A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the
QUESTION 151A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the
infant. The nurse advises the mother to do which of the following?
A. “Start the child on solid food.”
B. “Nurse the child more frequently during this growth spurt.”
C. “Provide supplements for the child between breastfeeding so you will have enough milk.”
D. “Wait 4 hours between feedings so that your breasts will fill up.”
QUESTION 152An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant’s mother to care for the infant at home. Which one of the
following statements by the nurse is appropriate regarding the infant’s home care?
A. “Lay the infant flat on her left side after feeding.”
B. “Feed the infant every 4 hours with half-strength formula.”
C. “Antacids need to be given an hour before feeding.”
D. “Play activities should be carried out before instead of after feedings.”
QUESTION 153The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a
potentially painful procedure?
A. “Some say this feels like a pinch or a bug bite. You tell me what it feels like.”
B. “This is going to hurt a lot; close your eyes and hold my hand.”
C. “This is a terrible procedure, so don’t look.”
D. “This will hurt only a little; try to be a big boy.”
QUESTION 154The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
A. Place a tongue blade in the child’s mouth.
B. Restrain the child so he will not injure himself.
C. Go to the nurses station and call the physician.
D. Move furniture out of the way and place a blanket under his head.
QUESTION 155A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?
A. Oral
B. IM
C. IV
D. Aerosol
QUESTION 156A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the
child for which one of the following complications?
A. Fluid volume deficit
B. Fluid volume excess
C. Decreased cardiac output
D. Severe hypotension
QUESTION 157Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and
fullthickness burns to 25% of her body?
A. Urine output
B. Edema
C. Hypertension
D. Bulging fontanelle
QUESTION 158
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the
child’s mother for the home treatment of croup?
A. Take him in the bathroom, turn on the hot water, and close the door.
B. Give him a dose of antihistamine.
C. Give large amounts of clear liquids if drooling occurs.
D. Place him near a cool mist vaporizer and encourage crying.
QUESTION 159A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse’s initial assessment reveals a temperature of 104.5F
(40.3C), difficulty swallowing, drooling, absence of a spontaneous cough, and agitation. These symptoms are indicative of which one of the following?
A. Acute tracheitis
B. Acute spasmodic croup
C. Acute epiglottis
D. Acute laryngotracheobronchitis
QUESTION 160The nurse is teaching a mother care of her child’s spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological
technique the nurse might suggest would be:
A. “Blowing air under the cast using a hair dryer on cool setting often relieves itching.”
B. “Slide a ruler under the cast and scratch the area.”
C. “Guide a towel under and through the cast and moveit back and forth to relieve the itch.”
D. “Gently thump on cast to dislodge dried skin that causes the itching.”
QUESTION 161A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in
frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, “I don’t
know what to do, I’m afraid to go home.” The best response by the nurse to the client would be:
A. “I wouldn’t want to go home either; call a friend who could help you.”
B. “Did you do something that could have made him so angry?”
C. “Let’s talk about people and resources available to you so that you don’t have to go home.”
D. “I’ll call the police and they will take care of him, and you can go home and get some rest.”
QUESTION 162A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for “his nerves.” Included in the client’s plan of care is to identify alternate methods of coping with stress and anxiety other
than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as
being met if:
A. Client promises that he will not abuse aprazolam after discharge
B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life
C. Client is able to verbalize effects of substance abuse on the body
D. Client has remained substance free during hospitalization and is discharged
QUESTION 163
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests
special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The
nurse should respond to this behavior by:
A. Placing her in seclusion until the behavior is under control
B. Walking up to the client and touching her on the arm to get her attention
C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
D. Confronting the client, letting her know the consequences for getting angry and disrupting the unit
QUESTION 164A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is
unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies
around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse
determines that her behavior is consistent with:
A. Transient depression
B. Mild depression
C. Moderate depression
D. Severe depression
QUESTION 165A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around,
experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the
nurse would be to:
A. Tell the client to attend all structured activities on the unit
B. Encourage or direct client to attend activities that offer simple methods to attain success
C. Increase the client’s self-esteem by asking that she make all decisions regarding attendance in group activities
D. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff
QUESTION 166A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, “I just
couldn’t take it anymore.” The nurse’s best response to this disclosure would be:
A. “You shouldn’t do things like that, just tell someone you feel bad.”
B. “Tell me more about what you couldn’t take anymore.”
C. “I’m sure you probably didn’t mean to kill yourself.”
D. “How long have you been in the hospital.”
QUESTION 167A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the
time the client is anorexic and eats very little from her tray before she is up and about again. The nurse’s intervention would be to:
A. Confront the client with the fact that she will have to eat more from her tray to sustain her
B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition
C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times
D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently
QUESTION 168Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional
alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client’s depression alert the nurse to prioritize
problems and care by addressing which of the following problems first:
A. Nutritional status
B. Impaired thinking
C. Possible harm to self
D. Rest and activity impairment
QUESTION 169
The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect
associated with this antidepressant and the ingestion of tyramine in aged foods may be:
A. Hypertensive crisis
B. Severe rash
C. Severe hypotension
D. Severe diarrhea
QUESTION 170A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
A. Impaired communication
B. Sensory-perceptual alterations
C. Altered thought processes
D. Impaired social interaction
QUESTION 171A schizophrenic client who is experiencing thoughts of having special powers states that “I am a messenger from another planet and can rule the earth.” The nurse
assesses this behavior as:
A. Ideas of reference
B. Delusions of persecution
C. Thought broadcasting
D. Delusions of grandeur
QUESTION 172A client experiencing delusions states, “I came here because there were people surrounding my house that wanted to take me away and use my body for science.”
The best response by the nurse would be:
A. “Describe the people surrounding your house that want to take you away.”
B. “I need more information on why you think others want to use your body for science.”
C. “There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science.”
D. “I know that must be frightening for you; let the staff know when you are having thoughts that trouble you.”
QUESTION 173A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain
body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control,
the nurse uses the following strategy:
A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
C. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.
QUESTION 174A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, “I know that
alcohol is a problem for some people, but I can stop whenever I want to. I’m never sick or miss work, and no one can complain about me.” During the initial
assessment, the best response by the nurse would be:
A. “The fact is you are an alcoholic or you wouldn’t be here.”
B. “I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol- free.”
C. “If you can stop drinking when you want to, why don’t you stop?”
D. “It’s good that you can stop drinking when you want to.”
QUESTION 175A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations,
and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care:
A. Maintain routines and usual structure and adhere to schedules.
B. Encourage the client to attend all structured activities on the unit, whether she wants to or not.
C. Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing.
D. Give the client two or three choices to decide what she wants to do.
QUESTION 176The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
A. Approach the client on a continuum of least restrictive care.
B. Challenge client’s behavior immediately with steps to prevent injury to self or others.
C. Leave the aggressive client to himself or herself, and take other clients away.
D. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.
QUESTION 177When planning care for the passive-aggressive client, the nurse includes the following goal:
A. Allow the client to use humor, because this may be the only way this client can express self.
B. Allow the client to express anger by using “I” messages, such as “I was angry when . . .,” etc.
C. Allow the client to have time away from therapeutic responsibilities.
D. Allow the client to give excuses if he forgets to give staff information.
QUESTION 178A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first
visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to
Nägele’s rule, the estimated date of confinement is:
A. March 17
B. June 3
C. August 30
D. January 10
QUESTION 179At 16 weeks’ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to
the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure
is to:
A. Reinforce an incompetent cervix
B. Repair the amniotic sac
C. Evaluate cephalopelvic disproportion
D. Dilate the cervix
QUESTION 180A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that
she is becoming light- headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to:
A. Place the examining table in the Trendelenburg position
B. Assess the client to see if she is having vaginal bleeding
C. Obtain the client’s vital signs immediately
D. Help the client to a sitting position
QUESTION 181At 30 weeks’ gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the
suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is
still intact. She is very concerned about delivering prematurely. She asks the RN, “What is the greatest risk to my baby if it is born prematurely?” The RN’s answer
should be:
A. Hyperglycemia
B. Hypoglycemia
C. Lack of development of the intestines
D. Lack of development of the lungs
QUESTION 182At 30 weeks’ gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of
ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for
which one of the following side effects:
A. Hypoglycemia
B. Hyperkalemia
C. Tachycardia
D. Increase in hematocrit and hemoglobin
QUESTION 183At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, “How do I prepare for the test I am
scheduled for?” The RN will most likely inform her of the following instructions to help prepare her for the test:
A. “You need to know that an IV is always started before the test.”
B. “You will need to drink 6 to 8 glasses of water to fill your bladder.”
C. “Do not eat any food or drink any liquids before the test is started.”
D. “You will have to remain as still as you possibly can.”
QUESTION 184After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5
beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results
will be interpreted as:
A. A reactive test
B. A nonreactive test
C. An unsatisfactory test
D. A negative test
QUESTION 185At 38 weeks’ gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax
and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
A. “I am cold.”
B. “I have a backache.”
C. “I feel dizzy.”
D. “I am nauseous.”
QUESTION 186 After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses
that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
A. One centimeter below the ischial spines
B. One centimeter above the ischial spines
C. Has not entered the pelvic inlet yet
D. Located in the pelvic outlet
QUESTION 187A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client’s fetus position is left occipital posterior.
Which of the following statements best describes what this means to the labor process:
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A. Decreases the overall time of the labor process
B. Prolongs the client’s first stage of labor
C. Decreases the time of the client’s first stage of labor
D. Prolongs the client’s third stage of labor
QUESTION 188A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated
5 cm, effaced 85%, and the fetus’s head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is
bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:
A. Hypertension
B. Hypotension
C. Hypoglycemia
D. Hyperglycemia
QUESTION 189A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and
effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue
the infusion if which one of the following occur?
A. The client’s contractions are <2 minutes apart.
B. Duration of the contractions are 60 seconds.
C. The uterus relaxes between contractions.
D. The client complains that she is tired.
QUESTION 190The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine
contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The
physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should
the RN question?
A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
B. Discontinue the oxytocin infusion.
C. Insert an indwelling Foley catheter prior to delivery.
D. Prepare abdominal area from below the nipples to below the symphysis pubis area.
QUESTION 191After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the
Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
A. Cold stress
B. Cyanosis
C. Respiratory distress syndrome
D. Seizures
QUESTION 192After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery
room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN
makes sure that which of the following interventions was completed?
A. The physician verifies the exact time of birth.
B. The nurse counts the instruments and sponges with the scrub nurse.
C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn’s eyes.
D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
QUESTION 193
On a mother’s 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best
position for the client to be placed in for this assessment is:
A. Sims’
B. Fowler’s
C. Prone
D. Any position that the RN chooses
QUESTION 194While the RN is assessing a mother’s perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left
of the mother’s perineum. Which one of the following interventions should the RN initiate at this time?
A. Have the client expose the area to air.
B. Apply ice to the perineum.
C. Encourage the client to take warm sitz baths.
D. Inform the physician.
QUESTION 195A mother who is breast-feeding her newborn asks the RN, “How can I express milk from my breasts manually?” The RN tells her that the correct method for
manual milk expression includes using the thumb and the index finger to:
A. Alternately compress and release each nipple
B. Roll the nipple and gently pull the nipple forward
C. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple
D. Compress and release each breast at the outer border of the areola
QUESTION 196A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, “I need to start exercising so that I can
get back into shape. Could you suggest an exercise I could begin with?” The RN could suggest which one of the following?
A. Push-ups
B. Jumping jacks
C. Leg lifts
D. Kegel exercises
QUESTION 197A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing
weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:
A. An extension of his myocardial infarction
B. Pneumonia
C. Pulmonary edema
D. Pulmonary emboli
QUESTION 198On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary
edema, which is:
A. High Fowler
B. Lying on the left side
C. Sitting in a chair
D. Supine with feet elevated
QUESTION 199A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be
achieved by administering:
A. Digoxin (Lanoxin) 0.25 mg po every day
B. Furosemide (Lasix) 40 mg po every morning
C. O22 L/min via nasal cannula
D. Nitroglycerin (Nitrol) 1 inch topically every 4 hours
QUESTION 200A client’s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices
a 2-lb weight gain in a 24- hour period. Increased weight gain may indicate:
A. A diet too high in calories and saturated fat
B. Decreasing cardiac output
C. Decreasing renal function
D. Development of diabetes insipidus
QUESTION 201A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment
findings include:
A. Crackles and paradoxical chest wall movement
B. Decreased breath sounds on the left and chest pain with movement
C. Rhonchi and frothy sputum
D. Wheezing and dry cough
QUESTION 202A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
A. Prevent air from entering the pleural space
B. Prevent fluid from entering the pleural space
C. Provide a means to measure chest drainage
D. Provide an indicator of respiratory effort
QUESTION 203A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side
to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing
hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
A. Pneumonia
B. Pulmonary contusions
C. Pulmonary edema
D. Tension pneumothorax
QUESTION 204A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg;
PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
A. Compensated metabolic acidosis
B. Compensated respiratory acidosis
C. Compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
QUESTION 205A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and
increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial
blood gases reflect:
A. Compensated respiratory acidosis
B. Normal blood gases
C. Uncompensated metabolic acidosis
D. Uncompensated respiratory acidosis
QUESTION 206A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically
stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
A. Autonomic dysreflexia
B. Bradycardia
C. Central cord syndrome
D. Spinal shock
QUESTION 207A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, “This is too much trouble. I would rather just have
a Foley.” An appropriate response for the RN teaching him would be:
A. “I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.”
B. “It is not too much trouble. This is the best way to manage urination.”
C. “OK. I’ll ask your physician if we can replace the Foley.”
D. “You need to learn this because your doctor ordered it.”
QUESTION 208A client’s physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client’s COPD. Instructions that should be given
to the client include:
A. “Call your physician if you develop palpitations, dizziness, or restlessness.”
B. “Cigarette smoking may significantly increase the risk for theophylline toxicity.”
C. “Take this medication on an empty stomach.”
D. “Do not take your medicine if your pulse is less than 60 beats per minute.”
QUESTION 209A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have
a scalp laceration sutured. The nurse instructs the client to:
A. Clean the sutured laceration twice a day with povidone- iodine (Betadine)
B. Remove his scalp sutures after 5 days
C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
D. Take meperidine 50 mg po q46h prn for headache
QUESTION 210A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his
beclomethasone, the client should be instructed to:
A. Clean his inhaler with warm water and soak it in a10% bleach solution
B. Drink a glass of water
C. Sit and rest
D. Use his bronchodilator inhaler
QUESTION 211A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his
chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:
A. Inappropriate endotracheal tube size
B. Left-sided pneumothorax
C. Right mainstem bronchus intubation
D. Pneumonia
QUESTION 212A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a smallbore silicone feeding tube (Keofeed, Duo-Tube). After
the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:
A. Aspirate gastric contents
B. Auscultate air insufflated through the tube
C. Obtain a chest x-ray
D. Place the tip of the tube under water and observe for air bubbles
QUESTION 213A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of
breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
A. Raise the client’s head and place her feet in a dependent position
B. Notify the physician
C. Place the client on 2 liters of O2 via nasal cannula
D. Administer furosemide (Lasix) 20 mg IV push
QUESTION 214A 52-year-old client’s abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood
administration for which she is especially at risk is:
A. Air embolus
B. Circulatory overload
C. Hypocalcemia
D. Hypokalemia
QUESTION 215A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:
A. Bed rest with bathroom privileges will be ordered
B. He will be kept NPO for 812 hours
C. Some oozing of blood at the arterial puncture site is normal
D. The leg used for arterial puncture should be keptstraight for 812 hours
QUESTION 216A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his
ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
A. “No, but you must be able to ride on a stationary bicycle while the test is being performed.”
B. “No, but you will have to lie still and the gel that is used may be cool.”
C. “Yes, but your physician will be there and will order pain medicine for you.”
D. “Your physician has ordered medicine, which you will be given before you go for the test, which will make you sleepy.”
QUESTION 217A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low- sodium diet for him. When he asks, “What does salt have to do with
high blood pressure?” the nurse’s initial response would be:
A. “The reason is not known why hypertension is associated with a high-salt diet.”
B. “Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure.”
C. “Salt affects your blood vessels and causes your blood pressure to be high.”
D. “Salt is needed to maintain blood pressure, but too much causes hypertension.”
QUESTION 218A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the
Trendelenburg position:
A. Allows the physician to visualize the subclavian vein
B. Reduces the possibility of air embolism
C. Reduces the possibility of hematoma formation
D. Makes the procedure more comfortable for the client
QUESTION 219A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
A. Cyanosis
B. Increased respirations
C. Sternal and subcostal retractions
D. Decreased respirations
QUESTION 220A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor
and delivery are the ischial spines because:
A. Ischial spines are the narrowest diameter of the pelvis
B. Ischial spines are the widest diameter of the pelvis
C. They represent the inlet of birth canal
D. They measure pelvic floor
QUESTION 221The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:
A. Uterine contractions will weaken with walking.”
B. Uterine contractions will strengthen with walking.”
C. The cervix does not dilate.”
D. The fetus does not descend.”
QUESTION 222A first-trimester primigravida is diagnosed with anemia. The nurse should suspect that this anemia is a result of:
A. Mother’s increased blood volume
B. Mother’s decreased blood volume
C. Fetal blood volume increase
D. Increase in iron absorption
QUESTION 223In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A. First trimester
B. Second trimester
C. Third trimester
D. Every trimester
QUESTION 224A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?
A. Reverse Trendelenburg
B. Fowler’s
C. Trendelenburg
D. Sims’
QUESTION 225A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of
confinement would be:
A. November 7
B. November 10
C. May 7
D. May 10
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