A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy

QUESTION 376A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy

 

designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive

 

about having another. Which of the following interventions will be most effective in relieving her anxiety?

 

A. Explain what will take place and what she will see, feel, and hear.

 

B. Remind her that she has had this procedure before and that it is nothing to be afraid of.

 

C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.

 

D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.

 

QUESTION 377Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:

 

A. Children seldom show concern about losing their hair

 

B. The hair will come out gradually, and the loss will not be noticeable for some time

 

C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out

 

D. The parents will soon get used to seeing their children without hair, and it will no longer bother them

 

QUESTION 378A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in

 

encouraging the child to eat?

 

A. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well.

 

B. Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime.

 

C. Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet.

 

D. Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible.

 

QUESTION 379A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

 

A. Protect the child from infection

 

B. Provide the child with privacy

 

C. Protect the family from curious visitors

 

D. Isolate the child from other clients and the nursing staff

 

QUESTION 380A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her.

 

Which of the following interventions would be most effective in getting her to eat?

 

A. Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals

 

B. A bland, moist, soft diet

 

C. Staying with the client and providing distraction during meals

 

D. Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before meals

 

QUESTION 381A 15-year-old client was diagnosed as having cystic fibrosis at 8 months of age. He is in the hospital for a course of IV antibiotic therapy and vigorous chest

 

physiotherapy. He has a poor appetite. The nurse can best help him to meet the desired outcome of consuming a prescribed number of calories by:

 

A. Including the client in planning sessions to select the type of meal plan and foods for his diet

 

B. Working with the nutritionist to devise a diet with significantly increased calories

 

C. Selecting foods for the client’s diet that are high in calories and instituting a strict calorie count

 

D. Constantly providing him with chips, dips, and candies, because the number of calories consumed is more important than the quality of foods

 

QUESTION 382The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:

 

A. Careful monitoring of weight loss or gain

 

B. Carefully recording amounts and types of foods ingested

 

C. Keeping a strict account of the number of calories ingested

 

D. Keeping a careful account of the amount of pancreatic enzymes ingested

 

QUESTION 383A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to

 

participate in daily physical exercise. The ultimate aim of exercise is to:

 

A. Create a sense of well-being and self-worth

 

B. Help him overcome respiratory infections

 

C. Establish an effective, habitual breathing pattern

 

D. Promote normal growth and development

 

QUESTION 384As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of

 

worthlessness. This is an important factor to consider in planning for his care because:

 

A. It may be a bid for attention and an indication that more diversionary activity should be planned for him

 

B. No threat of suicide should be ignored or challenged in any way

 

C. He needs to be observed carefully for signs that his depression has been relieved

 

D. He needs to be confronted with his feelings and forced to work through them

 

QUESTION 385A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that

 

he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

 

A. Hyperextension of the neck with evidence of pain on flexion

 

B. Holding the head to one side and pointing the chin toward the other side

 

C. Holding the head erect and in the midline when in a vertical position

 

D. Significant head lag when raised to a sitting position

 

QUESTION 386During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following

 

nursing interventions will be most effective in resolving the condition?

 

A. Coating the inflamed areas with zinc oxide

 

B. Using talcum powder on the inflamed areas to promote drying

 

C. Removing the diaper entirely for extended periods of time

 

D. Cleaning the inflamed area thoroughly with disposable wet “wipes” at each diaper change

 

QUESTION 387A 10-month-old infant’s mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of

 

his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse’s response is based on the knowledge that:

 

A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices

 

B. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods

 

C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily

 

D. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day

 

QUESTION 388A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The

 

infant’s parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?

 

A. By assigning the same nurses to the child, the nurses can begin to learn the infant’s cues and feeding behaviors.

 

B. The same nurses will prevent parental fatigue and frustration.

 

C. The same nurses will prevent infant fatigue and frustration.

 

D. Primary nurses will ensure privacy.

 

QUESTION 389The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would

 

the nurse identify as readiness in this child?

 

A. Patience by the child when wearing soiled diapers

 

B. Communicating the urge to defecate or urinate

 

C. The child awakening wet from his naps

 

D. The age at which the child’s siblings were trained

 

QUESTION 390A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse’s rationale?

 

A. To reduce fear of the unknown

 

B. To keep the child calm

 

C. To establish a trusting relationship

 

D. To prevent or minimize separation anxiety

 

QUESTION 391A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse’s

 

frequent monitoring of the child’s temperature frightened her parents. Which response by the nurse would be most appropriate?

 

A. Monitoring the temperature prevents undue chilling.

 

B. Rapid temperature elevations can occur in children.

 

C. Checking the temperature will prevent febrile seizures.

 

D. Taking the child’s temperature can prevent airway obstruction.

 

QUESTION 392A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an

 

oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first

 

nursing actions would be essential in this situation?

 

A. Hold the child’s discharge for 1 hour.

 

B. Notify the physician immediately.

 

C. Discharge the child as the physician ordered.

 

D. Administer an antiemetic as necessary.

 

QUESTION 393A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2

 

days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss.

 

Identify the number-one priority nursing diagnosis.

 

A. Fluid volume deficit

 

B. Altered nutrition

 

C. Altered bowel elimination

 

D. Anxiety

 

QUESTION 394A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:

 

A. Respiratory acidosis

 

B. Respiratory alkalosis

 

C. Metabolic acidosis

 

D. Metabolic alkalosis

 

QUESTION 395Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the

 

following toys and activities would the nurse suggest as appropriate for a toddler?

 

A. Cutting, pasting, string beads, music, dolls

 

B. Mobiles, rattle, squeeze toys

 

C. Pull-toys, large ball, dolls, sand and water play, music

 

D. Simple card games, puzzles, bicycle, television

 

QUESTION 396A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse

 

provide the child to assist her in expressing her feelings?

 

A. Books with colorful pictures

 

B. Music

 

C. Riding toys

 

D. Puppets

 

QUESTION 397During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse.

 

How could the nurse explain the child’s change in behavior?

 

A. Deep-seated feelings of hostility

 

B. A lack of interest in socializing

 

C. Usual behavior for this child

 

D. A coping response

 

QUESTION 398Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the

 

elbow. Which nursing action is most essential during the first

 

24 hours after surgery and cast application?

 

A. Mobilization of the child

 

B. Discharge teaching

 

C. Pain management

 

D. Assessment of neurovascular status

 

QUESTION 399A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be

 

concerned about the infant’s developmental progression?

 

A. She sits briefly alone with assistance.

 

B. She creeps and crawls.

 

C. She pulls herself to her feet with help.

 

D. She stands while holding onto furniture.

 

QUESTION 400Children often experience visual impairments. Refractive errors affect the child’s visual activity. The main refractive error seen in children is myopia. The nurse

 

explains to the child’s parents that myopia may also be described as:

 

A. Cataracts

 

B. Farsightedness

 

C. Nearsightedness

 

D. Lazy eye

 

QUESTION 401A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in

 

physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?

 

A. Astigmatism

 

B. Hyperopia

 

C. Myopia

 

D. Amblyopia

 

QUESTION 402An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse

 

notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

 

A. A tension pneumothorax

 

B. An asthma attack

 

C. Pneumonia

 

D. Pulmonary embolus

 

QUESTION 403The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow’s menu. Which vitamin is the most essential in promoting

 

tissue healing?

 

A. Vitamin C

 

B. Vitamin B1

 

C. Vitamin D

 

D. Vitamin A

 

.QUESTION 404As a postoperative cholecystectomy client completes tomorrow’s dinner menu, the nurse knows that one of the following meal choices will best provide the

 

essential vitamin(s) necessary for proper tissue healing?

 

A. Liver, white rice, spinach, tossed salad, custard pudding

 

B. Fish fillet, carrots, mashed potatoes, butterscotch pudding

 

C. Roast chicken, gelatin with sliced fruit

 

D. Chicken breast fillet in tomato sauce, potatoes, mustard greens, orange and strawberry slices

 

QUESTION 405A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a

 

local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The

 

nurse knows that this type of traction will be used:

 

A. By inserting pins to provide steady pull on the bone

 

B. To suspend the leg in a sling without pull on the extremity

 

C. Intermittently to place a pull over the pelvis and lower spine

 

D. With weights at both ends of the bed to maintain pull on the upper extremity

 

QUESTION 406Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse

 

know as an indicator of normal wound healing?

 

A. Exudate

 

B. Crust

 

C. Edema

 

D. Erythema

 

QUESTION 407A 47-year-old client comes to the emergency department complaining of moderate flank, abdominal, and testicular pain with nausea of 4 hours’ duration. After

 

physical examination and obtaining the client’s history, the physician suspects urethral obstruction by calculi. The nurse realizes that the physician will order which

 

one of the following diagnostic studies to best confirm the diagnosis?

 

A. Cystoscopy

 

B. Kidneys, ureter, bladder, x-ray of abdomen

 

C. Intravenous pyelogram with excretory urogram

 

D. Ureterolithotomy

 

QUESTION 408An obstructing stone in the renal pelvis or upper ureter causes:

 

A. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males

 

B. Urinary frequency and dysuria

 

C. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor

 

D. Dull, aching, back pain

 

QUESTION 409A client who has gout is most likely to form which type of renal calculi?

 

A. Struvite stones

 

B. Staghorn calculi

 

C. Uric acid stones

 

D. Calcium stones

 

QUESTION 410A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial

 

pneumonia?

 

A. Klebsiellapneumonia

 

B. Pneumococcal pneumonia

 

C. Legionella pneumophilapneumonia

 

D. Escherichia colipneumonia

 

.QUESTION 411The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client’s pneumonia is caused by

 

a gram-positive bacteria, the nurse experts to find the sputum to be:

 

A. Bright red with streaks

 

B. Rust colored

 

C. Green colored

 

D. Pink-tinged and frothy

 

QUESTION 412The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:

 

A. Prolonged bed rest

 

B. The client’s maintaining a semi-Fowler position

 

C. Cerebral hypoxia

 

D. IV fluids of 2.53 liters in 24 hours

 

QUESTION 413A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of

 

the following nursing interventions is most important?

 

A. Place the client in a supine position.

 

B. Draw a blood sample for arterial blood gases.

 

C. Start O2 at 4 L/min.

 

D. Establish a patent airway.

 

QUESTION 414A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, “The doctor said I have stones that need to be removed; where are they?” The nurse knows that the best explanation for this is to tell her that:

 

A. There are stones present in her gallbladder

 

B. There are stones present in her kidneys

 

C. There are stones present in her common bile duct

 

D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain

 

QUESTION 415A 48-year-old client is being seen in her physician’s office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days’ duration,

 

especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the

 

abdominal assessment?

 

A. Cullen’s sign

 

B. Rebound tenderness

 

C. Murphy’s sign

 

D. Turner’s sign

 

QUESTION 416When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the

 

expected amount of drainage during the first 24 hours postoperatively is:

 

A. 50100 mL

 

B. 200300 mL

 

C. 300500 mL

 

D. 10001200 mL

 

QUESTION 417The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:

 

A. Clay or gray colored

 

B. Watery and loose

 

C. Bright-red streaked

 

D. Black

 

QUESTION 418A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric

 

(NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start

 

eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

 

A. It is determined that he has no signs of wound infection

 

B. He is able to eat a full meal without evidence of nausea or vomiting

 

C. The nurse can detect bowel sounds in all four quadrants

 

D. His blood pressure returns to its preoperative baseline level or greater

 

QUESTION 419A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel decompression.

 

When preparing to insert a NG tube, the nurse measures from the:

 

A. Lower lip to the shoulder to the upper sternum

 

B. Tip of the nose to the lower lip to the umbilicus

 

C. End of the tube to the first measurement line on the tube

 

D. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

 

QUESTION 420A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the

 

client that to regulate the bowel, colostomy irrigation should be performed at the same time each day. The best time is:

 

A. After meals

 

B. Before meals

 

C. Every 2 hours

 

D. At bedtime

 

QUESTION 421A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that

 

which one of the following foods most likely caused this problem?

 

A. Fried chicken

 

B. Eggs

 

C. Tapioca

 

D. Cabbage

 

QUESTION 422When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling

 

him that the drying time for a plaster of Paris cast is approximately:

 

A. 30 minutes

 

B. 14 hours

 

C. 1224 hours

 

D. 2472 hours

 

QUESTION 423A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this

 

procedure means:

 

A. Removal of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland

 

B. Removal of prostate tissue by a resectoscope that is inserted through the penile urethra

 

C. Removal of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum

 

D. Removal of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland

 

QUESTION 424A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds

 

him to be confused and disoriented. She recognizes that this is most likely caused by:

 

A. Hypovolemic shock

 

B. Hypokalemia

 

C. Hypernatremia

 

D. Hyponatremia

 

QUESTION 425A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic

 

pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following

 

should be the initial nursing intervention?

 

A. Call the physician about the problem.

 

B. Irrigate the Foley catheter.

 

C. Change the Foley catheter.

 

D. Administer a prescribed narcotic analgesic.

 

QUESTION 426A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary

 

when he states:

 

A. “If I drink 10 to 12 glasses of fluids each day, that will help to prevent any clot formation in my urine.”

 

B. “The isometric exercises will help to strengthen my perineal muscles and help me control my urine.”

 

C. “If I feel as though I have developed a fever, I will take a rectal temperature, which is the most accurate.”

 

D. “I do not plan to do any heavy lifting until I visit my doctor again.”

 

QUESTION 427A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of the following

 

prescribed medications would best relieve this problem?

 

A. Acetaminophen suppository 650 mg

 

B. Meperidine 50 mg IM

 

C. Promethazine 25 mg IM

 

D. Aminocaproic acid (Amicar) 6 g/24 hr

 

QUESTION 428A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her

 

diaphragmatic breathing exercises. She will teach the client to:

 

A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth.

 

Repeat 23 more times to complete the series every 12 hours while awake

 

B. Purse the lips and take quick, short breaths approximately 1820 times/min

 

C. Take a large gulp of air into the mouth, hold it for 1015 seconds, and then expel it through the nose. Repeat 45 times to complete the series

 

D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 2024 times/min

 

QUESTION 429A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks’ gestation. She experienced a sudden onset of painless

 

vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings

 

concerning the abdomen would include:

 

A. A rigid, boardlike abdomen

 

B. Uterine atony

 

C. A soft relaxed abdomen

 

D. Hypertonicity of the uterus

 

QUESTION 430A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or

 

currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg,

 

temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range.

 

On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing

 

diagnosis for this client would be:

 

A. Decreased cardiac output related to excessive bleeding

 

B. Potential for fluid volume excess related to fluid resuscitation

 

C. Anxiety related to threat to self

 

D. Alteration in parenting related to potential fetal injury

 

QUESTION 431A 27-year-old primigravida at 32 weeks’ gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper

 

medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:

 

A. Dinitrophenylhydrazine

 

B. Metachromatic stain

 

C. Blood serum phenylalanine test

 

D. Lecithin-sphingomyelin ratio

 

QUESTION 432The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is

 

now at 36 weeks’ gestation and is presently having bright red bleeding of moderate amount. On admission, the nursing intervention that the nurse should give the

 

highest priority to is:

 

A. Shave the client’s abdomen and arrange her lab work

 

B. Determine the status of the fetus by fetal heart tones

 

C. Start an IV infusion in the client’s arm

 

D. Insert an indwelling catheter into her bladder

 

QUESTION 433A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of

 

shock that she may experience?

 

A. Marked elevation in blood pressure, respirations, and pulse

 

B. Decreased systolic pressure, cold skin, and anuria

 

C. Rapid pulse; narrowed pulse pressure; cool, moist skin

 

D. No urinary output, tachycardia, and restlessness

 

QUESTION 434 The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client

 

would be:

 

A. Length of her labor

 

B. Type of episiotomy

 

C. Amount of IV fluid to be infused

 

D. Character of the fundus

 

QUESTION 435On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal

 

drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken

 

is to:

 

A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia

 

B. Catheterize the client and reassess the uterus

 

C. Begin IV fluids and administer oxytocic medication

 

D. Administer analgesics as ordered to relieve discomfort

 

QUESTION 436The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of

 

the following correctly describes the character and amount of lochia?

 

A. Lochia alba, light

 

B. Lochia serosa, heavy

 

C. Lochia granulosa, heavy

 

D. Lochia rubra, moderate

 

QUESTION 437A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.

 

When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a

 

portion of the blood to bypass the:

 

A. Left ventricle

 

B. Pulmonary system

 

C. Liver

 

D. Superior vena cava

 

QUESTION 438A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her

 

heart sometimes feels like it will “beat out of her chest.” The physician has ordered her to receive 2 U of packed red blood cells.

 

The most important nursing action to be taken is:

 

A. Starting an 18-gauge IV infusion

 

B. Having the consent form on the chart

 

C. Administering the correct blood product to the correctclient

 

D. Transfusing the blood in a 2-hour time frame

 

QUESTION 439A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:

 

A. Take a baseline set of vital signs

 

B. Hang Ringer’s lactate as the companion fluid

 

C. Use microdrip tubing for the blood administration

 

D. Have the registered nurse in charge assume responsibility for verifying the client and blood product information

 

QUESTION 440A client’s transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing,

 

anxious, and very restless. The nurse knows these assessment findings are congruent with:

 

A. Hemolytic transfusion reaction

 

B. Febrile transfusion reaction

 

C. Circulatory overload

 

D. Allergic transfusion reaction

 

QUESTION 441Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:

 

A. A third heart sound

 

B. A diastolic murmur

 

C. Pulse pressure difference between the upper extremities

 

D. Diminished or absent femoral pulses

 

QUESTION 442Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:

 

A. Tetralogy of Fallot

 

B. Ventricular septal defect

 

C. Patent ductus arteriosus

 

D. Transposition of the great arteries

 

QUESTION 443A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse:

 

A. Uses pictures to explain the procedure to the child and his parents that evening

 

B. Explains the procedure using simple words and sentences just before the preoperative sedation

 

C. Asks the parents to explain the procedure to the child after she explains it to them

 

D. Asks the parents to leave the room while the preoperative medication and instructions are given

 

QUESTION 444Home-care instructions for the child following a cardiac catheterization should include:

 

A. Notify the physician if a slight bruise develops around the insertion site.

 

B. Use sponge bathing until stitches are removed.

 

C. Give aspirin if the child complains of pain at the insertion site.

 

D. Keep a clean, dry dressing on the insertion site for 2 days.

 

QUESTION 445Nursing care for the parents of a child with a congenital heart defect would include:

 

A. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible

 

B. Acknowledging the fear and concern surrounding their child’s health and assisting the parents through the grieving process as they mourn the loss of their

 

fantasized healthy child

 

C. Identifying anger and resentment as destructive emotions that serve no purpose

 

D. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve

 

QUESTION 446An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when

 

administering digoxin to the infant that:

 

A. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose

 

B. They need to mix it with formula so the infant swallows it easily

 

C. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify thephysician

 

D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed

 

QUESTION 447A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings

 

reveal tenderness in the abdomen. The child is most likely experiencing a/an:

 

A. Aplastic crisis

 

B. Vaso-occlusive crisis

 

C. Dactylitis crisis

 

D. Sequestration crisis

 

QUESTION 448The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:

 

A. Maintaining an adequate level of hydration

 

B. Providing pain relief

 

C. Preventing infection

 

D. O2 therapy

 

QUESTION 449A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:

 

A. Encourages the client to discuss the voices

 

B. Attempts to direct the client’s attention to the here and now

 

C. Exhibits sincere interest in the delusional voices

 

D. Gives the medication as necessary for the acting-out behavior

 

QUESTION 450 One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client’s level is 1.3

 

mEq/L. The nurse recognizes that this level is considered to be:

 

A. Within therapeutic range

 

B. Below therapeutic range

 

C. Above therapeutic range

 

D. At a level of toxic poisoning

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