NCLEX RN Pharmacology Actualtest Exam Part 3 With Answers-200 Solved Questions

NCLEX-RN
Part 3
QUESTION 401
A 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
Answer: C
Explanation:
(A) Visual images are blurred and distorted.
(B) Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading.
(C) These symptoms are classic for myopia.
(D) Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.
QUESTION 402
An 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
Answer: B
Explanation:
(A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical
assessment findings to confirm this condition include cyanosis, jugular vein distention, absent
breath sounds on the affected side, distant heart sounds, and lowered blood pressure.
(B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and
smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased

mucus production. Physical assessment reveals some important findings: agitation, nasal
flaring, tachypnea, and expiratory wheezing.
(C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in
the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to
confirm this condition include decreased chest expansion caused by pleuritic pain, dullness
on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus.
(D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or
amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of
blood supply to lung tissue. Specific assessment findings that confirm this condition include
tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and
cyanosis.
QUESTION 403
The 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
Answer: A
Explanation:
(A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen
formation.
(B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes
carbohydrates, and is essential for normal functioning of nervous tissue.
(C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps
prevent rickets.
(D) Vitamin A is necessary for the formation and maintenance of skin and mucous
membranes. It is also essential for normal growth and development of bones and teeth.
QUESTION 404
As 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
Answer: D
Explanation:
(A) This meal choice provides more of the vitamins A, D, and K than of vitamin C.
(B) This meal choice provides more of the vitamins A, B12, and D than of vitamin C.
(C) This meal choice provides more of the vitamins A, B1 (thiamine), niacin, and
microminerals than of vitamin C.
(D) This meal choice provides foods rich in vitamin C, which are essential in tissue healing.
QUESTION 405
A 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
Answer: A
Explanation:
(A) Skeletal traction is the application of traction directly to bone with the use of pins and
wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on
the bone. It is indicated for preoperative immobilization and positioning of hip and femur
fractures.
(B) A type of skeletal traction (balanced suspension with a Thomas splint and Pearson
attachment) uses a sling to support the extremity, but it also uses weights to provide a strong,
steady continuous pull on the extremity. A sling is used instead of pins.
(C) Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal
traction is continuous.

Pelvic traction does not use pins.
(D) Skeletal traction uses weights at the end of the bed to provide a continuous pull on long
bones. Weights are not applied to both ends of the bed.
QUESTION 406
Pin 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
Answer: B
Explanation:
(A) Exudate (moist, active drainage) is a clinical sign of wound infection.
(B) Crust (dry, scaly) is part of the normal stages of wound healing and should not be
removed from around the pin site. It usually sloughs off after the underlying tissue has
healed.
(C) Edema (swelling) is a clinical sign of wound infection.
(D) Erythema (redness) is a clinical sign of wound infection.
QUESTION 407
A 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
Answer: C
Explanation:

(A) Cystoscopy is an endoscopic procedure that uses an instrument (a cystoscope) to
visualize the internal bladder and ureter structures and to capture and remove an obstructing
stone.
(B) Kidney, ureter, bladder x-ray is used to outline gross structural changes in the kidneys,
ureter, and bladder and will determine the general location of a stone.
(C) An intravenous pyelogram with excretory urogram is used to visualize the kidneys,
kidney pelvis, ureters, and bladder. This procedure is used specifically to determine whether
urethral obstruction is partial or complete; it shows the exact location of the stone and
dilation of the ureter above the stone.
(D) Ureterolithotomy is a surgical procedure in which the ureter is incised and the stone is
manually removed because the stone is unable to pass through the ureter independently.
QUESTION 408
An 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
Answer: C
Explanation:
(A) Radiating pain in the urethra in both sexes, extending into the labia in females and into
the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter.
(B) Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter
within the bladder wall.
(C) An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal
pain with nausea, vomiting, diaphoresis, and pallor.
(D) Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the
renal pelvis or upper ureter causes severe flank and abdominal pain.
QUESTION 409
A 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
Answer: C
Explanation:
(A) The presence of urinary tract infection is a factor in the formation of struvite stones.
(B) Staghorn calculi is the other name for struvite stones associated with urinary tract
infection.
(C) Clients who have gout form uric acid stones.
(D) Clients who have increased urinary excretion of calcium form calcium stones.
QUESTION 410
A 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. Klebsiella pneumonia
B. Pneumococcal pneumonia
C. Legionella pneumophilapneumonia
D. Escherichia colipneumonia
Answer: B
Explanation:
(A) Klebsiella pneumonia is caused by gram-negative bacteria.
(B) Pneumococcal pneumonia is caused by gram-positive bacteria.
(C) Legionella pneumophilapneumonia is a nonbacterial pneumonia.
(D) E. colipneumonia is caused by gram-negative bacteria.
QUESTION 411
The 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
Answer: B
Explanation:

(A) Bright red sputum with streaks is associated with pneumonia caused by gram-negative
bacteria, such as Klebsiella pneumonia.
(B) Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic
productive cough with green or rust-colored sputum.
(C) Green- colored sputum is more characteristic of Pseudomonas than of gram-positive
bacterial pneumonia.
(D) Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of grampositive bacterial pneumonia.
QUESTION 412
The 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
Answer: C
Explanation:
(A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases
dyspnea and workload on the respiratory system.
(B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the
diaphragm from the abdominal organs, which facilitates comfort and easier breathing
patterns.
(C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and
restless and results from the client not obtaining enough O2 to meet metabolic needs.
(D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli
and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be
administered is at least 2.53 liters in a 24-hour period.
QUESTION 413
A 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.
Answer: D
Explanation:
(A) During impending respiratory failure or asthmatic complications, the client is placed in
the high-Fowler position to facilitate comfort and promote optimal gas exchange.
(B) Arterial blood gases are monitored in the treatment of respiratory failure during an asthma
attack, but it is not an initial intervention.
(C) O2 therapy is used during an asthma attack, but it is not the initial intervention. The usual
prescribed amount is a cautiously low flow rate of 12 L/min.
(D) Wheezing is a characteristic clinical finding during an asthma attack. If wheezing
suddenly ceases, it usually indicates a complete airway obstruction and requires immediate
treatment for respiratory failure or arrest.
QUESTION 414
A 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
Answer: C
Explanation:
(A) Cholelithiasis is the correct term used to describe the presence of stones in the
gallbladder.
(B) Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of
stones in the kidney.
(C) Choledocholithiasis is the correct term used to describe the presence of stones in the
common bile duct.

(D) Cholecystitis is the correct term used to describe inflammation of the gallbladder and can
be associated with cystic duct obstructions from impacted stones.
QUESTION 415
A 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
Answer: C
Explanation:
(A) This sign is a faint blue discoloration around the umbilicus found in clients who have
hemorrhagic pancreatitis.
(B) This sign indicates areas of inflammation within the peritoneum, such as with
appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and
when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at
an area of peritoneal inflammation.
(C) This sign is considered positive with acute cholecystitis when the client is unable to take
a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a
sudden, sharp gasp, which means the gallbladder is acutely inflamed.
(D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple
discoloration in the flanks.
QUESTION 416
When 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

Answer: C
Explanation:
(A) During the first 24 hours after surgery, the drainage is normally 300500 mL and then
decreases to about 200 mL in 24 hours during the next 34 days.
(B) This range is the amount of drainage after the first 24 hours postoperatively. During the
first 24 hours, it is 300-500 mL.
(C) During the first 24 hours after surgery, this range is the expected amount of drainage.
(D) The expected amount of drainage during the first 24 hours is 300500 mL. An output of
>500 mL should be reported to the physician, because an occlusion of some type, caused by a
retained gallstone or an inflammatory process within the biliary drainage system, is evident.
QUESTION 417
The 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
Answer: A
Explanation:
(A) Clients who have obstruction in the biliary tract so that bile is not released into the
duodenum experience a change in stools from brown to gray or clay colored.
(B) This type of stool can occur with other GI problems, such as bacterial or viral infections,
and other disease problems, and is not a common finding with biliary obstructions such as
cholecystitis and cholelithiasis.
(C) This type of stool is usually associated with a GI or bowel problem, such as lower GI
bleeding, rather than with biliary obstructions.
(D) This type of stool is usually associated with a GI or bowel problem, such as upper GI
bleeding, rather than with biliary obstructions.
QUESTION 418
A 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
Answer: C
Explanation:
(A) The absence of wound infection is related to his surgical wound and not to postoperative
GI functioning and return of peristalsis.
(B) Routine postoperative protocol involves detection of bowel sounds and return of
peristalsis before introduction of clear liquids, followed by progression of full liquids and a
regular diet versus a full regular meal first.
(C) Routine postoperative protocol for bowel obstruction is to assess for the return of bowel
sounds within 72 hours after major surgery, because that is when bowel sounds normally
return. If unable to detect bowel sounds, the surgeon should be notified immediately and have
the client remain NPO.
(D) Routine postoperative protocol for bowel obstruction and other major surgeries involves
frequent monitoring of vital signs in the immediate postoperative period (in recovery room)
and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This
includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the
first 24 hours postoperatively.
QUESTION 419
A 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
Answer: D
Explanation:

(A) This measurement is _50 cm (4849 cm). Fifty centimeters is considered the length
necessary for the distal end of the tube to be in place in the stomach. This measurement is too
short.
(B) This measurement is _50 cm (4748 cm). Fifty centimeters is considered the length
necessary for the distal end of the tube to be in place in the stomach. This measurement is too
short.
(C) This measurement gives an approximate indication of the length necessary for the distal
end of the tube to be in place in the stomach, but it is not as accurate as actually measuring
the client (nose-earxiphoid).
(D) This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the
earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is
approximately equal to the distance necessary for the distal end of the tube to be located in
the correct position in the stomach.
QUESTION 420
A 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
Answer: A
Explanation:
(A) Bowel movements should be regulated at a specific time each day to prevent "accidents."
Irrigating after meals takes advantage of the gastrocolic reflex and time of increased
peristalsis, so better results may be produced. After meals is the normal time that peristalsis
begins in most persons and evacuation of feces occurs.
(B) Irrigating before meals may cause poor results because of decreased gastrocolic reflex
and decreased peristalsis.
(C) Irrigating a colostomy every 2 hours may produce hyperactivity of the bowel, leading to
irritation and diarrhea. This would not aid in regulation of the bowel.

(D) If irrigation of a colostomy were done at bedtime, there is greater chance of having an
"accident" during sleep. This would not be an advantageous practice of bowel regulation.
QUESTION 421
A 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
Answer: C
Explanation:
(A) Fried, greasy food, such as fried chicken, will produce diarrheal Ike stools in individuals
with all types of GI ostomies.
(B) Eggs will cause odor-producing stools in individuals with all types of GI ostomies.
(C) Tapioca and rice products will cause constipation in individuals with all types of GI
ostomies.
(D) Cabbage will cause odor-producing and flatus-producing stools in individuals with all
types of GI ostomies.
QUESTION 422
When 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
Answer: D
Explanation:
(A) Synthetic cast materials harden in 315 minutes. Weight bearing is permitted in 1530
minutes. Drying time for plaster of Paris is about 2472 hours.

(B, C) Plaster of Paris cast materials are heavier than synthetic materials and require a drying
time of 2472 hours. Synthetic materials dry within 30 minutes.
(D) Plaster of Paris cast materials are heavier than synthetic materials and require a longer
period to set and dry. Even though setting time (hardening) is only 315 minutes, the drying
time for plaster of Paris is 2472 hours. This depends on the size and thickness of the cast,
exposure to air, and humidity in the air.
QUESTION 423
A 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
Answer: B
Explanation:
(A) This describes a suprapubic (trans vesical) prostatectomy procedure.
(B) This is the correct description of a TURP procedure.
(C) This describes a perineal prostatectomy procedure.
(D) This describes a retropubic (extravesical) prostatectomy procedure.
QUESTION 424
A 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
Answer: D
Explanation:

(A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor,
and diaphoresis.
(B) Early signs of potassium depletion include muscular weakness or paralysis, tetany,
postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and
electrocardiographic changes.
(C) Early signs of an elevated sodium level include dry oral mucous membranes, marked
thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation.
(D) This answer is correct. Important early clinical findings of a decreased sodium
concentration include confusion and disorientation. Hyponatremia can occur after a TURP
because absorption during surgery through the prostate veins can increase circulating blood
volume and decrease sodium concentration.
QUESTION 425
A 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.
Answer: B
Explanation:
(A) The physician should be notified as problems arise, but in this case, the nurse can attempt
to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful.
Notifying the physician of problems is a subsequent nursing intervention.
(B) This answer is correct. Assessing catheter patency and irrigating as prescribed are the
initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge
blood clots that have blocked the catheter and prevent problems of bladder distention, pain,
and possibly fresh bleeding.
(C) The Foley catheter would not be changed as an initial nursing intervention, but irrigation
of the catheter should be done as ordered to dislodge clots that interfere with patency.

(D) Even though the client complains of increasing suprapubic pain, administration of a
prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask
the symptoms of a distended bladder and lead to more serious complications.
QUESTION 426
A 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."
Answer: C
Explanation:
(A) This is correct health teaching. Drinking 1012 glasses of clear liquid will help increase
urine volumes and prevent clot formation.
(B) This is correct health teaching. These types of exercises are prescribed by physicians to
assist postprostatectomy clients to strengthen their perineal muscles.
(C) This action is not recommended post-TURP because of the close proximity of the prostate
and rectum.
(D) This is correct healthcare teaching. The client should limit walking long distances, lifting
heavy objects, or driving a car until these activities are cleared by the physician at the first
office visit.
QUESTION 427
A 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

Answer: D
Explanation:
(A) Acetaminophen (Tylenol) has analgesic and antipyretic actions approximately equivalent
to those of aspirin. It produces analgesia possibly by action on the peripheral nervous system.
It reduces fever by direct action on the hypothalamus heat-regulating center with consequent
peripheral vasodilation. It is generally used for temporary relief of mild to moderate pain,
such as a simple headache, minor joint and muscle pains, and control of fever.
(B) Meperidine is a narcotic agonist analgesic with properties similar to morphine except that
it has a shorter duration of action and produces less depression of urinary retention and
smooth muscle spasm. It is used for moderate to severe pain, for a preoperative medication,
for support of anesthesia, and for obstetrical analgesia. In a postoperative TURP client, it
would be used in conjunction with other medications for relief of moderate to severe pain, but
not specifically for bladder spasms associated with TURP surgery.
(C) Promethazine hydrochloride is an antihistamine, antiemetic preparation. It exerts
antiserotonin, anticholinergic, and local anesthetic actions. It is used for symptomatic relief of
various allergic conditions, motion sickness, nausea, and vomiting. It is used for preoperative,
postoperative, and obstetrical sedation and as an adjunct to analgesics for control of pain.
(D) This answer is correct because aminocaproic acid is prescribed specifically for hematuria.
Aminocaproic acid is excreted in the urine. The nurse should be alert for possible signs of
thrombosis, particularly in the extremities.
QUESTION 428
A 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
Answer: A

Explanation:
(A) This is the correct method of teaching diaphragmatic breathing, which allows full lung
expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the
lungs to decrease risk of pneumonia.
(B) Quick, short breaths do not allow for full lung expansion and movement of secretions up
and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and
hypoxia.
(C) Expelling breaths through the nose does not allow for full lung expansion and the use of
diaphragmatic muscles to assist in moving secretions up and out of the lungs.
(D) Inhaling and exhaling at a rate of 2024 times/min does not allow time for full lung
expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.
QUESTION 429
A 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, beard like abdomen
B. Uterine atony
C. A soft relaxed abdomen
D. Hypertonicity of the uterus
Answer: C
Explanation:
(A) A rigid, board like abdomen is an assessment finding indicative of placenta abruptio.
(B) A cause of post birth hemorrhage is uterine atony. With placenta previa, uterine tone is
within normal range.
(C) The placenta is located directly over the cervical os in complete previa. Blood will escape
through the os, resulting in the uterus and abdomen remaining soft and relaxed.
(D) In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood
between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta
previa.
QUESTION 430

A 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 peri pad 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
Answer: A
Explanation:
(A) Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin
value on admission, the priority nursing diagnosis would be decreased cardiac output related
to excessive bleeding.
(B) This nursing diagnosis is a potential problem that does not exist at the present time, and
therefore is not the priority problem.
(C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe
if the decreased cardiac output is resolved.
(D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother
or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and
survival is likely.
QUESTION 431
A 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

Answer: D
Explanation:
(A) Dinitrophenylhydrazine is a laboratory test used to detect phenylketonuria, maple syrup
urine disease, and Lowe's syndrome.
(B) Metachromatic stain is a laboratory test that may be used to diagnose Tay-Sachs and other
lipid diseases of the central nervous system.
(C) The blood serum phenylalanine test is diagnostic of phenylketonuria and can be used for
wide-scale screening.
(D) A lecithin-sphingomyelin ratio of at least 2:1 is indicative of fetal lung maturity, and
survival of the fetus is likely.
QUESTION 432
The 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
Answer: B
Explanation:
(A) These nursing actions are necessary prior to the cesarean section, but not immediately
necessary to maintain physiological equilibrium.
(B) Determining the physiological status of the fetus would constitute the highest priority in
evaluating and maintaining fetal life.
(C) These nursing actions are necessary prior to the cesarean section, but not immediately
necessary to maintain physiological equilibrium.
(D) These nursing actions are necessary prior to the cesarean section, but not immediately
necessary to maintain physiological equilibrium.
QUESTION 433

A 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
Answer: C
Explanation:
(A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A
narrowing of the pulse pressure is indicative of early shock.
(B) Anuria is a clinical finding in late shock.
(C) All of these clinical findings are congruent with early shock.
(D) Absence of urinary output is a clinical finding in the late phase of shock.
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
Answer: D
Explanation:
The length of labor has little bearing on the fourth stage of labor. The type of labor and
delivery is significant.
(B) The type of episiotomy will affect the client's comfort level. However, the nurse's
assessment and implementations center on prevention of hemorrhage during the fourth stage
of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher
priority than the type of episiotomy.
(C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is
lower in priority than determining if hemorrhaging is occurring.
(D) Character of the fundus would be the priority nursing assessment because changes in
uterine tone may identify possible postpartum hemorrhage.

QUESTION 435
On 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
Answer: A
Explanation:
(A) Gentle massage and expression of clots will let the fundus return to a state of firmness,
allowing the uterus to function as the "living ligature."
(B) A distended bladder may promote uterine atony; however, after determining the bladder is
distended, the nurse would have the client void. Catheterization is only done if normal
bladder function has not returned.
(C) Oxytocic medications are ordered and administered if the uterus does not remain
contracted after gentle massage and determining if the bladder is empty.
(D) The client is not complaining of discomfort or pain; therefore, analgesics are not
necessary.
QUESTION 436
The nurse assesses a client on the second postpartum day and finds a dark red discharge on
the peri pad. 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
Answer: D
Explanation:

(A) Lochia alba occurs approximately 10 days after birth and is yellow to white. A discharge
is classified as light when less than a 4-inch stain exists.
(B) Lochia serosa is pink to brown and occurs 34 days after delivery. A stain is classified as
heavy when a peri pad is saturated in 1 hour.
(C) Lochia granulosa is not a proper classification.
(D) Lochia rubra is red, consisting mainly of blood, debris, and bacteria, and lasts from the
time of delivery to 34 days afterward. A stain is classified as moderate when less than a 6inch stain exists.
QUESTION 437
A 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
Answer: B
Explanation:
(A) The foramen ovale permits a percentage of the blood to shunt from the right atrium to the
left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation
with blood containing a higher O2 saturation.
(B) As the blood shunts from the right atrium to the left atrium, the pulmonary system is
bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial
bypass of the pulmonary system.
(C) The foramen ovale is located in the atrial septum of the heart and does not affect the liver.
(D) The superior vena cava returns blood to the heart, bringing blood to the location of the
foramen ovale.
QUESTION 438
A 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 correct client
D. Transfusing the blood in a 2-hour time frame
Answer: C
Explanation:
(A) An 18-gauge IV is an appropriate size for administering blood; however, client safety
demands that the right blood product must be administered.
(B) The consent form is legally necessary to be on the chart, but client safety is maintained by
giving the correct blood component to the correct client.
(C) Administering the correct blood product to the correct client will maintain physiological
safety and minimize transfusion reactions.
(D) The blood administration should take place over the ordered time frame designated by the
physician.
QUESTION 439
A 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 micro drip tubing for the blood administration
D. Have the registered nurse in charge assume responsibility for verifying the client and
blood product information
Answer: A
Explanation:
(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as
the blood product is being administered.
(B) The only companion fluid to be used during a blood transfusion is normal saline. The
calcium in Ringer's lactate can cause clotting.
(C) Only a blood administration set should be used. A micro drip tube would cause lysis of
the red blood cells.

(D) Proper identification of the recipient and the blood product must be validated by at least
two people.
QUESTION 440
A 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
Answer: D
Explanation:
(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain,
hypotension, and tachypnea.
(B) Fever, chills, and headaches are indicative of a febrile transfusion reaction.
(C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles.
(D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion
reaction.
QUESTION 441
Diagnostic 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
Answer: D
Explanation:
(A) S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not
exist with this diagnosis.
(B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect
will be heard along the left upper sternal border. A diastolic murmur is not associated with
coarctation of the aorta.

(C) Pulse pressure differences of>20 mm Hg exist between the upper extremities and the
lower extremities. It is important to evaluate the upper and lower extremities with the
appropriate- sized cuffs.
(D) Femoral and pedal pulses will be diminished or absent in infants with coarctation of the
aorta.
QUESTION 442
Decreased 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
Answer: A
Explanation:
(A) Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD,
pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is
obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts
blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood the
reach the systemic circulation.
(B) A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than
that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle,
increasing the blood flow to the lungs. No deoxygenated blood will reach the systemic
circulation.
(C) In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary
artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the
unoxygenated blood of the pulmonary artery.
(D) Transposition of the great arteries results in two separate and parallel circulatory systems.
The only mixing or shunting of blood is based on the presence of associated lesions.
QUESTION 443
A 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
Answer: B
Explanation:
(A) A toddler is not capable of conceptualizing about the inside of his body and is concerned
about body intactness; therefore, diagrams would not be useful. Also, the previous evening is
too far from the procedure for the toddler to remember the instructions.
(B) A simple explanation the morning of the procedure is the best developmental strategy to
use, because it focuses on the toddler's need for parental support, body intactness, and short
attention span.
(C) A relationship between the nurse and the child needs to develop. Also, misinformation
may be given to the child if the parents explain the procedure to the child.
(D) The parents are the child's support system and need to be there to strengthen the child.
QUESTION 444
Home-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.
Answer: B
Explanation:
(A) A small bruise may develop around the insertion site and is not a reason for alarm.
(B) It is best to keep the child out of the bathtub until the sutures are removed.
(C) Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site.
(D) The insertion site should be kept clean and dry and open to air.
QUESTION 445
Nursing 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
Answer: B
Explanation:
(A) It is important to discuss with parents the need to treat the child as they would any other
children, but they must be truthful and honest with the child about the heart defect. As the
child grows older, explanations can go into greater depth.
(B) Parents of children with congenital heart defects go through a grieving process over the
loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents
a role in the child's care when they are ready.
(C) Anger and resentment are normal feelings that must be dealt with appropriately.
(D) Parents may go through a second grieving process after the repair of the cardiac defect.
During this grieving period, they mourn the loss of the "defective" child who now may be
essentially "normal."
QUESTION 446
An 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
the physician
D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration
must be developed
Answer: C
Explanation:
(A) Occasionally the child may vomit. They should not repeat the dose because the amount of
digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are
more dangerous than those that are temporarily too low.
(B) To ensure that the entire dose of digoxin is received, never mix it with food or formula.

(C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be
reported to the physician immediately.
(D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip
that dose and to continue the next dose as scheduled.
QUESTION 447
A 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
Answer: D
Explanation:
(A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white
blood cell counts are usually not depressed. It is usually self-limiting, lasting 510 days.
(B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled
cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities
are the most commonly affected areas.
(C) Dactylitis crisis, or "hand-foot syndrome," causes symmetrical infarction of the bones in
the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet.
(D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The
spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness
result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
QUESTION 448
The 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
Answer: A

Explanation:
(A) Maintaining the hydration level is the focus for nursing intervention because dehydration
enhances the sickling process. Both oral and parenteral fluids are used.
(B) The pain is a result of the sickling process. Analgesics or narcotics will be used for
symptom relief, but the underlying cause of the pain will be resolved with hydration.
(C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all
times, not just during the acute period of a crisis.
(D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling
process. Hydration is the primary intervention to alleviate the dehydration that enhances the
sickling process.
QUESTION 449
A 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
Answer: B
Explanation:
(A) This answer is incorrect. Encouraging discussion of the voices will reinforce the
delusion.
(B) This answer is correct. The nurse should appropriately present reality.
(C) This answer is incorrect. Showing interest would reinforce the delusional system.
(D) This answer is incorrect. The statement only indicates that the client is hearing voices. It
does not state that the client is acting out.
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
Answer: A
Explanation:
(A) This answer is correct. The therapeutic range is 1.01.5 mEq/L in the acute phase.
Maintenance control levels are 0.61.2 mEq/L.
(B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range.
(D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher.
QUESTION 451
A client was exhibiting signs of mania and was recently started on lithium carbonate. She has
no known physical problems. A teaching plan for this client would include which of the
following?
A. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8
juice, and tomato juice.
B. Restrict fluids to 1000 mL/day.
C. Restrict foods that contain salt or sodium.
D. Discontinue the medication if nausea occurs.
Answer: A
Explanation:
(A) This answer is correct. A balanced diet with adequate salt intake is necessary.
(B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day
(20003000 mL/day).
(C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium
intake. Diet should be balanced, with an adequate salt intake.
(D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with
administration of drug with meals or after eating food.
QUESTION 452
A behavioral modification program is recommended by the multidisciplinary team working
with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality
would include:
A. Role playing the client's eating behaviors
B. Restriction to the unit until she has gained 2 lb
C. Encouraging her to verbalize her feelings concerning food and food intake

D. Provision for a high-calorie, high-protein snack between meals
Answer: B
Explanation:
(A) This answer is incorrect. Role playing is based on learning but is not based on the
behavioral modification model.
(B) This answer is correct. The behavioral modification model is based on negative and
positive reinforcers to change behavior.
(C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral
modification.
(D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on
behavioral modification.
QUESTION 453
A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history
of using drugs, writing numerous checks with insufficient funds, and stealing. He appears
charming and intelligent, and the other clients are impressed and want to be liked by him. The
greatest problem that may arise from this situation is that:
A. He will manipulate the other clients for his own benefit
B. He will cause the other clients to become psychotic
C. He will become delusional and hallucinate as a result of the excess attention given to him
by peers
D. He may exhibit self-mutilative behavior
Answer: A
Explanation:
(A) This answer is correct. Persons with antisocial personality disorder typically are very
manipulative.
(B) This answer is incorrect. The client's behavior cannot cause another person to become
psychotic.
(C) This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the
criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client
would love the attention.
(D) This answer is incorrect. Self-mutilative behavior is characteristic of the borderline
personality disorder.

QUESTION 454
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations
of the unit. A client with antisocial personality disorder makes the following remark, "Forget
all those rules. I always get along well with the nurses." Which nursing response to him
would be most effective?
A. "OK, don't listen to the rules. See where you end up."
B. "I'm pleased that you get along so well with the staff. You must still know and abide by the
rules."
C. "It is irrelevant whether you get along with the nurses."
D. "I'm not the other nurses. You better read the rules yourself."
Answer: B
Explanation:
(A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not
appropriate. No limit setting was stated.
(B) This answer is correct. The nurse made a positive statement followed by a simple, clear,
concise setting of limits.
(C) This answer is incorrect. It appears to have a negative connotation. There was no limit
setting.
(D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning
takes place more readily when one is accepted, not rejected. No limits were set.
QUESTION 455
A client was admitted to the hospital after falling in her home. At the time of admission, her
blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of
vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission.
Alcohol withdrawal symptoms would most likely be exhibited by her:
A. Two to 4 hours after the last drink
B. Six to 8 hours after the last drink
C. Immediately on admission
D. Twenty-four hours after the last drink
Answer: B
Explanation:
(A) This answer is incorrect. Alcohol withdrawal usually begins approximately 68 hours after
the last drink.

(B) This answer is correct. It takes approximately 68 hours for metabolism of alcohol.
(C) This answer is incorrect. The alcohol is still in the system, as indicated by the high blood
alcohol level.
(D) This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 68 hours
of the last drink.
QUESTION 456
A client has begun to exhibit signs of alcohol withdrawal. Her blood pressure has risen from
120/60 to 190/100, pulse is increased from 88 to 110 bpm, and she is irritable and agitated
and has gross motor tremors of the hands. The nurse notifies the doctor. The nurse can
anticipate that the doctor will order which of the following?
A. An opiate such as propoxyphene napsylate (Darvocet)
B. A benzodiazepine such as chlordiazepoxide (Librium)
C. A tricyclic antidepressant such as amitriptyline (Elavil)
D. A phenothiazine such as chlorpromazine (Thorazine)
Answer: B
Explanation:
(A) This answer is incorrect. Benzodiazepines are drugs of choice for alcohol withdrawal.
(B) This answer is correct. The drug has a sedative effect, is safe, and has an anticonvulsant
effect.
(C) This answer is incorrect. Amitriptyline is an antidepressant.
(D) This answer is incorrect. Chlorpromazine is most effective in psychotic disorders.
QUESTION 457
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased
concentration. She has been unable to perform activities of daily living without assistance.
After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An
appropriate nursing intervention to decrease the anxiety of this client would include:
A. Allowing the client to perform activities of daily living as much as possible unassisted
B. Confronting confabulations
C. Reality testing
D. Providing a highly stimulating environment
Answer: A
Explanation:

(A) This answer is correct. The more the client is able to control her daily routine, the less
anxiety she will experience.
(B) This answer is incorrect. Confrontation tends to increase anxiety.
(C) This answer is incorrect. Reality testing is an assessment tool. It does not decrease
anxiety.
(D) This answer is incorrect. A highly stimulating environment increases distractibility and
anxiety.
QUESTION 458
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family
states that he has not slept, eaten, or taken fluids for the past 24 hours.
The planning of nursing care for a delirious client is based on which of the following
premises?
A. The delirious client is capable of returning to his previous level of functioning.
B. The delirious client is incapable of returning to his previous level of functioning.
C. Delirium entails progressive intellectual and behavioral deterioration.
D. Delirium is an insidious process.
Answer: A
Explanation:
(A) This answer is correct. If the cause is removed, the delirious client will recover
completely.
(B) This answer is incorrect. The demented client is incapable of returning to previous level
of functioning. The delirious client is capable of returning to previous functioning.
(C) This answer is incorrect. The demented client, not the delirious client, has progressive
intellectual and behavioral deterioration.
(D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.
QUESTION 459
A 48-year-old client presents with a long history of severe depression unrelieved by
medication. He is admitted to the hospital for electroconvulsive therapy. Family members are
very concerned about this therapy and are requesting information about aftereffects of the
treatment. The nurse informs the family that he will:
A. Have transient memory loss, confusion, and headache
B. Be alert and oriented immediately after the treatment

C. Have insomnia for the first few days
D. Require no special care after the procedure
Answer: A
Explanation:
(A) This answer is correct. The client will be confused and have a memory loss, which is
usually temporary, after electroconvulsive shock therapy.
(B) This answer is incorrect. The client will experience transient memory loss, look
bewildered, and be confused initially.
(C) This answer is incorrect. The client will sleep immediately following the treatment.
(D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is
monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity.
QUESTION 460
An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has
been making weekly visits to draw blood for a prothrombin time test. The client is taking 5
mg of coumadin per day. She appears more debilitated, and bruises are noted on her face.
Elder abuse is suspected. Which of the following are signs of persons who are at risk for
abusing an elderly person?
A. A family member who is having marital problems and is regularly abusing alcohol
B. A person with adequate communication and coping skills who is employed by the family
C. A friend of the family who wants to help but is minimally competent
D. A lifelong friend of the client who is often confused
Answer: A
Explanation:
(A) This answer is correct. Two risk factors are identified in this answer.
(B) This answer is incorrect. Persons at risk tend to lack communication skills and effective
coping patterns.
(C) This answer is incorrect. Persons at risk are usually family members or those reluctant to
provide care.
(D) This answer is incorrect. This individual has a vested interest in providing care.
QUESTION 461
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence
toward another child. In managing a potentially violent client, the nurse:

A. Must use the least restrictive measure possible to control the behavior
B. Should put the client in seclusion until he promises to behave appropriately
C. Should apply full restraints until the behavior is under control
D. Should allow other clients to observe the acting out so that they can learn from the
experience
Answer: A
Explanation:
(A) This answer is correct. Least restrictive measures should always be attempted before a
client is placed in seclusion or restraints. The nurse should first try a calm verbal approach,
suggest a quiet room, or request that the client take "time-out" before placing the client in
seclusion, giving medication as necessary, or restraining.
(B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room
should be attempted before restraining.
(C) This answer is incorrect. Restraints should be applied only after all other measures fail to
control the behavior.
(D) This answer is incorrect. Other clients should be removed from the area. It is often very
anxiety producing for other clients to see a peer out of control. It could also lead to mass
acting- out behaviors.
QUESTION 462
The nurse is planning a reality orientation program for a group of clients with organic brain
syndrome at the mental health center. Props that could be used for this program are:
A. Month-old magazines that are provided by volunteers
B. Large maps and posters depicting area of current residence
C. A litter of kittens for the clients to pet
D. A library of biographical books
Answer: B
Explanation:
(A) This answer is incorrect. Current magazines would be appropriate.
(B) This answer is correct. Maps of the state and town and posters that depict current events
in the area are appropriate props.
(C) This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy.
(D) This answer is incorrect. Biographies depict a past, not a present, orientation.

QUESTION 463
In working with a manipulative client, which of the following nursing interventions would be
most appropriate?
A. Bargaining with the client as a strategy to control the behavior
B. Redirecting the client
C. Providing a consistent set of guidelines and rules
D. Assigning the client to different staff persons each day
Answer: C
Explanation:
(A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect
from the client.
(B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative
behavior. Redirection is appropriate for the client who is out of touch with reality.
(C) This answer is correct. Manipulative clients must abide by consistent rules.
(D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is
assigned to the client. Often the client will attempt to play staff persons against each other.
QUESTION 464
Primary nursing diagnoses for the antisocial client are:
A. Alteration in perception and altered self-concept
B. Impaired social interaction, ineffective individual coping, and altered self-concept
C. Altered communication processes and altered recreational patterns
D. Altered body image and altered thought processes
Answer: B
Explanation:
(A) This answer is incorrect. Perception is not altered because the client is not psychotic.
(B) This answer is correct. The antisocial client lacks responsibility, accountability, and social
commitment; has impaired problem-solving ability; tends to overuse defense mechanisms;
lies and steals; and is often grandiose concerning self.
(C) This answer is incorrect. Altered communication processes do not characterize this client.
The antisocial person communicates well and tends to have a charming personality.
(D) This answer is incorrect. Altered thought processes refer to delusional thinking, which is
bizarre and fixed, and do not characterize this client.

QUESTION 465
A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His
coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with
trivial details and schedules. A nursing intervention appropriate for this client would include:
A. Encouraging him to engage in recreational activities
B. Avoiding discussion of his annoying behavior
C. Encouraging the client to set a time schedule and deadlines for himself
D. Contracting with him for the amount of time he will spend on the compulsive behaviors
Answer: D
Explanation:
(A) This answer is incorrect. The client will work hard at the activity instead of enjoying it.
(B) This answer is incorrect. The nurse should allow the client to discuss these thoughts,
within limits, not to avoid discussing them.
(C) This answer is incorrect. The compulsive client tends to control time to excess. It should
not be encouraged.
(D) This answer is correct. A contract with the client regarding the amount of time that will
be spent discussing the compulsive activities is appropriate. Time allotted should be gradually
decreased.
QUESTION 466
The serial sevens test is often used to determine delirium and dementia. This test aids in
assessing which of the following?
A. Abstract thinking
B. Ability to focus and concentrate thoughts
C. Judgment
D. Memory
Answer: B
Explanation:
(A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The
use of proverbs is the most common way to test abstraction.
(B) This answer is correct. The serial sevens test is a common test of calculation ability. It is
difficult for the demented or delirious client to perform.
(C) This answer is incorrect. The test for judgment should predict whether the individual will
behave in a socially accepted manner.

(D) This answer is incorrect. In testing memory, the nurse would attempt to get the client
either to recall recent events or to think about past events.
QUESTION 467
A 14-year-old client has a history of lying, stealing, and destruction of property. Personal
items of peers have been found missing. After group therapy, a peer approaches the nurse to
report that he has seen the 14- year-old with some of the missing items. The best response of
the nurse is to:
A. Request that he explain to the group why he took personal items from peers
B. Approach him when he is alone to inquire about his involvement in the incident
C. Imply to him that you doubt his involvement in the incident and request his denial
D. Confront him openly in group and request an apology
Answer: B
Explanation:
(A) This answer is incorrect. There is no proof that he removed the missing items.
(B) This answer is correct. Anxiety and defensiveness are lessened if the individual is
approached in this manner.
(C) This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach.
(D) This answer is incorrect. He has not yet been proved guilty. Confrontation will only
increase defensiveness and anxiety.
QUESTION 468
A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging
a client to speak openly depends on how clearly questions are phrased. Which of the
following statements is most desirable in eliciting information from an adolescent client?
A. "Do you get along well with your family?"
B. "Do you communicate with your parents?"
C. "You don't hate your family, do you?"
D. "What is it like between you and your family?"
Answer: D
Explanation:
(A, B) This statement can be answered with a simple yes or no.
(C) This statement is asked in a negative manner and therefore has a negative connotation.
(D) This statement is open ended and positively stated.

QUESTION 469
A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse
observes her walking with a shuffling gait and postural rigidity and notes a masklike
expression on her face. Which side effect is this client exhibiting?
A. Dystonia
B. Parkinsonism
C. Tardive dyskinesia
D. Akathesia
Answer: B
Explanation:
(A) This answer is incorrect. Dystonia refers to severe, painful muscle contractions.
(B) This answer is correct. Parkinsonism commonly occurs approximately 12 weeks after
initiation of antipsychotic drug therapy. Traditional signs are masklike facies, postural
rigidity, shuffling gait, and resting tremor.
(C) This answer is incorrect. Tardive dyskinesia is characterized by involuntary muscle
movements of the face, jaw, and tongue.
(D) This answer is incorrect. Akathesia is motor restlessness.
QUESTION 470
Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects
that are reversible with which of the following agents ordered by the physician?
A. Phenothiazines
B. Anticholinergics
C. Anti-Parkinsonian drugs
D. Tricyclic agents
Answer: B
Explanation:
(A) This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the
symptoms.
(B) This answer is correct. Anticholinergic agents are often used prophylactically for
extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain.
(C) This answer is incorrect. Anti- Parkinsonian drugs would increase the symptoms.
(D) This answer is incorrect. Tricyclic agents are used for symptoms of depression.

QUESTION 471
A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge
from the hospital. Compliance with the medication regimen is important despite the mild side
effects encountered. In order to increase the likelihood of medication compliance, the nurse
would:
A. Discuss the disease process and the importance of the medication in prevention of
symptoms.
B. Inform the client that additional side effects are to be expected and need not be reported.
C. Discuss the importance of getting blood drawn weekly to determine medication
therapeutics.
D. Inform the client to cease taking the medication when all psychotic symptoms have
cleared.
Answer: A
Explanation:
(A) This answer is correct. If the client is well informed about what reactions to expect from
her medication, she is more likely to follow the treatment regimen.
(B) This answer is incorrect. There are many side effects that are reversible by medication,
and these must be reported to the nurse or physician. There are also more severe side effects,
such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis,
which can be life threatening.
(C) This answer is incorrect. There is no need for weekly blood tests if the drug regimen has
been followed properly.
(D) This answer is incorrect. The client should continue the medication until the physician
recommends any change in the drug regimen. Symptoms will usually reappear if medication
is discontinued.
QUESTION 472
A depressed client is seen at the mental health center for follow-up after an attempted suicide
1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO)
inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains
that the drug must accumulate to an effective level before symptoms are totally relieved.
Symptom relief is expected to occur within:
A. 10 days

B. 24 weeks
C. 2 months
D. 3 months
Answer: B
Explanation:
(A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the
medication.
(B) This answer is correct. Because MAO inhibitors are slow to act, it takes 24 weeks before
improvement of symptoms is noted.
(C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the
medication.
(D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month
of drug therapy.
QUESTION 473
Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence
to a low-tyramine diet. Which of the following are foods that she should avoid?
A. Pickled, aged, smoked, and fermented foods
B. Fresh vegetables
C. Broiled fresh fish and fowl
D. Fresh fruit such as apples and oranges
Answer: A
Explanation:
(A) These foods may produce elevation in blood pressure when consumed during MAO
inhibition therapy.
(B) These foods have not been pickled, fermented, smoked, or aged. They contain very little,
if any, tyramine or tryptophan.
(C) As long as the meat has not been aged or smoked, it is within the dietary regimen.
(D) Fresh fruits can be consumed as desired. However, the consumption of bananas is
limited.
QUESTION 474

In working with mental health clients who are prescribed medication that must be taken on a
routine basis, it is important for education to begin when the drug therapy is initiated. One of
the first steps in the teaching process is to:
A. Explain the side effects of the medication
B. Discuss the danger of overmedication
C. Distribute written material to supplement verbal instructions
D. Explore the client's perception regarding medication therapy
Answer: D
Explanation:
(A, B, C) The nurse must first obtain information regarding the client's perception of the
medication regimen.
(D) The first step in the teaching process is to determine the client's perception.
QUESTION 475
A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the
nurse's anger by using a condescending tone of voice with other clients and staff persons.
Which of the following statements from the nurse would be most appropriate in
acknowledging feelings regarding the client's behavior?
A. "I feel angry when I hear that tone of voice."
B. "You make me angry when you talk to me that way."
C. "Are you trying to get me angry?"
D. "Why do you treat me that way?"
Answer: A
Explanation:
The nurse appropriately states how he or she feels when the client speaks in a condescending
manner.
(B) This statement indicates that the client has control over the nurse. No one makes another
person angry; each individual has a choice.
(C) "Why" questions usually put a person on the defensive. In addition, the client cannot
"make" the nurse angry. The client does not have that control.
(D) Again, a "why" statement places the client on the defensive.
QUESTION 476

The mother of a 7-year-old mental health center client reports that the client has refused to
attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class
and was attending 3 times a week. In talking with the client, the nurse would:
A. Ask her why she doesn't like gymnastics anymore
B. Ask her to describe how things were at gymnastics before she started refusing to go
C. Tell her that it is OK to be afraid of this activity
D. Reassure her that things will get better once she begins the classes again
Answer: B
Explanation:
(A) The child has not said that she dislikes gymnastics.
(B) The nurse will be able to obtain information on what events occurred at gymnastics prior
to her refusal to attend. The nurse will also gain information about the child's perception of
the problem.
(C) The child has not said she is afraid to go to gymnastics.
(D) False reassurance is inappropriate.
QUESTION 477
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become
increasingly restless and verbally argumentative, and her speech has become pressured. She
is exhibiting signs of:
A. Depression
B. Agitation
C. Psychotic ideation
D. Anhedonia
Answer: B
Explanation:
(A) Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early
awakening, etc.
(B) These clinical features are classic signs of agitation.
(C) Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking,
etc.
(D) Anhedonia is the inability to experience pleasure.
QUESTION 478

A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his
hospital room. Nursing care would include:
A. Forcing the client to attend all unit activities
B. Encouraging the client to discuss why he is so sad
C. Monitoring elimination patterns
D. Providing sensory stimulation
Answer: C
Explanation:
(A) The client should be encouraged to attend the unit activities. The nurse and client should
choose a few activities for the client to attend that will be positive experiences for him.
(B) The nurse should encourage the client to discuss his feelings and to begin to deal with the
depression.
(C) Depressed persons often have little appetite and poor fluid intake. Constipation is
common.
(D) A calm, consistent level of stimuli is most effective. Sensory deprivation and
overstimulation should be avoided.
QUESTION 479
A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours
postoperatively, both the blood pressure and pulse increased. He became agitated, thought
snakes were crawling on his arms and legs, and generally became unmanageable. He pulled
out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating
profusely. The admission nurse's notes indicated that the client admitted to "having a few
drinks now and then." He is probably experiencing which of the following?
A. Major psychotic depression
B. Delirium tremens
C. Generalized anxiety disorder
D. Adjustment disorder with mixed features
Answer: B
Explanation:
(A) Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms
must represent a change from previous functioning.
(B) Delirium tremens occur approximately on the second or third day following cessation or
reduction of alcohol intake. Symptoms would be all those described in the situation.

(C) Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who
manifest excessive or unrealistic worry about life circumstances for at least 6 months.
(D) Symptoms for adjustment disorders with mixed emotional features (e.g., depression and
anxiety) are different from those exhibited by the client in this situation.
QUESTION 480
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for
pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later,
numerous attempts to wean him from mechanical ventilation were ineffective, and a
tracheostomy was created. For the first 24 hours following tracheostomy, it is important to
minimize bleeding around the insertion site. The nurse can accomplish this by:
A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
B. Avoiding manipulation of the tracheostomy including cuff deflation
C. Reporting any signs of crepitus immediately to the physician
D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen
peroxide to cleanse the site
Answer: B
Explanation:
(A) The tracheal cuff should not be deflated within the first 24 hours following surgery.
(B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided.
(C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of
the area of crepitus should be reported to the physician.
(D) The tracheostomy site may be changed as often as necessary, but site care should be done
with normal saline.
QUESTION 481
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular
disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The
nurse notes that her left leg is cold to touch. She complains of having recently experienced
muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent
claudication, the nurse would begin her assessment with the following question:
A. "Would you describe the intensity, duration, and symptoms associated with your pain?"
B. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
C. "Have you had any lesions of the affected leg that have been difficult to heal?"

D. "Do your muscle spasms occur following rest, walking, or exercising?"
Answer: D
Explanation:
(A) Describing pain is an important aspect of the assessment; however, assessing activity
preceding muscle spasms is equally important.
(B) Edema may occur with peripheral vascular disease, but it is not of particular importance
in assessing intermittent claudication.
(C) Lesions may be present with peripheral vascular disease, but they are not an indication of
intermittent claudication.
(D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking
and after exercising. Rest may relieve muscle spasms.
QUESTION 482
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her
postoperative recovery progressed without complications, and she is ready for discharge.
Client education in preparation for discharge began 7 days ago on her admission to the
nursing unit. Evaluation of nursing care related to client education is based on evaluation of
expected outcomes. Which statement made by the client would indicate that she is ready for
discharge?
A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's
appointment."
B. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."
C. "I am allowed to exercise by walking for short periods."
D. "Teach my husband about the diet. He'll be doing all the cooking now."
Answer: C
Explanation:
(A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving,
riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh
incision. She should ride in back seat without a seat belt.
(B) Clients should not sit in the tub and allow the incision to soak in water because this may
predispose the client to infection. A short, cool shower would be preferable. Allowing soap to
come in contact with the incision would not harm it and is frequently used as postoperative
wound care at home on discharge from the hospital.

(C) Activity instructions include: avoid sitting for long periods and get exercise by walking.
Lifting more than 5 lb of weight is also prohibited.
(D) The client must also learn her diet. Her husband cooking is probably a temporary
measure unless he did the cooking prior to her hospitalization. A statement such as this may
indicate the need for further exploration of feelings regarding her illness, dependence, and
self-care expectations.
QUESTION 483
A 67-year-old man had a physical examination prior to beginning volunteer work at the
hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure
was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong
family history of hypertension. The client is placed on antihypertensive medication; a lowsodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be
determined by:
A. A blood pressure reading of 130/70 with a 5-lb weight loss
B. No side effects from antihypertensive medication and an accurate pill count
C. No evidence of increased left ventricular hypertrophy on chest x-ray
D. Serum blood levels of the antihypertensive medication within therapeutic range
Answer: A
Explanation:
(A) A blood pressure within acceptable range best demonstrates compliance, but weight loss
cannot be accomplished without adherence to medication, diet, and exercise.
(B) Absence of side effects does not indicate compliance with medication. Pill counts can be
misleading because the client can alter pill counts prior to visit.
(C) Left ventricular hypertrophy is not an accurate measure of compliance because
hypertrophy frequently does not decrease even with pharmacological management.
(D) Therapeutic blood levels measure the drug level at the time of the test. There is no
indication of compliance several days before testing.
QUESTION 484
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is
chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the
following findings in the client's nursing assessment demand immediate nursing action?
A. Associated symptoms of indigestion and nausea

B. Restlessness and apprehensiveness
C. Inability to tolerate assessment session with the admitting nurse
D. History of hypertension treated with pharmacological therapy
Answer: B
Explanation:
(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not
indicate imminent danger for the client.
(B) Restlessness and apprehensiveness require immediate nursing action because they are
indicative of very low oxygenation of body tissues and are frequently the first indication of
impending cardiac or respiratory arrest.
(C) It is common for the cardiac client to experience fatigue and inability to physically
tolerate long assessment sessions.
(D) A history of hypertension requires no immediate nursing intervention. In the situation
described, the blood pressure is not given and therefore cannot be assumed to be elevated.
QUESTION 485
A 48-year-old client is in the surgical intensive care unit after having had three-vessel
coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is
receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which
abnormality would require immediate intervention by the nurse after contacting the
physician?
A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV
fluid rate.
B. Serum sodium is low. The nurse should change IV fluids to normal saline.
C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet
as soon as possible.
D. Serum potassium is low. The nurse should administer KCl as ordered.
Answer: D
Explanation:
(A) An elevated serum osmolality poses no immediate danger and is not corrected rapidly.
(B) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other
assessment parameters, such as hydration status, must be considered.
(C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It
may also be the result of overhydration.

(D) A low serum potassium potentiates the effects of digitalis, predisposing the client to
dangerous arrhythmias. It must be corrected immediately.
QUESTION 486
A male client received a heart-lung transplant 1 month ago at a local transplant center. While
visiting the nursing center to have his blood pressure taken, he complains of recent weakness
and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it
is expensive and is causing his face to become round. He fears he will catch viruses and be
more susceptible to infections. The nurse responds to this last statement by explaining that
cyclosporine:
A. Is given to prevent rejection and makes him less susceptible to infection than other oral
corticosteroids
B. Is available at discount pharmacies for a reduced price
C. Is usually not necessary after the first year following transplantation
D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually
resolve themselves
Answer: A
Explanation:
(A) Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression
but does not lower the white blood cell count; therefore, the client is less susceptible to
infection.
(B) Cyclosporine is available at discount pharmacies. The cost may be absorbed by health
insurance, or Medicare, if the client is eligible. However, this statement does not address the
entire problem verbalized by the client.
(C) Immunosuppressive agents will be taken for the client's entire life because rejection can
occur at any time.
(D) These side effects do not necessarily resolve in time; however, the client may adapt.
QUESTION 487
A 23-year-old college student seeks medical attention at the college infirmary for complaints
of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the
hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is
prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, "Can't

you just get the doctor to give me a transfusion and let me go. This weekend begins spring
break, and I have plans to go to Florida." At this time the nurse's greatest concern is that:
A. The client may contract an infection as a result of being exposed to large crowds at spring
break
B. The client does not grasp the full impact of her illness
C. The client may require transfusion before leaving for spring break
D. The causative agent be identified and treatment begun
Answer: B
Explanation:
(A) The client could contract an infection, but at this point it is not the most pertinent issue.
(B) The client's statement indicates that she does not grasp the full impact of her illness.
Further client education must be given, along with allowing her to express her feelings
regarding her illness.
(C) The client may require a transfusion, but this is a temporary measure because the
causative agent has not been identified. Her feelings regarding her illness must be addressed
in order for care to continue.
(D) A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
QUESTION 488
A 68-year-old man was recently diagnosed with end stage renal disease. He has not yet begun
dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion
and chest pain. Which statement best describes the management of anemia in renal failure?
A. Hematocrit levels usually remain slightly below normal in clients with renal failure.
B. Transfusion is often begun as early as possible to prevent complications of anemia such as
dyspnea and angina.
C. Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected
by oral iron and ferritin replacement therapy.
D. The renal secretion of erythropoiesis is decreased. The bone marrow requires
erythropoietin to mature red blood cells.
Answer: D
Explanation:
(A) Clients in renal failure typically have very low hematocrits, often in the range of 1622%.

(B) Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest
pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone
marrow adjusts by producing less red blood cells.
(C) Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron
and ferritin may aggravate the anemia and require treatment.
(D) Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The
bone marrow requires this hormone to mature red blood cells. Treatment is with replacement
therapy.
QUESTION 489
A female client has married recently. A month ago she visited her physician with complaints
of burning on urination. She was given a prescription for trimethoprim sulfamethoxazole
(Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday
evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis
revealed 31 bacteria along with red and white blood cells in the urine. A preliminary
diagnosis of pyelonephritis was made. During a nursing admission assessment, which
statement by the client demonstrates a possible cause for pyelonephritis?
A. "I have not been drinking six to eight glasses of water each day as the nurse had
instructed."
B. "I'm afraid I may have something wrong with my bladder because I have been getting
bladder infections frequently since I've been married."
C. "I took the Bactrim for 6 or 7 days. The burning stopped, so I saved the rest of the
medication for the next time."
D. "I recently had the flu, which could be settling in my kidneys now."
Answer: C
Explanation:
(A) Although it is important that the client drink adequate fluids while treating a bladder
infection with trimethoprim sulfamethoxazole, the failure to do so will not cause
pyelonephritis.
(B) A stricture or abnormality may cause the progression of bladder infection to urinary tract
infection, but this is rare. There is no indication in this situation that this has occurred.
(C) The most common cause of pyelonephritis is improper treatment of bladder infections.
The client typically feels better after several days, discontinues the medication, and saves the

remainder for the next occurrence of a bladder infection. For this reason, it is imperative to
provide client education related to completion of the prescribed medication.
(D) There is no evidence that infection in another body system could cause pyelonephritis.
QUESTION 490
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The
progression of the disease has been aggressive. He is unable to maintain his personal hygiene
without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely
on assistance for mobility. He recently has become severely dysphasic. Nursing interventions
for dysphasia would be aimed toward prevention of:
A. Loss of ability to speak and communicate effectively
B. Aspiration and weight loss
C. Secondary infection resulting from poor oral hygiene
D. Drooling
Answer: B
Explanation:
(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty
communicating, alternative measures can be developed to enhance communication. This goal,
while important, is of a lesser priority.
(B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability
to eat, causing weight loss.
(C) A secondary infection could result from poor oral hygiene, which could enhance the
client's inability to eat, but this goal is of a lesser priority.
(D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require
suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
QUESTION 491
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of
cerebrovascular accident (CVA). She is semi-comatose, responding to pain and change in
position. She is unable to speak or cough. In planning her nursing care for the first 24 hours
following a CVA, which nursing diagnosis should receive the highest priority?
A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level
of consciousness

B. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood
flow
C. Potential for injury related to impaired mobility and seizures
D. Impaired verbal communication related to aphasia
Answer: A
Explanation:
(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest.
(B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal
is secondary to maintenance of an effective airway.
(C) While prevention of injury is important, it is secondary to maintaining an effective airway
and cerebral tissue perfusion.
(D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is
the lowest priority of the nursing diagnoses listed.
QUESTION 492
A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of
gradually increasing muscle weakness over the past several days. She has noticed an
increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment,
which finding would indicate a need for immediate further evaluation?
A. Complaints of a headache
B. Loss of superficial and deep tendon reflexes
C. Complaints of shortness of breath
D. Facial paralysis
Answer: C
Explanation:
(A) Headaches are not associated with Guillain-Barré syndrome.
(B) Loss of superficial and deep tendon reflexes is expected with this diagnosis.
(C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients
have some detectable respiratory weakness and should be prepared for a possible
tracheostomy. Pneumonia is also a common complication of this syndrome.
(D) Facial paralysis is expected and is not considered abnormal.
QUESTION 493

A 19-year-old male client arrived via ambulance to the emergency room following a
motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment,
the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an
obvious eye injury is:
A. Reclining to control bleeding
B. Any position in which the client is comfortable
C. Side-lying, either left or right
D. Sitting with head support
Answer: D
Explanation:
(A) A reclining position can cause a penetrating object to advance further into the eye.
(B) Prevention of further injury is the priority, not comfort.
(C) A side-lying position may increase intraocular and intracranial pressure if an
accompanying head injury is suspected.
(D) A sitting position with the head supported will prevent further injury while allowing
injury care to take place.
QUESTION 494
A female client has been hospitalized for several months following major abdominal surgery
for a ruptured colon. A colostomy was created, and the large abdominal wound was left open
and allowed to heal through granulation. She is receiving gentamicin IV for treatment of
wound infection. Knowing this drug is ototoxic, the nurse would implement which of the
following measures?
A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
B. Advise the client to discontinue the drug at the first sign of dizziness.
C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic
drug or other cause.
D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent
hearing loss.
Answer: A
Explanation:
(A) The first nursing measure is to instruct the client in which drug side effects to report.
(B) Discontinuing the drug is not an independent nursing intervention and may compromise
client care.

(C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause.
(D) Equalizing middle ear pressure will not prevent hearing loss.
QUESTION 495
A male client has experienced low back pain for several years. He is the primary support of
his wife and six children. Although he would qualify for disability, he plans to continue his
employment as long as possible. His back pain has increased recently, and he is unable to
control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take
narcotics and remain alert enough to concentrate at work. His physician has suggested
application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the
following is an appropriate rationale for using a TENS unit for relief of pain?
A. TENS units have an ultrasonic effect that relaxes muscles, decreases joint stiffness, and
increases range of motion.
B. TENS units produce endogenous opioids that affect the central nervous system with
analgesic potency comparable to morphine.
C. TENS units work on the gate-control theory of pain; bio stimulation therapy of large fibers
block painful stimuli.
D. TENS units prevent muscle spasms, decrease the potential for further injury, and minimize
pressure on joints.
Answer: C
Explanation:
(A) TENS units do not have this effect, but whirlpool therapy does.
(B) TENS units do not produce endogenous opioids, only the body can do that.
(C) TENS units do work based on the gate control theory of pain control.
(D) TENS units do not have this effect, but possibly changing the client's position would.
QUESTION 496
A male client had a right below-the-knee amputation 4 days ago. His incision is healing well.
He has gotten out of bed several times and sat at the side of the bed. Each time after returning
to bed, he has experienced pain as if it were located in his right foot. Which nursing measure
indicates the nurse has a thorough understanding of phantom pain and its management?
A. Phantom pain is entirely in the client's mind. The client should be instructed that the pain
is psychological and should not be treated.

B. The basis for phantom pain may occur because the nerves still carry pain sensation to the
brain even though the limb has been amputated. The pain is real, intense, and should be
treated.
C. The cause of phantom pain is unknown. The nurse should provide the client with support,
promote sleep, and handle the injured limb smoothly and gently.
D. Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will
decrease when postoperative edema decreases. It should be treated with nonnarcotic
medication whenever possible.
Answer: B
Explanation:
(A) This statement is entirely false.
(B) Phantom pain may be caused by nerves continuing to carry sensation to the brain even
though the limb is removed. It is real, intense, and should be treated as ordinary pain would.
(C) Although the cause of phantom pain is still unknown, these measures may promote the
relief of any type of pain, not just phantom pain.
(D) Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by
decreasing edema.
QUESTION 497
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is
taken to the postanaesthetic care unit for several hours. In preparing for the client's return to
her room, which nursing measure best demonstrates the nurse's thorough understanding of
possible post thyroidectomy complications?
A. Dressings are placed at the bedside for dressing changes, which are to be done every 2
hours to best detect postoperative bleeding.
B. Narcotics are readily available and administered when the client returns to her room to
prevent excruciating pain.
C. A tracheostomy set, O2, and suction are available at the bedside.
D. The nurse should instruct the client as soon as possible on alternative means of
communication.
Answer: C
Explanation:

(A) Dressing changes are done as necessary for bleeding. However, frequently, postthyroidectomy bleeding may not be visible on the dressing, but blood may drain down the
back of the neck by gravity.
(B) Narcotics are administered for acute pain as necessary. They are not necessarily given on
return of the client to her room.
(C) The most serious post thyroidectomy complication is ineffective airway and breathing
pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction
should be available at bedside for at least the first 24 hours postoperatively.
(D) Impaired verbal communication may occur due to laryngeal edema or nerve damage, but
most commonly, it occurs due to endotracheal intubation. The client is usually able to
communicate but is hoarse.
QUESTION 498
A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several
years. He is experiencing symptoms such as numbness of the lips, muscle weakness,
carpopedal spasms, and wheezing. Given the client's symptoms, nursing assessment would
focus on:
A. Detection of tetany
B. Detection of hypocalcemia to prevent seizures
C. Evidence of depression
D. Detection of premature cataract formation
Answer: A
Explanation:
(A) Assessment should focus on detection of tetany, which is the most common symptom of
hypoparathyroidism. Left undetected and untreated, tetany resulting from hypocalcemia can
progress to seizures.
(B) Hypocalcemia is difficult to detect on nursing assessment alone. Abdominal cramping
may be an indication of hypocalcemia, but laboratory data are required to confirm diagnosis.
(C) Depression can be a symptom of hypoparathyroidism, but it is not definitive.
(D) Premature cataract formation can occur, but it also is not specific to parathyroidism and
poses no immediate danger to the client.
QUESTION 499

A male client has been an insulin-dependent diabetic for approximately 30 years. He
frequently indulges in high sugar foods and forgets to take his insulin. He has not experienced
acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of
diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite
pastimes. He decides to question his wife's home health nurse about diabetic peripheral
neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen.
The client answers the nurse, "It has been my experience that the diabetic diet is very difficult
to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's
actions and response best demonstrate:
A. Depression
B. Anger
C. Denial
D. Bargaining
Answer: C
Explanation:
(A) Depression may be an underlying feature, but it is not evident from limited data presented
here.
(B) Anger is not exhibited in his response.
(C) Denial is evident in the client's actions; through the years, he has had a casual approach to
his illness. He only becomes concerned when bodily changes affect his present lifestyle,
when in fact he should have been concerned all along. His verbal response also reflects
denial.
(D) There is no evidence of bargaining in the client's actions or verbal response.
QUESTION 500
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a
total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On
conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle
changes with the client. In order to prevent pernicious anemia, the nurse stresses that the
client must:
A. Receive monthly blood transfusions
B. Increase the amount of iron in her diet
C. Eat small quantities several times daily until she is able to tolerate food in moderate
portions

D. Understand the need for Vitamin B12 replacement therapy
Answer: D
Explanation:
(A) Monthly blood transfusions are not indicated post gastrectomy.
(B) Increasing iron in the client's diet may cause irritation and will not alleviate pernicious
anemia.
(C) It may be necessary that the client eat small meals several times per day, but this measure
has no relevance to prevention of pernicious anemia.
(D) Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be
necessary because the client's stomach has been removed.
QUESTION 501
A female client was employed as a client care technician in a hemodialysis unit. She recently
began to experience extreme fatigue, being able to sleep for 1620 hours at a time. She also
noted that her urine was tea colored, which she rationalized was a result of the vitamins she
began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital
stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are
necessary to prevent transmission to the client's family. The nurse explains necessary
precautions, which include:
A. Isolation of the client from the remainder of the family
B. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a
chloride solution
C. No necessary precautions because she is beyond the contagious phase
D. Laundering clothes separately in cold water with a chloride solution
Answer: B
Explanation:
(A) Isolation is not necessary, even in the acute phase.
(B) Separate bathroom facilities are recommended. If unavailable, daily cleansing with a
chloride solution is recommended.
(C) Precautions continue to be necessary while the client is in the active phase of hepatitis.
(D) Clothes are to be laundered separately in hot water with a chloride solution.
QUESTION 502

A male client is admitted to the medical-surgical unit from the emergency room with a
diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is
NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal
pain. Based on an analysis of these data, which nursing diagnosis would receive the highest
priority?
A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic
tract
B. Fluid volume deficit related to vomiting and nasogastric tube drainage
C. Knowledge deficit related to treatment regimen
D. Altered nutrition: less than body requirements, related to inadequate intake associated with
current anorexia, nausea, vomiting, and digestive enzyme loss
Answer: A
Explanation:
(A) Relief of pain is the primary goal of nursing intervention because this client is
experiencing acute pain.
(B) Fluid volume deficit is being treated with IV fluid replacement.
(C) Knowledge deficit will not be addressed at this time because a client in acute pain is not
ready to learn.
(D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
QUESTION 503
A male client has burns over 90% of his body after an automobile accident resulting in a fire.
He was trapped inside the auto and pulled out by a bystander. After several months in the
hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization
the nursing staff has been aware of psychological changes the client faces after burns over a
large portion of his body resulting in disfigurement. The nursing staff can best foster the
client's self-esteem by:
A. Adhering to a strict schedule of diet, exercise, and wound care
B. Allowing him to go to physical therapy for whirlpool treatment when other clients were
not in physical therapy
C. Following a standardized plan of care for burn clients formulated by a world-renowned
burn center
D. Allowing him to plan, assist in, and perform his own care whenever possible
Answer: D

Explanation:
(A) A regimented schedule, allowing no flexibility, will not foster the client's self-esteem.
(B) Isolating the client may only enhance his feelings of social isolation due to his
disfigurement.
(C) Standardized care plans must be personalized and adapted to each client's situation.
(D) Allowing the client control over his care will foster his self-esteem and prepare him for
life outside of the hospital.
QUESTION 504
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells
the nurse that she is pregnant and wants to start prenatal care. After collecting some initial
assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The
nurse estimates the fetal gestational age to be approximately:
A. 10 weeks
B. 16 weeks
C. 20 weeks
D. 30 weeks
Answer: C
Explanation:
(A) At 10 weeks, the fundus is located slightly above the symphysis pubis.
(B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus.
(C) At 20 weeks, the fundus is located approximately at the umbilicus.
(D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
QUESTION 505
A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result
which turns out to be positive. Her last menstrual period began December 10, 1993. Using
Nägele's rule, the nurse estimates her date of delivery to be:
A. September 17, 1994
B. September 10, 1994
C. September 3, 1994
D. August 17, 1994
Answer: A
Explanation:

(A) According to Nägele's rule, the estimated date of delivery is calculated by adding 7 days
to the date of the first day of the normal menstrual period (December 10 + 7 days =
December 17), and then by counting back 3 months (December 17 -3 mo = September 17).
(B, C, D) These answers are incorrect.
QUESTION 506
A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood
tests reveal that you do not show immunity to the German measles." Which notation will the
nurse include in her plan of care for the client? "Will need . . .
A. Rh-immune globulin at the next visit"
B. Rh-immune globulin within 3 days of delivery"
C. Rubella vaccine at the next visit"
D. Rubella vaccine after delivery on the day of discharge"
Answer: D
Explanation:
(A) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune
response.
(B) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune
response.
(C) The rubella vaccine is not given during pregnancy because of its teratogenicity.
(D) Nonimmune mothers are vaccinated early in the postpartum period to prevent future
infection with the rubella virus.
QUESTION 507
A female client at 37 weeks' gestation has just undergone a nonstress test. The results were
two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm
lasting 15 seconds within a 20-minute period. Her results would be classified as:
A. Reactive; needs follow-up contraction stress test
B. Reactive; no contraction stress test required
C. Non-reactive; needs follow-up contraction stress test
D. Non-reactive; no contraction stress test required
Answer: B
Explanation:
(A) A contraction stress test is unnecessary following a reactive (normal) nonstress test.

(B) The results are considered reactive, indicating that the fetus is not showing distress.
Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is
unnecessary.
(C) A nonreactive test would show fewer than two fetal movements or a failure of the FHR to
increase at least 15 bpm with the movements in a 20-minute period.
(D) A contraction stress test should follow a nonreactive nonstress test to validate fetal
distress.
QUESTION 508
A female client at 36 weeks' gestation has been treated successfully for premature labor for 4
weeks. She has begun having uterine contractions today and has been admitted to the labor
and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2
and positive phosphatidylglycerol (PG). These lab values indicate:
A. Placental maturity
B. Suspected chronic asphyxia
C. Cord compression
D. Fetal lung maturity
Answer: D
Explanation:
(A) Placental maturity is assessed by a biophysical profile.
(B) L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia.
A biophysical profile score of6 may indicate this condition.
(C) Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol.
Variable decelerations observed through electronic fetal monitoring could reflect umbilical
cord compression.
(D) An L/S ratio>2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal
lung maturity.
QUESTION 509
A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician
has ordered a RhoGAM injection. Which statement by the client demonstrates that more
teaching is needed related to this therapy?
A. "I'm getting this shot so that my baby won't develop antibodies against my blood, right?"
B. "I understand that if my baby is Rh positive I'll be getting another one of these injections."

C. "This shot should help to protect me in future pregnancies if this baby is Rh positive, like
my husband."
D. "This shot will prevent me from becoming sensitized to Rh-positive blood."
Answer: A
Explanation:
(A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response
to fetal Rh-positive antigens.
(B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent
maternal sensitization.
(C) Prevention of maternal sensitization will protect future pregnancies because the mother's
blood will be free of antibodies against her fetus.
(D) RhoGAM prevents maternal sensitization to Rh-positive blood.
QUESTION 510
At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure
should be included in her plan of care to help alleviate it?
A. Restrict fluid intake.
B. Use Alka-Seltzer as necessary.
C. Eat small, frequent bland meals.
D. Lie down after eating.
Answer: C
Explanation:
(A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents,
thereby decreasing irritation.
(B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should
be avoided.
(C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux.
(D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.
QUESTION 511
A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the
laboring woman during transition are:
A. Frustration, vague in communication
B. Seriousness, some difficulty following directions

C. Calmness, follows directions easily
D. Excitement, openness to instructions
Answer: A
Explanation:
(A) During the transition phase, the mother may become frustrated and unclear in her
communication owing to severe pain and fear of loss of control.
(B) These behaviors are common in the active phase of labor.
(C) These behavioral clues are seen in the latent phase of labor.
(D) These characteristics are observed in the latent phase of labor.
QUESTION 512
The FHR pattern in a laboring client begins to show early decelerations. The nurse would
best respond by:
A. Notifying the physician
B. Changing the client to the left lateral position
C. Continuing to monitor the FHR closely
D. Administering O2 at 8 L/min via face mask
Answer: C
Explanation:
(A) Early decelerations are reassuring and do not warrant notification of the physician.
(B) Because early decelerations is a reassuring pattern, it would not be necessary to change
the client's position.
(C) Early decelerations warrant the continuation of close FHR monitoring to distinguish them
from more ominous signs.
(D) O2 is not warranted in this situation, but it is warranted in situations involving variable
and/or late decelerations.
QUESTION 513
A female client is admitted to the emergency department complaining of severe right-sided
abdominal pain and vaginal spotting. She states that her last menstrual period was about 2
months ago. A positive pregnancy test result and ultrasonography confirm an ectopic
pregnancy. The nurse could best explain to the client that her condition is caused by:
A. Abnormal development of the embryo
B. A distended or ruptured fallopian tube

C. A congenital abnormality of the tube
D. A malfunctioning of the placenta
Answer: B
Explanation:
(A) The embryo itself may develop normally in the first several weeks of an ectopic
pregnancy.
(B) An ectopic pregnancy in the fallopian tube causes severe pain owing to the size of the
growing embryo within the narrow lumen of the tube, causing distention and finally rupture
within the first 12 weeks of pregnancy.
(C) The Fallopian tube may either be normal or contain adhesions caused by a history of
pelvic inflammatory disease or tubal surgeries, neither of which are congenital causes.
(D) An ectopic pregnancy does not involve a dysfunctional placenta, but the implantation of
the blastocyst outside the uterus.
QUESTION 514
A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding
and mild cramps. On examination, her physician determines that her cervix is closed. The
client is exhibiting signs of:
A. An inevitable abortion
B. A threatened abortion
C. An incomplete abortion
D. A missed abortion
Answer: B
Explanation:
(A) An inevitable abortion includes the signs of cervical dilation and effacement as well as
pain and bleeding.
(B) A threatened abortion is a condition in which intrauterine bleeding occurs early in
pregnancy, the cervix remains undilated, and the uterine contents are not necessarily expelled.
(C) An incomplete abortion occurs when some portions of the products of conception are
expelled from the uterus.
(D) A missed abortion occurs when the embryo dies in utero and is retained in the uterus.
QUESTION 515

A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has
prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is
receiving this drug to:
A. Treat fetal respiratory distress syndrome
B. Prevent uterine infection
C. Promote fetal lung maturation
D. Increase uteroplacental circulation
Answer: C
Explanation:
(A) Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated
postnatally with surfactant therapy.
(B) Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not
prevent uterine infection.
(C) Betamethasone binds with glucocorticoid receptors in alveolar cells to increase
production of surfactant, thus increasing lung maturity in the preterm fetus.
(D) Betamethasone does not affect uteroplacental circulatory exchange.
QUESTION 516
A female client at 30 weeks' gestation is brought into the emergency department after falling
down a flight of stairs. On examination, the physician notes a rigid, board like abdomen; FHR
in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric
emergency must be anticipated?
A. Abruptio placentae
B. Ectopic pregnancy
C. Massive uterine rupture
D. Placenta previa
Answer: A
Explanation:
(A) Abruptio placentae, the complete or partial separation of the placenta from the uterine
wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid
increase in uterine size with rigidity.
(B) Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity.

(C) Massive uterine rupture occurs during labor when the uterine contents are extruded
through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and
trauma from instruments or an obstetrical intervention.
(D) Placenta previa is the condition in which the placenta is implanted in the lower uterine
segment and either completely or partially covers the cervical os.
QUESTION 517
A 4 days postpartum client who is gravida 3, para 3, is examined by the home health nurse
during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge
with a serosanguineous consistency. The nurse would most accurately chart the client's lochia
as:
A. Rubra
B. Rosa
C. Serosa
D. Alba
Answer: C
Explanation:
(A) Lochia rubra is bloody with clots and occurs 13 days postpartum.
(B) There is no such term as lochia rosa.
(C) Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs
49 days postpartum.
(D) Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
QUESTION 518
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be
boggy.
The nurse's first action should be to:
A. Call the physician
B. Assess her vital signs
C. Give the prescribed oxytocic drug
D. Massage her fundus
Answer: D
Explanation:

(A) The nurse should first implement independent and dependent measures to achieve uterine
tone before calling the physician.
(B) Assessment of vital signs will not help to restore uterine atony, which is the priority need.
(C) Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone
with massage.
(D) Fundal massage generally restores uterine tone within a few moments and should be
attempted first.
QUESTION 519
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine
(Parlodel) to suppress lactation. Which of the following instructions about bromocriptine
should be given by the nurse?
A. Bromocriptine stimulates the production of prolactin.
B. Hypertension is a primary side effect.
C. Bromocriptine is generally taken for 5 days.
D. Her blood pressure must be stable before starting bromocriptine.
Answer: D
Explanation:
(A) Bromocriptine inhibits the secretion of prolactin.
(B) Hypotension is a side effect of this drug; hypertension is not.
(C) Bromocriptine is generally taken for 14 days.
(D) The administration of bromocriptine is delayed at least 4 hours postpartum and given
only when the client's blood pressure is stable, because it can cause hypotension and syncope.
QUESTION 520
The postpartum nurse should include which of the following instructions to breast-feeding
mothers?
A. Limit feeding times for several days to avoid nipple soreness.
B. Wash the nipples with soap and water before and after each feeding.
C. Daily caloric intake should be increased by 500 cal.
D. Breast milk is totally digestible by the baby because it contains lactose.
Answer: C
Explanation:

(A) Limiting initial feeding times will only delay nipple soreness as well as the establishment
of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules.
(B) Soap should be avoided because it may be excessively drying, predisposing nipples to
cracking.
(C) For optimal milk production, an additional 500 kcal over maintenance levels are needed
daily.
(D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible
by infants.
QUESTION 521
At 12 hours postvaginal delivery, a female client is without complications. Which of the
following assessment findings would warrant further nursing interventions?
A. Apical pulse of 52 bpm
B. Uterine fundus palpable left of midline
C. No bowel movement since delivery
D. Oral temperature of 100.4F
Answer: B
Explanation:
(A) Bradycardia of 5070 bpm may be considered normal postpartally because the heart
compensates for the decreased resistance in the pelvis.
(B) The uterus is displaced from the midline by a full bladder. This condition could lead to a
boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be
kept empty.
(C) Re-establishment of normal bowel function is delayed into the first postpartum week.
(D) A postpartum woman's oral temperature may go as high as 100.4_F within 24 hours of
delivery resulting from muscular exertion, dehydration, and hormonal changes.
QUESTION 522
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at
nine weeks' gestation. An appropriate response by the nurse would be:
A. "It must be God's will and probably is for the best."
B. "This must be a difficult time for you. Would you like to talk about it?"
C. "I'm sure your other children will be a comfort for you."
D. "Don't worry, you're still young. If I were you I'd just try again."

Answer: B
Explanation:
(A) This response is nontherapeutic because it belittles the client's response and gives a
meaningless rationalization.
(B) This response acknowledges the client's feelings and demonstrates the therapeutic
offering of self by the nurse.
(C) This response is nontherapeutic because it does not focus on the client's feelings and
offers false reassurance.
(D) This response is nontherapeutic because it belittles the client's feelings and offers her
advice.
QUESTION 523
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the
nurse about its purpose, the nurse explains that phototherapy:
A. Prevents the development of ophthalmia neonatorum
B. Assists the baby's clotting mechanism
C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
Answer: C
Explanation:
(A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents
ophthalmia neonatorum.
(B) The administration of vitamin K
(AquaMEPHYTON) assists the infant's clotting mechanism.
(C) Excessive bilirubin accumulates when the infant's liver cannot handle the increased load
caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of
the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of
bilirubin from the skin by breaking it down into substances that can be excreted in stool or
urine.
(D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
QUESTION 524

After instructing a female client on circumcision care, the nursery nurse asks her to restate
some of the key points covered. Which statement shows that the client will properly care for
her son's circumcision?
A. "I'll make sure I soak the gauze with warm water first, before I take it off each time."
B. "I'll make sure that I report any drainage around where they operated."
C. "I'll apply alcohol to the area daily to clean it and prevent any infection."
D. "I'll keep a close watch on it for a day or two."
Answer: A
Explanation:
(A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent
trauma to adherent tissues.
(B) A yellow exudate often forms normally over the surgical site. Only if it becomes foulsmelling and purulent would it need to be reported.
(C) Alcohol should never be used on the site; this would be extremely painful to the infant.
(D) Special care and observance should continue until the site is completely covered with
clean, pink granulation tissue, which could take 710 days.
QUESTION 525
A male infant is to be discharged home this morning. Which instruction related to his cord
care should be included in his mother's discharge teaching plan?
A. Keep the umbilical area moist with Vaseline until the stump falls off.
B. Keep the umbilical area covered at all times with the diaper.
C. Clean the umbilical cord with alcohol at each diaper change.
D. Clean the umbilical cord daily with soap and water during the bath.
Answer: C
Explanation:
(A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to
bacterial growth and therefore could lead to infection at the site.
(B) The diaper should be folded below the cord to allow the cord stump to be exposed to the
air for healing.
(C) The umbilical cord should be swabbed with alcohol at each diaper change to remove
urine and stool and to facilitate the desiccation process through drying.
(D) Soap and water should not be used to clean the umbilical area because the area could
retain moisture, thus making it susceptible to bacterial growth and infection.

QUESTION 526
Which behavior by a female client feeding her newborn demonstrates that she needs more
teaching related to safety and infant feeding?
A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
B. She places her infant on her right side after feeding her.
C. She props the bottle in the crib to feed her baby, which allows her to write birth
announcements and feed her baby at the same time.
D. She burps her baby by placing her in a sitting position, supporting her head and neck and
gently massaging her back.
Answer: C
Explanation:
(A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of
regurgitation.
(B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated
milk.
(C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration.
(D) This practice is one correct way of burping an infant.
QUESTION 527
Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this
screening test is performed:
A. Immediately after birth, because the most accurate result is obtained at this time
B. After 23 days of milk ingestion
C. At 23 days of age regardless of amount of milk feedings
D. At 1 month, because the biochemical buildup of phenylalanine takes 1 month to detect
Answer: B
Explanation:
(A) The infant has not ingested any protein immediately after birth, which is necessary to
detect excessive serum phenylalanine.
(B) It is important that the infant take in 23 full days of milk or formula feedings to preclude
a false-negative reading.
(C) At 23 days of age, inadequate milk could have been ingested owing to a delay in the
initial feeding.

(D) The biochemical buildup of serum phenylalanine is detectable after 23 days of milk or
formula ingestion.
QUESTION 528
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea,
vomiting, and sore throat for the past several days. In caring for a young child with symptoms
of influenza, the mother must be cautioned about:
A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
B. Giving clear liquids too soon
C. Allowing the child to come in contact with other children for 3 days
D. The possibility of pneumonia as a complication
Answer: A
Explanation:
(A) Aspirin should never be given to children with influenza because of the possibility of
causing Reye's syndrome. Pepto- Bismol is also classified as a salicylate and should be
avoided.
(B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear
liquids.
(C) The disease has a 13 day incubation period and affected children are most infectious 24
hours before and after the onset of symptoms.
(D) Although viral pneumonia can be a complication of influenza, this would not be an initial
priority.
QUESTION 529
A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client's
responses would indicate compliance during initial therapy?
A. Drinking large amounts of milk
B. Not bearing weight on affected extremity
C. Walking short distances 3 times/day
D. Putting self on weight reduction diet
Answer: B
Explanation:
(A) This condition causes aseptic necrosis of the head of the femur in the acetabulum.
Drinking large quantities of milk at this time cannot hasten recovery.

(B) The aim of treatment is to keep the head of the femur in the acetabulum. No weightbearing is essential. Activity causes microfractures of the epiphysis.
(C) In addition to no weight-bearing, clients are often placed on bedrest, which helps to
reduce inflammation. Later, active motion is encouraged.
(D) Weight is not generally an issue with this disease. Slipped femoral capital epiphysis,
which is most frequently observed in obese pubescent children, usually requires a weight
reduction diet.
QUESTION 530
A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily
aspirin. Which statement made by the parent indicates a need for further teaching?
A. "My daughter takes her aspirin with her meals."
B. "Her gums have been bleeding frequently. Maybe she is brushing too hard."
C. "I give her aspirin on a regular schedule every day."
D. "One sign of aspirin toxicity can be ringing in the ears."
Answer: B
Explanation:
(A) Aspirin should not be given on an empty stomach because it is irritating to the mucosa.
(B) Bleeding from decreased clotting capacity may be caused by aspirin toxicity.
(C) A regular schedule of aspirin administration is important to maintain a satisfactory drug
level in the body.
(D) Aspirin toxicity may affect cranial nerve VIII, leading to tinnitus (ringing in the ears).
QUESTION 531
A young child has been placed in a spica cast. The chief concern of the nurse during the first
few hours is:
A. Prevention of neurovascular complications
B. Prevention of loss of muscle tone
C. Immobilization of the affected limb
D. Using heated fans to dry the cast
Answer: A
Explanation:

(A) Because the extremity may continue to swell and the cast could constrict circulation, the
nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and
circulation.
(B) Although muscle tone may diminish over time in the affected limb, this is not the
immediate concern.
(C) The limb has been immobilized already by the cast, and therefore immobilization is not a
concern.
(D) Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the
area beneath the cast remains wet and could cause burns.
QUESTION 532
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral
griseofulvin. The nurse should emphasize which of these instructions to the mother and/or
child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
Answer: D
Explanation:
(A) Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the
drug with a fatty meal (ice cream or milk) increases absorption rate.
(B) Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of
food intake is important, and inadequate nutrient intake should be reported to the physician.
(C) The child may experience symptomatic relief after 4896 hours of therapy. It is important
to stress continuing the drug therapy to prevent relapse (usually about 6 weeks).
(D) The incidence of side effects is low; however, headaches are common. Nausea, vomiting,
diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the
physician.
QUESTION 533
A 12-year-old girl has been diagnosed with insulin dependent diabetes mellitus. Which of
these principles would best guide her nutritional management?
A. Concentrated sweets are taken during increased activity.

B. Food restriction is imposed to reduce weight.
C. Caloric distribution should be calculated to fit activity patterns.
D. Fat requirements are increased owing to the possibility of ketoacidosis.
Answer: C
Explanation:
(A) Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be
taken at the time of increased activity.
(B) Food restriction is not used for diabetic control of growing children. Caloric restriction
may be imposed for weight control if necessary.
(C) Total caloric intake and proportions of basic nutrients should be consistent from day to
day. Distribution of these calories should fit the activity pattern. Extra food is needed for
increased activity. A balance of food, exercise, and insulin should be maintained.
(D) Because of the increased risk of atherosclerosis, the fat percentage of the total caloric
intake is reduced.
QUESTION 534
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing
measures should be included in the postoperative care?
A. Encourage the child to cough up blood if present.
B. Give warm clear liquids when fully alert.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
Answer: D
Explanation:
(A) The nurse should discourage the child from coughing, clearing the throat, or putting
objects in his mouth. These may induce bleeding.
(B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a
blood clot. The nurse should avoid red- or brown- colored liquids to distinguish fresh or old
blood from ingested liquid should the child vomit.
(C) Gargles and vigorous toothbrushing could initiate bleeding.
(D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for
bleeding by looking directly into the throat and for vomiting of bright red blood, continuous
swallowing, and changes in vital signs.

QUESTION 535
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the
following statements indicates the nurse's knowledge of the anatomy of the respiratory
system in pediatric clients?
A. The diameter of the trachea is much smaller in children than in adults.
B. The tongue is proportionally smaller in children than in adults.
C. The pediatric airway is more rigid than that of the adults.
D. The length of the pediatric airway is longer in children than in adults.
Answer: A
Explanation:
(A) The airway in children is much smaller than it is in adults. The diameter of the trachea in
the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the
airway can make a major difference in the pediatric client.
(B) The tongue is proportionally larger in children and fills most of the oral cavity, thereby
decreasing air space.
(C) The entire pediatric airway is elastic. Elasticity diminishes with age, however.
(D) The distances between respiratory structures are shorter than that of adults, and therefore
organisms are able to move more rapidly down the throat, leading to more extensive
respiratory involvement.
QUESTION 536
A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The
clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema.
Which dietary plan is most appropriate for this client?
A. Low-protein diet
B. Low-sodium diet
C. Increased fluid intake
D. High-cholesterol diet
Answer: B
Explanation:
(A) A high-protein diet is usually indicated because protein is excreted in urine. Protein
restriction is usually prescribed with severe azotemia.
(B) The kidneys usually enlarge in these children, and sodium and water are retained.

(C) Fluid restriction may be ordered to help reduce edema; however, monitoring for
dehydration is indicated.
(D) A high-cholesterol diet would not be indicated for any child, especially one with elevated
blood pressure.
QUESTION 537
A 6-year-old girl has been diagnosed with a urinary tract infection secondary to vesicoureteral
reflux. Which statement by her mother indicates a need for further teaching?
A. "I have taught her to wipe from front to back after urinating."
B. "I make sure she drinks plenty of fluids every day."
C. "She enjoys wearing nylon panties, but I make her change them every day."
D. "She tries to empty her bladder completely after she urinates, like I told her."
Answer: C
Explanation:
(A) Wiping from front to back is wiping from an area of lesser contamination (urethra) to an
area of greater contamination (rectum).
(B) Generous fluid intake reduces the concentration of urine.
(C) Cotton is a natural, absorbent fabric. Nylon often predisposes the client to urinary tract
infections. Dark, warm, moist areas are excellent media for bacterial growth.
(D) With vesicoureteral reflux, urine refluxes into the ureter(s) during voiding and then
returns to the bladder (residual), which becomes a source for future infection.
QUESTION 538
A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen
asleep in his mother's arms when the nurse approaches. Which approach is most appropriate
at this time?
A. Give the injection in the vastus lateralis site before the child awakens.
B. Awaken the child first and give the injection in the ventrogluteal site.
C. Awaken the child first and give the injection in the dorsogluteal site.
D. Ask the mother to place the child on the examination table and leave the room, and then
give the injection in an appropriate site.
Answer: B
Explanation:

(A) If awakened first, the child will know that nothing painful will be done without the child
being alerted.
(B) The ventrogluteal site is a safe site for children because it is a large muscle free of major
nerves and blood vessels.
(C) The dorsogluteal site is not recommended in children who have not been walking for at
least 1 year because the muscle is not fully developed.
(D) The parent will be able to offer support and comfort during and after the injection.
QUESTION 539
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The
medication is diluted as recommended in 10 mL in the volume control chamber of a set that
has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
A. Infuse volume at 44 mL/hr.
B. Infuse volume at 22 mL/hr.
C. Infuse volume at 10 mL/hr.
D. Infuse volume at 30 mL/hr.
Answer: A
Explanation:
(A) The volume to be infused should be diluted medication volume added to the volume
control chamber (10 mL) plus the tubing volume (12 mL). The general formula for
calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set
Drop Factor (micro drop: 60 gtts/min) Desired Time to Infuse in Minutes Rate = (10 + 12) 22
X 60 30 = 44 mL/hr.
(B, C, D) These values are incorrect.
QUESTION 540
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge
instructions by the nurse will include maintenance fluid requirements for the pediatric client.
Which of the following values best indicates the nurse's understanding of normal fluid
requirements for this infant?
A. 240 mL/day
B. 680 mL/day
C. 330 mL/day
D. 960 mL/day

Answer: B
Explanation:
(A, C, D) These answers are incorrect.
(B) Normal fluid requirement for this pediatric client is based on the fact that 010 kg of
weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X
6.8 = 680 mL/day.
QUESTION 541
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar
puncture. In light of this procedure and developmental characteristics of this age group,
which nursing measure is most appropriate?
A. Emphasize those aspects of the procedure that require cooperation.
B. Tell the child not to cry or yell.
C. Tell the child that he will get a "stick" in his back.
D. Use medical terminology when explaining the procedure to the client.
Answer: A
Explanation:
(A) The nurse should emphasize what is required to elicit cooperation and help to develop a
sense of autonomy.
(B) The child may express discomfort verbally and should be encouraged to express his
feelings.
(C) Selecting nonthreatening words to explain a procedure will prevent misinterpretation.
(D) When explaining the procedure to the parent with the child present, the nurse should use
words that the child can understand to avoid misunderstanding.
QUESTION 542
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine
examination and screening. Which of these plans by the nurse would be most successful?
A. Examine the 4 year old first.
B. Provide time for play and becoming acquainted.
C. Have the mother leave the room with one child, and examine the other child privately.
D. Examine painful areas first to get them "over with."
Answer: B
Explanation:

(A) The 6 month old should be examined first. If several children will be examined, begin
with the most cooperative and less anxious child to provide modeling.
(B) Providing time for play and getting acquainted minimizes stress and anxiety associated
with assessment of body parts.
(C) Children generally cooperate best when their mother remains with them.
(D) Painful areas are best examined last and will permit maximum accuracy of assessment.
QUESTION 543
An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of
the following best describes the characteristic clinical manifestations of pyloric stenosis?
A. Pain, especially when eating
B. Poor appetite and sucking reflex
C. Increased frequency and quantity of stools
D. Palpable olive-shaped mass in the epigastrium just right of the umbilical cord
Answer: D
Explanation:
(A) There is no evidence of pain in infants with pyloric stenosis whether eating or not.
(B) There are both good appetite and feeding habits in these children.
(C) Because of regurgitation, there is usually decreased frequency and quantity of stools and
also signs of dehydration and weight loss.
(D) Along with upper abdominal distention, there is a characteristic palpable olive-shaped
mass located to the right of the umbilicus.
QUESTION 544
As soon as a child has been diagnosed as "hearing impaired," special education should begin.
Which of the following special education tasks is the most difficult for a severely hearingimpaired child?
A. Auditory training
B. Speech
C. Lip reading
D. Signing
Answer: B
Explanation:
(A) With the slight and mild hard of hearing, auditory training is beneficial.

(B) Speech is the most difficult task because it is learned by visual and auditory stimulation,
imitation, and reinforcement.
(C, D) Lip reading and signing are aimed at establishing communicative skills, but they are
learned more easily by visual stimulation.
QUESTION 545
A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of
the following would be included in educating the mother and child as part of discharge
planning?
A. Give oral iron medication every day.
B. Have the child's blood pressure monitored every week.
C. Know the signs and symptoms of iron overload.
D. Keep exercise at a minimum to reduce stress.
Answer: C
Explanation:
(A) Oral iron supplements are contraindicated in thalassemia.
(B) Although heart failure may be an end result of this disease, this action is unnecessary.
(C) Iron overload is a potential complication of frequent blood transfusions of children with
thalassemia.
(D) Children should be encouraged to pursue activities related to their exercise tolerance.
QUESTION 546
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic
blood studies is characteristically abnormal in this disorder?
A. Partial thromboplastin time
B. Platelet count
C. Complete blood count
D. Bleeding time
Answer: A
Explanation:
(A) Partial thromboplastic time measures activity of thromboplastin, which depends on the
intrinsic clotting factors deficient in children who are hemophiliacs.
(B) Platelet counts are normal in hemophilia.
(C) Hemophilia does not affect the complete blood count.

(D) Bleeding times are normal in hemophiliacs. They measure the time interval for the
bleeding from small superficial wounds to cease.
QUESTION 547
A murmur has been discovered during the routine physical examination of a 1-year-old child.
The parent is extremely concerned about this diagnosis. Which of the following explanations
by the nurse indicates understanding of this dysfunction?
A. The blood shifts from the right to the left atrium.
B. Surgical closure by suture or patch is recommended before school age.
C. Most atrial septal defects close spontaneously.
D. The child can be treated medically with antibiotics to prevent bacterial endocarditis.
Answer: B
Explanation:
(A) Because the left atrial pressure is greater than right atrial pressure, oxygenated blood
flows from the left to the right atria.
(B) Because of the risk of pulmonary obstructive diseases and congestive heart failure later in
life, surgery is usually performed between age 4 and 6 years, with essentially no operative
mortality or postoperative complications.
(C) Many ventricular septal defects close spontaneously (2060%) as a result of growth and
proliferation of the muscular septum or formation of a membrane across the opening.
(D) This management is usually recommended with children with mild pulmonary stenosis.
QUESTION 548
An alcoholic client who is completing the inpatient segment of a substance abuse program
was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the
discharge instructions?
A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and
elevated blood pressure.
B. Disulfiram is most effective when prescribed as late as possible in a recovery program.
C. Disulfiram works on the desensitization principle.
D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is
discontinued.
Answer: D
Explanation:

(A) When alcohol is ingested with disulfiram therapy, the client experiences nausea,
vomiting, and a potentially serious drop in blood pressure.
(B) Disulfiram is most successful when used early in the recovery process while the
individual makes major lifestyle changes necessary for long-term recovery.
(C) Disulfiram works on the classical conditioning principle.
(D) The effects of disulfiram can be felt when alcohol is ingested 12 weeks after disulfiram is
discontinued.
QUESTION 549
An 82-year-old former restaurant owner walks to the nursing station and states, "I have to go.
The restaurant opens at 11 am." Which response by the nurse is the most appropriate?
A. "Go back to your room. You do not own a restaurant."
B. "You are in the hospital now. Calm down."
C. "You once owned a restaurant. Tell me about it."
D. "It is snowing outside. The restaurant is closed."
Answer: C
Explanation:
(A) This response cuts off communication with the client. It does not address her feelings.
(B) Reality orientation frequently does not work alone. Feelings must be addressed. Telling a
client to calm down is frequently ineffective.
(C) Reminiscence is used here to reorient and recall past pleasant events. Talking about the
restaurant will allay anxiety.
(D) This response may confirm to the client that she indeed does still own a restaurant,
buying into her confusion. Her feelings and anxiety require nursing intervention.
QUESTION 550
A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the
unit and was found smoking in the bathroom and spending a large amount of time in the male
ward. Which statement by the nurse would best explain to the teenager why she must follow
the rules of the unit?
A. "It is not easy, but the rules must be followed so that everyone can get a fair chance."
B. "If you do not follow the rules, you will be transferred to the closed, locked unit."
C. "You are not being fair to the other clients by getting them involved in your deviant
behavior."

D. "Break the rules, all you want, but don't get caught again!"
Answer: A
Explanation:
(A) This statement acknowledges that it is difficult but is not threatening or punitive.
(B) This statement is threatening and describes specific punishment for further deviant
behavior.
(C) This response elicits shame by blaming her for involving others.
(D) This response gives her permission to break the rules but indicates that getting caught is
wrong.
QUESTION 551
A 45-year-old male client experiences a sense of depression because he has not yet achieved
his life's goals. His career has not been satisfying. He is still looking for the right job. His
wife spends too much money, and his children seem to ignore him while being very selfish.
He is tired of all of their attitudes and is considering buying a red Corvette convertible. While
obtaining these data concerning the client's feelings about his life, the nurse is able to
determine he is experiencing what psychological crisis according to Erikson's stages?
A. Identity versus role confusion
B. Integrity versus despair
C. Intimacy versus isolation
D. Generativity versus self-absorption
Answer: D
Explanation:
(A) Identity versus role confusion is experienced by adolescents making the transition from
childhood to adulthood as they attempt to develop a sense of identity.
(B) Integrity versus despair is experienced by the elderly as they reflect on their life in an
attempt to find meaning.
(C) Intimacy versus isolation is experienced by young adults as they establish intimate bonds
of love and friendship.
(D) Generativity versus self-absorption is experienced by middle-aged adults as they fulfill
life goals that involve family, career, and society. The client is experiencing this crisis.
QUESTION 552

A female client is anticipating a visit with her parents over the Thanksgiving holidays. She
has recently begun experiencing periods of extreme shortness of breath, which her physician
has labeled as panic attacks. Which of the following statements by the nurse would enhance
therapeutic communication?
A. "Why do you feel this way?"
B. "Tell me about your dislike for your parents."
C. "Don't worry, everything will be all right on your visit with your parents."
D. "Perhaps you and I can discover what produces your anxiety."
Answer: D
Explanation:
(A) Asking the client to provide an explanation for her feelings is often intimidating.
(B) This response is probing and may make the client feel used and valued only for the
information she can provide.
(C) This underrates the client's feelings and belittles her concerns. It may cause the client to
stop sharing feelings for fear that they will be ridiculed.
(D) The emphasis is on working with the client. It shows that there is hope for change
through collaboration.
QUESTION 553
A female client has experienced varying degrees of depression throughout her life. Now that
she is postmenopausal, her depression has increased. She is unable to motivate herself to
clean her house or even to get out of bed and get dressed in the morning. The client was
begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the
nurse caution her about?
A. A daily dose of fluoxetine may be taken in the morning or evening.
B. Fluoxetine is not sedating; therefore, restrictions on driving and other hazardous activities
are not necessary.
C. Rashes or pruritus usually occur early in the therapy and are treatable without
discontinuing the medication.
D. It is safe to take over-the-counter or other prescription medications with fluoxetine.
Answer: C
Explanation:
(A) A daily dose of fluoxetine should be taken in the morning. Afternoon doses may cause
nervousness and insomnia.

(B) Although fluoxetine is less sedating than other antidepressants, it may still cause
dizziness or drowsiness in some clients. The nurse should caution clients to avoid driving or
hazardous activities until the central nervous system effects of the drug are demonstrated.
(C) Rashes or pruritus do commonly occur early in therapy and respond to antihistamines or
topical corticosteroids.
(D) Advise the client not to take over-the-counter or other prescription drugs without
consulting with the physician. Fluoxetine does interact with other common drugs such as
monoamine oxidase inhibitors, diazepam, insulin, oral antidiabetic agents, tricyclic
antidepressants, and tryptophan.
QUESTION 554
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most
of their marriage, he has physically and verbally abused her. When asked about his behavior
in the process of the nursing assessment, the client states, "I was mean to my wife because
she insists on cooking meals and wearing clothes that I do not like." This defense mechanism
is an example of:
A. Repression
B. Regression
C. Reaction formation
D. Rationalization
Answer: D
Explanation:
(A) Repression is blocking a desire from conscious expression. The client is conscious of his
desires.
(B) Regression is returning to an earlier form of expression, which is not demonstrated here.
(C) Reaction formation is acting out the opposite of true feelings. The client felt anger
concerning his wife's cooking and acted out his feelings.
(D) Rationalization is unconsciously falsifying an experience by giving a "rational"
explanation. The client is attempting to justify his behavior by giving an explanation.
QUESTION 555
A male client is admitted to the psychiatric unit after experiencing severe depression. He
states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other

staff members. Which response demonstrates understanding and appropriate action on the
part of the nurse?
A. "I understand you're depressed, but killing yourself is not a reasonable option."
B. "We need to discuss this further, but right now let's complete these forms."
C. "Don't do that, you have so much to live for. You have a wonderful wife and children. The
client in the next room has no one."
D. "This is very serious. I do not want any harm to come to you. I will have to report this to
the rest of the staff."
Answer: D
Explanation:
(A) To the client, suicide may be a reasonable action and the only one he can cope with at this
time.
(B) This response indicates to the client that his intention to commit suicide is not important
to the nurse at this time.
(C) The client is so depressed that he is not able to see the positive aspects of his life. At no
time should the nurse discuss another client's problems in conversation.
(D) This statement tells the client that the nurse recognizes his problem is of a serious nature
and will take all steps necessary to help him.
QUESTION 556
During the admitting mental health assessment, a client demonstrates involuntary muscular
activity. He has a marked facial tic around the mouth that is distracting to the nurse during the
interview. The nurse recognizes the behavior and documents it as:
A. Dyskinesia
B. Akathisia
C. Echopraxia
D. Echolalia
Answer: A
Explanation:
(A) The client is demonstrating dyskinesia, which is involuntary muscular activity, such as
tic, spasm, or myoclonus.
(B) Akathisia is regular rhythmic movements usually of the lower limbs, such as constant
motor restlessness.
(C) Echopraxia is mimicking the movements of another person.

(D) Echolalia is mimicking the speech of another person.
QUESTION 557
A female client is seeking counseling for personal problems. She admits to being very
unhappy lately at both home and work. During the nursing assessment, she uses many
defense mechanisms. Which statement or action made by the client is an example of adaptive
suppression?
A. "I did not get the raise because my boss does not like me."
B. "I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's
wedding."
C. "My son died 3 years ago. I still cannot bring myself to clean out his room."
D. "My husband told me this morning that he wants a divorce. I am upset, but I cannot
discuss the matter with him until after my company's board meeting today."
Answer: D
Explanation:
(A) This statement is an example of adaptive rationalization. She is coping with her
disappointment by rationalizing. This is adaptive because no harm is done to self or others. It
is used to protect her ego.
(B) This is an example of maladaptive suppression. She is suppressing the seriousness of the
lump. It is maladaptive because delaying treatment will cause harm to her.
(C) The client's actions are an example of maladaptive denial. She is denying her son's death
by not facing his possessions. Until she faces his death, she cannot face reality.
(D) This is an example of adaptive suppression. She realizes the impact of her husband's
statement but delays discussion until she can devote her full attention to the matter.
QUESTION 558
When interviewing parents who are suspected of child abuse, the nurse would use which of
the following interview techniques?
A. Be direct, honest, and attentive.
B. Approach them in the emergency room as soon as you suspect abuse to "clear the air" right
away.
C. Ask the parents what they could have done differently to prevent this from happening to
the child.
D. After the interview, call child protective services.

Answer: A
Explanation:
(A) The nurse must be honest, direct, professional, and attentive in her interview to gain the
parent's trust.
(B) The nurse should approach the parents in private, away from the child.
(C) Asking them to relive and evaluate the situation may be looked at as placing blame on the
parents for the child's "accident." At this point, the parents may get defensive and stop
communicating.
(D) Although you may call child protective services, the nurse should inform the parents of
their responsibility to do this and explain the process to them.
QUESTION 559
In an interview for suspected child abuse, the child's mother openly discusses her feelings.
She feels her husband is too aggressive in disciplining their child. The child's father states,
"Being a school custodian, I see kids every day that are bad because they did not get enough
discipline at home. That will not happen to our child." Based on this remark, the nurse would
make the following nursing diagnosis:
A. Fear related to retaliation by the father
B. Actual injury related to poor impulse control by the father
C. Ineffective coping
D. Altered family process related to physical abuse
Answer: D
Explanation:
(A) There is no evidence of fear as the child is unable to communicate.
(B) There is actual injury, but the parents have not yet admitted causing the child's injuries.
(C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified
in this nursing diagnosis.
(D) Altered family process best describes the family dynamics in this situation. The parents
have admitted severe disciplinary action.
QUESTION 560
A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in
her senior year of high school after becoming pregnant. Shortly after the baby was born, he
began to physically abuse her. She has attempted to leave him several times, but she has

always returned. She is unable to support herself financially, and her husband threatens to kill
her if she leaves him. This time, her husband has beaten her so badly she cannot stop the
bleeding from the gash above her eye. She admits her husband caused her injury. In assessing
a person after experiencing spousal abuse, which need has the highest priority?
A. Assess the level of anxiety, coping responses, and support systems.
B. Assess the history of physical abuse.
C. Assess suicide potential.
D. Assess drug and alcohol use.
Answer: C
Explanation:
(A) Assessing the level of anxiety, coping responses, and support systems is very important,
but not of highest priority at this time.
(B) A history of physical abuse is an important part of assessment. The nurses must also
always ask if there is abuse of the children.
(C) Although all of these answers are very important in assessment, the highest priority is
assessment of suicide potential, because this could cause the greatest harm to the client.
Feeling there is no other way out, abused spouses may consider suicide.
(D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful
situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should
encourage the spouse to seek counseling and not to return to the home.
QUESTION 561
As a nurse in the emergency room, you receive an outside call from an elderly woman who
states she has just been raped. She states, "I know I must come to the hospital, but what do I
do next?" You advise her to call the police, then come to the hospital emergency room. What
action by the nurse would indicate an understanding of the examination process once the
victim enters the emergency room?
A. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink
anything.
B. Inform the victim to bring insurance information with her to the hospital so she can be
properly cared for.
C. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
D. Do not leave the victim alone to collect her thoughts.
Answer: A

Explanation:
(A) Providing the victim with these instructions will aid in the determination of physical
evidence of rape. Victims frequently feel "dirty" after rape, and their first instinct is to take
care of personal hygiene before facing anyone.
(B) This action is of lesser importance at this time.
(C) Although this is a nursing measure appropriate in this situation, contacting a counselor
can be done once the victim enters the hospital. Frequently victims call but do not follow up
with the visit.
(D) Once the victim enters the emergency room, it is important not to leave her alone.
QUESTION 562
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive
disorder. She is obsessed with her appearance. She will not leave her room until her hair,
clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed
disgust over her appearance after she gained 5 lb. After observing a marked weight loss over
a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on
her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail
all of the events leading to her bulimia, but not her feelings. What defense mechanism is she
using?
A. Dissociation
B. Intellectualization
C. Rationalization
D. Displacement
Answer: B
Explanation:
(A) Dissociation is separating a group of mental processes from consciousness or identity,
such as multiple personalities. That is not evident in this situation.
(B) Intellectualization is excessive use of reasoning, logic, or words usually without
experiencing associated feelings. This is the defense mechanism that this client is using.
(C) Rationalization is giving a socially acceptable reason for behavior rather than the actual
reason. She is discussing events, not reasons.
(D) Displacement is a shift of emotion associated with an anxiety-producing person, object,
or situation to a less threatening object.

QUESTION 563
A male client is experiencing extreme distress. He begins to pace up and down the corridor.
What nursing intervention is appropriate when communicating with the pacing client?
A. Ask him to sit down. Speak slowly and use short, simple sentences.
B. Help him to recognize his anxiety.
C. Walk with him as he paces.
D. Increase the level of his supervision.
Answer: C
Explanation:
(A) The nurse should not ask him to sit down. Pacing is the activity he has chosen to deal
with his anxiety. The nurse dealing with this client should speak slowly and with short,
simple sentences.
(B) The client may already recognize the anxiety and is attempting to deal with it.
(C) Walk with the client as he paces. This gives support while he uses anxiety-generated
energy.
(D) Increasing the level of supervision may be appropriate after he stops pacing. It would
minimize self-injury and/ or loss of control.
QUESTION 564
A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety
when he is in darkness. It has altered his lifestyle because he is unable to go to a movie
theater, concert, and other events that may require absence of light. The client is seeking
assistance because he is no longer able to socialize with friends due to his phobia. The
psychologist working with him is using desensitization. He has asked the nursing staff to
assist the client in muscle relaxation techniques. What result would indicate client education
has been successful?
A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the
theater darkens.
B. He enters a concert, but as the lights dim, he does not experience anxiety.
C. He states that he no longer fears dark places.
D. He takes a part-time job as a photographic assistant. His job necessitates his working in a
darkroom.
Answer: A
Explanation:

(A) This situation provides specific evidence that the client is able to integrate muscle
relaxation technique into his lifestyle to alleviate anxiety.
(B) The client may not experience anxiety at the concert, but there is no evidence regarding
the technique that he used to alleviate anxiety.
(C) The client may state he no longer experiences anxiety, but there is no evidence
demonstrating this. He may be denying anxiety to discontinue therapy prematurely.
(D) Does he experience anxiety in the darkroom? He may have taken this job to force himself
to deal with the phobia directly.
QUESTION 565
A female client has just died. Her family is requesting that all nursing staff leave the room.
The family's religious leader has arrived and is ready to conduct a ceremony for the deceased
in the room, requesting that only family members be present. The nurse assigned to the client
should perform the appropriate nursing action, which might include:
A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in
client rooms.
B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it
can be brought to the morgue.
C. Tell the family that they may conduct their ceremony in the client's room; however, the
nurse must attend.
D. Respect the client's family's wishes.
Answer: D
Explanation:
(A) It is rare that a hospital has a specific policy addressing this particular issue. If the
statement is true, the nurse should show evidence of the policy to the family and suggest
alternatives, such as the hospital chapel.
(B) Refusal to leave the room demonstrates a lack of understanding related to the family's
need to grieve in their own manner.
(C) The nurse should leave the room and allow the family privacy in their grief.
(D) The family's wish to conduct a religious ceremony in the client's room is part of the grief
process. The request is based on specific cultural and religious differences dictating social
customs.
QUESTION 566

A female client has been recently diagnosed as bipolar. She has taken lithium for the past
several weeks to control mania. What must be included in client education regarding lithium
toxicity?
A. Maintain a normal diet; however, limit salt intake to no more than 3 g/day.
B. Take lithium between meals to increase absorption.
C. Withhold lithium if experiencing diarrhea, vomiting, or diaphoresis.
D. For pain or fever, avoid aspirin or acetaminophen (Tylenol). Nonsteroidal antiinflammatory drugs are preferred.
Answer: C
Explanation:
(A) The client should maintain a normal diet including normal salt intake. A low-sodium diet
can cause lithium retention, leading to toxicity.
(B) Lithium must be taken with meals because it is irritating to the gastric mucosa.
(C) Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium
blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium.
(D) Lithium is not to be taken with over-the-counter drugs without specific instruction. Some
drugs raise lithium levels, whereas others lower lithium levels.
QUESTION 567
For the past several months, an elderly female client with Alzheimer's disease has
experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is
utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that
the client demonstrates involuntary movements of the tongue and fingers. This may most
likely indicate:
A. Tardive dyskinesia, which may be a side effect of antipsychotic medication
B. Early symptoms of Parkinson's disease
C. A more advanced stage of Alzheimer's disease than previously experienced by the client
D. The need to change her medication from haloperidol to another antipsychotic drug to
lessen symptoms
Answer: A
Explanation:
(A) Tardive dyskinesia is a common side effect of antipsychotic medications such as
haloperidol. Discontinuing the medication can alleviate symptoms.

(B) Although mild tremors are an early sign of Parkinson's disease, haloperidol must be
discontinued first and the client further evaluated.
(C) These symptoms do not necessarily indicate a more advanced stage of Alzheimer's
disease.
(D) Most antipsychotic drugs are chemically similar and will produce the same side effects.
QUESTION 568
A 32-year-old male client is a marketing representative. His job requires him to have a
tremendous amount of energy during the day. He frequently uses cocaine to sustain his
energy level. Lately he has increased his use of cocaine and even experimented with crack
cocaine. Realizing he can no longer continue this destructive behavior, he is seeking
treatment for cocaine addiction. In planning nursing care for the client's inpatient stay, which
expected outcome is most appropriate?
A. He will attend four consecutive group educational sessions on substance abuse.
B. He will name activities that he would most likely be involved in posttreatment.
C. He will meet with his family in counseling sessions and discuss his feelings.
D. He will be able to deal with his feelings through participation in group therapy sessions.
Answer: D
Explanation:
(A) This expected outcome is specific as related to attendance, but not specific as related to
outcome criteria.
(B) Stating activities does not guarantee involvement.
(C) This goal may help the recovery process, but post counseling behavior is not addressed.
(D) This statement best describes the expected outcome. The client will be attending group
therapy sessions and through them he will deal with his feelings.
QUESTION 569
A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her
instructions knows the client understands the information when she tells her:
A. "I should contact my physician if I have headaches after I take this medicine."
B. "I should keep the tablets in the refrigerator."
C. "I should call the doctor if three doses of the medicine do not relieve my pain."
D. "I should take these with water but not with milk."
Answer: C

Explanation:
(A) Headaches may occur after taking nitroglycerin because of vasodilation.
(B) The tablets do not need to be refrigerated. The client should carry them with her.
(C) The client should contact the physician if repeated doses of nitroglycerin do not relieve
the discomfort.
(D) Nitroglycerin tablets should be dissolved under the tongue, not swallowed.
QUESTION 570
A client has renal failure. Today's lab values indicate he has an elevated serum potassium.
What additional priority information does the nurse need to obtain?
A. Evaluation of his level of consciousness
B. Evaluation of an electrocardiogram
C. Measurement of his urine output for the past 8 hours
D. Serum potassium lab values for the last several days
Answer: B
Explanation:
(A) The level of consciousness is not affected by elevated potassium levels.
(B) An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any
cardiac dysfunction or arrhythmias related to the elevated potassium level.
(C) Measurement of the urine output is not a priority nursing action at this time.
(D) The client's serum potassium values for the past several days may provide information
about his renal function, but they are not a priority at this time.
QUESTION 571
A client's wife is concerned over his behavior in recent months. He has been diagnosed with
Parkinson's disease, and she is telling his nurse that he has been doing "strange things." The
nurse reassures the wife that the following behavior is normal with Parkinson's disease:
A. "Your husband will experience some periods of muscle flaccidity. Be sure to make him sit
down during these periods."
B. "Your husband may move his hands in motions that look like he is rolling a pill between
his fingers."
C. "Twitching of the muscles is to be expected and can occur at any time during the day."
D. "Parkinson's disease causes severe pain in the joints. You should give your husband
Tylenol at those times."

Answer: B
Explanation:
(A) Clients with Parkinson's disease generally experience stiffness and rigid movement.
(B) Pill- rolling movements are a symptom experienced by the Parkinson client.
(C) Twitching of the muscles is not an expected symptom of Parkinson's disease.
(D) Parkinson's disease does not cause joint pain. Mild muscular pain may be present.
QUESTION 572
A male client tells his nurse that he has had an ulcer in the past and is afraid it is "flaring up
again." The nurse begins to ask him specific questions about his symptoms. The nurse knows
that a symptom that might indicate a serious complication of an ulcer is:
A. Pain in the middle of the night
B. A bowel movement every 35 days
C. Melena
D. Episodes of nausea and vomiting
Answer: C
Explanation:
(A) Clients with ulcers generally experience abdominal pain. It is common to have pain in the
early morning hours with an ulcer.
(B) Constipation is not a symptom associated with ulcers and would indicate a need to look at
other factors.
(C) Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could
result in significant amounts of blood loss over time.
(D) Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric
ulcer. This does not indicate an immediate life-threatening complication.
QUESTION 573
A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her
daughter is very concerned about increasing her nutrition. The nurse helps the daughter
devise a plan of care for her mother. The plan of care should include which of the following
interventions to promote nutrition?
A. Offer her oral hygiene before and after meals.
B. Encourage her to consume milk products.
C. Encourage her to engage in an activity before a meal to stimulate her appetite.

D. Restrict her fluid intake to three glasses of water a day.
Answer: A
Explanation:
(A) Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity
may improve the client's appetite, increase her feelings of well-being, and remove the taste
and odor of sputum.
(B) Milk causes thick sputum; therefore, milk products would not be beneficial for this client.
(C) Exercise prior to a meal would require increased O2 consumption and most likely would
decrease the client's ability to eat.
(D) Clients with respiratory diseases need increased fluid to liquefy secretions.
QUESTION 574
A female client is concerned that she is in a "high-risk" group for the development of
acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of
donating blood. Which of the following responses is correct?
A. "Individuals who donate blood are at risk of getting the AIDS virus. You should not
donate."
B. "It's OK for you to donate because the blood bank has a test that is 100% effective."
C. "You should not donate since it takes time to develop antibodies to the AIDS virus. If you
donate blood before you develop the antibody, you could pass it on in the blood."
D. "It is not a good idea for you to donate. If you have AIDS, the information is made public
and could destroy your personal life."
Answer: C
Explanation:
(A) The AIDS virus cannot be transmitted to the donor through the blood donation procedure.
(B) The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a
person with known risk factors to donate blood.
(C) It takes time for antibodies to the AIDS virus to develop. An infected individual could
donate contaminated blood without it testing positive for the virus.
(D) For reasons of confidentiality, information about individuals infected with AIDS is not
made public.
QUESTION 575

A 50-year-old male client is to receive chemotherapy. The physician's orders include
antiemetics. When planning his care, the nurse should take into consideration that antiemetics
are best administered in the following way:
A. Give antiemetics when nausea is experienced and continue on a regular schedule for 1224
hours.
B. Give antiemetics prior to the client receiving chemotherapy and continue on a regular
basis for at least2448 hours after chemotherapy.
C. Give antiemetics one at a time because combinations of antiemetics cause overwhelming
side effects.
D. Give antiemetics intermittently during the entire course of chemotherapy.
Answer: B
Explanation:
(A) Nausea is more difficult to control if antiemetics are withheld until nausea is experienced.
(B) Antiemetics should be given prophylactically at the beginning of chemotherapy and
continued on an around-the-clock basis to prevent nausea.
(C) Combinations of antiemetics give the best control for nausea by blocking various causes
of nausea induced by chemotherapy.
(D) Antiemetics should be given around the clock during the course of chemotherapy. This
prevents nausea from developing and prevents anticipatory nausea during subsequent
chemotherapy administrations.
QUESTION 576
A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following
symptoms should especially concern the nurse when caring for her?
A. Respiratory rate of 16 breaths/min
B. Pulse rate of 80 bpm
C. Complaints of muscle aches
D. A sore throat
Answer: D
Explanation:
(A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm.
(B) A pulse rate of 80 bpm is normal and is not a cause for alarm.
(C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be
other causes related to her hospital stay or the disease process.

(D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at
risk of neutropenia. An infection in the presence of neutropenia can result in a life-threatening
situation.
QUESTION 577
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well
otherwise. Which of the following long-term objectives would be unrealistic?
A. She should be able to control evacuation of her bowels.
B. She should be able to return to a regular diet.
C. She should be able to resume sexual activity.
D. She should be able to manage her own care.
Answer: A
Explanation:
(A) Because of the location of an ileostomy, the client will not be able to control the
evacuation of her bowels. The ileostomy will drain liquid stool continuously.
(B) The client should be able to return to a normal, well-balanced diet. She should avoid
foods that cause diarrhea or excessive gas production, and she should eat small meals.
(C) The client should be able to resume sexual activity. She will be able to wear a pouch.
(D) The client has no other health or mental problems and should be able to manage her own
ileostomy.
QUESTION 578
A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24
hours postoperatively, the nurse would be concerned if the client:
A. Cries easily and says she is having abdominal pain
B. Develops a temperature of 102_F
C. Has no bowel sounds
D. Has a urine output of 200 mL for 4 hours
Answer: B
Explanation:
(A) The client may be more tearful than normal due to the stress of the surgery and its
implications for her future life. She would be expected to have pain following surgery.
(B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to
surgery and indicates a need for further assessment.

(C) The client is expected to have no bowel sounds for 2448 hours after surgery because of
the trauma to the bowel.
(D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater
than normal.
QUESTION 579
A 44-year-old female client is receiving external radiation to her scapula for metastasis of
breast cancer. Teaching related to skin care for the client would include which of the
following?
A. Teach her to completely clean the skin to remove all ointments and markings after each
treatment.
B. Teach her to cover broken skin in the treated area with a medicated ointment.
C. Encourage her to wear a tight-fitting vest to support her scapula.
D. Encourage her to avoid direct sunlight on the area being treated.
Answer: D
Explanation:
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should
be left intact, and the skin should not be scrubbed.
(B) Clients should avoid putting any creams or lotions on the treated area. This could
interfere with treatment.
(C) Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating
fabrics.
(D) The area of skin being treated is sensitive to sunlight, and the client should take care to
prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.
QUESTION 580
A male client is being treated in the burn unit for third-degree burns on his head, neck, and
upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid
resuscitation. Which of the following indicates effective fluid balance?
A. His weight increases from 165 to 175 lb.
B. His urine output is equal to his total fluid intake.
C. His urine output has been>35 mL/hr for the past 12 hours.
D. His blood pressure is 94/62.
Answer: C

Explanation:
(A) A weight gain of 10 lb represents a state of overhydration.
(B) He is losing fluids through insensible losses; a urine output equal to his intake indicates
that he is receiving too little fluids.
(C) A urine output greater than his intake indicates that he is receiving adequate fluid
resuscitation to account for urinary and insensible losses.
(D) A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory
volume.
QUESTION 581
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse
discusses his disease with him and emphasizes the following information:
A. He should monitor his sputum, stools, and urine for signs of bleeding.
B. His daily diet should include a large amount of fluid.
C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.
D. He should not worry about having children because this disease is passed on only by
female carriers.
Answer: B
Explanation:
(A) Bleeding is not a symptom of sickle cell anemia or sickle cell crisis.
(B) Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake
maintains adequate circulating blood volume and decreases the chance of sickling.
(C) Hypoxia leads to sickling of cells. Flying in no pressurized planes places the client in a
situation of low O2 tension, which can lead to sickling.
(D) Male and female clients with sickle cell disease can pass the trait on to their offspring.
Therefore, this client should receive genetic counseling prior to having children.
QUESTION 582
A female client has been diagnosed with chronic renal failure. She is a candidate for either
peritoneal dialysis or hemodialysis and must make a choice between the two. Which
information should the nurse give her to help her decide?
A. Hemodialysis involves less time to filter the blood; but the client must consider travel
time, distance, and inconvenience.
B. Hemodialysis involves more time to filter the blood than does peritoneal dialysis.

C. Peritoneal dialysis has almost no complications and is less time consuming than
hemodialysis. Therefore it is preferred.
D. Peritoneal dialysis requires that a home health nurse prepare and administer the
treatments.
Answer: A
Explanation:
(A) Hemodialysis is faster in clearing the blood of toxins than peritoneal dialysis. However,
clients must consider the time that they spend traveling to the dialysis center and the
disruption in their daily lives.
(B) Peritoneal dialysis requires several exchanges with dwelling time for the dialysate and
therefore takes longer than hemodialysis.
(C) Several serious complications of peritoneal dialysis include peritonitis, catheter
displacement and/or plugging, or pain during dialysis.
(D) A client can be taught to self-administer peritoneal dialysis without the aid of a
professional.
QUESTION 583
A female client decides on hemodialysis. She has an internal vascular access device placed.
To ensure patency of the device, the nurse must:
A. Assess the site for leakage of blood or fluids
B. Auscultate the site for a bruit
C. Assess the site for bruising or hematoma
D. Inspect the site for color, warmth, and sensation
Answer: B
Explanation:
(A) This is an internal device. Assessment of the site should include assessing for swelling,
pain, warmth, and discoloration. This measure does not assess patency.
(B) The presence of a bruit indicates good blood flow through the device.
(C) The nurse should inspect the site for bruising or hematoma; however, this measure does
not assure patency of the device.
(D) The nurse should inspect the vascular access site frequently for signs of infection.
However, this does not assure patency.
QUESTION 584

A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior
to instilling it because:
A. Warmed solution helps keep the body temperature maintained within a normal range
during instillation
B. Warmed solution helps dilate the peritoneal blood vessels
C. Warmed solution decreases the risk of peritoneal infection
D. Warmed solution promotes a relaxed abdominal muscle
Answer: B
Explanation:
(A) Instilling a cool solution does not significantly lower the body temperature during
peritoneal dialysis.
(B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange
of fluids.
(C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique
decreases this risk.
(D) Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
QUESTION 585
A female client is exhibiting signs of respiratory distress. Which of the following signs
indicate a possible pneumothorax?
A. Crackles or rales on the affected side
B. Bradypnea and bradycardia
C. Shortness of breath and sharp pain on the affected side
D. Increased breath sounds on the affected side
Answer: C
Explanation:
(A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with
increased fluid or secretions and would not be present with air in the space.
(B) With a pneumothorax, the client would experience tachypnea and tachycardia to
compensate for the decrease in oxygenation.
(C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side
with movement or coughing, asymmetrical chest expansion, and diminished or absent breath
sounds on the affected side.

(D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates
air in the pleural space).
QUESTION 586
A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space
when she is ambulating. The first action the nurse should take is to:
A. Instruct the client to cough deeply to re-expand her lung
B. Put on sterile gloves and replace the tube
C. Apply a petrolatum dressing over the site
D. Auscultate the lung to determine if she needs the tube replaced
Answer: C
Explanation:
(A) This action is inappropriate. Coughing will not re-expand the lung and could result in
further harm.
(B) This action is a medical procedure, not a nursing procedure.
(C) An occlusive dressing will prevent further air leak until the physician institutes further
treatment.
(D) The decision to reinsert the tube is a medical decision, not a nursing one.
QUESTION 587
A male client has heart failure. He has been instructed to gradually increase his activities.
Which signs and symptoms of worsening heart failure should the nurse tell him to watch for
that would indicate a need for him to lower his activity level?
A. Pain in his legs when he walks
B. Thirst, weight loss, and polyuria
C. Drowsiness and lethargy after his activities
D. Weight gain, edema in his lower extremities, and shortness of breath
Answer: D
Explanation:
(A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening
heart failure. The client should be cautioned to increase his activities slowly.
(B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client
should report these symptoms to his physician.

(C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should
report these symptoms to his physician.
(D) All of these symptoms indicate a worsening cardiac condition possibly associated with
too much activity. The client's activity level should be evaluated.
QUESTION 588
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor.
The nurse knows she has included the appropriate information in her teaching when the client
tells her:
A. "He should remove the electrodes for bathing."
B. "Damage to his heart muscle will be recorded by the monitor."
C. "He is to keep a record of everything he does during the day."
D. "He is to refrain from activities that cause chest pain."
Answer: C
Explanation:
(A) The client should leave the electrodes in place during the entire time the test is ordered.
He should not even remove the electrodes for bathing.
(B) The Holter monitor will record cardiac electrical activity but will not record damage to
his myocardium.
(C) The client should keep a record of all of his activities so the physician can correlate the
ECG findings with his activities.
(D) The client should continue doing his regular activities. The purpose of the Holter monitor
is to record heart activity during routine activities.
QUESTION 589
To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should
include:
A. Dangle the client's legs over the edge of the bed every shift.
B. Massage the client's calves briskly every shift.
C. Keep the client's legs extended and discourage any movement.
D. Have the client tighten and relax leg muscles several times daily.
Answer: D
Explanation:

(A) Dangling the client's legs over the edge of the bed will contribute to stasis and pooling of
blood and increases the risk of thrombus formation.
(B) Massaging the client's calves could result in dislodging an embolus.
(C) Decreased movement will contribute to pooling of blood and increased risk of venous
thrombosis.
(D) Tightening and relaxing leg muscles increases circulation and decreases the risk of
venous thrombosis.
QUESTION 590
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of
the following is contraindicated?
A. Encourage exercises in the unaffected extremities.
B. Encourage her to cross and uncross her legs.
C. Check neurological and circulatory status of the affected leg hourly.
D. Place a trochanter roll along the upper thigh of the affected leg.
Answer: B
Explanation:
(A) Exercising the unaffected extremities will prevent contractures and emboli.
(B) Crossing and uncrossing the affected leg after surgery can dislocate the joint.
(C) Neurological and circulatory status of the affected leg has been compromised by surgery.
Hourly checks are needed to monitor the status of the leg.
(D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the
chances of dislocation.
QUESTION 591
A male client has a history of diverticulosis. He has questions about the foods that he should
eat.
His nurse gives him the following information:
A. He should be on a high-fiber diet.
B. He should eat a low-residue diet.
C. He should drink minimal amounts of fluids.
D. He does not need to make any modifications.
Answer: A
Explanation:

(A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with
bran or bulk laxatives.
(B) Low residue diets lead to constipation and are contraindicated in clients with
diverticulosis.
(C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent
constipation.
(D) Clients with diverticulosis should modify their diet to include high-fiber foods and bulk
laxatives.
QUESTION 592
A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother
has asked to breastfeed her following delivery. Immediately after birth, the neonate was most
susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote
bonding is to:
A. Place her under the radiant warmer
B. Dry her with blankets
C. Place her to her mother's breast
D. Place her on a heated pad
Answer: C
Explanation:
(A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin
sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it
is not an intervention that promotes infant attachment.
(B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile
stimuli promote crying and lung expansion. This intervention does not promote attachment,
however.
(C) Skin-to-skin contact is an effective way to conserve heat after delivery and promotes
parental attachment following birth in the healthy term infant. The first period of reactivity
lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake
newborn characterize this period.
(D) Surfaces of objects warmer than the infant promote overheating by conduction, and
neonatal hyperthermia may result.
QUESTION 593

A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline
episiotomy at delivery. When assessing the level of her uterus immediately following
delivery, the nurse would expect the fundus to be located:
A. At the umbilicus
B. At the symphysis pubis
C. Midway between the umbilicus and the xiphoid process
D. Midway between the umbilicus and the symphysis pubis
Answer: D
Explanation:
(A) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below,
the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day.
(B) The uterus descends into the pelvic cavity at approximately 1012 postpartal days and can
no longer be palpated abdominally.
(C) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below,
the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged
uterus may indicate subinvolution or postpartal hemorrhage.
(D) Immediately following delivery, the uterus lies midline, about midway between the
umbilicus and the symphysis pubis.
QUESTION 594
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her
husband is accompanying her. The couple tells the nurse that this is the first hospital
admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at
_0 station. Based on the vaginal exam, she is in:
A. Stage 2, latent phase
B. Stage 1, active phase
C. Stage 3, transition phase
D. Stage 1, latent phase
Answer: D
Explanation:
(A) The second stage of labor is from full cervical dilation through birth of the baby. The
three phases of this stage include latency or resting, descent, and final transition. The client is
less than fully dilated so she is not in stage 2.

(B) The first stage of labor begins with regular uterine contractions and continues until the
woman is 10 cm dilated. The three phases of this stage include the early or latent phase (03
cm), the active phase (47 cm), and the transitional phase (710 cm). The client is <4 cm dilated
so she is in the latent phase of the first stage of labor.
(C) The third stage of labor is from the birth of the baby until the delivery of the placenta.
The client is less than fully dilated.
(D) The first stage of labor begins with regular uterine contractions and continues until the
woman is 10 cm dilated. The three phases of this stage include the early or latent phase (03
cm), the active phase (47 cm), and the transitional phase (710 cm). The client is 30%
necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal
and/or maternal compromise. Turning the client on her left side will promote uteroplacental
perfusion and is appropriate.
(C) Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal
hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would
be increased to expand the circulating blood volume and promote increased blood pressure.
(D) Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are
administered to increase the circulating blood volume, and O2 is administered to promote
fetal oxygenation and decrease the nausea accompanying the hypotension.
QUESTION 597
A 28-year-old client comes to the clinic for her first prenatal examination. In relating her
obstetrical history, she tells the nurse that she has been pregnant twice before. She had a
"miscarriage" with the first pregnancy after 6 weeks. With the second pregnancy, she
delivered twin girls at 31 weeks' gestation. One of the twins was stillborn and the other twin
died at 4 days of age. Using a five-digit system, the nurse records her as being:
A. 2-0-2-1-0
B. 2-2-2-1-2
C. 3-0-1-1-0
D. 2-1-1-0-0
Answer: C
Explanation:

(A) The first digit represents the total number of pregnancies. This client has been pregnant 3
times including this pregnancy. The twin pregnancy counts as only one pregnancy, and
because she delivered prior to 37 weeks' gestation, the third digit is recorded as 1.
(B) The first digit represents the total number of pregnancies. This client has been pregnant 3
times including this pregnancy. The second digit represents the total number of full-term
deliveries; she has lost two pregnancies before 37 weeks' gestation. At present, she has no
living children, so the fifth digit is noted as 0.
(C) The client is pregnant for the third time, and the first digit reflects the total number of
pregnancies. She has had no full-term deliveries, because she delivered prior to 37 gestational
weeks, so the second digit is recorded as 0. The third digit represents the number of preterm
deliveries, and a twin pregnancy counts as only one delivery. She lost an earlier pregnancy
prior to 20 gestational weeks, and the fourth digit reflects spontaneous or elective abortions.
Lastly, the fifth digit indicates the number of children currently living, and she has no living
children.
(D) She is pregnant for the third time, and the first digit reflects the total number of
pregnancies. In the previous two pregnancies, she delivered prior to 37 gestational weeks,
thus having no full-term deliveries, which is indicated by the second digit. The fourth digit
represents the total number of abortions, spontaneous or elective, and she reported a
spontaneous abortion with her first pregnancy.
QUESTION 598
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby.
The client tells the nurse that her last normal menstrual period was February 16, with 3 days
of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to
be:
A. November 23rd
B. December 26th
C. September 14th
D. December 9th
Answer: A
Explanation:
(A) Naele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract
3 months, and then add 1 year.

(B) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception
occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation
for unknown reasons but is insignificant in the calculation of Naele's rule.
(C) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception
occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation
for unknown reasons but is insignificant in the calculation of Naele's rule.
(D) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception
occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for
unknown reasons but is insignificant in the calculation of Naele's rule.
QUESTION 599
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the
nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle
feeding. The nurse should initially recommend to her to:
A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for
feeding in 20 minutes
B. Allow the infant to breast-feed at the next feeding time to empty the breasts
C. Apply ice packs to the breasts and wear a supportive, well-fitting bra
D. Take a warm shower and express milk from both breasts until empty
Answer: C
Explanation:
(A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical
suppression would be the initial recommendation.
(B) Breast-feeding every 11/23 hours will reduce and/or prevent breast engorgement. Breastfeeding will promote milk production, which will compound the distention and stasis of the
venous circulation of engorgement in a bottle-feeding mother.
(C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical
suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace
bandages may be used for some women.
(D) Warmth promotes milk production and may stimulate the let-down reflex. These
measures would contribute to the venous congestion of engorgement.
QUESTION 600

A registered nurse is trying to determine the appropriate care that she should provide for her
obstetrical clients. Which of the following documents is considered the legal standard of
practice?
A. State nursing practice act
B. AWHONN Standards for the Nursing Care of Women and Newborns
C. American Nurses' Association Standards of Maternal- Child Health Nursing
D. International Council of Nurses' Code
Answer: A
Explanation:
(A) The state nursing practice act determines the standard of care for the professional nurse.
(B) AWHONN Standards are published as recommendations and guidelines for maternalnewborn nursing.
(C) American Nurses' Association Standards are published as recommendations and
guidelines for maternal child health nursing.
(D) The International Council of Nurses' Code emphasizes the nurse's obligations to the client
rather than to the physician. It is published as recommendations and guidelines by the
international organization for professional nursing.