NCLEX RN Child Care Practice Exam Part 4 With Answers-200 Solved Questions

NCLEX-RN
Part 4
601. A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her
physical examination are normal. How does the nurse interpret the effectiveness of the instruction about
diet and weight control?
A. She is compliant with her diet as previously taught.
B. She needs further instruction and reinforcement.
C. She needs to increase her caloric intake.
D. She needs to be placed on a restrictive diet immediately.
Answer: B
Explanation:
(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during
second and third trimesters is approximately 12 lb.
(B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits
and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most
pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight
gain, PIH should also be suspected.
(C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten
pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted.
(D) Restrictive dieting is not recommended during pregnancy.
602. 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. Ureter lithotomy
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) Ureter lithotomy 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.
603. A child has a nursing diagnosis of fluid volume excess related to compromised regulatory
mechanisms. Which of the following nursing interventions is the most accurate measure to include in his
care?
A. Weigh the child twice daily on the same scale.
B. Monitor intake and output.
C. Check urine specific gravity of each voiding.
D. Observe for edema.
Answer: A
Explanation:
(A) Although all of these interventions are important aspects of care, weight is the most sensitive indicator
of fluid balance.
(B) Although monitoring intake and output is important, weight is a more accurate indicator of fluid status.
(C) Urine specific gravity does not necessarily indicate fluid volume excess.
(D) Edema may not be apparent, yet the client may have fluid volume excess.
604. A client is being discharged from the hospital today. The discharge teaching for care of her colostomy
included which of the following basic principles for protecting the skin around her stoma:
A. Taping a pouch that is leaking
B. Cutting the skin barrier 112 inches larger than the stoma
C. Changing the pouch only when leakage occurs
D. Using a skin sealant under pouch adhesives
Answer: D
Explanation:

(A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held against the
skin can quickly result in severe irritation.
(B) The skin barrier should be cut only slightly larger than the stoma (one-half inch).
(C) The client should be taught to change pouches whenever possible before leakage occurs.
(D) When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no
skin sealant is used, this layer is removed when the tape is removed.
605. 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 1-2 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.
606. The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the
nurse remember about fluoxetine?
A. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.
B. The therapeutic effect of the drug occurs 2-4 weeks after treatment is begun.
C. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug.
D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors.
Answer: B

Explanation:
(A) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant.
(B) This statement is true.
(C) These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors.
Fluoxetine is not an MAO inhibitor.
(D) Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.
607. The following medications were noted on review of the client's home medication profile. Which of
the medications would most likely potentiate or elevate serum digoxin levels?
A. KCl
B. Thyroid agents
C. Quinidine
D. Theophylline
Answer: C
Explanation:
(A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this.
(B) Thyroid agents decrease digoxin levels.
(C) Quinidine increases digoxin levels dramatically.
(D) Theophylline is not noted to have an effect on digoxin levels.
608. In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies
that the purpose of weighing the child is to:
A. Measure adequacy of nutritional management
B. Check the accuracy of the fluid intake record
C. Impress the child with the importance of eating well
D. Determine changes in the amount of edema
Answer: D
Explanation:
(A) Weighing a child with nephrosis is to assess for edema, not nutrition.
(B, C) This is not the purpose for weighing the child.
(D) Weight and measurement are the primary ways of evaluating edema and fluid shifts.

609. The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be
correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A. Nicotine withdrawal
B. A birth defect
C. Anemia
D. A low birth weight
Answer: D
Explanation:
(A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in
the fetus.
(B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus,
it has not been directly linked to fetal anomalies.
(C) Smoking during pregnancy has not been directly linked to anemia in the fetus.
(D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
610. The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment,
is that the garment:
A. Decreases hypertrophic scar formation
B. Assists with ambulation
C. Covers burn scars and decreases the psychological impact during recovery
D. Increases venous return and cardiac output by normalizing fluid status
Answer: A
Explanation:
(A) Tubular support, such as that received with a Jobst garment, applies tension of 10-20 mm Hg. This
amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear
a pressure garment for 6-12 months during the recovery phase of their care.
(B) Pressure garments have no ambulatory assistive properties.
(C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face.
(D) Pressure garments do not normalize fluid status.
611. A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse
should be alert for the signs of ischemia, which include:
A. Bleeding, bruising, and haemorrhage

B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
C. Pain, pallor, pulselessness, paresthesia, and paralysis
D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Answer: C
Explanation:
(A) Bleeding, bruising, and haemorrhage may occur due to injury but are not classic signs of ischemia.
(B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to
the disruption of muscle integrity.
(C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five
"P's": pain, pallor, pulselessness, paresthesia, and paralysis.
(D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are
common clinical manifestations of a fracture but not ischemia.
612. 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 de-compression. 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 (48-49 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 (47-48 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 (noseearxiphoid).
(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.

613. Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above
100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability:
Vigorous cry Color: Body pink, blue extremities
A. 7
B. 10
C. 8
D. 9
Answer: A
Explanation:
(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1
point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in
assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed
for color when the body is pink with blue extremities (acrocyanosis).
(B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a
good cry, active motion, and be completely pink.
(C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point
rather than the 1-point category.
(D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2
points and one area, a rating of 1 point.
614. 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 2-3 days of milk ingestion
C. At 2-3 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 2-3 full days of milk or formula feedings to preclude a falsenegative reading.
(C) At 2-3 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 2-3 days of milk or formula
ingestion.
615. A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an
overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this
time is to:
A. Assess level of consciousness
B. Assess suicide potential
C. Observe for sedation and hypotension
D. Orient to her room and unit rules
Answer: B
Explanation:
(A) The client was stabilized in the ED and consequently would not be sent to the psychiatric unit if
comatose.
(B) Suicide assessment is always appropriate for clients with a history of previous attempts or depression,
because either of these factors places the client at high risk.
(C) The admission assessment should include observation for sedation and hypotension, but this is not in
priority over suicide assessment.
(D) Orientation to room and unit rules is of low priority at this time.
616. Which stage of labor lasts from delivery of the baby to delivery of the placenta?
A. Second
B. Third
C. Fourth
D. Fifth
Answer: B
Explanation:
(A) This stage is from complete dilatation of the cervix to delivery of the fetus.
(B) This is the correct stage for the definition.
(C) This stage lasts for about 2 hours after the delivery of the placenta.
(D) There is no fifth stage of labor.

617. A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low,
intermittent suction with orders to "Irrigate NG tube with sterile saline q1h and prn." The rationale for
using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
A. Water will deplete electrolytes resulting in metabolic acidosis.
B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
D. Saline will increase peristalsis in the bowel.
Answer: A
Explanation:
(A) Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for
nasogastric irrigation.
(B) Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a
symptom of intestinal obstruction.
(C) Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness
and insomnia can be emotional complications of surgery.
(D) A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline
ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.
618. A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring.
Which of the following observations necessitates notifying the physician?
A. Contractions every 2 minutes, lasting 100 seconds
B. Fetal heart decelerations during a contraction
C. Beat-to-beat variability between contractions
D. Fetal heart decelerations at the beginning of contractions
Answer: A
Explanation:
(A) These are tetanic in nature and can cause rupture of the uterus.
(B) The FHR decreases during contractions owing to vasoconstriction and should recover after the
contraction.
(C) Beat-to-beat variability is a normal finding and demonstrates fetal wellbeing.
(D) The FHR may decrease at the beginning of a contraction owing to head compression.

619. In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate
that the client was developing MgSO4 toxicity?
A. A 31 patellar tendon reflex
B. Respirations of 12 breaths/min
C. Urine output of 40 mL/hr
D. A 21 proteinuria value
Answer: B
Explanation:
(A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO 4 toxicity. A value of
21 is considered a normal tendon reflex; 3+ is considered brisker than normal.
(B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory
rate is <16 bpm magnesium toxicity may be developing.
(C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium. Urinary output
of <100 mL in a 4-hour period may result in toxic levels of magnesium.
(D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical
syndrome for which magnesium sulfate is frequently used in medical management. Protein in the urine is
not induced by magnesium sulfate intake.
620. An infant weighing 15 lb has just been treated for severe diarrhoea in the hospital. Discharge
instructions by the nurse will include maintenance fluid requirements for the paediatric 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 paediatric client is based on the fact that 0-10 kg of weight equals
100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL × 6.8 = 680 mL/day.
621. Discharge teaching was effective if the parents of a child with atopic dermatitis could state the
importance of:

A. Showering 3-4 times a day
B. Maintaining a high-humidified environment
C. Wrapping hands in soft cotton gloves
D. Furry, soft stuffed animals for play
Answer: C
Explanation:
(A) Maintaining a low-humidified environment.
(B) Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy.
(C) Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid
bath for temporary relief.
(D) Wrapping hands in soft cotton gloves to prevent skin damage during scratching.
622. A young boy tells the nurse, "I don't like my Dad to kiss or hug my Mom. I love my Mom and want to
marry her." The nurse recognizes this stage of growth and development as:
A. Electra complex
B. Oedipus complex
C. Superego
D. Ego
Answer: B
Explanation:
(A) The Electra complex is the erotic attachment of the female child to the father.
(B) The Oedipus complex is characterized by jealousy toward the parent of the same sex and erotic
attachment to the parent of the opposite sex.
(C) The superego as described by Freud is the part of personality that is associated with internalized
parental and societal control.
(D) The ego as described by Freud is the part of personality that is associated with reality assessment.
623. 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 6-8 hours after the last
drink.
(B) This answer is correct. It takes approximately 6-8 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 6-8 hours of the last
drink.
624. The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client's
urine output pattern as:
A. Anuria
B. Oliguria
C. Dysuria
D. Polyuria
Answer: D
Explanation:
(A) Anuriais defined as absence of urine output, which is not indicative of the urinary pattern of diabetes
insipidus.
(B) Oliguriais defined as 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.
641. A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheese like
substance is under the baby's arms. The nurse should respond:
A. "This is a normal skin variation in newborns. It will go away in a few days."
B. "Let me have a closer look at it. The baby may have an infection."
C. "This material, called vernix, covered the baby before it was born. It will disappear in a few days."

D. "Babies sometimes have sebaceous glands that get plugged at birth. This substance is an example of
that condition."
Answer: C
Explanation:
(A) This response identifies the fact that vernix is a normal neonatal variation, but it does not teach the
client medical terms that may be useful in understanding other healthcare personnel.
(B) This response may raise maternal anxiety and incorrectly identifies a normal neonatal variation.
(C) This response correctly identifies this neonatal variation and helps the client to understand medical
terms as well as the characteristics of her newborn.
(D) Blocked sebaceous glands produce milia, particularly present on the nose.
642. A 13-year-old haemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the
nurse should:
A. Place on bed rest; elevate and splint the right knee
B. Apply moist heat to the right knee
C. Administer aspirin for pain
D. Encourage active range of motion to right knee
Answer: A
Explanation:
(A) Immobilization, splinting, and bed rest will reduce the bleeding. Once bleeding is reduced or stopped,
the pain will subside.
(B) Moist heat causes vasodilation and bleeding. Ice or cold compresses should be applied.
(C) Aspirin decreases platelet aggregation, which causes bleeding.
(D) Active range of motion aggravates bleeding and damages the synovial sac during bleeding episodes.
643. 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.
644. One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce
his risk of falls, the nurse would teach him to take this medication:
A. On arising and no later than 6 PM
B. At evenly spaced intervals, such as 8 AM and 8 PM
C. With at least one glass of water per pill
D. With breakfast and at bedtime
Answer: A
Explanation:
(A) This option provides adequate spacing of the medication and will limit the client's need to get up to go
to the bathroom during the night hours, when he is especially at high risk for falls.
(B) This option would result in the need to get up during the night to urinate and would thus increase the
risk of falls. This option also does not take into consideration the client's usual daily routine.
(C) Taking this medication with at least one glass of water would not have an impact on the risk of falls.
(D) This option would result in the need to get up during the night to urinate and would thus increase the
risk of falls.
645. A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a
motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred
to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops
increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as
being consistent with:
A. Pneumonia
B. Pulmonary contusions
C. Pulmonary edema
D. Tension pneumothorax
Answer: B
Explanation:

(A) Pneumonia may be reflected by patchy infiltrates. In addition, fever, an increasing white blood cell
count, and copious sputum production would be present.
(B) Blunt chest trauma causes a bruising process in which interstitial and alveolar edema and hemorrhage
occur. This is manifest by gradual deterioration over 24 hours of arterial blood gases and the continued
production of bloody sputum. Patchy infiltrates are evident on chest x-ray 24 hours postinjury.
(C) Pulmonary edema usually results from left heart failure. It is manifest by pink, frothy sputum;
increasing dyspnea; tachycardia; and crackles on auscultation.
(D) Tension pneumothorax is a potential complication for someone with rib fractures and a chest tube. It is
manifest by diminished breath sounds on the affected side, rapidly deteriorating arterial blood gases in the
presence of an open airway, and shock that is unexplained by other injuries.
646. A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick."
She continues, "My bowels aren't moving either." In counseling her based on these complaints, the nurse's
most appropriate response would be, "It would be beneficial for you to eat . . .
A. prunes."
B. green leafy vegetables."
C. red meat."
D. eggs."
Answer: A
Explanation:
(A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the
prenatal client is not taking her supplemental iron and iron-deficiency anemia is common during
pregnancy.
(B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both.
(C) Red meat is a good iron source but will not address the constipation problem.
(D) Eggs are a good iron source but do not address the constipation problem.
647. During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic
fever to assist in minimizing joint pain and promoting healing by:
A. Putting all joints through full range-of-motion twice daily
B. Massaging the joints briskly with lotion or liniment after bath
C. Immobilizing the joints in functional position using splints, rolls, and pillows
D. Applying warm water bottle or heating pads over involved joints

Answer: C
Explanation:
(A) Any movement of the joint causes severe pain.
(B) Touching or moving the joint causes severe pain.
(C) Immobilization in a functional position allows the joint to rest and heal.
(D) Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
648. A client is placed on lithium therapy for her manic depressive illness. When monitoring the client, the
nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level
is above:
A. 1.0 mEq/L
B. 2.2 mEq/L
C. 0.03 mEq/L
D. 1.5 mEq/L
Answer: D
Explanation:
(A) This value is a low blood level.
(B) This value is a toxic blood level.
(C) This value is a low blood level.
(D) This value is the level at which most clients are maintained, and toxicity may occur if the level
increases. The client should be monitored closely for symptoms, because some clients become toxic even
at this level.
649. A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets
would be appropriate?
A. High calcium, low phosphorus
B. Low calcium, high phosphorus
C. Two-gram sodium diet
D. Low calcium and phosphorus, acid ash
Answer: D
Explanation:
(A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A highcalcium diet is contraindicated.

(B) A high-phosphorus diet is contraindicated.
(C) A 2-g sodium diet is a cardiac diet.
(D) A low-calcium and phosphorus diet will reduce further calculi formation.
650. A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in
duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an
oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that
the RN discontinue the infusion if which one of the following occur?
A. The client's contractions are <2 minutes apart.
B. Duration of the contractions are 60 seconds.
C. The uterus relaxes between contractions.
D. The client complains that she is tired.
Answer: A
Explanation:
(A) It is very important that there is a resting phase or relaxation period between the contractions. During
this period, the uterus, placenta, and umbilical vessels re-establish blood flow. No resting phase between
contractions can lead to fetal bradycardia, fetal hypoxia, and acidosis. It can also result in a tetanic
contraction, which can cause uterine rupture.
(B) The goal of the oxytocin infusion is to help establish a contraction pattern lasting 45-60 seconds
occurring every 2 minutes and a uterine tonus of 60-70 mm Hg.
(C) This choice is correct. The uterus has time to recover from the contraction.
(D) The client's tiring is no indication to stop the infusion. She will be tired even without the infusion.
651. The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival
stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival
stimulation technique would be:
A. Using a water pik
B. Rinsing with water
C. Rinsing with hydrogen peroxide
D. Rinsing with baking soda
Answer: A
Explanation:
(A) This technique provides effective rinsing and gingival stimulation.

(B) This technique does not provide gingival stimulation.
(C) This technique provides effective rinsing but not gingival stimulation.
Using peroxide is not pleasant for the child.
(D) This technique provides effective rinsing but not gingival stimulation.
652. The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be
admitted to the hospital for a caesarean 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 caesarean 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 caesarean section, but not immediately necessary to
maintain physiological equilibrium.
(D) These nursing actions are necessary prior to the caesarean section, but not immediately necessary to
maintain physiological equilibrium.
653. A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow.
Appropriate nursing actions to help control hyperventilating include:
A. Administering diazepam (Valium) 10-15 mg po q4h and q1h prn for hyperventilating episode
B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation
C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
D. Using distraction to help control the client's hyperventilation episodes
Answer: C
Explanation:

(A) An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written
would place a client at risk for overdose.
(B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory
system.
(C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both
measures increase CO2 retention.
(D) Distraction will not prevent or control hyperventilation caused by anxiety or fear.
654. A group of nursing students at a local preschool day care center are going to screen each child's fine
and gross motor, language, and social skills. The students will use which one of the most widely used
screening tests?
A. Revised Pre-screening Developmental Questionnaire
B. Goodenough Draw-a-Person Screening Test
C. Denver Development Screening Test
D. Caldwell Home Inventory
Answer: C
Explanation:
(A) The Revised Pre-screening Developmental Questionnaire is more age appropriate and offers simplified
parent scoring and easier comparison. It is used by parents instead of professionals.
(B) The Goodenough Draw-a-Person test is used to assess intellectual development.
(C) The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a
concise, easyto-administer, systematic approach to assessing the preschool child. It is widely used because
of its reliability and validity.
(D) The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional,
and cognitive supports.
655. When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses
the importance of consuming the recommended daily allowance of which of the following electrolytes?
A. Potassium
B. Magnesium
C. Sodium
D. HCO3
Answer: B

Explanation:
(A) Potassium intake that meets the recommended daily allowance is important, especially in clients who
have a history of cardiac disease.
(B) Low levels of magnesium can cause an increase in resistance to insulin and can lead to carbohydrate
intolerance.
(C) Sodium is an important electrolyte for all clients but has no direct effect on diabetes mellitus.
(D) Bicarbonate plays an important role in acid base balance. It is equally necessary for maintenance of all
body functions.
656. The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only
be mixed with which of the following solutions?
A. Ringer's lactate
B. D5 in water
C. D5 with Ringer's lactate
D. Normal saline
Answer: D
Explanation:
(A) Phenytoin will precipitate if mixed with Ringer's lactate and should not be administered.
(B, C) Phenytoin will precipitate if mixed with D5 in Ringer's lactate and should not be administered.
(D) Phenytoin is compatible only with normal saline and should be mixed only with normal saline for
administration.
657. The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel
he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
A. Patience by the child when wearing soiled diapers
B. Communicating the urge to defecate or urinate
C. The child awakening wet from his naps
D. The age at which the child's siblings were trained
Answer: B
Explanation:
(A) Children experience impatience with soiled diapers when readiness for training is apparent. They often
desire to be changed immediately.
(B) A child must be able to use verbal or nonverbal skills to communicate needs.

(C) A readiness indicator would be awaking dry from naps.
(D) The age at which a sibling was toilet trained has no implications for training this child.
658. The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis
client. The nurse instructs the client that B6 is given because it:
A. Increases activity of isoniazid
B. Increases activity of rifampin
C. Improves nutritional status
D. Reduces peripheral neuropathy
Answer: D
Explanation:
(A) Vitamin B6does not enhance the activity of isoniazid.
(B) Vitamin B6does not enhance the activity of rifampin.
(C) A vitamin alone does not improve nutritional status.
(D) Isoniazid leads to Vitamin B6deficiency, which is manifested as peripheral neuropathy.
659. A male client has been hospitalized with congestive heart failure. Medical management of heart
failure focuses on improving myocardial contractility. This can be achieved by administering:
A. Digoxin (Lanoxin) 0.25 mg po every day
B. Furosemide (Lasix) 40 mg po every morning
C. O2 2 L/min via nasal cannula
D. Nitro-glycerine (Nitrol) 1 inch topically every 4 hours
Answer: A
Explanation:
(A) Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial
contractility.
(B) Furosemide is a loop diuretic given to clients in heart failure to promote diuresis.
(C) O2 is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia.
(D) Nitro-glycerine is a nitrate given to clients in heart failure to increase their cardiac output by
decreasing the peripheral resistance that the left ventricle must pump against.
660. Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in
the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the

presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The
nurse should :
A. Begin the oxytocin induction as ordered
B. Increase the dosage by 2 mU/min increments at 15-minute intervals
C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 212-4 minute
intervals
D. Question the order
Answer: D
Explanation:
(A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out
in a dysfunctional labor.
(B) This answer is the correct protocol for oxytocin administration, but the medication should not be used
until CPD is ruled out.
(C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used
until CPD is ruled out.
(D) This answer is the appropriate nursing action because the scenario presents a dysfunctional labor
pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
661. During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule
out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
A. A loss of phagocytic activity
B. Faulty processing of bilirubin
C. Enhanced detoxification of drugs
D. The formation of collateral circulation
Answer: B
Explanation:
(A) A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases
the susceptibility to infections.
(B) The faulty processing of bilirubin produces bilesalts, which are irritating to the skin.
(C) The detoxification of drugs is impaired with cirrhosis of the liver.
(D) Collateral circulation develops due to portal hypertension. This is manifest through the development of
esophageal varices, hemorrhoids, and caput medusae.

662. A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34
days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation
should occur on day:
A. 14 + 2 days
B. 16 + 2 days
C. 20 + 2 days
D. 22 + 2 days
Answer: C
Explanation:
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days.
(B) Ovulation occurs 14 + 2 days before next menses (34 minus 14 does not equal 16).
(C) Ovulation occurs 14 + 2 days before next menses (34 minus 14 equals 20).
(D) Ovulation occurs 14 + 2 days before next menses (34 minus 14 does not equal 22).
663. Which of the following nursing orders has the highest priority for a child with epiglottitis?
A. Vital signs every shift
B. Tracheostomy set at bedside
C. Intake and output
D. Specific gravity every shift
Answer: B
Explanation:
(A) Because of the possibility of fever or respiratory failure, vital signs should be done more often than
every eight hours.
(B) If the epiglottitis worsens, the edema and laryngospasm may close the airway and an emergency
tracheostomy may be necessary.
(C) Although intake and output are a part of the nursing care of a child with epiglottitis, it is not as
important as the safety measure of keeping the tracheostomy set at the bedside.
(D) Specific gravity will indicate hydration status, but it is not as important as keeping the tracheostomy
set at the bedside.
664. At 12 hours post vaginal 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 50-70 bpm may be considered normal post partally 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 post partal haemorrhage; therefore, the bladder should be kept empty.
(C) Reestablishment 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.
665. 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.
666. Which of the following nursing care goals has the highest priority for a child with epiglottitis?
A. Sleep or lie quietly 10 hr/day.

B. Consume foods from all four food groups.
C. Be afebrile throughout her hospital stay.
D. Participate in play activities 4 hr/day.
Answer: A
Explanation:
(A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is
the most important.
(B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more
than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling.
(C) This goal is unrealistic because fever is a common symptom of the infection associated with
epiglottitis.
(D) If overexerted, the child will need more O2 and energy than available, and these requirements may
exacerbate the condition.
667. Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving
heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to
observe during postpartum care of the client?
A. Dysuria
B. Epistaxis, hematuria, dysuria
C. Vertigo, hematuria, ecchymosis
D. Hematuria, ecchymosis, and epistaxis
Answer: D
Explanation:
(A) Dysuria is not a common symptom of heparin overdose.
(B) Although epistaxis and hematuria are common symptoms of heparin overdose, dysuria is not.
(C) Vertigo is not a common symptom of heparin overdose.
(D) Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin
overdose. Others are thrombocytopenia, elevated liver enzymes, and local injection site complications.
668. Which of the following symptoms might the nurse observe in a client with a lithium blood level over
2.0?
A. Fine hand tremor, headache, mental dullness
B. Vomiting, impaired consciousness, decreased blood pressure

C. Polyuria, polydipsia, edema
D. Gastric irritation, nausea, diarrhea
Answer: B
Explanation:
(A) These symptoms are acute, common, and usually harmless central nervous system side effects of
lithium.
(B) These symptoms of lithium toxicity are usually dose related.
(C) These symptoms are acute, common, and usually harmless renal side effects of lithium.
(D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium.
669. 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.
670. A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge
of nutritional needs of her child when she is able to state the foods which are included in a:
A. Lactose-restricted diet
B. Gluten-restricted diet

C. Phenylalanine-restricted diet
D. Fat-restricted diet
Answer: B
Explanation:
(A) A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhoea.
(B) A gluten-restricted diet is the diet for children with celiac disease.
(C) A phenylalanine restricted diet is prescribed for children with phenylketonuria.
(D) A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.
671. Discharge teaching for the client who has a total gastrectomy should include which of the following?
A. Need for the client to increase fluid intake to 3000 mL/day
B. Follow-up visits every 3 weeks for the first 6 months
C. B12 injections needed for the rest of the client's life
D. Need to eat three full meals with plenty of fiber per day
Answer: C
Explanation:
(A) There will be no need to increase fluid intake excessively, because dumping syndrome could present a
problem.
(B) Follow up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly
individualized.
(C) With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary
for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the
person's life.
(D) Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems
with dumping syndrome.
672. The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The
client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in
which of the following laboratory tests?
A. Number of platelets
B. WBC count
C. Haemoglobin level
D. Number of lymphocytes

Answer: A
Explanation:
(A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation
and thrombus formation.
(B) Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection.
(C) Clients with lupus may have a decrease in the haemoglobin level causing anemia.
(D) Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.
673. A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody
drainage on his surgical dressing. The nurse would document this as what type of drainage?
A. Serosanguinous
B. Purulent
C. Sanguinous
D. Catarrhal
Answer: C
Explanation:
(A) Drainage from a surgical incision usually proceeds from sanguinous to serosanguinous.
(B) Purulent drainage usually indicates infection and should not be seen initially from a surgical incision.
(C) Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to
serous.
(D) Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
674. 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.
675. A client is experiencing muscle weakness and lethargy. His serum K+ is 3.2. What other symptoms
might he exhibit?
A. Tetany
B. Dysrhythmias
C. Numbness of extremities
D. Headache
Answer: B
Explanation:
(A) Tetany is seen with low calcium.
(B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity.
(C) Numbness of extremities is seen with high potassium.
(D) Headache is not associated with potassium excess or deficiency.
676. To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:
A. Avoid touching the baby while in the room.
B. Stay outside of the baby's room.
C. Wear a gown and gloves and wash her hands before and after leaving the room.
D. Wear a mask while in the room.
Answer: C
Explanation:
(A) The mother should be allowed and encouraged to touch her baby.
(B) With care, transmission can be prevented. There is no need for the mother to stay outside the room.
(C) Everyone entering the baby's room should take appropriate measures to prevent transmission of
pathogens.
(D) Wearing a mask will not protect against transmission of pathogens.

677. 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
diarrhoea. 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.
678. Which of the following would indicate the need for further teaching for the client with COPD? The
client verbalizes the need to:
A. Eat high-calorie, high-protein foods
B. Take vitamin supplementation
C. Eliminate intake of milk and milk products
D. Eat small, frequent meals
Answer: C
Explanation:
(A) Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat
than carbohydrate content is given because clients are unable to breathe off the excess CO 2 that is an end
product of carbohydrate metabolism.
(B) Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to
infection.

(C) Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing
the mouth with water after drinking milk will prevent this problem.
(D) Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work
of breathing and SOB are also reduced.
679. 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.
680. A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
A. Provide him with a safe and structured environment.
B. Assist him to develop more effective coping mechanisms.
C. Have him sign a "no-suicide" contract.
D. Isolate him from stressful situations that may precipitate a depressive episode.
Answer: B
Explanation:
(A) This statement represents a short-term goal.
(B) Long-term therapy should be directed toward assisting the client to cope effectively with stress.
(C) Suicide contracts represent short-term interventions.
(D) This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.
681. The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4
minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal
movement. Which nursing intervention is appropriate?

A. Notify physician of non reassuring FHR pattern.
B. Turn the client to her left side.
C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
D. Evaluate to see if the monitor strip is reassuring.
Answer: D
Explanation:
(A) These indices are within normal parameters; therefore, the nurse does not need to contact the
physician.
(B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the
above assessment, there is no indication that blood flow is compromised.
(C) These interventions are appropriate nursing interventions for late and prolonged decelerations.
Following these interventions, the nurse should notify the physician. These indices are within normal
parameters; therefore, the nurse does not need to start an IV and administer O2.
(D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range
from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with
contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes,
with an appropriate duration of 60 sec.
682. The nurse provides a male client with diet teaching so that he can help prevent constipation in the
future. Which food choices indicate that this teaching has been understood?
A. Omelette and hash browns
B. Pancakes and syrup
C. Bagel with cream cheese
D. Cooked oatmeal and grapefruit half
Answer: D
Explanation:
(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent
constipation.
(B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation.
(C) Bagel and cream cheese do not provide intestinal bulk.
(D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.

683. 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.
684. 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).
685. A client experiencing delusions states, "I came here because there were people surrounding my house
that wanted to take me away and use my body for science." The best response by the nurse would be:
A. "Describe the people surrounding your house that want to take you away."

B. "I need more information on why you think others want to use your body for science."
C. "There were no people surrounding your house, your relatives brought you here, and no one really
wants your body for science."
D. "I know that must be frightening for you; let the staff know when you are having thoughts that trouble
you."
Answer: D
Explanation:
(A) Focusing on the delusional content does not reinforce reality.
(B) Pursuing details or more information on the delusion reinforces the false belief and further distances
the client from reality.
(C) Challenging the client's delusional system may force the client to defend it, and you cannot change the
delusion through logic.
(D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when
thoughts are troublesome can help to decrease anxiety.
686. 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.

687. Pregnant women with diabetes often have problems related to the effectiveness of insulin in
controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this
is due to:
A. Decreased glomerular filtration and increased tubular absorption
B. Decreased estrogen levels
C. Decreased progesterone levels
D. Increased human placental lactogen levels
Answer: D
Explanation:
(A) There is a rise in glomerular filtration rate in the kidneys in conjunction with decreased tubular glucose
reabsorption, resulting in glycosuria.
(B) Insulin is inhibited by increased levels of estrogen.
(C) Insulin is inhibited by increased levels of progesterone.
(D) Human placental lactogen levels increase later in pregnancy. This hormonal antagonist reduces
insulin's effectiveness, stimulates lipolysis, and increases the circulation of free fatty acids.
688. A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client,
who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of
her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be
to:
A. Raise the client's head and place her feet in a dependent position
B. Notify the physician
C. Place the client on 2 liters of O2 via nasal cannula
D. Administer furosemide (Lasix) 20 mg IV push
Answer: A
Explanation:
(A) Raising the client's head and placing her feet in a dependent position is an independent nursing action
that can be taken to decrease venous return and to reduce pulmonary congestion.
(B) Notifying the physician is an appropriate action that should be taken after the client is positioned to
maximize her respiratory status.
(C) Placing the client on O2 may be done with a physician's order or according to an institution's standing
orders; however, other actions should be taken first.

(D) Furosemide 20 mg IV push is an appropriate medication for the client, but it must be ordered by her
physician.
689. A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a highcarbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is
transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three
days after her transfer, the client tells the nurse, "I haven't exercised in 6 days. I won't be eating lunch
today." This statement by her most likely reflects:
A. Her lack of internal awareness about the outcome of the behavior
B. Increased knowledge about personal exercise plans
C. A manipulative technique to trick the nurse into allowing her to miss a meal
D. A true desire to stay fit while in the hospital
Answer: A
Explanation:
(A) Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client's
lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will
ultimately result in death if uninterrupted.
(B) Although the client is knowledgeable about exercise, knowledge about the balance between nutrition,
exercise, and rest is absent.
(C) The client's level of denial and lack of awareness disallow this behavior as a manipulative trick.
(D) The client's illness-maintaining behaviors are inconsistent with fitness.
690. When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
A. Anemia and vomiting
B. Polyuria and polydipsia
C. Irritability relieved by feeding formula
D. Hypothermia and azotemia
Answer: B
Explanation:
(A) Anemia and vomiting are not cardinal signs of diabetes insipidus.
(B) Polyuria and polydipsia are the cardinal signs of diabetes insipidus.
(C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of
diabetes insipidus.

(D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
691. Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for
depressed clients. The nurse explains that the purpose of the drug is to:
A. Relax muscles
B. Relieve anxiety
C. Reduce secretions
D. Act as an anesthetic
Answer: A
Explanation:
(A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure.
(B) Succinylcholine chloride does not relieve anxiety.
(C) Atropine is given to reduce secretions.
(D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.
692. The physician orders medication for a client's unpleasant side effects from the haloperidol. The most
appropriate drug at this time is:
A. Lorazepam
B. Triazolam (Halcion)
C. Benztropine
D. Thiothixene
Answer: C
Explanation:
(A) Lorazepam is a benzodiazepine, or antianxiety agent, that potentiates the effects of _aminobutyric acid
in the CNS, which is not the CNS neurotransmitter EPS.
(B) Triazolam is a benzodiazepine sedative-hypnotic whose action is mediated in the limbic, thalamic, and
hypothalamic levels of the CNS by - aminobutyric acid.
(C) Benztropine is an anticholinergic agent, and the drug of choice for blocking CNS synaptic response,
which causes EPS.
(D) Thiothixene is an antipsychotic and neuroleptic drug that blocks dopamine neurotransmission at the
CNS synapses, thereby causing EPS.

693. 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 antiinflammatory 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.
694. Which of the following signs and symptoms indicates a tension pneumothorax as compared to an
open pneumothorax?
A. Ventilation-perfusion (V/Q) mismatch
B. Hypoxemia and respiratory acidosis
C. Mediastinal tissue and organ shifting
D. Decreased tidal volume and tachypnea
Answer: C
Explanation:
(A, B, D) These occur in both tension pneumothorax and open pneumothorax.
(C) The tension pneumothorax acts like a one- way valve so that the pneumothorax increases with each
breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away

from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac
output will occur. The other three options will occur in both types of pneumothorax.
695. Often children are monitored with pulse oximeter. The pulse oximeter measures the:
A. O2 content of the blood
B. Oxygen saturation of arterial blood
C. PO2
D. Affinity of haemoglobin for O2
Answer: B
Explanation:
(A) The O2 content of whole blood is determined by the partial pressure of oxygen (PO2) and the oxygen
saturation. The pulse oximeter does not measure the PO2.
(B) The pulse oximeter is a non-invasive method of measuring the arterial oxygen saturation.
(C) The PO2 is the amount of O2 dissolved in plasma, which the pulse oximeter does not measure.
(D) The affinity of haemoglobin for O2 is the relationship between oxygen saturation and PO2 and is not
measured by the pulse oximeter.
696. A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal
dialysis or haemodialysis and must make a choice between the two. Which information should the nurse
give her to help her decide?
A. Haemodialysis involves less time to filter the blood; but the client must consider travel time, distance,
and inconvenience.
B. Haemodialysis involves more time to filter the blood than does peritoneal dialysis.
C. Peritoneal dialysis has almost no complications and is less time consuming than haemodialysis.
Therefore it is preferred.
D. Peritoneal dialysis requires that a home health nurse prepare and administer the treatments.
Answer: A
Explanation:
(A) Haemodialysis 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 haemodialysis.

(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.
697. A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory
studies will be ordered to monitor the therapeutic effects of heparin?
A. Partial thromboplastin time
B. Haemoglobin
C. Red blood cell (RBC) count
D. Prothrombin time
Answer: A
Explanation:
(A) Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending
on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors
VII and XIII and platelets.
(B) Haemoglobin is the main component of RBCs. Its main function is to carry O2 from the lungs to the
body tissues and to transport CO2 back to the lungs.
(C) RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood.
(D) PT is used to monitor the effects of oral anticoagulants, e.g., coumarin type anticoagulants.
698. Which of the following findings would be abnormal in a postpartal woman?
A. Chills shortly after delivery
B. Pulse rate of 60 bpm in morning on first postdelivery day
C. Urinary output of 3000 mL on the second day after delivery
D. An oral temperature of 101F (38.3C) on the third day after delivery
Answer: D
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a
nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous.
(B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The
body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood
flow to the vascular bed.

(C) Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The
kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal
pregnancy.
(D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of
labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious
process.
699. The priority nursing goal when working with an autistic child is:
A. To establish trust with the child
B. To maintain communication with the family
C. To promote involvement in school activities
D. To maintain nutritional requirements
Answer: A
Explanation:
(A) The priority nursing goal when working with an autistic child is establishing a trusting relationship.
(B) Maintaining a relationship with the family is important but having the trust of the child is a priority.
(C) To promote involvement in school activities is inappropriate for a child who is autistic.
(D) Maintaining nutritional requirements is not the primary problem of the autistic child.
700. A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem
in the category of:
A. Impaired communication
B. Sensory-perceptual alterations
C. Altered thought processes
D. Impaired social interaction
Answer: B
Explanation:
(A) Impaired communication refers to decreased ability or inability to use or understand language in an
interaction.
(B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to
incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real
external stimuli).

(C) An altered thought processes problem statement is used when an individual experiences a disruption in
cognitive operations and activities (i.e., delusions, loose associations, ideas of reference).
(D) In impaired social interaction, the individual participates too little or too much in social interactions.
701. 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.
702. When assessing fetal heart rate status during labor, the monitor displays late decelerations with
tachycardia and decreasing variability. What action should the nurse take?
A. Continue monitoring because this is a normal occurrence.
B. Turn client on right side.
C. Decrease IV fluids.

D. Report to physician or midwife.
Answer: D
Explanation:
(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant
recovery.
(B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side.
(C) IV fluids should be increased, not decreased.
(D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering
O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing
for immediate caesarean delivery, and explaining plan of action to client.
703. Which of the following lab data is representative of a client with aplastic anemia?
A. Haemoglobin 9.2, haematocrit 27, red blood cells 3.2 million
B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
C. White blood cells 3000, haematocrit 27, red blood cells 2.8 million
D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000
Answer: D
Explanation:
(A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic
anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts.
(D) Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1
million, white cell count <2,000, and thrombocytes 45 mm Hg, HCO3 > 26 mEq/L.
(B) Respiratory acidosis would be reflected by the following: pH 45 mm Hg, HCO3 within
normal limits (22-26 mEq/L).
(C) Partially compensated metabolic alkalosis would be reflected by the following: pH > 7.45, PCO 2 > 45
mm Hg, HCO3 > 26 mEq/L.
(D) Combined respiratory and metabolic acidosis would be reflected by the following: pH
45 mm Hg, HCO3 2.0 ng/mL.
755. A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The
finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the
left side of the chest of a newly intubated client is probably due to:
A. A left haemothorax
B. A right haemothorax
C. Intubation of the right mainstem bronchus
D. An inadequate mechanical ventilator
Answer: C
Explanation:
(A) Although a left haemothorax could cause diminished and distant breath sounds, it is irrelevant to this
situation.
(B) A right haemothorax will not cause diminished and distant breath sounds on the left side of the chest.
(C) The right mainstem bronchus is most frequently intubated in error because the angle of the right
mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation
is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the
left.
(D) An inadequate mechanical ventilator has no relationship to this situation.

756. 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.
757. 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 (Aqua MEPHYTON) 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.
758. A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30
weeks' gestation. The nurse should be alert to which condition related to her age?
A. Iron-deficiency anemia
B. Sexually transmitted disease (STD)
C. Intrauterine growth retardation
D. Pregnancy-induced hypertension (PIH)
Answer: D
Explanation:
(A) Iron-deficiency anemia can occur throughout pregnancy and is not age related.
(B) STDs can occur prior to or during pregnancy and are not age related.
(C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are
delayed. It is not age related.
(D) Physical risks for the pregnant client older than 35 include increased risk for PIH, caesarean delivery,
fetal and neonatal mortality, and trisomy.
759. The nurse needs to be aware that the most common early complication of a myocardial infarction is:
A. Diabetes mellitus
B. Anaphylactic shock
C. Cardiac hypertrophy
D. Cardiac dysrhythmia
Answer: D
Explanation:
(A) Diabetes mellitus is not a common complication of myocardial infarction.
(B) Anaphylactic shock is an allergic reaction.
(C) Cardiac hypertrophy is a late potential complication. It is a common complication of congestive heart
failure.
(D) Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial
irritability results from lack of oxygenated tissue.

760. On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her
perineum and anus as part of her daily assessment. The best position for the client to be placed in for this
assessment is:
A. Sims'
B. Fowler's
C. Prone
D. Any position that the RN chooses
Answer: A
Explanation:
(A) The Sims' position is the best position for assessment of the perineum and anus. The top leg is placed
over the bottom leg, and the RN raises the upper buttocks to fully expose the perineum and anus.
(B) Fowler's position is a sitting position, and the perineum and anus would not be exposed.
(C) The prone position would have the mother on her back, and her perineum and anus would not be
exposed.
(D) The position of choice should always be the Sims'.
761. On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with
great difficulty.
He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau,
straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of
anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his
anxiety?
A. "You will not be allowed to remain in your room if you continue to bother things."
B. "I can see how uncomfortable you are, but I would like you to walk with me so I can show you around
the unit."
C. "Tell me why your room needs to be so clean."
D. "I've inspected this room and it is perfectly clean."
Answer: B
Explanation:
(A) This statement is punitive.
(B) Acknowledging the anxiety and channelling it into some positive activity is therapeutic.
(C) The client cannot say "why"; this statement puts the client on the defensive.
(D) A rational approach, especially a judgmental one, is nontherapeutic.

762. The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He
was admitted for depression and thoughts of suicide. He looks at the nurse and says, "My life is so bad no
one can do anything to help me." The most helpful initial response by the nurse would be:
A. "It concerns me that you feel so badly when you have so many positive things in your life."
B. "It will take a few weeks for you to feel better, so you need to be patient."
C. "You are telling me that you are feeling hopeless at this point?"
D. "Let's play cards with some of the other clients to get your mind off your problems for now."
Answer: C
Explanation:
(A) This response does not acknowledge the client's feelings and may increase his feelings of guilt.
(B) This response denotes false reassurance.
(C) This response acknowledges the client's feelings and invites a response.
(D) This response changes the subject and does not allow the client to talk about his feelings.
763. A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed
clients is the potential of suicide. The time that suicide is most likely to occur is:
A. In the acutely depressed state
B. When the depression starts to lift
C. In the denial phase
D. During a manic episode
Answer: B
Explanation:
(A) The client may be too disorganized in the acute phase to make a workable plan.
(B) When the depression starts to lift, the client is able to make a workable plan.
(C) There usually is not a significant denial phase related to depression. Suicide occurs in a state of despair
and hopelessness.
(D) Suicide is uncommon in the manic state. In this state, clients do not feel hopeless, but euphoric and
overly confident.
764. 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.
765. A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD).
She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline
level is drawn. Which of the following values represents a therapeutic level?
A. 14 u g/mL
B. 25 u g/mL
C. 4 u g/mL
D. 30 u g/mL
Answer: A
Explanation:
(A) The therapeutic blood level range of theophylline is 10-20 mg/mL. Therapeutic drug monitoring
determines effective drug dosages and prevents toxicity.
(B, D) This value is a toxic level of the drug.
(C) This value is a nontherapeutic level of the drug.
766. 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.
767. Which of the following statements relevant to a suicidal client is correct?
A. The more specific a client's plan, the more likely he or she is to attempt suicide.
B. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts.
C. A client who threatens suicide is just seeking attention and is not likely to attempt suicide.
D. Nurses who care for a client who has attempted suicide should not make any reference to the word
"suicide" in order to protect the client's ego.
Answer: A
Explanation:
(A) This is a high-risk factor for potential suicide.
(B) A previous suicide attempt is a definite risk factor for subsequent attempts.
(C) Every threat of suicide should be taken seriously.
(D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt
by direct, respectful questions.
768. A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial
containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
A. 0.06 mL
B. 0.38 mL
C. 2.7 mL
D. Information given insufficient to determine the amount of atropine to be administered
Answer: B
Explanation:
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer.

(B) The answer is correct. 0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15 x = 0.15/0.4 x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of
atropine available and the amount of atropine ordered is required to determine the amount of atropine to be
given.
769. A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly
rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my
labor." Which reply by the nurse identifies the physiological response of the client?
A. "Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles
to contract."
B. "Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel
engorgement."
C. "The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes
the uterus to contract."
D. "There is probably a small blood clot or placental fragment in your uterus, and your uterus is
contracting to expel it."
Answer: C
Explanation:
(A) Mammary growth as well as milk production and maintenance in the breast occur in response to
hormones produced primarily by the hypothalamus and the pituitary gland.
(B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of
breast-feeding.
(C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of
the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine
involution.
(D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are
other symptoms that occur in response to retained placental fragments.
770. A client has been uncomfortable in crowds all her life. After the birth of her child, she has been
housebound unless her husband can accompany her to the grocery store and for medical appointments. His
schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has

increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true
about this disorder?
A. The behavior is not considered disabling.
B. More men suffer from agoraphobia than women.
C. The fears are persistent, and avoidance is used as the coping mechanism.
D. Agoraphobia moves into remission when treated with chlorpromazine.
Answer: C
Explanation:
(A) Agoraphobia is the most pervasive and serious phobic disorder.
(B) Women compose 70%-85% of agoraphobia sufferers.
(C) Agoraphobia is an acute disorder that immobilizes the sufferer with extreme anxiety.
(D) Chlorpromazine is not a drug used to treat phobias.
771. A client tells the nurse that she has had a history of urinary tract infections. The nurse would do
further health teaching if she verbalizes she will:
A. Drink at least 8 oz of cranberry juice daily
B. Maintain a fluid intake of at least 2000 mL daily
C. Wash her hands before and after voiding
D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
Answer: D
Explanation:
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth.
(B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the
bladder.
(C) Hand washing is an effective means of preventing pathogen transmission.
(D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial
growth.
772. When teaching a sex education class, the nurse identifies the most common STDs in the United States
as:
A. Chlamydia
B. Herpes genitalis
C. Syphilis

D. Gonorrhea
Answer: A
Explanation:
(A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for
Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and
women with multiple sex partners.
(B) Herpes simplex genitalia is estimated to be found in 5-20 million people in the United States and is
rising in occurrence yearly.
(C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number
of people infected has begun to increase.
(D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea
is common, chlamydia is still the most common STD.
773. A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the
nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
A. Assist her with a sitz bath
B. Administer the prescribed medication for pain
C. Teach her Kegel exercises
D. Apply an ice pack
Answer: A
Explanation:
(A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before
medication is given.
(B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications
are ineffective.
(C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for
pain control or sustained comfort level.
(D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to
reduce edema to the area.
774. 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.
775. 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.
776. 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.
777. An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible
fecal impaction. Which of the following assessment findings would be most indicative of a fecal
impaction?
A. Board like, rigid abdomen
B. Loss of the urge to defecate
C. Liquid stool
D. Abdominal pain
Answer: C
Explanation:
(A) A board like, rigid abdomen would point to a perforated bowel, not a fecal impaction.
(B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so.
(C) When an impaction is present, only liquid stool will be able to pass around the impacted site.
(D) Abdominal pain without distention is not a sign of a fecal impaction.
778. The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her
back. The nurse explains that this is to avoid "vena caval syndrome," a condition which:
A. Occurs when blood pressure increases sharply with changes in position
B. Results when blood flow from the extremities is blocked or slowed
C. Is seen mainly in first pregnancies
D. May require medication if positioning does not help
Answer: B
Explanation:
(A) Blood pressure changes are predominantly due to pressure of the gravid uterus.
(B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities.
(C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity.

(D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure
by position changes is effective.
779. 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 (20-60%) 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.
780. A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He
became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's
psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies
that the best approach to this problem is to:
A. Allow him to eat late
B. Suggest that he do the rituals after breakfast
C. Get him up early so that he can complete the ritual before breakfast
D. Ask him to get all the other clients up so that he will forget about his ritual
Answer: C
Explanation:
(A) Allowing him to eat late is not a solution to the problem because the ritual affects more than just this
meal.

(B) He is helpless to change this behavior because the rituals occur as a result of an irrational effort to
control his anxiety.
(C) To interfere with the ritual will increase anxiety. Until the basic problem is resolved, and in turn his
need for the ritual relieved, arrange the schedule so that essential activities may be included (such as meals
with the group).
(D) This approach would be very disruptive to the other clients and would not serve to relieve the anxiety
of the client.
781. 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.
782. The nurse would be concerned if a client exhibited which of the following symptoms during her
postpartum stay?
A. Pulse rate of 50-70 bpm by her third postpartum day
B. Diuresis by her second or third postpartum day
C. Vaginal discharge or rubra, serosa, then rubra
D. Diaphoresis by her third postpartum day
Answer: C
Explanation:
(A) Bradycardia is an expected assessment during the postpartum period.
(B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation.

(C) A return of rubra after the serosa period may indicate a postpartal complication.
(D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an
infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses
to adjust the cardiac output and blood volume to the nonpregnant state.
783. The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been
augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as
95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The
physician orders that she be prepared for a caesarean delivery. In preparing the client for the caesarean
delivery, which one of the following physician's orders should the RN question?
A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
B. Discontinue the oxytocin infusion.
C. Insert an indwelling Foley catheter prior to delivery.
D. Prepare abdominal area from below the nipples to below the symphysis pubis area.
Answer: A
Explanation:
(A) Meperidine is a narcotic analgesic medication that crosses the placental barrier and reaches the fetus,
causing respiratory depression in the fetus. A narcotic medication should never be included in the
preoperative order for a caesarean delivery.
(B) Oxytocin infusion would be discontinued if client is being prepared for a caesarean delivery because
the medication would not be needed.
(C) The bladder is always emptied prior to and during the surgical intervention to prevent the urinary
bladder from accidentally being incised while the uterine incision is made.
(D) The abdominal area is always prepared to rid the area of hair before the abdominal incision is made.
Abdominal hair cannot be sterilized and could become a source for postoperative incisional infection.
784. 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.
785. When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus.
Which of the following descriptions correctly describes this rash?
A. Small round or oval reddish brown macules scattered over the entire body
B. Scattered clusters of macules, papules, and vesicles over the body
C. Bright red appearance of the palmar surface of the hands
D. Reddened butterfly shaped rash over the cheeks and nose
Answer: D
Explanation:
(A) The appearance of small, round or oval reddish brown macules scattered over the entire body is
characteristic of rubeola.
(B) The appearance of scattered clusters of macules, papules, and vesicles throughout the body is
characteristic of chickenpox.
(C) Palmar redness is seen in clients with cirrhosis of the liver.
(D) The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus
erythematosus.
786. Before giving methergine postpartum, the nurse should assess the client for:
A. Decreased amount of lochial flow
B. Elevated blood pressure
C. Flushing
D. Afterpains
Answer: B
Explanation:

(A) Methergine is given to contract the uterus and to control post partal hemorrhage; therefore, lochial
flow should decrease.
(B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive
methergine, but she could be given oxytocin if necessary.
(C) Flushing is not a side effect of methergine.
(D) Afterpains are increased with methergine usage.
The client should be informed that this is a normal response.
787. 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 microdrip 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.
788. A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the
child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature
frightened her parents. Which response by the nurse would be most appropriate?
A. Monitoring the temperature prevents undue chilling.
B. Rapid temperature elevations can occur in children.
C. Checking the temperature will prevent febrile seizures.
D. Taking the child's temperature can prevent airway obstruction.
Answer: A

Explanation:
(A) The refrigerated cool mist tent creates a cool, moist environment. The child as well as bedding and
clothing may become dampened. Monitoring the temperature of the child will ensure warmth and prevent
chilling.
(B) Only a low-grade fever is expected in laryngotracheobronchitis.
(C) Febrile seizures are not expected with the low-grade fever.
(D) Inflammation of the mucosal lining in the respiratory tract can cause airway obstruction. However,
monitoring the child's temperature would not prevent airway obstruction.
789. A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching
has been successful?
A. Pork chop, baked acorn squash, brussel sprouts
B. Chicken breast, rice, and green beans
C. Roast beef, baked potato, and diced carrots
D. Tuna casserole, noodles, and spinach
Answer: A
Explanation:
(A) Both acorn squash and brussels sprouts are potassium-rich foods.
(B) None of these foods is considered potassium rich.
(C) Only the baked potato is a potassium-rich food.
(D) Spinach is the only potassium-rich food in this option.
790. 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.
791. A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that
psychiatrists often use categories of medications and that it is important that she recall that some categories
of medications have synonyms. Another name used to describe minor tranquilizers is which of the
following?
A. Antipsychotic medications
B. Antidepressant medications
C. Antianxiety medications
D. Antimania medication
Answer: C
Explanation:
(A) Antipsychotic medications are also known as major tranquilizers.
(B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors.
(C) Antianxiety medications are also known as minor tranquilizers.
(D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).
792. A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the
following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
A. Fluid volume deficit secondary to alteration in skin integrity
B. Alteration in comfort secondary to alteration in skin integrity
C. Alteration in sensation secondary to third-degree burn
D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to
alteration in skin integrity
Answer: D

Explanation:
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36
hours postburn.
(B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on
discharge.
(C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may
be indicative of lack of circulation.
(D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure
to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition
to an inability to intubate the client secondary to excessive edema formation in the neck.
793. Which of the following nursing orders should be included in the plan of care for a client with hepatitis
C?
A. The nurse should use universal precautions when obtaining blood samples.
B. Total bed rest should be maintained until the client is asymptomatic.
C. The client should be instructed to maintain a low semi-Fowler position when eating meals.
D. The nurse should administer an alcohol backrub at bedtime.
Answer: A
Explanation:
(A) The source of infection with hepatitis C is contaminated blood products.
(B) Modified bed rest should be maintained while the client is symptomatic. Routine activities can be
slowly resumed once the client is asymptomatic.
(C) Nausea and vomiting occur frequently with hepatitis C.
A high Fowler position may decrease the tendency to vomit.
(D) The buildup of bilirubin in the client's skin may cause pruritus. Alcohol is a drying agent.
794. A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on
evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood
transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss
has occurred?
A. Whole blood
B. Platelets
C. Fresh frozen plasma

D. Packed red blood cells
Answer: A
Explanation:
(A) Whole blood is the transfusion component of choice when large volumes of blood need to be replaced.
Whole blood contains all blood components that are lost during active bleeding.
(B) Platelet therapy is indicated for thrombocytopenia if the client's platelet count is below 15,000/mm 3.
(C) Infusion of fresh frozen plasma is required when the prothrombin time and partial thromboplastic time
are prolonged.
(D) Packed red blood cells are transfused in instances of anemia with decreases in haematocrit and
haemoglobin.
795. 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.
796. A psychotic client who believes that he is God and rules all the universe is experiencing which type of
delusion?
A. Somatic
B. Grandiose
C. Persecutory
D. Nihilistic
Answer: B
Explanation:
(A) These delusions are related to the belief that an individual has an incurable illness.
(B) These delusions are related to feelings of self-importance and uniqueness.
(C) These delusions are related to feelings of being conspired against.
(D) These delusions are related to denial of self-existence.
797. During discharge planning, parents of a child with rheumatic fever should be able to identify which of
the following as toxic symptoms of sodium salicylate?
A. Tinnitus and nausea
B. Dermatitis and blurred vision
C. Unconsciousness and acetone odor of the breath
D. Chills and an elevation of temperature
Answer: A
Explanation:
(A) These are toxic symptoms of sodium salicylate.
(B, C, D) These are not symptoms associated with sodium salicylate.
798. The nurse teaches a male client ways to reduce the risks associated with furosemide therapy.
Which of the following indicates that he understands this teaching?
A. "I'll be sure to rise slowly and sit for a few minutes after lying down."

B. "I'll be sure to walk at least 2-3 blocks every day."
C. "I'll be sure to restrict my fluid intake to four or five glasses a day."
D. "I'll be sure not to take any more aspirin while I am on this drug."
Answer: A
Explanation:
(A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this
drug and a common reason for falls.
(B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with
diuretic therapy.
(C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000-3000
mL daily, unless contraindicated.
(D) Aspirin is a safe drug to take along with furosemide.
799. Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be
designed to:
A. Reinforce attempts to eat
B. Help the child gain weight
C. Increase his appetite
D. Make mealtimes pleasant
Answer: A
Explanation:
(A) Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing
intake.
(B) This goal is not specific enough or related to the loss of appetite.
(C) This goal is not possible at this time based on his illness.
(D) This goal is helpful, but alone will not address his loss of appetite.
800. A baby is circumcised. Immediate postoperative care should include:
A. Applying a loose diaper
B. Keeping the baby NPO for 4 hours to avoid vomiting
C. Changing the dressing frequently using dry, sterile gauze
D. Taking the baby to his mother for cuddling
Answer: D

Explanation:
(A) A pressure diaper should be applied to discourage hemorrhage.
(B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any
distress and is stable.
(C) Dressing changes should not be dry. Dry dressing will stick.
(D) Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was
withheld prior to the procedure or it is time for a feeding.