An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

QUESTION 226An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

 

A. Water satiety

 

B. Thirst

 

C. Edema

 

D. Diabetes insipidus

 

QUESTION 227Assessment of a newborn for Apgar scoring includes observation for:

 

A. Pupil response

 

B. Respiratory rate

 

C. Heart rate

 

D. Babinski’s reflex

 

QUESTION 228Painless vaginal bleeding in the last trimester may be caused by:

 

A. Menstruation

 

B. Abruptio placentae

 

C. Placenta previa

 

D. Polyhydramnios

 

QUESTION 229The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

 

A. Mother is concerned about her recovery.

 

B. Mother calls infant by name.

 

C. Mother lightly touches infant.

 

D. Mother is concerned about her weight gain.

 

QUESTION 230The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:

 

A. Oxytocin (Pitocin)

 

B. Progesterone

 

C. Vasopressin (Pitressin)

 

D. Ergonovine maleate

 

QUESTION 231A primigravida is at term. The nurse can recognize the second stage of labor by the client’s desire to:

 

A. Push during contractions

 

B. Hyperventilate during contractions

 

C. Walk between contractions

 

D. Relax during contractions

 

QUESTION 232A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

 

A. Fourth stage of labor

 

B. Third stage of labor

 

C. Transition stage of labor

 

D. Second stage of labor

 

QUESTION 233A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

 

A. Assess the client’s respirations

 

B. Notify the physician

 

C. Auscultate fetal heart rate

 

D. Transfer to delivery suite

 

QUESTION 234A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

 

A. Control the delivery by guiding expulsion of fetus

 

B. Leave the room to call the physician

 

C. Push against the perineum to stop delivery

 

D. Cross client’s legs tightly

 

QUESTION 235Following a vaginal delivery, the postpartum nurse should observe for:

 

A. Dystocia, kraurosis

 

B. Chadwick’s sign

 

C. Fatigue, hemorrhoids

 

D. Hemorrhage and infection

 

QUESTION 236A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

 

A. Oxytocin

 

B. Magnesium sulfate (MgSO4)

 

C. Ampicillin

 

D. Tetracycline

 

QUESTION 237A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:

 

A. Central nervous system damage

 

B. Hypoglycemia

 

C. Hyperglycemia

 

D. These are normal newborn responses to extrauterine life

 

QUESTION 238A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

 

A. Maintain O2at <40%

 

B. Maintain O2at>40%

 

C. Give moist O2at>40%

 

D. Maintain on 100% O2

 

QUESTION 239A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

 

A. Demand that she relax

 

B. Ask what is the problem

 

C. Stand or sit next to her

 

D. Give her something to do

 

QUESTION 240A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?

 

A. Anger

 

B. Apathy and flatness

 

C. Smiling

 

D. Hostility

 

QUESTION 241A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurseshould suspect a diagnosisof:

 

A. Anorexia nervosa

 

B. Anorexia hysteria

 

C. Bulimia

 

D. Conversion reaction

 

QUESTION 242A 24-year-old client presents to the emergency department protesting “I am God.” The nurse identifies this as a:

 

A. Delusion

 

B. Illusion

 

C. Hallucination

 

D. Conversion

 

QUESTION 243A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and

 

diagnostic testing reveal no organic cause. The nurse recognizes this as:

 

A. Delusion

 

B. Illusion

 

C. Hallucination

 

D. Conversion

 

QUESTION 244

 

A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff.

 

The nurse identifies this behavior as which defense mechanism?

 

A. Denial

 

B. Displacement

 

C. Regression

 

D. Projection

 

QUESTION 245A young boy tells the nurse, “I don’t like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.” The nurse recognizes this stage of growth and

 

development as:

 

A. Electra complex

 

B. Oedipus complex

 

C. Superego

 

D. Ego

 

QUESTION 246A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine

 

therapy is effective?

 

A. Smooth, coordinated voluntary movement

 

B. Tremors

 

C. Rigidity

 

D. Muscle weakness

 

QUESTION 247A client is diagnosed with organic brain disorder. The nursing care should include:

 

A. Organized, safe environment

 

B. Long, extended family visits

 

C. Detailed explanations of procedures

 

D. Challenging educational programs

 

QUESTION 248A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse’s primary goal is to:

 

A. Provide respite care for the mother

 

B. Facilitate optimal development

 

C. Provide a demanding and challenging educational program

 

D. Prepare child to enter mainstream education

 

QUESTION 249A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the nurse should:

 

A. Place on bed rest; elevate and splint the right knee

 

B. Apply moist heat to the right knee

 

C. Administer aspirin for pain

 

D. Encourage active range of motion to right knee

 

Correct Answer: A

 

Section: (none)

 

QUESTION 250A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:

 

A. Gavage tube

 

B. Nipple and bottle

 

C. A straw and cup

 

D. Syringe

 

QUESTION 251A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial

 

pressure?

 

A. Bulging fontanelles

 

B. Seizure

 

C. Headache

 

D. Ataxia

 

QUESTION 252What is the appropriate nursing action for a child with increased intracranial pressure?

 

A. Head of bed elevated 45 degrees with child’s head maintained in a neutral position

 

B. Child lying flat

 

C. Head turned to side

 

D. Frequent visitation for stimulation

 

QUESTION 253

 

A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

 

A. Head of bed elevated 30 degrees on nonoperative side

 

B. Head of bed elevated 30 degrees on operative side

 

C. Bed flat on operative side

 

D. Bed flat on nonoperative side

 

QUESTION 254A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this

 

newborn?

 

A. Bonding

 

B. Maintain normal blood sugar

 

C. Maintain normal nutrition

 

D. Monitor intake and output

 

QUESTION 255A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires

 

notification of physician?

 

A. pH 7.39

 

B. White blood cell (WBC) count 10,000 WBCs/mm3

 

C. Hematocrit 60%

 

D. Bleeding time of 4 minutes

 

QUESTION 256A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing because it:

 

A. Prevents administration of other drugs

 

B. Prevents entry of air into tubing

 

C. Prevents inadvertent administration of a large amount of fluids

 

D. Prevents phlebitis

 

QUESTION 257Which type of insulin can be administered by a continuous IV drip?

 

A. Humulin N

 

B. NPH insulin

 

C. Regular insulin

 

D. Lente insulin

 

QUESTION 258A physician’s order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the

 

nurse give to this infant?

 

A. 5 mg

 

B. 0.5 mg

 

C. 0.05 mg

 

D. 20 mg

 

QUESTION 259A physician’s order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.

 

What dosage should the nurse administer to the infant?

 

A. 1 mEq

 

B. 1.13 mEq

 

C. 2 mEq

 

D. Not enough information to calculate

 

QUESTION 260A 1000-mL dose of lactated Ringer’s solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse

 

administer?

 

A. 125 gtt/min

 

B. 48 gtt/min

 

C. 20 gtt/min

 

D. 21 gtt/min

 

QUESTION 261A 1000-mL dose of D5W 1/2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse

 

administer?

 

A. 75 gtt/min

 

B. 100 gtt/min

 

C. 125 gtt/min

 

D. 150 gtt/min

 

QUESTION 262A physician’s order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the

 

nurse administer?

 

A. 1 gtt/min

 

B. 5 gtt/min

 

C. 50 gtt/min

 

D. 100 gtt/min

 

QUESTION 263A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?

 

A. Hearing test

 

B. Gait

 

C. Strabismus

 

D. Papilledema

 

QUESTION 264An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in

 

excruciating pain with charred clothing to both legs. What is the first nursing action?

 

A. Apply ice packs to both legs.

 

B. Begin débridement by removing all charred clothing from wound.

 

C. Apply Silvadene cream (silver sulfadiazine).

 

D. Immerse both legs in cool water.

 

QUESTION 265A burn victim’s immunization history is assessed by the nurse. Which immunization is of priority concern?

 

A. Oral poliovirus vaccine

 

B. Inactivated poliovirus vaccine

 

C. Tetanus toxoid

 

D. Hepatitis B vaccine

 

QUESTION 266A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn:

 

A. Prone

 

B. Supine

 

C. Side lying

 

D. Semi-Fowler

 

QUESTION 267Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

 

A. Cover sac with dry sterile dressing

 

B. Cover sac with saline-soaked sterile dressing

 

C. Do not apply dressing; keep sac open to air

 

D. Aspirate any fluid from sac

 

QUESTION 268A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The

 

nursing assessment of arterial blood gases indicate the presence of:

 

A. Respiratory alkalosis

 

B. Respiratory acidosis

 

C. Metabolic alkalosis

 

D. Metabolic acidosis

 

QUESTION 269A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28,

 

PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:

 

A. Respiratory alkalosis

 

B. Respiratory acidosis

 

C. Metabolic alkalosis

 

D. Metabolic acidosis

 

QUESTION 270A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.

 

What tests should the nurse anticipate?

 

A. Reticulocyte count, creatinine phosphokinase (CPK)

 

B. Aspartate transaminase, alanine transaminase

 

C. Sedimentation rate, WBC count

 

D. Lactic dehydrogenase, CPK

 

QUESTION 271The nurse needs to be aware that the most common early complication of a myocardial infarction

 

is:

 

A. Diabetes mellitus

 

B. Anaphylactic shock

 

C. Cardiac hypertrophy

 

D. Cardiac dysrhythmia

 

QUESTION 272A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which

 

laboratory test should the nurse monitor?

 

A. Intake and output

 

B. Calcium

 

C. Potassium

 

D. Magnesium

 

QUESTION 273In the coronary care unit, a client has developed multifocal premature ventricular contractions.

 

The nurse should anticipate the administration of:

 

A. Furosemide

 

B. Nitroglycerin

 

C. Lidocaine

 

D. Digoxin

 

UESTION 274

 

A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?

 

A. 0.5 ng/mL

 

B. 1.0 ng/mL

 

C. 2.0 ng/mL

 

D. 3.0 ng/mL

 

QUESTION 275A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of:

 

A. Fresh vegetables and fruit

 

B. Canned vegetables and fruit

 

C. Breads, cereals, and rice

 

D. Fish

 

QUESTION 276A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication’s effectiveness, the nurse should monitor the:

 

A. prothrombin time (PT)

 

B. partial thromboplastin time (PTT)

 

C. PTT-C

 

D. Fibrin split products

 

QUESTION 277Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:

 

A. Respiratory rate for 1 minute

 

B. Radial pulse for 1 minute

 

C. Radial pulse for 2 minutes

 

D. Apical pulse for 1 minute

 

QUESTION 278A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing

 

suctioning, the nurse should:

 

A. Suction for a maximum of 20 seconds

 

B. Hyperoxygenate before and after suctioning

 

C. Suction for a maximum of 30 seconds

 

D. Maintain clean technique during suctioning

 

QUESTION 279The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client. The nurse instructs the client that B6 is given because it:

 

A. Increases activity of isoniazid

 

B. Increases activity of rifampin

 

C. Improves nutritional status

 

D. Reduces peripheral neuropathy

 

QUESTION 280Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?

 

A. Monitor liver function.

 

B. Monitor renal function.

 

C. Assess knowledge of respiratory isolation.

 

D. Monitor compliance with drug therapy.

 

QUESTION 281To facilitate maximum air exchange, the nurse should position the client in:

 

A. High Fowler

 

B. Orthopneic

 

C. Prone

 

D. Flat-supine

 

QUESTION 282A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of

 

coffee. His intake would be recorded as:

 

A. 500 mL

 

B. 540 mL

 

C. 600 mL

 

D. 655 mL

 

QUESTION 283The client tells the nurse, “I have pain in my left shoulder.” This is considered:

 

A. Evaluation process

 

B. Objective information

 

C. Subjective information

 

D. Complaining

 

QUESTION 284Before completing a nursing diagnosis, the nurse must first:

 

A. Write goals and objectives

 

B. Perform an assessment

 

C. Plan interventions

 

D. Perform evaluation

 

QUESTION 285A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by

 

nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

 

A. Tilt her head backwards

 

B. Swallow as tube passes

 

C. Hold breath as tube passes

 

D. Cough as tube passes

 

QUESTION 286When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:

 

A. 20 mL

 

B. 25 mL

 

C. 30 mL

 

D. 50 mL

 

QUESTION 287A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?

 

A. High protein and high calorie

 

B. High calorie and high carbohydrate

 

C. Low-fat 2-g sodium diet

 

D. High protein and high fat

 

QUESTION 288A client has ascites, which is caused by:

 

A. Decreased plasma proteins

 

B. Electrolyte imbalance

 

C. Decreased renal function

 

D. Portal hypertension

 

QUESTION 289A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer?

 

A. Vitamin C

 

B. Vitamin K

 

C. Vitamin E

 

D. Vitamin A

 

QUESTION 290A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?

 

A. Peanut butter and jelly sandwich and milk

 

B. Corn beef and cabbage and boiled potatoes

 

C. Oatmeal, whole-wheat toast, and milk

 

D. Tuna on whole-wheat bread and iced tea

 

QUESTION 291On an assessment of a client’s mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion

 

cannot be rubbed off. The nurse would suspect that this lesion is:

 

A. Xerosteromia

 

B. Candidiasis

 

C. Leukoplakia

 

D. Stomatitis

 

QUESTION 292A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).

 

The nurse would need to provide more client education based on which client statement?

 

A. “HIV is a virus transmitted by sexual contact.”

 

B. “Condoms reduce the transmission of HIV.”

 

C. “HIV is a virus that is easily transmitted by casual contact.”

 

D. “HIV can be transmitted to an unborn infant.”

 

QUESTION 293A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse’s knowledge of the central nervous system, the nurse knows that

 

benign tumors:

 

A. Can be just as dangerous as malignant tumors

 

B. Grow more rapidly than malignant tumors

 

C. Do not warrant concern because they do not become malignant tumors

 

D. Can be removed surgically

 

QUESTION 294A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action

 

for him at this time is:

 

A. Intake and output measurement

 

B. Daily weights

 

C. Straining of all urine

 

D. Administration of O2 therapy

 

QUESTION 295A client’s renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?

 

A. High calcium, low phosphorus

 

B. Low calcium, high phosphorus

 

C. Two-gram sodium diet

 

D. Low calcium and phosphorus, acid ash

 

QUESTION 296A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:

 

A. Humulin N

 

B. Humulin R

 

C. Humulin U

 

D. Humulin L

 

QUESTION 297A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?

 

A. D5in normal saline

 

B. D5W

 

C. 0.9 normal saline

 

D. D5in lactated Ringer’s

 

QUESTION 298The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client’s urine

 

output pattern as:

 

A. Anuria

 

B. Oliguria

 

C. Dysuria

 

D. Polyuria

 

QUESTION 299A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot

 

of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?

 

A. Whole blood

 

B. Platelets

 

C. Fresh frozen plasma

 

D. Packed red blood cells

 

QUESTION 300An expected response to sodium polystyrene sulfonate (Kayexalate) is:

 

A. Increase in serum magnesium

 

B. Increase in serum HCO3

 

C. Decrease in serum potassium

 

D. Decrease in serum calcium

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