Kaplan Question Trainer 4 Rationales

1. After abdominal surgery, a client has a nasogastric tube attached to low suctioning.
The client becomes nauseated, and the nurse observes a decrease in the flow of
gastric secretions. Which of the following nursing interventions is MOST
appropriate?
Aspirate the gastric contents with a syringe. To confirm placement,
nurse should aspirate and test the pH of the aspirate & results should
be 0 to 4
Irrigate tube w/ NS after placement is confirmed
2. The nurse performs triage on a group of clients in the emergency department. Which
of the following clients should the nurse see FIRST?
~A 12-year-old oozing blood from a laceration of the left thumb due to cut on
a rusty metal can.
~A 19-year-old with a fever of 103.8F (39.8C) who is able to identify
her sister but not the place and time.
>>>>>DISORIENTED, requires STAT assessment to determine underlying cause
~A 49-year-old with a compound fracture of the right leg who is complaining
of severe pain.
~A 65-year-old with a flushed face, dry mucous membranes, and a blood
sugar of 470 mg/dL.
3. The nurse cares for a postcholecystectomy client who had the T-tube removed this
morning. Two hours after removal of the T-tube, the nurse notes that the 4 4
dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is
MOST appropriate for the nurse to take which of the following actions?
Remove the dressing, and replace it with a more absorbent
dressing b/c its expected that a stab wound will continue to drain
until the wound seals. Keep wound clean and dry. The drainage
described is bile, which is expected.
4. .Perphenazine (an anti-psychotic), for mood disorders like, bipolar & schizophrenia
(Akineton) Biperiden given for EPS symptoms (muscles spams, tremors,
jerking)
Other drugs for EPS: Artane, Benadryl, Cogentin, Sinemet
5. Client received regular insulin 3 hours ago. Signs of hypoglycemia will MOST concern
the nurse. Regular insulin peaks in 2-3 hours. Give skim milk or orange juice.
Hypoglycemia: Diaphoresis, Tremors

6. Which symptom suggests to the nurse that a child has strabismus (cross-eyed)?
The child closes one eye to see a poster on the wall b/c the visual
axes are not parallel, so the brain receives two images

Myopia: nearsighted, can only see objects at close range.

Ex: The child places his head close to the table when drawing.

7. Crooked smile: assess Cranial Nerve VII (Facial)

8. The home nurse cares for a client with type 1 diabetes. The client is maintained on a
regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal
blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2
days were 205 and 233 mg/dL. The nurse expects the MD to take which of the
following actions?
Reduce the client's diet to 1,500 calorie ADA.
Order three additional units of NPH insulin at 10 P.M
Order an additional 10 units of regular insulin at 8 P.M.
Eliminate the client's bedtime snack
Rationale: dawn phenomena, treatment is to adjust evening diet, bedtime snack,
insulin dose, and exercise to prevent early morning hyperglycemia. NPH is
intermediate.
9. Nitroglycerin: can cause hypotension, so avoid abrupt changes in posture to risk of falls
10. The nurse cares for clients in the pediatric clinic. The mother of a child calls the
nurse to say that after administering Dimetane-DC cough syrup to her child, her child
becomes very excitable and restless. Which of the following actions by the nurse is
MOST appropriate?

Report the child's behavior to the physician to alert the physician

to the potential need for a change in medication.
Instruct the mother to administer half the ordered amount in all future
doses to limit this behavioral response.
Instruct the mother to give the child a glass of warm milk to dilute any
medication left in the stomach.
Chart the child's response to the medication, and alert the staff about
the mother's phone call.

11. Clients receiving blood transfusions. See the client who is vomiting 1st. Vomiting
indicates a hemolytic reaction.
Hemolytic React: BP, N/V, Fever, Backache, Hematuria, Lower Back Pain
Tx: Stop transfusion, get urine specimen, maintain blood volume & renal
perfusion

12. An older man is seen in the outpatient clinic for treatment of an acute attack of gout.
Which of the following nursing interventions is MOST beneficial in decreasing the
client's pain during ambulation?
Perform passive range-of-motion exercises before walking.
Encourage partial weight bearing while ambulating b/c it would
relieve weight, pressure, and stress on affected leg, may use walker
Immobilize the extremity between activities.
Restrict the amount of time and the distance the man walks.
13. Delegating to LPNs: No Evaluating, Assessing, or Teaching no client scheduled for
surgery or returning from surgery bc they require teaching & assessment
14. Sucralfate & Digoxin prescribed: take Carafate 1 hour before breakfast &

Digoxin 1 hour after breakfast

15. Non-Stress Test:
Instruct client to push a button when she feels fetal movement.
Evaluates the response of the fetal heart rate to the stress of fetal
movement
16. A client who is positive for human immunodeficiency virus (HIV) is to be discharged
and will be taking zidovudine (AZT) at home. Which of the following actions by the
nurse is BEST? Write the schedule of when the med should be taken.
17. A young adult patient constantly seeks attention from the nurses, stomping away
from the nurses' station and pouting when requests are refused. Which of the
following responses by the nurse is MOST appropriate?

Give the patient unsolicited attention when the patient is

exhibiting acceptable behaviors (reward non-attention-seeking
behaviors by giving the patient unsolicited attention)

18. The nurse assesses the development of a 3-month-old boy. Which of the following
behaviors, if observed by the nurse, is UNEXPECTED?
The boy holds his head erect when sitting on the examination table.
The boy tries to grasp a toy just out of reach. (Unexpected until 6 months)
The boy turns his head to try to locate a sound.
The boy smiles spontaneously when he sees his mother.
19. Chronic Cocaine Use: nasal septum disruption, holes in nasal septum, mucous
membrane disruption
20. Gemfibrozil (Lopid): s lipids, monitor liver fx labs, take 30 min before
breakfast/supper, side effects: abd pain and cholelithiasis

21. Intermittent self-cath at home: store catheter in a plastic food-storage bag

22. The nurse administers terbutaline (Brethine) to a client in labor. Prior to
administration of the medication, the nurse assesses the client's pulse to be 144.
Which of the following actions should the nurse take FIRST? Withhold the
medication b/c maternal tachycardia is a side effect.
Brethine treats asthma & stops labor (Tocolytic)
23. Child scheduled surgery. Both parents have joint legal custody & only the mom signed
the consent. RN should: continue the childs pre-op prep b/c only one parents signature
is required.
24. Client that requires immediate attention: pt. admitted for a CVA whose Warfarin
prescription that expired 2 days ago (client is at risk for another CVA)
25. Addisons: steroid replacement is most important, not F&E balance
26. The nurse cares for a 26-year-old woman immediately after delivery of 8-lb, 4-oz
baby girl. The patient's history indicates that she was diagnosed with type 1 diabetes
at age 12. The nurse expects which of the following changes to occur in the patient?
The blood sugar will fall because of a sudden decrease in insulin requirements.