temperature is 188., de"rees 0ahrenheit. The priority nursin" "oal for this client is A) $aintain fluid and electrolyte balance ) #ontrol nausea K #) $ana"e pain %) ?re!ent urinary tract infection &e!iew Information' The correct answer is #' $ana"e pain The immediate "oal of therapy is to alle!iate the client2s pain.

4. An &C who usually works in a spinal rehabilitation unit is floated to the emer"ency department. .hich of these clients should the char"e nurse assi"n to this &C? A middle-a"ed client who says "I took too many diet pills" and A) "my heart feels like it is racin" out of my chest." A youn" adult who says "I hear son"s from hea!en. I need ) money for beer. I 1uit drinkin" ) days a"o for my family. .hy are my arms and le"s 3erkin"?" An adolescent who has been on pain medications for terminal K #) cancer with an initial assessment findin" of pinpoint pupils and a rela7ed respiratory rate of 18 An elderly client who reports ha!in" taken a "lar"e crack hit" 18 %) minutes prior to walkin" into the emer"ency room &e!iew Information' The correct answer is c' An adolescent who has been on pain medications for terminal cancer with an initial assessment findin" of pinpoint pupils and a rela7ed respiratory rate of 18 Curses who are floated to other units should be assi"ned to a client who has minimal anticipated immediate complications of their problem. The client in option # e7hibits opoid to7icity with the pinpoint pupils and has the least risk of complications to occur in the near future. 4. .hile plannin" care for a toddler+ the nurse teaches the parents about the e7pected de!elopmental chan"es for this a"e. .hich statement by the mother shows that she understands the child=s de!elopmental needs? A) "I want to protect my child from any falls." ) "I will set limits on e7plorin" the house." K #) "I understand the need to use those new skills." %) "I intend to keep control o!er our child." &e!iew Information' The correct answer is #' "I understand the need to use those new skills." Hrikson describes the sta"e of the toddler as bein" the time when there is normally an increase in autonomy. The child needs to use motor skills to e7plore the en!ironment. 6. A client who is pre"nant comes to the clinic for a first !isit. The nurse "athers data about her obstetric history+ which includes 4 yearold twins at home and a miscarria"e 18 years a"o at 1) weeks "estation. @ow would the nurse accurately document this information? A) /ra!ida 4 para ) ) /ra!ida ) para 1 K #) /ra!ida 4 para 1 %) /ra!ida 4 para ) &e!iew Information' The correct answer is #' /ra!ida 4 para 1 /ra!ida is the number of pre"nancies and ?arity is the number of pre"nancies that reach !iability Anot the number of fetuses). Thus+ for this woman+ she is now pre"nant+ had ) prior pre"nancies+ and 1 !iable birth Atwins). <. A child who in"ested 16 ma7imum stren"th acetaminophen tablets 46 minutes a"o is seen in the emer"ency department. .hich of these orders should the nurse do first? K A) /astric la!a"e ?&C ) Acetylcysteine Amucomyst) for a"e per pharmacy (tart an IB %e7trose 6: with 8.44: normal saline to keep !ein #) open %) Acti!ated charcoal per pharmacy &e!iew Information' The correct answer is A' /astric la!a"e ?&C &emo!in" as much of the dru" as possible is the first step in treatment for this dru" o!erdose. This is best done by "astric la!a"e. The ne7t dru" to "i!e would be acti!ated charcoal+ then mucomyst and lastly the IB fluids. -. The nurse is preparin" to administer an enteral feedin" to a client !ia a naso"astric feedin" tube. The most important action of the nurse is K A) Berify correct placement of the tube ) #heck that the feedin" solution matches the dietary order Aspirate abdominal contents to determine the amount of last #) feedin" remainin" in stomach %) Hnsure that feedin" solution is at room temperature &e!iew Information' The correct answer is A' Berify correct placement of the tube ?roper placement of the tube pre!ents aspiration. ,. The nurse anticipates that for a family who practices #hinese medicine the priority "oal would be to A) Achie!e harmony ) $aintain a balance of ener"y #) &espect life K %) &estore yin and yan" &e!iew Information' The correct answer is %' &estore yin and yan" 0or followers of #hinese medicine+ health is maintained throu"h balance between the forces of yin and yan".

9. .hich complication of cardiac catheteri5ation should the nurse monitor for in the initial )4 hours after the procedure? A) an"ina at rest K ) thrombus formation #) di55iness %) fallin" blood pressure &e!iew Information' The correct answer is ' thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial )4 hours after a cardiac catheteri5ation. A fallin" ? occurs alon" with hemorrha"e of the insertion site which is associated with the first 1) hours after the procedure. 18. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? K A) The muscles ) The cerebellum #) The kidneys %) The le" bones &e!iew Information' The correct answer is A' All striated muscles &habdomyosarcoma is the most common children==s soft tissue sarcoma. It ori"inates in striated Askeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is EmyoD which typically means muscle. 11. A client comes to the clinic for treatment of recurrent pel!ic inflammatory disease. The nurse reco"ni5es that this condition most fre1uently follows which type of infection? A) Trichomoniasis K ) #hlamydia #) (taphylococcus %) (treptococcus &e!iew Information' The correct answer is ' #hlamydia #hlamydial infections are one of the most fre1uent causes of salpin"itis or pel!ic inflammatory disease. 1). %urin" the e!aluation of the 1uality of home care for a client with Al5heimer=s disease+ the priority for the nurse is to reinforce which statement by a family member? A) At least ) full meals a day is eaten. .e "o to a "roup discussion e!ery week at our community ) center. .e ha!e safety bars installed in the bathroom and ha!e )4 hour K #) alarms on the doors. %) The medication is not a problem to ha!e it taken 4 times a day. &e!iew Information' The correct answer is #' .e ha!e safety bars installed in the bathroom and ha!e )4 hour alarms on the doors. Hnsurin" safety of the client with increasin" memory loss is a priority of home care. Cote all options are correct statements. @owe!er+ safety is most important to reinforce. 14. The nurse is carin" for a client with a !enous stasis ulcer. .hich nursin" inter!ention would be most effecti!e in promotin" healin"? A) Apply dressin" usin" sterile techni1ue K ) Impro!e the client=s nutrition status #) Initiate limb compression therapy %) e"in proteolytic debridement &e!iew Information' The correct answer is ' Impro!e the client==s nutrition status The "oal of clinical mana"ement in a client with !enous stasis ulcers is to promote healin". This only can be accomplished with proper nutrition. The other answers are correct+ but without proper nutrition+ the other inter!entions would be of little help. 14. %urin" an assessment of a client with cardiomyopathy+ the nurse finds that the systolic blood pressure has decreased from 146 to 118 mm @" and the heart rate has risen from -) to 9< beats per minute and the client complains of periodic di55y spells. The nurse instructs the client to A) Increase fluids that are hi"h in protein ) &estrict fluids K #) 0orce fluids and reassess blood pressure %) >imit fluids to non-caffeine be!era"es &e!iew Information' The correct answer is #' 0orce fluids and reassess blood pressure ?ostural hypotension+ a decrease in systolic blood pressure of more than 16 mm @" and an increase in heart rate of more than 16 percent usually accompanied by di55iness indicates !olume depletion+ inade1uate !asoconstrictor mechanisms+ and autonomic insufficiency. 16. .hich indi!idual is at "reatest risk for de!elopin" hypertension? K A) 46 year-old African American attorney ) <8 year-old Asian American shop owner #) 48 year-old #aucasian nurse %) 66 year-old @ispanic teacher &e!iew Information' The correct answer is A' 46 year-old African American attorney

The incidence of hypertension is "reater amon" African Americans than other "roups in the *(. The incidence amon" the @ispanic population is risin". 1<. The nurse is carin" for a client with a serum potassium le!el of 4.6 mH1G>. The client is placed on a cardiac monitor and recei!es 48 mH1 M#> in 1888 ml of 6: de7trose in water IB. .hich of the followin" HM/ patterns indicates to the nurse that the infusions should be discontinued? A) Carrowed Q&( comple7 ) (hortened "?&" inter!al K #) Tall peaked T wa!es %) ?rominent "*" wa!es &e!iew Information' The correct answer is #' Tall peaked T wa!es A tall peaked T wa!e is a si"n of hyperkalemia. The health care pro!ider should be notified re"ardin" discontinuin" the medication. 1-. A client has been takin" furosemide A>asi7) for the past week. The nurse reco"ni5es which findin" may indicate the client is e7periencin" a ne"ati!e side effect from the medication? A) .ei"ht "ain of 6 pounds ) Hdema of the ankles #) /astric irritability K %) %ecreased appetite &e!iew Information' The correct answer is %' %ecreased appetite >asi7 causes a loss of potassium if a supplement is not taken. (i"ns and symptoms of hypokalemia include anore7ia+ fati"ue+ nausea+ decreased /I motility+ muscle weakness+ dysrhythmias. 1,. .hich of these statements best describes the characteristic of an effecti!e reward-feedback system? K A) (pecific feedback is "i!en as close to the e!ent as possible ) (taff are "i!en feedback in e1ual amounts o!er time #) ?ositi!e statements are to precede a ne"ati!e statement %) ?erformance "oals should be hi"her than what is attainable &e!iew Information' The correct answer is A' (pecific feedback is "i!en as close to the e!ent as possible 0eedback is most useful when "i!en immediately. ?ositi!e beha!ior is stren"thened throu"h immediate feedback+ and it is easier to modify problem beha!iors if the standards are clearly understood. 19. The nurse practicin" in a maternity settin" reco"ni5es that the post mature fetus is at risk due to A) H7cessi!e fetal wei"ht ) >ow blood su"ar le!els #) %epletion of subcutaneous fat K %) ?ro"ressi!e placental insufficiency &e!iew Information' The correct answer is %' ?ro"ressi!e placental insufficiency The placenta functions less efficiently as pre"nancy continues beyond 4) weeks. Immediate and lon" term effects may be related to hypo7ia. )8. A child who has recently been dia"nosed with cystic fibrosis is in a pediatric clinic where a nurse is performin" an assessment. .hich later findin" of this disease would the nurse not e7pect to see at this time? A) ?ositi!e sweat test ) ulky "reasy stools K #) $oist+ producti!e cou"h %) $econium ileus &e!iew Information' The correct answer is #'$oist+ producti!e cou"h ;ption c is a later si"n. Coisy respirations and a dry non-producti!e cou"h are commonly the first of the respiratory si"ns to appear in a newly dia"nosed client with cystic fibrosis A#0). The other options are the earliest findin"s. #0 is an inherited A"enetic) condition affectin" the cells that produce mucus+ sweat+ sali!a and di"esti!e 3uices. Cormally+ these secretions are thin and slippery+ but in #0+ a defecti!e "ene causes the secretions to become thick and sticky. Instead of actin" as a lubricant+ the secretions plu" up tubes+ ducts and passa"eways+ especially in the pancreas and lun"s. &espiratory failure is the most dan"erous conse1uence of #0. )1. .hich of the followin" should the nurse implement to prepare a client for a M* AMidney+ *reter+ ladder) radio"raph test? A) #lient must be C?; before the e7amination ) Hnema to be administered prior to the e7amination $edicate client with >asi7 )8 m" IB 48 minutes prior to the #) e7amination K %) Co special orders are necessary for this e7amination &e!iew Information' The correct answer is %' Co special orders are necessary for this e7amination Co special preparation is necessary for this e7amination.

)). The hospital has sounded the call for a disaster drill on the e!enin" shift. .hich of these clients would the nurse put first on the list to be dischar"ed in order to make a room a!ailable for a new admission? A middle a"ed client with a history of bein" !entilator dependent K A) for o!er - years and admitted with bacterial pneumonia fi!e days a"o A youn" adult with diabetes mellitus Type ) for o!er 18 years and ) admitted with antibiotic induced diarrhea )4 hours a"o An elderly client with a history of hypertension+ #) hypercholesterolemia and lupus+ and was admitted with (te!ensSohnson syndrome that mornin" An adolescent with a positi!e @IB test and admitted for acute %) cellulitus of the lower le" 4, hours a"o &e!iew Information' The correct answer is A' A middle a"ed client with a history of bein" !entilator dependent for o!er - years and admitted with bacterial pneumonia fi!e days a"o The best candidate for dischar"e is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home. )4. A tria"e nurse has these 4 clients arri!e in the emer"ency department within 16 minutes. .hich client should the tria"e nurse send back to be seen first? A ) month old infant with a history of rollin" off the bed and has A) buld"in" fontanels with cryin" K ) A teena"er who "ot a sin"ed beard while campin" An elderly client with complaints of fre1uent li1uid brown colored #) stools A middle a"ed client with intermittent pain behind the ri"ht %) scapula &e!iew Information' The correct answer is ' A teena"er who "ot sin"ed a sin"ed beard while campin" This client is in the "reatest dan"er with a potential of respiratory distress+ Any client with sin"ed facial hair has been e7posed to heat or fire in close ran"e that could ha!e caused dama"e to the interior of the lun". Cote that the interior linin" of the lun" has no ner!e fibers so the client will not be aware of swellin". )4. A client is recei!in" di"o7in A>ano7in) 8.)6 m". %aily. The health care pro!ider has written a new order to "i!e metoprolol A>opressor) )6 m". .I.%. In assessin" the client prior to administerin" the medications+ which of the followin" should the nurse report immediately to the health care pro!ider? K A) lood pressure 94G<8 ) @eart rate -< #) *rine output 68 mlGhour %) &espiratory rate 1< &e!iew Information' The correct answer is A' lood pressure 94G<8 oth medications decrease the heart rate. $etoprolol affects blood pressure. Therefore+ the heart rate and blood pressure must be within normal ran"e A@& <8-188I systolic G? o!er 188) in order to safely administer both medications. )6. A nurse enters a client=s room to disco!er that the client has no pulse or respirations. After callin" for help+ the first action the nurse should take is A) (tart a peripheral IB ) Initiate closed-chest massa"e K #) Hstablish an airway %) ;btain the crash cart &e!iew Information' The correct answer is #' Hstablish an airway Hstablishin" an airway is always the primary ob3ecti!e in a cardiopulmonary arrest. )<. A 4 year-old child comes to the pediatric clinic after the sudden onset of findin"s that include irritability+ thick muffled !oice+ croakin" on inspiration+ hot to touch+ sit leanin" forward+ ton"ue protrudin"+ droolin" and suprasternal retractions. .hat should the nurse do first? A) ?repare the child for 7-ray of upper airways ) H7amine the child=s throat #) #ollect a sputum specimen K %) Cotify the healthcare pro!ider of the child=s status &e!iew Information' The correct answer is %' Cotify the health care pro!ider of the child==s status These findin"s su""est a medical emer"ency and may be due to epi"lottises. Any child with an acute onset of an inflammatory response in the mouth and throat should recei!e immediate attention in a facility e1uipped to perform intubation or a tracheostomy in the e!ent of further or complete obstruction. )-. A nurse is to administer meperidine hydrochloride A%emerol) 188 m"+ atropine sulfate AAtropisol) 8.4 m"+ and promethi5ine hydrochloride A?hener"an) 68 m" I$ to a pre-operati!e client. .hich action should the nurse take first? A) &aise the side rails on the bed ) ?lace the call bell within reach #) Instruct the client to remain in bed K %) @a!e the client empty bladder &e!iew Information' The correct answer is %' @a!e the client empty bladder The first step in the process is to ha!e the client !oid prior to administerin" the pre-operati!e medication. The other actions follow this initial step in this se1uence' 4 4 1 )

),. In children suspected to ha!e a dia"nosis of diabetes+ which one of the followin" complaints would be most likely to prompt parents to take their school a"e child for e!aluation? A) ?olypha"ia ) %ehydration K #) ed wettin" %) .ei"ht loss &e!iew Information' The correct answer is #' ed wettin" In children+ fati"ue and bed wettin" are the chief complaints that prompt parents to take their child for e!aluation. ed wettin" in a school a"e child is readily detected by the parents. )9. A client has been newly dia"nosed with hypothyroidism and will take le!othyro7ine A(ynthroid) 68 mc"Gday by mouth. As part of the teachin" plan+ the nurse emphasi5es that this medication' K A) (hould be taken in the mornin" ) $ay decrease the client=s ener"y le!el #) $ust be stored in a dark container %) .ill decrease the client=s heart rate &e!iew Information' The correct answer is A' (hould be taken in the mornin" Thyroid supplement should be taken in the mornin" to minimi5e the side effects of insomnia 48. A client has a (wan-/an5 catheter in place. The nurse understands that this is intended to measure A) &i"ht heart function K ) >eft heart function #) &enal tubule function %) #arotid artery function &e!iew Information' The correct answer is ' >eft heart function The (wan-/an5 catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readin"s are inferred from pressure measurements obtained on the ri"ht side of the circulation. &i"ht-sided heart function is assessed throu"h the e!aluation of the central !enous pressures A#B?). 41. .hich of these findin"s indicate that a pump to deli!er a basal rate of 18 ml per hour plus ?&C for pain break throu"h for morphine drip is not workin"? A) The client complains of discomfort at the IB insertion site ) The client states "I 3ust can=t "et relief from my pain." K #) The le!el of dru" is 188 ml at , A$ and is ,8 ml at noon %) The le!el of the dru" is 188 ml at , A$ and is 68 ml at noon &e!iew Information' The correct answer is #' The le!el of dru" is 188 ml at , A$ and is ,8 ml at noon The minimal dose of 18 ml per hour which would be 48 ml "i!en in a 4 hour period. ;nly <8 ml should be left at noon. The pump is not functionin" when more than e7pected medicine is left in the container. 4). The nurse is performin" a neurolo"ical assessment on a client post ri"ht #BA. .hich findin"+ if obser!ed by the nurse+ would warrant immediate attention? K A) %ecrease in le!el of consciousness ) >oss of bladder control #) Altered sensation to stimuli %) Hmotional lability &e!iew Information' The correct answer is A' %ecrease in le!el of consciousness A further decrease in the le!el of consciousness would be indicati!e of a further pro"ression of the #BA. 44. .hen teachin" a client with coronary artery disease about nutrition+ the nurse should emphasi5e A) Hatin" 4 balanced meals a day ) Addin" comple7 carbohydrates K #) A!oidin" !ery hea!y meals %) >imitin" sodium to - "ms per day &e!iew Information' The correct answer is #' A!oidin" !ery hea!y meals Hatin" lar"e+ hea!y meals can pull blood away from the heart for di"estion and is dan"erous for the client with coronary artery disease. 44. The nurse is speakin" at a community meetin" about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. .hat should be the focus of the nurse2s response? A) Hlectrical ener"y fields K ) (pinal column manipulation #) $ind-body balance %) H7ercise of 3oints &e!iew Information' The correct answer is ' (pinal column manipulation The theory underlyin" chiropractic is that interference with transmission of mental impulses between the brain and body or"ans

produces diseases. (uch interference is caused by misali"nment of the !ertebrae. $anipulation reduces the sublu7ation. 46. The home health nurse !isits a male client to pro!ide wound care and finds the client lethar"ic and confused. @is wife states he fell down the stairs ) hours a"o. The nurse should A) ?lace a call to the client=s health care pro!ider for instructions K ) (end him to the emer"ency room for e!aluation #) &eassure the client=s wife that the symptoms are transient Instruct the client=s wife to call the doctor if his symptoms %) become worse &e!iew Information' The correct answer is ' (end him to the emer"ency room for e!aluation This client re1uires immediate e!aluation. A delay in treatment could result in further deterioration and harm. @ome care nurses must prioriti5e inter!entions based on assessment findin"s that are in the client==s best interest. 4<. .hile assessin" a 1 month-old infant+ which findin" should the nurse report immediately? A) Abdominal respirations ) Irre"ular breathin" rate K #) Inspiratory "runt %) Increased heart rate with cryin" &e!iew Information' The correct answer is #' Inspiratory "runt Inspiratory "runtin" is abnormal and may be a si"n of respiratory distress in this infant. 4-. A client with multiple sclerosis plans to be"in an e7ercise pro"ram. In addition to discussin" the benefits of re"ular e7ercise+ the nurse should caution the client to a!oid acti!ities which A) Increase the heart rate K ) >ead to dehydration #) Are considered aerobic %) $ay be competiti!e &e!iew Information' The correct answer is ' >ead to dehydration The client must take in ade1uate fluids before and durin" e7ercise periods. 4,. The nurse is carin" for a client who had a total hip replacement 4 days a"o. .hich assessment re1uires the nurse2s immediate attention? I ha!e bad muscle spasms in my lower le" of the affected A) e7tremity. "I 3ust can=t =catch my breath= o!er the past few minutes and I K ) think I am in "ra!e dan"er." "I ha!e to use the bedpan to pass my water at least e!ery 1 to ) #) hours." %) "It seems that the pain medication is not workin" as well today." &e!iew Information' The correct answer is ' "I 3ust can==t ==catch my breath== o!er the past few minutes and I think I am in "ra!e dan"er." The nurse would be concerned about all of these comments. @owe!er the most life threatenin" is option . #lients who ha!e had hip or knee sur"ery are at "reatest risk for de!elopment of post operati!e pulmonary embolism. (udden dyspnea and tachycardia are classic findin"s of pulmonary embolism. $uscle spasms do not re1uire immediate attention. ;ption # may indicate a urinary tract infection. And option % re1uires further in!esti"ation and is not life threatenin". 49. The nurse is "i!in" dischar"e teachin" to a client - days post myocardial infarction. @e asks the nurse why he must wait < weeks before ha!in" se7ual intercourse. .hat is the best response by the nurse to this 1uestion? "Fou need to re"ain your stren"th before attemptin" such A) e7ertion." ".hen you can climb ) fli"hts of stairs without problems+ it is K ) "enerally safe." #) "@a!e a "lass of wine to rela7 you+ then you can try to ha!e se7." "If you can maintain an acti!e walkin" pro"ram+ you will ha!e %) less risk." &e!iew Information' The correct answer is ' ".hen you can climb ) fli"hts of stairs without problems+ it is "enerally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about < weeks. (car tissue should form about that time. .aitin" until the client can tolerate climbin" stairs is the usual ad!ice "i!en by health care pro!iders. 48. .hat would the nurse e7pect to see while assessin" the "rowth of children durin" their school a"e years? A) %ecreasin" amounts of body fat and muscle mass ) >ittle chan"e in body appearance from year to year #) ?ro"ressi!e hei"ht increase of 4 inches each year K %) Fearly wei"ht "ain of about 6.6 pounds per year &e!iew Information' The correct answer is %' Fearly wei"ht "ain of about 6.6 pounds per year (chool a"e children "ain about 6.6 pounds each year and increase about ) inches in hei"ht. &esults for QYA-&andom W)

1. The nurse is assi"ned to care for a client who has a leakin" intracranial aneurysm. To minimi5e the risk of rebleedin"+ the nurse should plan to K A) &estrict !isitors to immediate family ) A!oid arousal of the client e7cept for family !isits #) Meep client=s hips fle7ed at no less than 98 de"rees Apply a warmin" blanket for temperatures of 9, de"rees %) 0ahrenheit or less &e!iew Information' The correct answer is A' &estrict !isitors to immediate family $aintainin" a 1uiet en!ironment will assist in minimi5in" cerebral rebleedin". .hen family !isit the client should not be distrubed. @owe!er if the client is awake topics of a "eneral nature are better choices for discussion than topics that result in emotional or physiolo"ical stimulation. ). The nurse is performin" a "estational a"e assessment on a newborn deli!ered ) hours a"o. .hen comparin" findin"s to the allard scale+ which situation may affect the score? A) irth wei"ht ) &acial differences K #) 0etal distress in labor %) irth trauma &e!iew Information' The correct answer is #' 0etal distress in labor The effects of earlier distress may alter the findin"s of refle7 responses as measured on the allard tool. ;ther physical characteristics that estimate "estational a"e+ such as amount of lanu"o+ sole creases and ear cartila"e+ are unaffected. 4. A 4 year-old hospitali5ed child be"ins to ha!e a sei5ure while playin" with hard plastic toys in the hallway. ;f the followin" nursin" actions+ which one should the nurse do first? A) ?lace the child in the nearest bed ) Administer IB medication to slow down the sei5ure #) ?lace a padded ton"ue blade in the child=s mouth K %) &emo!e the child=s toys from the immediate area &e!iew Information' The correct answer is %' &emo!e the child==s toys from the immediate area Cursin" care for a child ha!in" a sei5ure includes+ maintainin" airway patency+ ensurin" safety+ administerin" medications+ and pro!idin" emotional support. (ince the sei5ure has already started+ nothin" should be forced into the child==s mouth and they should not be mo!ed. ;f the choices "i!en+ first priority would be for safety. 4. A client asks the nurse to e7plain the basic ideas of homeopathic medicine. The response that best e7plains this approach is that remedies A) %estroy or"anisms causin" disease ) $aintain fluid balance K #) oost the immune system %) Increase bodily ener"y &e!iew Information' The correct answer is #' oost the immune system The practitioner treats with minute doses of plant+ mineral or animal substances which pro!ide a "entle stimulus to the body==s own defenses. 6. The nurse is carin" for a ) year-old who is bein" treated with chelation therapy+ calcium disodium edetate+ for lead poisonin". The nurse should be alert for which of the followin" side effects? A) Ceuroto7icity ) @epatome"aly K #) Cephroto7icity %) ;toto7icity &e!iew Information' The correct answer is #' Cephroto7icity Cephroto7icity is a common side effect of calcium disodium edetate+ in addition to lead poisonin" in "eneral. <. The nurse is carin" for a 1 year-old child who has < teeth. .hat is the best way for the nurse to "i!e mouth care to this child? K A) *sin" a moist soft brush or cloth to clean teeth and "ums ) (wabbin" teeth and "ums with fla!ored mouthwash #) ;fferin" a bottle of water for the child to drink %) rushin" with toothpaste and flossin" each tooth &e!iew Information' The correct answer is A' *sin" a moist soft brush or cloth to clean teeth and "ums The nurse should use a soft cloth or soft brush to do mouth care so that the child can ad3ust to the routine of cleanin" the mouth and teeth. -. At a senior citi5ens meetin" a nurse talks with a client who has diabetes mellitus Type 1. .hich statement by the client durin" the con!ersation is most predicti!e of a potential for impaired skin inte"rity? A) "I "i!e my insulin to myself in my thi"hs."

"(ometimes when I put my shoes on I don=t know where my toes are." "@ere are my up and down "lucose readin"s that I wrote on my #) calendar." %) "If I bathe more than once a week my skin feels too dry." &e!iew Information' The correct answer is ' "(ometimes when I put my shoes on I don==t know where my toes are." ?eripheral neuropathy can lead to lack of sensation in the lower e7tremities. #lients do not feel pressure andGor pain and are at hi"h risk for skin impairment. )

,. A couple tryin" to concei!e asks the nurse when o!ulation occurs. The woman reports a re"ular 4) day cycle. .hich response by the nurse is correct? A) %ays --18 ) %ays 18-14 #) %ays 14-1< K %) %ays 1--19 &e!iew Information' The correct answer is %' %ays 1--19 ;!ulation occurs 14 days prior to menses. #onsiderin" that the woman==s cycle is 4) days+ subtractin" 14 from 4) su""ests o!ulation is at about the 1,th day. 9. Included in teachin" the client with tuberculosis takin" IC@ about follow-up home care+ the nurse should emphasi5e that a laboratory appointment for which of the followin" lab tests is critical? K A) >i!er function ) Midney function #) lood su"ar %) #ardiac en5ymes &e!iew Information' The correct answer is A' >i!er function IC@ can cause hepatocellular in3ury and hepatitis. This side effect is a"e-related and can be detected with re"ular assessment of li!er en5ymes+ which are released into the blood from dama"ed li!er cells. 18. A -, year-old client with pneumonia has a producti!e cou"h but is confused. (afety protecti!e de!ices Arestraints) ha!e been ordered for this client. @ow can the nurse pre!ent aspiration? A) (uction the client fre1uently while restrained ) (ecure all 4 restraints to 1 side of bed K #) ;btain a sitter for the client while restrained %) &e1uest an order for a cou"h suppressant &e!iew Information' The correct answer is #' ;btain a sitter for the client while restrained The plan to use safety de!ices Arestraints) should be rethou"ht. &estraints are used to protect the client from harm caused by remo!in" tubes or "ettin" out of bed. In the e!ent that this restricted mo!ement could cause more harm+ such as aspiration+ then a sitter should be re1uested. These are to be pro!ided by the facility in the e!ent the family cannot do so. This client needs to cou"h and be watched rather than restricted. (uctionin" will not pre!ent aspiration in this situation. #ou"h suppressants should be a!oided for this client. 11. A client with a fractured femur has been in &ussell2s traction for )4 hours. .hich nursin" action is associated with this therapy? A) #heck the skin on the sacrum for breakdown ) Inspect the pin site for si"ns of infection #) Auscultate the lun"s for atelectasis K %) ?erform a neuro!ascular check for circulation &e!iew Information' The correct answer is %' ?erform a neuro!ascular check for circulation .hile each of these is an important assessment+ the neuro!ascular inte"rity is most associated with this type of traction. &ussell2s traction is uck2s traction with a slin" under the knee. 1). The nurse is carin" for a client with e7tracellular fluid !olume deficit. .hich of the followin" assessments would the nurse anticipate findin"? A) oundin" pulse ) &apid respirations K #) ;li"uria %) Ceck !eins are distended &e!iew Information' The correct answer is #' ;li"uria Midneys maintain fluid !olume throu"h ad3ustments in urine !olume. 14. .hen suctionin" a client=s tracheostomy+ the nurse should instill saline in order to A) %ecrease the client=s discomfort ) &educe !iscosity of secretions #) ?re!ent client aspiration K %) &emo!e a mucus plu" &e!iew Information' The correct answer is %' &emo!e a mucus plu" (aline will thin and loosen secretions+ makin" it easier to suction. Altman+ /. A)884). %elmar2s 0undamental and Ad!anced Cursin" (kills+ )nd ed. Albany+ CF' %elmar. >ewis+ (.$.+ @eitkemper+ $.$.+ Y %irksen+ (. &. A)884). $edical-(ur"ical Cursin"' Assessment Y mana"ement of clinical problems. (t. >ouis' $osby. 14. A woman in her third trimester complains of se!ere heartburn. .hat is appropriate teachin" by the nurse to help the woman alle!iate these symptoms? A) %rink small amounts of li1uids fre1uently ) Hat the e!enin" meal 3ust before retirin"

#) Take sodium bicarbonate after each meal K %) (leep with head propped on se!eral pillows &e!iew Information' The correct answer is %' (leep with head propped on se!eral pillows @eartburn is a burnin" sensation caused by re"ur"itation of "astric contents that is best relie!ed by sleepin" position+ eatin" small meals+ and not eatin" before bedtime. 16. A nurse is carin" for a client who had a closed reduction of a fractured ri"ht wrist followed by the application of a fiber"lass cast 1) hours a"o. .hich findin" re1uires the nurse2s immediate attention? A) #apillary refill of fin"ers on ri"ht hand is 4 seconds ) (kin warm to touch and normally colored K #) #lient reports pricklin" sensation in the ri"ht hand %) (li"ht swellin" of fin"ers of ri"ht hand &e!iew Information' The correct answer is #' #lient reports pricklin" sensation in the ri"ht hand ?ricklin" sensation is an indication of compartment syndrome and re1uires immediate action by the nurse. The other findin"s are normal for a client in this situation. 1<. A newborn is ha!in" difficulty maintainin" a temperature abo!e 9, de"rees 0ahrenheit and has been placed in a warmin" isolette. .hich action is a nursin" priority? A) ?rotect the eyes of the neonate from the heat lamp K ) $onitor the neonate2s temperature #) .arm all medications and li1uids before "i!in" %) A!oid touchin" the neonate with cold hands &e!iew Information' The correct answer is ' $onitor the neonate2s temperature .hen usin" a warmin" de!ice the neonate2s temperature should be continuously monitored for undesired ele!ations. The use of heat lamps is not safe as there is no way to re"ulate their temperature. .armin" medications and fluids is not indicated. .hile touchin" with cold hands can startle the infant it does not pose a safety risk. 1-. The nurse is carin" for a client with a myocardial infarction. .hich findin" re1uires the nurse=s immediate action? A) ?eriorbital edema K ) %i55iness spells #) >ethar"y %) (hortness of breath &e!iew Information' The correct answer is ' %i55iness spells #ardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Cear syncope refers to li"htheartedness+ di55iness+ temporary confusion. (uch "spells" may indicate runs of !entricular tachycardia or periods of asystole and should be reported immediately. 1,. A client is admitted with the dia"nosis of pulmonary embolism. .hile takin" a history+ the client tells the nurse he was admitted for the same thin" twice before+ the last time 3ust 4 months a"o. The nurse would anticipate the health care pro!ider orderin" A) ?ulmonary embolectomy K ) Bena ca!al interruption #) Increasin" the coumadin therapy to an IC& of 4-4 %) Thrombolytic therapy &e!iew Information' The correct answer is ' Bena ca!al interruption #lients with contraindications to heparin+ recurrent ?H or those with complications related to the medical therapy may re1uire !ena ca!al interruption by the placement of a filter de!ice in the inferior !ena ca!a. A filter can be placed trans!enously to trap clots before they tra!el to the pulmonary circulation. 19. A -8 year-old woman is e!aluated in the emer"ency department for a wrist fracture of unknown causes. %urin" the process of takin" client history+ which of these items should the nurse identify as related to the client2s "reatest risk factors for osteoporosis? A) $enopause at a"e 68 K ) @as taken hi"h doses of steroids for arthritis for many years #) $aintains an inacti!e lifestyle for the past 18 years %) %rinks ) "lasses of red wine each day for the past 48 years &e!iew Information' The correct answer is ' Takes steroids for arthritis The use of steroids especially hi"h doses o!er time increases the risk for osteoporosis. ;ther risk factors are in each option+ as well as low bone mass+ poor calcium absorption and moderate to hi"h alcohol in"estion. )8. %ecentrali5ed schedulin" is used on a nursin" unit. A cheif ad!anta"e of this mana"ement strate"y is that it K A) #onsiders client and staff needs ) #onser!es time for plannin" #) 0rees the nurse mana"er to handle other priorities %) Allows for re1uests about special pri!ile"es

&e!iew Information' The correct answer is A' #onsiders client and staff needs %ecentrali5ed staffin" takes into consideration specific client needs and staff interests and abilities. )1. A newborn has hyperbilirubinemia and is under"oin" phototherapy with a blanket. .hich safety measure is most important durin" this process? A) &e"ulate the neonate2s temperature usin" a radiant heater ) .ithhold feedin"s while under the phototherapy K #) ?ro!ide water feedin"s at least e!ery ) hours %) ?rotect the eyes of neonate from the phototherapy li"hts &e!iew Information' The correct answer is #' ?ro!ide water feedin"s at least e!ery ) hours (ince the blanket is used the protection of the eyes is inappropriate. ?rotectin" the eyes of the neonates is !ery important to pre!ent dama"e when under the ultra!iolet li"hts. It is recommended that the neonate remain under the li"hts for e7tended periods.The neonate2s skin is e7posed to the li"ht and the temperature is monitored+ but a heater may not be necessary. There is no reason to withhold feedin"s. 0re1uent water or feedin"s are "i!en to help with the e7cretion of the bilirubin throu"h the bowel in the stool. )). The nurse is at the community center speakin" with retired people. To which comment by one of the retirees durin" a discussion about "laucoma would the nurse "i!e a supporti!e comment to reinforce correct information? "I usually a!oid dri!in" at ni"ht since li"hts sometimes seem to A) make thin"s blur." "I take half of the usual dose for my sinuses to maintain my ) blood pressure." "I ha!e to sit at the side of the pool with the "randchildren since #) I can=t swim with this eye problem." "I take e7tra fiber and drink lots of water to a!oid "ettin" K %) constipated." &e!iew Information' The correct answer is %' "I take e7tra fiber and drink lots of water to a!oid "ettin" constipated." Any acti!ity that in!ol!es strainin" should be a!oided in clients with "laucoma. (uch acti!ities would increase intraocular pressure. )4. ;n daily cleanin" of a tracheostomy+ the client cou"hs and displaces the tracheostomy tube. The nurse could ha!e a!oided this by A) placin" an obturator at the client2s bedside ) ha!in" another nurse assist with the procedure K #) fastenin" clean tracheostomy ties before remo!in" old ties %) .ithdraw catheter in a circular motion &e!iew Information' The correct answer is #' fastenin" clean tracheostomy ties before remo!in" old ties 0astenin" clean tracheostomy ties before remo!in" old ones will ensure that the tracheostomy is secured durin" the entire cleanin" procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is cou"hed out. A second nurse is not needed. #han"in" the position may not pre!ent a dislod"ed tracheostomy. )4. .hich contraindication should the nurse assess for prior to "i!in" a child immuni5ations? A) $ild cold symptoms ) #hronic asthma K #) %epressed immune system %) Aller"y to e""s &e!iew Information' The correct answer is #' %epressed immune system #hildren who ha!e a depressed immune system related to @IB or chemotherapy should not be "i!en routine immuni5ations. )6. The nurse is teachin" home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is A) (edation as needed to pre!ent e7haustion ) Antibiotic therapy for 18 to 14 days K #) @umidified air and increased oral fluids %) Antihistamines to decrease aller"ic response &e!iew Information' The correct answer is #' @umidified air and increased oral fluids The most important aspect of home care for a child with acute spasmodic croup is to pro!ide humidified air and increased oral fluids. $oisture soothes inflamed membranes. Ade1uate systemic hydration aids is mucocillary clearance and keeps secretions thin+ white+ watery+ and easily remo!ed with minimal cou"hin". )<. A newborn deli!ered at home without a birth attendant is admitted to the hospital for obser!ation. The initial temperature is 46 de"rees #elsius A96 de"rees 0ahrenheit) a7illary. The nurse reco"ni5es that cold stress may lead to what complication? A) >owered $& K ) &educed ?a;) #) >ethar"y %) $etabolic alkalosis &e!iew Information' The correct answer is ' &educed ?a;) #old stress causes increased risk for respiratory distress. The baby deli!ered in such circumstances needs careful monitorin". In this situation+ the newborn must be warmed immediately to increase its temperature to at least 4< de"rees #elsius A9- de"rees 0ahrenheit).

)-. In addition to standard precautions+ a nurse should implement contact precautions for which client? K A) <8 year-old with herpes simple7 ) < year-old with mononucleosis #) 46 year-old with pneumonia %) 4 year-old with scarlet fe!er &e!iew Information' The correct answer is A' <8 year-old with herpes simple7 #lients who ha!e herpes simple7 infections must ha!e contact precautions in addition to standard precautions because of skin lesions. #ontact precautions are used for clients who are infected by microor"anisms that are transmitted by direct contact with the client+ includin" hand or skin-to-skin contact. ),. .hich of the followin" situations is most likely to produce sepsis in the neonate? A) $aternal diabetes K ) ?rolon"ed rupture of membranes #) #esarean deli!ery %) ?recipitous !a"inal birth &e!iew Information' The correct answer is ' ?rolon"ed rupture of membranes ?remature rupture of the membranes A?&;$) is a leadin" cause of newborn sepsis. After 1)-)4 hours of leakin" fluid+ measures are taken to reduce the risk to mother and the fetusGnewborn. )9. .hich client is at hi"hest risk for de!elopin" a pressure ulcer? A) )4 year-old in traction for fractured femur -) year-old with peripheral !ascular disease+ who is unable to ) walk without assistance -6 year-old with left sided paresthesia and is incontinent of urine K #) and stool %) 48 year-old who is comatose followin" a ruptured aneurysm &e!iew Information' The correct answer is #' -6 year-old client with left sided paresthesia and is incontinent of urine and stool &isk factors for pressure ulcers include' immobility+ absence of sensation+ decreased >;#+ poor nutrition and hydration+ skin moisture+ incontinence+ increased a"e+ decreased immune response. This client has the "reatest number of risk factors. 48. A new nurse mana"er is responsible for inter!iewin" applicants for a staff nurse position. .hich inter!iew strate"y would be the best approach? Bary the inter!iew style for each candidate to learn different A) techni1ues *se simple 1uestions re1uirin" "yes" and "no" answers to "ain ) definiti!e information ;btain an inter!iew "uide from human resources for consistency K #) in inter!iewin" each candidate Ask personal information of each applicant to assure meetin" of %) 3ob demands &e!iew Information' The correct answer is #' ;btain an inter!iew "uide from human resources for consistency in inter!iewin" each candidate An inter!iew "uide used for each candidate enables the nurse mana"er to be more ob3ecti!e in the decision makin". The nurse should use resources a!ailable in the a"ency before attempts to de!elop one from scratch. 41. A client who is 1) hour post-op becomes confused and says' E/iant sharks are swimmin" across the ceilin".D .hich assessment is necessary to ade1uately identify the source of this client=s beha!ior? A) #ardiac rhythm strip ) ?upillary response K #) ?ulse o7imetry %) ?eripheral "lucose stick &e!iew Information' The correct answer is #' ?ulse o7imetry A sudden chan"e in mental status in any post-op client should tri""er a nursin" inter!ention directed toward further respiratory e!aluation. ?ulse o7imetry would be the initial assessment. If a!ailable+ arterial blood "ases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain ade1uate "as e7chan"e which may result in hypercapnia andGor hypo7emia. #linical findin"s of hypo7emia include these findin" which are listed in order of initial to later findin"s' restlessness+ irritability+ a"itation+ dyspnea+ disorientation+ confusion+ delirium+ hallucinations+ and loss of consciousness. .hile there may be other factors influencin" the client==s findin"s+ the first nursin" action should be directed toward o7y"enation issues. ;nce respiratory or o7y"enation issues are ruled out then si"nificant chan"es in "lucose would be ne7t to e!aluate. 4). A client returns from sur"ery after an open reduction of a femur fracture. There is a small bloodstain on the cast. 0our hours later+ the nurse obser!es that the stain has doubled in si5e. .hat is the best action for the nurse to take? A) #all the health care pro!ider ) Access the site by cuttin" a window in the cast

#) &ecord the findin"s in the nurse=s notes only ;utline the spot with a pencil and note the time and date on the K %) cast &e!iew Information' The correct answer is %' ;utline the spot with a pencil and note the time and date on the cast This is a "ood way to assess the amount of bleedin" o!er a period of time. The bleedin" does not appear to be e7cessi!e and some bleedin" is e7pected with this type of sur"ery. The bleedin" should also be documented in the nurse2s notes. 44. A nurse assessin" the newborn of a mother with diabetes understands that hypo"lycemia is related to what pathophysiolo"ical process? K A) %isruption of fetal "lucose supply ) ?ancreatic insufficiency #) $aternal insulin dependency %) &educed "lyco"en reser!es &e!iew Information' The correct answer is A' %isruption of fetal "lucose supply After deli!ery+ the hi"h "lucose le!els which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of "lucose. .hen oral feedin"s be"in+ the newborn will ad3ust insulin production within a day or two. 44. The nurse is teachin" a parent about side effects of routine immuni5ations. .hich of the followin" must be reported immediately? A) Irritability ) (li"ht edema at site #) >ocal tenderness K %) Temperature of 18).6 0 &e!iew Information' The correct answer is %' Temperature of 18).6 0 An ad!erse reaction of a fe!er should be reported immediately. ;ther reactions that should be reported include cryin" for [ 4 hours+ sei5ure acti!ity+ and tender+ swollen+ reddened areas. 46. The parents of a toddler ask the nurse how lon" their child will ha!e to sit in a car seat while in the automobile. .hat is the nurse2s best response to the parents? EFour child must use a care seat until he wei"hs at least 48 K A) pounds." ) The child must be 6 years of a"e to use a re"ular seat belt. #) EFour child must reach a hei"ht of 68 inches to sit in a seat belt." %) EThe child can use a re"ular seat belt when he can sit still." &e!iew Information' The correct answer is A' EFour child must use a care seat until he wei"hs at least 48 pounds." A child should use a car seat until they wei"h 48 pounds. 4<. A 1< year-old boy is admitted for Hwin"=s sarcoma of the tibia. In discussin" his care with the parents+ the nurse understands that the initial treatment most often includes A) Amputation 3ust abo!e the tumor ) (ur"ical e7cision of the mass #) one marrow "raft in the affected le" K %) &adiation and chemotherapy &e!iew Information' The correct answer is %' &adiation and chemotherapy The initial treatment of choice for Hwin"==s sarcoma is a combination of radiation and chemotherapy. 4-. A client complains of some discomfort after a below the knee amputation. .hich action by the nurse is appropriate to do initially? A) #onduct "uided ima"ery or distraction K ) Hnsure that the stump is ele!ated for the initial day #) .rap the stump snu"ly in an elastic banda"e %) Administer opioid narcotics as ordered &e!iew Information' The correct answer is ' Hnsure that the stump is ele!ated for the initial day The priority is to ele!ate the stump+ pre!entin" pressure caused by poolin" of blood and thus minimi5in" the pain. .ithout this measure+ a firm elastic banda"e+ opioid narcotics+ or "uided ima"ery will ha!e little effect. The opioid would be "i!en for se!ere pain. 4,. .hat is the best way that parents of pre-schoolers can be"in teachin" their child about in3ury pre!ention? K A) (et "ood e7amples themsel!es ) ?rotect their child from outside influences #) $ake sure their child understands all the safety rules %) %iscuss the conse1uences of not wearin" protecti!e de!ices &e!iew Information' The correct answer is A' (et "ood e7amples themsel!es ?reschool years is the time for parents to be"in emphasi5in" safety education as well as pro!idin" protection. (ettin" a "ood e7ample themsel!es is crucial because of the imitati!e beha!iors of pre-schoolersI they are 1uick to notice discrepancies between what they see and what they are told. 49. .hich o7y"en deli!ery system would the nurse apply that would pro!ide the hi"hest concentrations of o7y"en to the client? A) Benturi mask ) ?artial rebreather mask K #) Con-rebreather mask

%) (imple face mask &e!iew Information' The correct answer is #' Con-rebreather mask The non-rebreather mask has a one-way !al!e that pre!ents e7hales air from enterin" the reser!oir ba" and one or more !al!es co!erin" the air holes on the face mask itself to pre!ent inhalation of room air but to allow e7halation of air. .hen a ti"ht seal is achie!ed around the mask up to 188: of o7y"en is a!ailable. 48. The nurse is teachin" the mother of a 6 month-old about nutrition for her baby. .hich statement by the mother indicates the need for further teachin"? A) "I=m "oin" to try feedin" my baby some rice cereal." ) ".hen he wakes at ni"ht for a bottle+ I feed him." K #) "I dip his pacifier in honey so he=ll take it." %) "I keep formula in the refri"erator for )4 hours." &e!iew Information' The correct answer is #' "I dip his pacifier in honey so he==ll take it." @oney has been associated with infant botulism and should be a!oided. ;lder children and adults ha!e di"esti!e en5ymes that kill the botulism spores. &esults for QYA-&andom W1 1. The nurse is performin" an assessment on a client who is cachectic and has de!eloped an enterocutaneous fistula followin" sur"ery to relie!e a small bowel obstruction. The client=s total protein le!el is reported as 4.6. .hich of the followin" would the nurse anticipate? . A) Additional potassium will be "i!en IB ) lood for coa"ulation studies will be drawn K #) Total parenteral nutrition AT?C) will be started %) (erum lipase le!els will be e!aluated &e!iew Information' The correct answer is #' Total parenteral nutrition AT?C) will be started The client is not absorbin" nutrients ade1uately as e!idenced by the cache7ia and low protein le!els. AA normal total serum protein le!el is <.8-,.8.) T?C will maintain a positi!e nitro"en balance in the client who is unable to di"est and absorb nutrients ade1uately. ). The nurse is assi"ned to care for 4 clients. .hich of the followin" should be assessed immediately after hearin" the report? A) The client with asthma who is now ready for dischar"e K ) The client with a peptic ulcer who has been !omitin" all ni"ht #) The client with chronic renal failure returnin" from dialysis %) The client with pancreatitis who was admitted yesterday &e!iew Information' The correct answer is ' The client with a peptic ulcer who has been !omitin" all ni"ht A perforated peptic ulcer could cause nausea+ !omitin" and abdominal distention+ and may be a life threatenin" situation. The client should be assessed immediately and findin"s reported to the health care pro!ider. 4. A newborn wei"hed - pounds ) ounces at birth. The nurse assesses the newborn at home ) days later and finds the wei"ht to be < pounds - ounces. .hat should the nurse tell the parents about this wei"ht loss? A) The newborn needs additional assessments ) The mother should breast feed more often #) A chan"e to formula is indicated K %) The loss is within normal limits &e!iew Information' The correct answer is %' The loss is within normal limits A newborn is e7pected to lose 6-18: of the birth wei"ht in the first few days because of chan"es in elimination and feedin". 4. %urin" a situation of pain mana"ement+ which statement is a priority to consider for the ethical "uidelines of the nurse? K A) The client=s self-report is the most important consideration ) #ultural sensiti!ity is fundamental to pain mana"ement #) #lients ha!e the ri"ht to ha!e their pain relie!ed %) Curses should not pre3ud"e a client=s pain usin" their own !alues &e!iew Information' The correct answer is A' The client==s selfreport is the most important consideration ?ain is a comple7 phenomenon that is percei!ed differently by each indi!idual. ?ain is whate!er the client says it is. The other statements are correct but not the priority. 6. A 46-year-old client of ?uerto &ican-American descent is dia"nosed with o!arian cancer. The client states EI refuse both radiation and chemotherapy because they are =hot.=D The ne7t action for the nurse to take is to A) %ocument the situation in the notes ) &eport the situation to the health care pro!ider #) Talk with the client=s family about the situation Ask the client to talk about the concerns about the "hot" K %) treatments

&e!iew Information' The correct answer is %' Ask the client to talk about the concerns about the "hot" treatments The "hot-cold" system is found amon" $e7ican-Americans+ ?uerto &icans+ and other @ispanic->atinos. $ost foods+ be!era"es+ herbs+ and medicines are cate"ori5ed as hot or cold+ which are symbolic desi"nations and do not necessarily indicate temperature or spiciness. #are and treatment re"imens can be ne"otiated with clients within this framework. <. .hich of the followin" dru"s should the nurse anticipate administerin" to a client before they are to recei!e electrocon!ulsi!e therapy? A) en5odia5ephines ) #hlorproma5ine AThora5ine) K #) (uccinylcholine AAnectine) %) Thiopental sodium A?entothal (odium) &e!iew Information' The correct answer is #' (uccinylcholine AAnectine) (uccinylcholine is "i!en intra!enously to promote skeletal rela7ation. -. A client is brou"ht to the emer"ency room followin" a motor !ehicle accident. .hen assessin" the client one-half hour after admission+ the nurse notes se!eral physical chan"es. .hich chan"es would re1uire the nurse=s immediate attention? A) Increased restlessness ) Tachycardia K #) Tracheal de!iation %) Tachypnea &e!iew Information' The correct answer is #' Tracheal de!iation The de!iated trachea is a si"n that a mediastinal shift has occurred. This is a medical emer"ency. ,. .hich approach is a priority for the nurse who works with clients from many different cultures? A) (peak at least ) other lan"ua"es of clients in the nei"hborhood >earn about the cultures of clients who are most often ) encountered @a!e a list of persons for referral when interaction with these #) clients occur &eco"ni5e personal attitudes about cultural differences and real K %) or e7pected biases &e!iew Information' The correct answer is %' &eco"ni5e personal attitudes about cultural differences and real or e7pected biases The nurse must disco!er personal attitudes+ pre3udices and biases specific to different cultures. (ensiti!ity to these will affect interactions with clients and families across cultures. 9. A client with chronic obstructi!e pulmonary disease A#;?%) and a history of coronary artery disease is recei!in" Aminophylline+ )6m"Ghour. .hich one of the followin" findin"s by the nurse would re1uire immediate inter!ention? A) %ecreased blood pressure and respirations. ) 0lushin" and headache. K #) &estlessness and palpitations. %) Increased heart rate and blood pressure. &e!iew Information' The correct answer is #' &estlessness and palpitations. (ide effects of Aminophylline include restlessness and palpitations. 18. The nurse is plannin" care for an , year-old child. .hich of the followin" should be included in the plan of care? K A) Hncoura"e child to en"a"e in acti!ities in the playroom ) ?romote independence in acti!ities of daily li!in" #) Talk with the child and allow him to e7press his opinions %) ?ro!ide fre1uent reassurance and cuddlin" &e!iew Information' The correct answer is A' Hncoura"e child to en"a"e in acti!ities in the playroom Accordin" to Hrikson+ the school a"e child is in the sta"e of industry !ersus inferiority. To help them achie!e industry+ the nurse should encoura"e them to carry out tasks and acti!ities in their room or in the playroom. 11. A pre"nant client who is at 44 weeks "estation is dia"nosed with a pulmonary embolism A?H). .hich of these mediations would the nurse anticipate the health care pro!ider orderin"? A) ;ral #oumadin therapy ) @eparin 6888 units subcutaneously b.i.d. @eparin infusion to maintain the ?TT at 1.6-).6 times the control #) !alue @eparin by subcutaneous in3ection to maintain the ?TT at 1.6 K %) times the control !alue &e!iew Information' The correct answer is %' @eparin by subcutaneous in3ection to maintain the ?TT at 1.6 times the control !alue (e!eral studies ha!e been conducted in pre"nant women where oral anticoa"ulation a"ents are contraindicated. .arfarin A#oumadin) is known to cross the placenta and is therefore reported to be terato"enic. 1). The nurse is carin" for a client with @od"kin=s disease who will be recei!in" radiation therapy. The nurse reco"ni5es that+ as a result of the radiation therapy+ the client is most likely to e7perience A) @i"h fe!er K ) Causea

#) 0ace and neck edema %) Ci"ht sweats &e!iew Information' The correct answer is ' Causea ecause the client with @od"kin==s disease is usually healthy when therapy be"ins+ the nausea is especially troublin". 14. .hile assessin" the !ital si"ns in children+ the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what a"e? A) 1 year of a"e K ) ) years of a"e #) 4 years of a"e %) 4 years of a"e &e!iew Information' The correct answer is ' ) years of a"e A child should be at least ) years of a"e to use the radial pulse to assess heart rate. 14. .hich of these clients+ who all ha!e the findin"s of a board-like abdomen+ would the nurse su""est that the health care pro!ider e7amine first? An elderly client who stated that "$y awful pain in my ri"ht side K A) suddenly stopped about 4 hours a"o." A pre"nant woman of , weeks newly dia"nosed with an ectopic ) pre"nancy A middle-a"ed client admitted with di!erticulitis and has taken #) only clear li1uids for the past week A teena"er with a history of fallin" off a bicycle and did not hit %) the handle bars &e!iew Information' The correct answer is A' An elderly client who stated that "$y awful pain in my ri"ht side suddenly stopped about 4 hours a"o." This client has the hi"hest risk for hypo!olemic and septic shock since the appendi7 has most likely ruptured as based on the history of the pain suddenly stoppin" o!er three hours a"o. ein" elderly there+ is less reser!e for the body to cope with shock and infection o!er lon" periods. The others are at risk for shock also. @owe!er+ "i!en that they fall in youn"er a"e "roups+ they would more likely be able to tolerate an inbalance in circulation. A common complication of fallin" off a bicycle is hittin" the handle bars in the upper abdomen often on the left+ resultin" in a ruptured spleen. 16. A client with a panic disorder has a new prescription for Pana7 AAlpa5olam). In teachin" the client about the dru"=s actions and side effects+ which of the followin" should the nurse emphasi5e? K A) (hort-term relief can be e7pected ) The medication acts as a stimulant #) %osa"e will be increased as tolerated %) Initial side effects often continue &e!iew Information' The correct answer is A' (hort-term relief can be e7pected Pana7 is a short-actin" ben5odia5epine useful in controllin" panic symptoms 1uickly 1<. .hich of these 1uestions is priority when assessin" a client with hypertension? K A) ".hat o!er-the-counter medications do you take?" ) "%escribe your usual e7ercise and acti!ity patterns." #) "Tell me about your usual diet." %) "%escribe your family=s cardio!ascular history." &e!iew Information' The correct answer is A' ".hat o!er-thecounter medications do you take?" ;!er-the-counter medications+ especially those that contain cold preparations can increase the blood pressure to the point of hypertension. 1-. %urin" a routine check-up+ an insulin-dependent diabetic has his "lycosylated hemo"lobin checked. The results indicate a le!el of 11:. ased on this result+ what teachin" should the nurse emphasi5e? A) &otation of in3ection sites ) Insulin mi7in" and preparation K #) %aily blood su"ar monitorin" %) &e"ular hi"h protein diet &e!iew Information' The correct answer is #' %aily blood su"ar monitorin" Cormal hemo"lobin A1# A"lycosylated hemo"lobin) le!el is - to 9:. Hle!ation indicates ele!ated "lucose le!els o!er time. 1,. .hich of these clients would the nurse monitor for the complication of #. difficile diarrhea? A) An adolescent takin" medications for acne ) An elderly client li!in" in a retirement center takin" prednisone #) A youn" adult at home takin" a prescribed amino"lycoside K %) A hospitali5ed middle a"ed client recei!in" clindamycin &e!iew Information' The correct answer is %' A hospitali5ed middle a"ed client recei!in" clindamycin

@ospitali5ed patients+ especially those recei!in" antibiotic therapy+ are primary tar"ets for #. difficile. ;f patients recei!in" antibiotics+ 6-4,: e7perience antibiotic-associated diarrheaI #. difficile causes 16 to )8: of the cases. (e!eral antibiotic a"ents ha!e been associated with #. difficile. road-spectrum a"ents+ such as clindamycin+ ampicillin+ amo7icillin+ and cephalosporins+ are the most fre1uent sources of #. difficile. Also+ #. difficile infection has been caused by the administration of a"ents containin" beta-lactamase inhibitors Aie+ cla!ulanic acid+ sulbactam+ ta5obactam) and intra!enous a"ents that achie!e substantial colonic intraluminal concentrations Aie+ ceftria7one+ nafcillin+ o7acillin). 0luoro1uinolones+ amino"lycosides+ !ancomycin+ and trimethoprim are seldom associated with #. difficile infection or pseudomembranous colitis. 19. The nurse is assessin" a comatose client recei!in" "astric tube feedin"s. .hich of the followin" assessments re1uires an immediate response from the nurse? K A) %ecreased breath sounds in ri"ht lower lobe ) Aspiration of a residual of 188cc of formula #) %ecrease in bowel sounds %) *rine output of )68 cc in past , hours &e!iew Information' The correct answer is A' %ecreased breath sounds in ri"ht lower lobe The most common problem associated with enteral feedin"s is atelectasis. $aintain client at 48 de"rees durin" feedin"s and monitor for si"ns of aspiration. #heck for tube placement prior to each feedin" or e!ery 4 to , hours if continuous feedin". )8. The nurse is preparin" to take a toddler=s blood pressure for the first time. .hich of the followin" actions should the nurse do first? A) H7plain that the procedure will help him to "et well ) (how a cartoon character with a blood pressure cuff #) H7plain that the blood pressure checks the heart pump K %) ?ermit handlin" the e1uipment before puttin" the cuff in place &e!iew Information' The correct answer is %' ?ermit handlin" the e1uipment before puttin" the cuff in place The best way to "ain the toddler==s cooperation is to encoura"e handlin" the e1uipment. %etailed e7planations are not helpful. )1. A -) year-old client is scheduled to ha!e a cardio!ersion. A nurse re!iews the client2s medication administration record. The nurse should notify the health care pro!ider if the client recei!ed which medication durin" the precedin" )4 hours? K A) di"o7in A>ano7in) ) diltia5am A#ardi5em) #) nitro"lycerine ointment %) metoprolol AToprol P>) &e!iew Information' The correct answer is A' di"o7in A>ano7in) %i"o7in increases !entricular irritability and increases the risk of !entricular fibrillation followin" cardio!ersion. The other medications do not increase !entricular irritability. )). To pre!ent dru" resistance common to tubercle bacilli+ the nurse is aware that which of the followin" a"ents are usually added to dru" therapy? A) Anti-inflammatory a"ent ) @i"h doses of comple7 !itamins #) Amino"lycoside antibiotic K %) Two anti-tuberculosis dru"s &e!iew Information' The correct answer is %' Two anti-tuberculosis dru"s &esistance of the tubercle bacilli often occurs to a sin"le antimicrobial a"ent. Therefore+ therapy with multiple dru"s o!er a lon" period of time helps to ensure eradication of the or"anism. )4. .hich statement made by a nurse about the "oal of total 1uality mana"ement or continuous 1uality impro!ement in a health care settin" is correct? A) EIt is to obser!e reacti!e ser!ice and product problem sol!in"." Impro!ement of the processes in a proacti!e+ pre!enti!e mode is K ) paramount. A chart audits to finds common errors in practice and outcomes #) associated with "oals. %) A flow chart to or"ani5e daily tasks is critical to the initial sta"es. &e!iew Information' The correct answer is ' Impro!ement of the processes in a proacti!e+ pre!enti!e mode is paramount. Total 1uality mana"ement and continuous 1uality impro!ement ha!e a ma3or "oal of identifyin" ways to do the ri"ht thin" at the ri"ht time in the ri"ht way by proacti!e problem-sol!in". )4. The nurse mana"er informs the nursin" staff at mornin" report that the clinical nurse specialist will be conductin" a research study on staff attitudes toward client care. All staff are in!ited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity ) eneficence #) Sustice K %) Autonomy &e!iew Information' The correct answer is %' Autonomy Indi!iduals must be free to make independent decisions about participation in research without coercion from others.

)6. .hen teachin" a client about the side effects of fluo7etine A?ro5ac)+ which of the followin" will be included? A) Tachycardia blurred !ision+ hypotension+ anore7ia ) ;rthostatic hypotension+ !erti"o+ reactions to tyramine rich foods K #) %iarrhea+ dry mouth+ wei"ht loss+ reduced libido %) ?hotosensiti!ity+ sei5ures+ edema+ hyper"lycemia &e!iew Information' The correct answer is #' %iarrhea+ dry mouth+ wei"ht loss+ reduced libido #ommonly reported side effects for fluo7etine A?ro5ac) are diarrhea+ dry mouth+ wei"ht loss and reduced libido. )<. The nurse is performin" an assessment of the motor function in a client with a head in3ury. The best techni1ue is A) A firm touch to the trape5ius muscle or arm ) ?inchin" any body part #) (ternal rub K %) /entle pressure on eye orbit &e!iew Information' The correct answer is %' /entle pressure on eye orbit This is an acceptable stimuli only after pro"ressin" from li"hter to stimuli to more obno7ious. )-. The nurse is teachin" about nonsteroidal anti-inflammatory dru"s to a "roup of arthritic clients. To minimi5e the side effects+ the nurse should emphasi5e which of the followin" actions? A) &eportin" 3oint stiffness in the mornin" K ) Takin" the medication 1 hour before or ) hours after meals #) *sin" alcohol in moderation unless dri!in" %) #ontinuin" to take aspirin for short term relief &e!iew Information' The correct answer is ' Takin" the medication 1 hour before or ) hours after meals Takin" the medication 1 hour before or ) hours after meals will result in a more rapid effect. ),. A client takin" isonia5ide AIC@) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediatley report which of these? A) %ouble !ision and !isual halos K ) H7tremity tin"lin" and numbness #) #onfusion and li"htheadedness %) (ensiti!ity of sunli"ht &e!iew Information' The correct answer is ' H7tremity tin"lin" and numbness ?eripheral neuropathy is the most common side effect of IC@ and should be reported to the health care pro!iderI it can be re!ersed. )9. The nurse admits a ) year-old child who has had a sei5ure. .hich of the followin" statement by the child=s parent would be important in determinin" the etiolo"y of the sei5ure? A) "@e has been takin" lon" naps for a week." K ) "@e has had an ear infection for the past ) days." #) "@e has been eatin" more red meat lately." %) "@e seems to be "oin" to the bathroom more fre1uently." &e!iew Information' The correct answer is ' "@e has had an ear infection for the past ) days." #ontributin" factors to sei5ures in children include those such as a"e Amore common in first ) years)+ infections Alate infancy and early childhood)+ fati"ue+ not eatin" properly and e7cessi!e fluid intake or fluid retention. 48. A client is recei!in" Total ?arenteral Cutrition AT?C) !ia @ickman catheter. The catheter accidentally becomes dislod"ed from the site. .hich action by the nurse should take priority? A) #heck that the catheter tip is intact K ) Apply a pressure dressin" to the site #) $onitor respiratory status %) Assess for mental status chan"es &e!iew Information' The correct answer is ' Apply a pressure dressin" to the site The client is at risk of bleedin" or the de!elopment of an air embolus if the catheter e7it site is not co!ered immediately. 41. An 1, month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. .hen the nurse obtains the child=s health history+ the mother indicates that the child has not had the first measles+ mumps+ rubella A$$&) immuni5ation. The nurse understands that which of the followin" is true in re"ards to "i!in" immuni5ations to this child? A) >i!e !accines are withheld in children with renal chronic illness K ) The $$& !accine should be "i!en now+ prior to the transplant #) An inacti!ated form of the !accine can be "i!en at any time %) The risk of !accine side effects precludes "i!in" the !accine &e!iew Information' The correct answer is ' The $$& !accine should be "i!en now+ prior to the transplant $$& is a li!e !irus !accine+ and should be "i!en at this time. ?osttransplant+ immunosuppressi!e dru"s will be "i!en and the

administration of the li!e !accine at that time would be contraindicated because of the compromised immune system. 4). The nurse is preparin" to administer a tube feedin" to a post-operati!e client. To accurately assess for a "astostomy tube placement+ the priority is to K A) Auscultate the abdomen while instillin" 18 cc of air into the tube ) ?lace the end of the tube in water to check for air bubbles #) &etract the tube se!eral inches to check for resistance %) $easure the len"th of tubin" from nose to epi"astrium &e!iew Information' The correct answer is A' Auscultate the abdomen while instillin" 18 cc of air into the tube If a swoosh of air is heard o!er the abdominal ca!ity while instillin" air into the "astric tube+ this indicates that it is accurately placed in the stomach. The feedin" can be"in after assessin" the client for bowel sounds. 44. The nurse is teachin" parents of a - month-old about addin" table foods. .hich of the followin" is an appropriate fin"er food? A) @ot do" pieces K ) (liced bananas #) .hole "rapes %) ?opcorn &e!iew Information' The correct answer is ' (liced bananas 0in"er foods should be bite-si5e pieces of soft food such as bananas. @ot do"s and "rapes can accidentally be swallowed whole and can occlude the airway. ?opcorn is too difficult to chew at this a"e and can irritate the airway if swallowed. 44. The clinic nurse is counselin" a substance-abusin" post partum client on the risks of continued cocaine use. In order to pro!ide continuity of care+ which nursin" dia"nosis is a priority ? A) (ocial isolation ) Ineffecti!e copin" K #) Altered parentin" %) (e7ual dysfunction &e!iew Information' The correct answer is #' Altered parentin" The cocaine abusin" mother puts her newborn and other children at risk for ne"lect and abuse. #ontinuin" to use dru"s has the potential to impact parentin" beha!iors. (ocial ser!ice referrals are indicated. 46. A client has "astroesopha"eal reflu7. .hich recommendation made by the nurse would be most helpful to the client? A) A!oid li1uids unless a thickenin" a"ent is used ) (it upri"ht for at least 1 hour after eatin" #) $aintain a diet of soft foods and cooked !e"etables K %) A!oid eatin" ) hours before "oin" to sleep &e!iew Information' The correct answer is %' A!oid eatin") hours before "oin" to sleep Hatin" before sleepin" enhances the re"ur"itation of stomach contents which ha!e increased acidity into the esopha"us. $aintainin" an upri"ht posture should be for about ) hours after eatin" to allow for the stomach emptyin". The options A and # are inter!entions for clients with swallowin" difficulties. 4<. A nurse admits a client transferred from the emer"ency room. The client+ dia"nosed with a myocardial infarction+ is complainin" of substernal chest pain+ diaphoresis and nausea. The first action by the nurse should be A) ;rder an HM/ K ) Administer morphine sulphate #) (tart an IB %) $easure !ital si"ns &e!iew Information' The correct answer is ' Administer pain medication as ordered %ecreasin" the clients pain is the most important priority at this time. As lon" as pain is present there is dan"er in e7tendin" the infarcted area. $orphine will decrease the o7y"en demands of the heart and act as a mild diuretic as well. 4-. The nurse is talkin" with the family of an 1, months-old newly dia"nosed with retinoblastoma. A priority in communicatin" with the parents is K A) %iscuss the need for "enetic counselin" ) Inform them that combined therapy is seldom effecti!e #) ?repare for the child=s permanent disfi"urement %) (u""est that total blindness may follow sur"ery &e!iew Information' The correct answer is A' %iscussin" the need for "enetic counselin" The hereditary aspects of this disease are well documented. .hile the parents focus on the needs of this child+ they should be aware that the risk is hi"h for future offsprin". 4,. A client is ordered warfarin sodium A#oumadin) to be continued at home. .hich focus is critical to be included in the nurse2s dischar"e instruction? A) $aintain a consistent intake of "reen leafy foods K ) &eport any nose or "um bleeds #) Take Tylenol for minor pains %) *se a soft toothbrush &e!iew Information' The correct answer is ' &eport any nose or "um bleeds The client should notify the health care pro!ider if blood is noted in their stools or urine+ or any other si"ns of bleedin" occur.

49. A client bein" dischar"ed from the cardiac step-down unit followin" a myocardial infarction A $I)+ is "i!en a prescription for a beta-blockin" dru". A nursin" student asks the char"e nurse why this dru" would be used by a client who is not hypertensi!e. .hat is the appropriate response by the char"e nurse? A) "$ost people de!elop hypertension followin" an $I." ) "A beta- locker will pre!ent orthostatic hypotension." K #) "This dru" will decrease the workload on his heart." %) " eta-blockers increase the stren"th of heart contractions." &e!iew Information' The correct answer is #' "This dru" will decrease the workload on his heart." ;ne action of beta-blockers is to decrease systemic !ascular resistance by dilatin" arterioles. This is useful for the client with coronary artery disease+ and will reduce the risk of another $I or sudden death. 48. As a part of a 9 pound full-term newborn=s assessment+ the nurse performs a de7tro-stick at 1 hour post birth. The serum "lucose readin" is 46 m"Gdl. .hat action by the nurse is appropriate at this time? A) /i!e oral "lucose water ) Cotify the pediatrician K #) &epeat the test in ) hours %) #heck the pulse o7imetry readin" &e!iew Information' The correct answer is #' &epeat the test in two hours This blood su"ar is within the normal ran"e for a full-term newborn. Cormal !alues are' ?remature infant' )8-<8 m"Gdl or 1.1-4.4 mmolG>+ Ceonate' 48-<8 m"Gdl or 1.--4.4 mmolG>+ Infant' 48-98 m"Gdl or ).)6.8 mmolG>. #ritical !alues are' Infant' N48 m"Gdl and in a Cewborn' N48 and [488 m"Gdl. ecause of the increased birth wei"ht which can be associated with diabetes mellitus+ repeated blood su"ars will be drawn.