Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?

Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?

 

A. Increased core body temperature

 

B. Decreased serum osmolality

 

C. Administration of hypo-osmolar fluids

 

D. Decreased PaCO2

 

 

 

QUESTION 77 When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:

 

A. Fruit juices

 

B. Diluted carbonated drinks

 

C. Soy-based, lactose-free formula

 

D. Regular formulas mixed with electrolyte solutions

 

 

 

 

 

QUESTION 78 The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic?

 

A. High protein and low carbohydrate

 

B. Low calorie and low protein

 

C. High carbohydrate and high calorie

 

D. Low carbohydrate and high calorie

 

 

 

QUESTION 79 A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:

 

A. Provide him with a safe and structured environment.

 

B. Assist him to develop more effective coping mechanisms.

 

C. Have him sign a “no-suicide” contract.

 

D. Isolate him from stressful situations that may precipitate a depressive episode.

 

 

 

QUESTION 80 The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:

 

A. Stroke volume and blood pressure will drop proportionately

 

B. Systolic ejection time will decrease, thereby decreasing cardiac output

 

C. Decreased contractile strength will occur due to decreased filling time

 

D. Decreased coronary artery perfusion due to decreased diastolic filling time will occur, which will increase ischemic damage to the myocardium

 

 

 

QUESTION 81 Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?

 

A. The nurse should use universal precautions when obtaining blood samples.

 

B. Total bed rest should be maintained until the client is asymptomatic.

 

C. The client should be instructed to maintain a low semi-Fowler position when eating meals.

 

D. The nurse should administer an alcohol backrub at bedtime.

 

 

 

QUESTION 82 When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:

 

A. Pericarditis

 

B. Anxiety

 

C. Congestive heart failure

 

D. Angina

 

 

 

QUESTION 83 The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?

 

A. Exercise should be performed 30 minutes before meals.

 

B. A snack may be needed before and/or during exercise.

 

C. Hyperglycemia may occur 2–4 hours after exercise.

 

D. The blood glucose level should be 100 mg or below before exercise is begun.

 

 

 

 

 

QUESTION 84 The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?

 

A. Neosporin sulfate

 

B. Mafenide acetate

 

C. Silver sulfadiazine

 

D. Povidone-iodine

 

 

 

QUESTION 85 The nurse practitioner determines that a client is approximately 9 weeks’ gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:

 

A. Nausea and vomiting

 

B. Quickening

 

C. A 6–8 lb weight gain

 

D. Abdominal enlargement

 

 

 

QUESTION 86 Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?

 

A. Verapamil (Isoptin)

 

B. Amrinone (Inocor)

 

C. Epinephrine (Adrenalin)

 

D. Propranolol (Inderal)

 

 

 

QUESTION 87 Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?

 

A. Diaphanography

 

B. Mammography

 

C. Thermography

 

D. Breast tissue biopsy

 

 

 

QUESTION 88 Pregnant women with diabetes often have problems related to the effectiveness of insulin in controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this is due to:

 

A. Decreased glomerular filtration and increased tubular absorption

 

B. Decreased estrogen levels

 

C. Decreased progesterone levels

 

D. Increased human placental lactogen levels

 

 

 

QUESTION 89 A pregnant woman at 36 weeks’ gestation is followed for PIH and develops proteinuri

 

A. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?

 

A. Fifty milliliters light cream and 2 tbsp corn syrup

 

B. Thirty grams powdered skim milk and 1 egg

 

C. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup

 

D. One package vitamin-fortified gelatin drink

 

 

 

QUESTION 90 A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?

 

A. Blood pressure

 

B. Serum potassium level

 

C. Urine output

 

D. Pulse rate

 

 

 

QUESTION 91 The medication that best penetrates eschar is:

 

A. Mafenide acetate (Sulfamylon)

 

B. Silver sulfadiazine (Silvadene)

 

C. Neomycin sulfate (Neosporin)

 

D. Povidone-iodine (Betadine)

 

 

 

QUESTION 92 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele’s rule is:

 

A. March 27

 

B. February 1

 

C. February 27

 

D. January 3

 

 

 

QUESTION 93 The therapeutic blood-level range for lithium is:

 

A. 0.25–1.0 mEq/L

 

B. 0.5–1.5 mEq/L

 

C. 1.0–2.0 mEq/L

 

D. 2.0–2.5 mEq/L

 

 

 

QUESTION 94 Which of the following ECG changes would be seen as a positive myocardial stress test response?

 

A. Hyperacute T wave

 

B. Prolongation of the PR interval

 

C. ST-segment depression

 

D. Pathological Q wave

 

 

 

QUESTION 95  A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?

 

A. Somatic

 

B. Grandiose

 

C. Persecutory

 

D. Nihilistic

 

 

 

QUESTION 96  During burn therapy, morphine is primarily administered IV for pain management because this route:

 

A. Delays absorption to provide continuous pain relief

 

B. Facilitates absorption because absorption from muscles is not dependable

 

C. Allows for discontinuance of the medication if respiratory depression develops

 

D. Avoids causing additional pain from IM injections

 

 

 

QUESTION 97 Assessment of the client with pericarditis may reveal which of the following?

 

A. Ventricular gallop and substernal chest pain

 

B. Narrowed pulse pressure and shortness of breath

 

C. Pericardial friction rub and pain on deep inspiration

 

D. Pericardial tamponade and widened pulse pressure

 

 

 

QUESTION 98  A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

 

A. Pass a nasogastric tube through the left nostril

 

B. Place a 4 X 4 gauze in the nares to impede the flow

 

C. Gently suction the nasal drainage to protect the airway

 

D. Perform a halo test and glucose level on the drainage

 

 

 

QUESTION 99  To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?

 

A. Positive inotropic therapy

 

B. Negative chronotropic therapy

 

C. Increase in balance of myocardial O2 supply and demand

 

D. Afterload reduction therapy

 

 

 

QUESTION 100  The most important reason to closely assess circumferential burns at least every hour is that they may result in:

 

A. Hypovolemia

 

B. Renal damage

 

C. Ventricular arrhythmias

 

D. Loss of peripheral pulses

 

 

 

QUESTION 101  A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:

 

A. 3-2-0-0-2

 

B. 2-2-0-2-2

 

C. 3-1-1-0-2

 

D. 2-1-1-0-2

 

 

 

QUESTION 102  A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?

 

A. 14 µ g/mL

 

B. 25 µ g/mL

 

C. 4 µ g/mL

 

D. 30 µ g/mL

 

 

 

QUESTION 103  A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:

 

A. Hyperkalemia

 

B. Hyponatremia

 

C. Metabolic acidosis

 

D. Metabolic alkalosis

 

 

 

QUESTION 104  A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best

 

auscultated just:

 

A. Below the umbilicus toward left side of mother’s abdomen

 

B. Below the umbilicus toward right side of mother’s abdomen

 

C. At the umbilicus

 

D. Above the umbilicus to the left side of mother’s abdomen

 

 

 

QUESTION 105  A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?

 

A. Take two or three favorite toys with the child.

 

B. Have a child-sized toilet seat or training potty on hand.

 

C. Explain to the child she is going to “void” and “defecate.”

 

D. Show disapproval if she does not void or defecate.

 

 

 

QUESTION 106 Which 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 107 The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:

 

A. Immediate treatment of mild PIH includes the administration of a variety of medications

 

B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation

 

C. Self-discipline is required to control caloric intake throughout the pregnancy

 

D. The client may not recognize the early symptoms of PIH

 

 

 

QUESTION 108  A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:

 

A. Presenting part is 2 cm above the level of the ischial spines

 

B. Biparietal diameter is at the level of the ischial spines

 

C. Presenting part is 2 cm below the level of the ischial spines

 

D. Biparietal diameter is 5 cm above the ischial spines

 

 

 

QUESTION 109   To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:

 

A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day

 

B. Rinse the mouth and gargle with warm water after each use of the inhaler

 

C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection

 

D. Rinse the mouth before each use to eliminate colonization of bacteria

 

 

 

QUESTION 110   A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edem

 

A. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client’s weight increase is most likely due to:

 

A. Overeating and subsequent obesity

 

B. Obesity prior to conception

 

C. Hypertension due to kidney lesions

 

D. Fluid retention

 

 

 

QUESTION 111   A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

 

A. Responsive to touch, wants to be held

 

B. Uncomforted by touch, refuses bottle

 

C. Maintains eye-to-eye contact

 

D. Finicky eater, easily pacified, cuddly

 

 

 

QUESTION 112  The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?

 

A. “I’ll be sure to rise slowly and sit for a few minutes after lying down.”

 

B. “I’ll be sure to walk at least 2–3 blocks every day.”

 

C. “I’ll be sure to restrict my fluid intake to four or five glasses a day.”

 

D. “I’ll be sure not to take any more aspirin while I am

 

 

 

QUESTION 113  A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse’s first intervention should be to:

 

A. Check FHT

 

B. Notify the attending physician

 

C. Turn off the IV oxytocin

 

D. Prepare for the delivery because the client is probably in transition

 

 

 

QUESTION 114  A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:

 

A. Explain that he will be kept NPO for 24 hours before the exam

 

B. Practice with him so he will be able to hold his breath for 1 minute

 

C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver

 

D. Explain that his vital signs will be checked frequently after the test

 

 

 

QUESTION 115  After a liver biopsy, the best position for the client is:

 

A. High Fowler

 

B. Prone

 

C. Supine

 

D. Right lateral

 

 

 

QUESTION 116  In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?

 

A. Menstrual phase

 

B. Proliferative phase

 

C. Secretory phase

 

D. Ischemic phase

 

 

 

QUESTION 117  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 118 A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?

 

A. Partial thromboplastin time

 

B. Hemoglobin

 

C. Red blood cell (RBC) count

 

D. Prothrombin time

 

 

 

QUESTION 119 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?

 

A. Increased pulse rate

 

B. Increased expectorate of secretions

 

C. Decreased inspiratory difficulty

 

D. Increased respiratory rate

 

 

 

QUESTION 120 Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:

 

A. Cleanse area around the meatus twice a day

 

B. Empty the catheter drainage bag at least daily

 

C. Change the catheter tubing and bag every 48 hours

 

D. Maintain fluid intake of 1200–1500 mL every day

 

 

 

QUESTION 121 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 122 A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:

 

A. Glucocorticoid followed by the bronchodilator

 

B. Bronchodilator followed by the glucocorticoid

 

C. Alternate successive administrations

 

D. According to the client’s preference

 

 

 

QUESTION 123 A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:

 

A. Notify the physician

 

B. Place the client on a pad count

 

C. Massage the uterus and re-evaluate in 30 minutes

 

D. Have the client void and then re-evaluate the fundus

 

 

 

QUESTION 124During a client’s first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to:

 

A. Endometritis

 

B. Fibroid tumor on the uterus

 

C. Displacement due to bowel distention

 

D. Urine retention or a distended bladder

 

 

 

QUESTION 125 The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid “vena caval syndrome,” a condition which:

 

A. Occurs when blood pressure increases sharply with changes in position

 

B. Results when blood flow from the extremities is blocked or slowed

 

C. Is seen mainly in first pregnancies

 

D. May require medication if positioning does not help

 

 

 

QUESTION 126 The 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 127 A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:

 

A. Give the child 15 mL of syrup of ipecac.

 

B. Give the child 10 mL of syrup of ipecac with a sip of water.

 

C. Give the child 1 cup of water to induce vomiting.

 

D. Bring the child to the ER immediately.

 

 

 

QUESTION 128 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 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 129 A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

 

A. “If he develops diarrhea lasting for more than 2–3 days, I will contact the doctor or nurse.”

 

B. “I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.”

 

C. “It is important to keep the head of his bed elevated or sit him in the chair during feedings.”

 

D. “I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.”

 

 

 

QUESTION 130 Which nursing implication is appropriate for a client undergoing a paracentesis?

 

A. Have the client void before the procedure.

 

B. Keep the client NPO.

 

C. Observe the client for hypertension following the procedure.

 

D. Place the client on the right side following the procedure.

 

 

 

QUESTION 131 One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:

 

A. On arising and no later than 6 PM

 

B. At evenly spaced intervals, such as 8 AM and 8 PM

 

C. With at least one glass of water per pill

 

D. With breakfast and at bedtime

 

 

 

QUESTION 132 The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:

 

A. Ordering a full liquid diet for her

 

B. Ordering five small meals for her

 

C. Ordering a mechanical soft diet for her

 

D. Ordering a puréed diet for her

 

 

 

QUESTION 133 In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?

 

A. Striae gravidarum

 

B. Chloasma

 

C. Dysuria

 

D. Colostrum

 

 

 

QUESTION 134 Assessment 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 135 The 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 move it back and forth to relieve the itch.”

 

D. “Gently thump on cast to dislodge dried skin that causes the itching.”

 

 

 

QUESTION 136 A 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 137 Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration?

 

A. Altered surfactant production

 

B. Paradoxical movements of the chest wall

 

C. Increased airway resistance

 

D. Continuous changes in respiratory rate and depth

 

 

 

QUESTION 138 A 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 139 Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension

 

(PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?

 

 

 

A. 136/88 to 144/93

 

B. 132/78 to 124/76

 

C. 114/70 to 140/88

 

D. 140/90 to 148/98

 

 

 

QUESTION 140 An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?

 

A. Boardlike, rigid abdomen

 

B. Loss of the urge to defecate

 

C. Liquid stool

 

D. Abdominal pain

 

 

 

QUESTION 141 A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:

 

A. Afterbirth pains

 

B. Constipation

 

C. Cystitis

 

D. A hematoma of the vagina or vulva

 

 

 

QUESTION 142 Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it:

 

A. Is also called intrinsic factor

 

B. Must be given in the abdomen

 

C. Requires use of the Z-track method

 

D. Should be given SC

 

 

 

QUESTION 143 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:

 

A. Blurred vision and dizziness

 

B. Eye pain and itching

 

C. Feeling of eye pressure and headache

 

D. Eye discharge and hemoptysis

 

 

 

QUESTION 144 The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1–2 minutes; strong, large amount of “bloody show.” The most appropriate nursing goal for this client would be:

 

A. Maintain client’s privacy.

 

B. Assist with assessment procedures.

 

C. Provide strategies to maintain client control.

 

D. Enlist additional caregiver support to ensure client’s safety.

 

 

 

QUESTION 145 A complication for which the nurse should be alert following a liver biopsy is:

 

A. Hepatic coma

 

B. Jaundice

 

C. Ascites

 

D. Shock

 

 

 

QUESTION 146 A 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 147 After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse’s appropriate response is:

 

A. “No vegetable exchanges are allowed.”

 

B. “Corn and other starchy vegetables are considered to be bread exchanges.”

 

C. “Yes, you may exchange any vegetable for any other vegetable.”

 

D. “Yes, but only one-half ear is allowed.”

 

 

 

 QUESTION 148 Which of the following signs might indicate a complication during the labor process with vertex presentation?

 

A. Fetal tachycardia to 170 bpm during a contraction

 

B. Nausea and vomiting at 8–10 cm dilation

 

C. Contraction lasting 60 seconds

 

D. Appearance of dark-colored amniotic fluid

 

 

 

QUESTION 149 The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

 

A. Pulse rate of 50–70 bpm by her third postpartum day

 

B. Diuresis by her second or third postpartum day

 

C. Vaginal discharge or rubra, serosa, then rubra

 

D. Diaphoresis by her third postpartum day

 

 

 

QUESTION 150 MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:

 

A. Magnesium oxide

 

B. Calcium hydroxide

 

C. Calcium gluconate

 

D. Naloxone (Narcan)

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