NCLEX RN Pharmacology Actualtest Exam Part 2 With Answers-200 Solved Questions

NCLEX-RN
Part 2
QUESTION 201
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6,
and 7 on the left and developed a left pneumothorax. Assessment findings include:
A. Crackles and paradoxical chest wall movement
B. Decreased breath sounds on the left and chest pain with movement
C. Rhonchi and frothy sputum
D. Wheezing and dry cough
Answer: B
Explanation:
(A) Crackles are caused by air moving through moisture in the small airways and occur with
pulmonary edema. Paradoxical chest wall movement occurs with flail chest when a segment
of the thorax moves outward on inspiration and inward on expiration.
(B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain
with movement occurs with rib fractures.
(C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may
occur with pulmonary edema.
(D) Wheezing is caused by fluid in large airways already narrowed by mucus or
bronchospasm. Dry cough could indicate a cardiac problem.
QUESTION 202
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a
closed-chest drainage system, the purpose of the water seal is to:
A. Prevent air from entering the pleural space
B. Prevent fluid from entering the pleural space
C. Provide a means to measure chest drainage
D. Provide an indicator of respiratory effort
Answer: A
Explanation:
(A) A chest tube extends from the pleural space to a collection device. The tube is placed
below the surface of the saline so that air cannot enter the pleural space.

(B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain
fluid from the pleural space, but the water seal is not involved in this.
(C) Chest drainage should be measured, but the water seal is not involved in this.
(D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory
effort, but that is not the purpose of the water seal.
QUESTION 203
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
xray 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.
QUESTION 204

A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her
arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg;
HCO3 32 mEq/L. These blood gases reflect:
A. Compensated metabolic acidosis
B. Compensated respiratory acidosis
C. Compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Answer: B
Explanation:
(A) In compensated metabolic acidosis, the pH level is normal, the PCO2 level is decreased,
and the HCO3 level is decreased. The client's primary alteration is an inability to remove
excess acid via the kidneys. The lungs compensate by hyperventilating and decreasing PCO2.
(B) In compensated respiratory acidosis, the pH level is normal, the PCO2 level is elevated,
and the HCO3 level is elevated. The client's primary alteration is an inability to remove CO2
from the lungs, so over time, the kidneys increase reabsorption of HCO3 to buffer the CO2.
(C) In compensated respiratory alkalosis, the pH level is normal, the PCO2 level is decreased,
and the HCO3 level is decreased. The client's primary alteration is hyperventilation, which
decreases PCO2. The client compensates by increasing the excretion of HCO3 from the body.
(D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2 level is
increased, and the HCO3 level is normal. The client's primary alteration is an inability to
remove CO2 from the lungs. The kidneys have not compensated by increasing HCO3
reabsorption.
QUESTION 205
A female client who has chronic obstructive pulmonary disease (COPD) has presented in the
emergency department with cough productive of yellow sputum and increasing shortness of
breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2
55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:
A. Compensated respiratory acidosis
B. Normal blood gases
C. Uncompensated metabolic acidosis
D. Uncompensated respiratory acidosis
Answer: D
Explanation:

(A) In compensated respiratory acidosis, the pH level is normal, the PCO2 level is elevated,
and the HCO3 level is elevated. The client's primary alteration is an inability to remove CO2
from the lungs, so over time, the kidneys increase reabsorption of HCO3 to buffer the CO2.
(B) Normal ranges for arterial blood gases for adults and children are as follows: pH
7.357.45, PO2 80100 mm Hg, PCO2 3545 mm Hg, HCO3 2128 mEq/L.
(C) In uncompensated metabolic acidosis the pH level is decreased, the PCO2 level is normal,
and the HCO3 level is decreased. The client's primary alteration is an inability to remove
excess acid via the kidneys. The lungs are unable to clear the increased acid.
(D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2 level is
increased, and the HCO3 level is normal. In a person with long-standing COPD, the HCO3
level will rise gradually over time to compensate for the gradually increasing PCO2, and the
person's pH level will be normal. When a person with COPD becomes acutely ill, the kidneys
do not have time to increase the reabsorption of HCO3, so the person's pH level will reflect
acidosis even though the HCO3 is elevated.
QUESTION 206
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being
partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he
has been transferred from the intensive care unit. A potential life-threatening complication the
nurse monitors the client for is:
A. Autonomic dysreflexia
B. Bradycardia
C. Central cord syndrome
D. Spinal shock
Answer: A
Explanation:
(A) Autonomic dysreflexia is the exaggerated sympathetic nervous system response to
various stimuli in the anesthetized area. Sympathetic stimulation results in severe,
uncontrolled hypertension, which may result in myocardial infarction or cerebral hemorrhage.
(B) Bradycardia occurs as a result of sympathetic blockade in the immediate postinjury
period. After spinal shock recedes, cardiovascular stability returns, but the client will be
bradycardiac for life.
(C) Central cord syndrome is a specific type of spinal cord injury that occurs as a result of
either hyperextension injuries or disrupted blood flow to the spinal cord.

(D) Spinal shock occurs in the immediate postinjury phase and usually resolves in
approximately 72 hours.
QUESTION 207
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize
himself. When he says, "This is too much trouble. I would rather just have a Foley.'' An
appropriate response for the RN teaching him would be:
A. "I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if
you do an intermittent catheterization program.''
B. "It is not too much trouble. This is the best way to manage urination.''
C. "OK. I'll ask your physician if we can replace the Foley.''
D. "You need to learn this because your doctor ordered it.''
Answer: A
Explanation:
(A) This response acknowledges the client's feelings, gives him factual information, and
acknowledges that the final decision is his.
(B) This response is judgmental and discourages the client from expressing his feelings about
the procedure.
(C) Catheterization is a procedure that takes time to learn, but which, for the spinal cord
injured client, can significantly reduce the incidence of urinary tract infections. A young
client with a T-4 injury has the hand function to learn this procedure fairly easily.
(D) The final decision about bladder elimination management ultimately rests with the client
and not the physician.
QUESTION 208
A client's physician has prescribed theophylline (Theo- Dur) to help control the
bronchospasm associated with the client's COPD. Instructions that should be given to the
client include:
A. "Call your physician if you develop palpitations, dizziness, or restlessness.''
B. "Cigarette smoking may significantly increase the risk for theophylline toxicity.''
C. "Take this medication on an empty stomach.''
D. "Do not take your medicine if your pulse is less than 60 beats per minute.''
Answer: A
Explanation:

(A) Indications of theophylline toxicity include palpitations, dizziness, restlessness, nausea,
vomiting, shakiness, and anorexia.
(B) Cigarette smoking significantly lowers theophylline plasma levels.
(C) Theophylline should be taken with food to decrease stomach upset.
(D) These instructions are appropriate for someone taking digoxin.
QUESTION 209
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose
consciousness but was taken to the emergency department by a friend to have a scalp
laceration sutured. The nurse instructs the client to:
A. Clean the sutured laceration twice a day with povidone- iodine (Betadine)
B. Remove his scalp sutures after 5 days
C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
D. Take meperidine 50 mg po q46h prn for headache
Answer: C
Explanation:
(A) Povidone-iodine is very irritating to skin and should not be routinely used.
(B) Sutures should not be removed by the client.
(C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial
pressure as a result of intracerebral bleeding.
(D) Use of a narcotic opiate such as meperidine is not recommended in clients with a possible
head injury because it may produce sedation, pupil changes, euphoria, and respiratory
depression, which may mask the signs of increasing intracranial pressure.
QUESTION 210
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs
tid in addition to his other medications. After taking his beclomethasone, the client should be
instructed to:
A. Clean his inhaler with warm water and soak it in a10% bleach solution
B. Drink a glass of water
C. Sit and rest
D. Use his bronchodilator inhaler
Answer: B
Explanation:

(A) Inhalers should be cleaned once a day. They should be taken apart, washed in warm
water, and dried according to manufacturer's instructions. Soaking in bleach is inappropriate.
(B) A common side effect of inhaled steroid preparations is oral candidal infection. This can
be prevented by drinking a glass of water or gargling after using a steroid inhaler.
(C) There is nothing wrong with sitting and resting after using a steroid inhaler, but it is not
necessary.
(D) If a person is using a steroid inhaler as well as a bronchodilator inhaler, the
bronchodilator should always be used first. The reason for this is that the bronchodilator
opens up the person's airways so that when the steroid inhaler is used next, there will be
better distribution of medication.
QUESTION 211
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been
intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds
were found to be absent on the left side. The nurse identifies the most likely cause of this as:
A. Inappropriate endotracheal tube size
B. Left-sided pneumothorax
C. Right mainstem bronchus intubation
D. Pneumonia
Answer: C
Explanation:
(A) Appropriate endotracheal tube sizes for adults range from 7.08.5 mm.
(B) Pneumothorax could be indicated by an absence of breath sounds on the affected side.
However, in a recently intubated client, the first priority would be to consider tube
malposition.
(C) During intubation, the right mainstem bronchus can be inadvertently entered if the
endotracheal tube is inserted too far. Left mainstem bronchus intubation almost never occurs
because of the angle of the left mainstem bronchus.
(D) Breath sounds for someone with pneumonia may be decreased over the areas of
consolidation. However, in a recently intubated client, the first priority would be to consider
tube malposition.
QUESTION 212

A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him
using a smallbore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the
nurse identifies the most reliable way to confirm appropriate placement is to:
A. Aspirate gastric contents
B. Auscultate air insufflated through the tube
C. Obtain a chest x-ray
D. Place the tip of the tube under water and observe for air bubbles
Answer: C
Explanation:
(A) Aspiration of gastric contents is usually a reliable way to verify tube placement.
However, if the client has dark respiratory secretions from bleeding, tube feedings could be
mistaken for respiratory secretions; in other words, aspirating an empty stomach is less
reliable in this instance. In addition, it is common for small-bore feeding tubes to collapse
when suction pressure is applied.
(B) Insufflation of air into large-bore nasogastric tubes can usually be clearly heard. In
smallbore tubes, it is more difficult to hear air, and it is difficult to distinguish between air in
the stomach and air in the esophagus.
(C) A chest x-ray is the most reliable means to determine placement of small-bore nasogastric
tubes.
(D) Observing for air bubbles when the tip is held under water is an unreliable means to
determine correct tube placement for all types of nasogastric tubes. Air may come from both
the respiratory tract and the stomach, and the client who is breathing shallowly may not force
air out of the tube into the water.
QUESTION 213
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.
QUESTION 214
A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood
transfusions for bleeding. One potential complication of blood administration for which she is
especially at risk is:
A. Air embolus
B. Circulatory overload
C. Hypocalcemia
D. Hypokalemia
Answer: C
Explanation:
(A) Air embolism is a potential complication of blood administration, but it is fairly rare and
can be prevented by using good IV technique.
(B) Circulatory overload is a potential complication of blood administration, but because this
client is actively bleeding, she is not at high risk for overload.
(C) Hypocalcemia is a potential complication of blood administration that occurs in situations
where massive transfusion has occurred over a short period of time. It occurs because the
citrate in stored blood binds with the client's calcium. Another potential complication for
which this client is especially at risk is hypothermia, which can be prevented by using a blood
warmer to administer the blood.
(D) Hypokalemia is not a complication of blood administration.
QUESTION 215

A 67-year-old client will be undergoing a coronary arteriography in the morning. Client
teaching about post procedure nursing care should include that:
A. Bed rest with bathroom privileges will be ordered
B. He will be kept NPO for 812 hours
C. Some oozing of blood at the arterial puncture site is normal
D. The leg used for arterial puncture should be kept straight for 812 hours
Answer: D
Explanation:
(A) Bed rest will be ordered for 812 hours post procedure. Flexing of the leg at the arterial
puncture site will occur if the client gets out of bed, and this is contraindicated after
arteriography.
(B) The client will be able to eat as soon as he is alert enough to swallow safely and that will
depend on what medications are used for sedation during the procedure.
(C) Oozing at the arterial puncture site is not normal and should be closely evaluated.
(D) The leg where the arterial puncture occurred must be kept straight for 812 hours to
minimize the risk of bleeding.
QUESTION 216
A client had a myocardial infarction 5 days ago. His physician has ordered an
echocardiogram to determine how his myocardial infarction has affected his ventricular wall
motion. When the client asks if this test is painful, an appropriate response is:
A. "No, but you must be able to ride on a stationary bicycle while the test is being
performed."
B. "No, but you will have to lie still and the gel that is used may be cool."
C. "Yes, but your physician will be there and will order pain medicine for you."
D. "Your physician has ordered medicine, which you will be given before you go for the test,
which will make you sleepy."
Answer: B
Explanation:
(A) Riding a stationary bicycle or walking on a treadmill is done during a stress test.
(B) During an echocardiogram, the client must lie supine while a technician performs the test.
To perform the test, the technician uses a conductive gel and a transducer to obtain ultrasound
tracings of the heart.

(C) A physician need not be present during an echocardiogram, and it is neither invasive nor
painful.
(D) There is no premedication required for an echocardiogram.
QUESTION 217
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a
low- sodium diet for him. When he asks, "What does salt have to do with high blood
pressure?'' the nurse's initial response would be:
A. "The reason is not known why hypertension is associated with a high-salt diet."
B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your
blood pressure."
C. "Salt affects your blood vessels and causes your blood pressure to be high."
D. "Salt is needed to maintain blood pressure, but too much causes hypertension."
Answer: B
Explanation:
(A) This response is untrue.
(B) Decreasing salt intake reduces fluid retention and decreases blood pressure.
(C) Salt does not have an effect on the blood vessels themselves, but on fluid retention, which
accompanies salt intake.
(D) This response is untrue.
QUESTION 218
A client has consented to have a central venous catheter placed. The best position in which to
place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
A. Allows the physician to visualize the subclavian vein
B. Reduces the possibility of air embolism
C. Reduces the possibility of hematoma formation
D. Makes the procedure more comfortable for the client
Answer: B
Explanation:
(A) The subclavian vein is not visible during central line insertion regardless of the client's
position.

(B) The Trendelenburg position reduces the possibility of air embolism because it places
slight positive pressure on the central veins. It also distends the veins, and distention
facilitates insertion.
(C) This response is untrue; it has no effect on hematoma formation.
(D) This position is not necessarily more comfortable for the client, and many clients,
especially those who may be short of breath, may find the position uncomfortable and
difficult to maintain.
QUESTION 219
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the
nurse recognize as the earliest clinical sign of respiratory distress?
A. Cyanosis
B. Increased respirations
C. Sternal and subcostal retractions
D. Decreased respirations
Answer: C
Explanation:
(A) Cyanosis is a late clinical sign of respiratory distress.
(B) Rapid respirations are normal in a newborn.
(C) The newborn has to exert an extra effort for ventilation, which is accomplished by using
the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature
and weak in the newborn.
(D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations
precede respiratory failure.
QUESTION 220
A nurse is performing a vaginal exam on a client in active labor. An important landmark to
assess during labor and delivery are the ischial spines because:
A. Ischial spines are the narrowest diameter of the pelvis
B. Ischial spines are the widest diameter of the pelvis
C. They represent the inlet of birth canal
D. They measure pelvic floor
Answer: A
Explanation:

(A) The fetal descent, or station, is determined by the relationship of the presenting part to the
spine.
(B) Ischial spines are the narrowest measurement.
(C) Ischial spines measure the pelvic outlet.
(D) Pelvic floor measurement is not related to fetal descent.
QUESTION 221
The nurse instructs a client on the difference between true labor and false labor. The nurse
explains, "In true labor:
A. Uterine contractions will weaken with walking."
B. Uterine contractions will strengthen with walking."
C. The cervix does not dilate."
D. The fetus does not descend."
Answer: B
Explanation:
(A) Uterine contractions increase with activity.
(B) Walking will increase the strength and regularity of uterine contractions in true labor.
(C) Uterine contractions that are strong and regular facilitate cervical dilation.
(D) Regular, strong uterine contractions, as in true labor, result in fetal descent.
QUESTION 222
A first-trimester primigravida is diagnosed with anemia. The nurse should suspect that this
anemia is a result of:
A. Mother's increased blood volume
B. Mother's decreased blood volume
C. Fetal blood volume increase
D. Increase in iron absorption
Answer: A
Explanation:
(A) Maternal blood volume increases at the end of the first trimester leading to a dilutional
anemia.
(B) Maternal blood volume increases.
(C) Fetal blood volume is minimal in the first trimester.

(D) Increased iron absorption would facilitate the manufacturing of erythrocytes and decrease
anemia.
QUESTION 223
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with
ingestion of drugs during:
A. First trimester
B. Second trimester
C. Third trimester
D. Every trimester
Answer: A
Explanation:
(A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation
during this period.
(B) Organogenesis has occurred by the second trimester.
(C) Fetal development is complete by this time.
(D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy.
QUESTION 224
A laboring client presents with a prolapsed cord. The nurse should immediately place the
client in what position?
A. Reverse Trendelenburg
B. Fowler's
C. Trendelenburg
D. Sims'
Answer: C
Explanation:
(A) Reverse Trendelenburg position increases pressure on the perineum. This position will
not relieve cord pressure.
(B) Fowler's position increases perineal pressure. Cord pressure would not be relieved.
(C) Trendelenburg position will decrease perineal pressure. Cord compression will be
decreased and increase in fetal blood flow occurs.
(D) Sims' position does not relieve pressure on cord or perineum.

QUESTION 225
A client suspects that she is pregnant. She reports two missed menstrual periods. The first day
of her last menstrual period was August 3. Her estimated date of confinement would be:
A. November 7
B. November 10
C. May 7
D. May 10
Answer: D
Explanation:
(A) Wrong calculation
(B) Wrong calculation
(C) Wrong calculation
(D) Nägele's rule is: Expected Date of Confinement = Last Menstrual Period - 3 months + 7
days + 1 year
QUESTION 226
An elective saline abortion has been performed on a 3- week primigravida. Following the
procedure, the nurse should be alert for which early side effect?
A. Water satiety
B. Thirst
C. Edema
D. Diabetes insipidus
Answer: B
Explanation:
(A) If the client is experiencing water satiety, there is no more desire for water.
(B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium
and desire for water.
(C) Edema can be a late side effect caused by water intoxication.
(D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.
QUESTION 227
Assessment of a newborn for Apgar scoring includes observation for:
A. Pupil response
B. Respiratory rate

C. Heart rate
D. Babinski's reflex
Answer: C
Explanation:
(A) Pupil response should be assessed but is not part of Apgar scoring.
(B) Respiratory effort is an essential part of Apgar scoring, not respiratory rate.
(C) Heart rate is the most critical component of Apgar scoring.
(D) Assessment of Babinski's reflex is not a component of Apgar scoring.
QUESTION 228
Painless vaginal bleeding in the last trimester may be caused by:
A. Menstruation
B. Abruptio placentae
C. Placenta previa
D. Polyhydramnios
Answer: C
Explanation:
(A) Menstruation should not occur during pregnancy.
(B) Abruptio placentae is marked by painful vaginal bleeding following a premature placental
detachment after 20th week of gestation.
(C) A low-lying placenta separates from the uterine wall as the uterus contracts and cervix
dilates. This separation causes painless bleeding in the 7th-8th month.
(D) Polyhydramnios is excessive amniotic fluid.
QUESTION 229
The nurse should facilitate bonding during the postpartum period. What should the nurse
expect to observe in the taking-hold phase?
A. Mother is concerned about her recovery.
B. Mother calls infant by name.
C. Mother lightly touches infant.
D. Mother is concerned about her weight gain.
Answer: B
Explanation:

(A) This observation can be made during the taking-in phase when the mother's needs are
more important.
(B) This observation can be made during the taking hold phase when the mother is actively
involved with herself and the infant.
(C, D) This observation can be made during the taking-in phase.
QUESTION 230
The physician is preparing to induce labor on a 40-week multigravida. The nurse should
anticipate the administration of:
A. Oxytocin (Pitocin)
B. Progesterone
C. Vasopressin (Pitressin)
D. Ergonovine maleate
Answer: A
Explanation:
(A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition
that produces strong uterine contractions.
(B) Progesterone has a quiescence effect on the uterus.
(C) Vasopressin is an antidiuretic hormone that promotes water reabsorption by the renal
tubules.
(D) Ergonovine produces dystocia as a result of sustained uterine contractions.
QUESTION 231
A primigravida is at term. The nurse can recognize the second stage of labor by the client's
desire to:
A. Push during contractions
B. Hyperventilate during contractions
C. Walk between contractions
D. Relax during contractions
Answer: A
Explanation:
(A) The second stage of labor is characterized by uterine contractions, which cause the client
to bear down.

(B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is
abnormal breathing resulting from loss of pain control.
(C) The client should remain on bed rest during labor.
(D) Contractions result in discomfort.
QUESTION 232
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should
recognize this as the:
A. Fourth stage of labor
B. Third stage of labor
C. Transition stage of labor
D. Second stage of labor
Answer: C
Explanation:
(A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue;
chills; scant, bloody vaginal discharge; and nausea.
(B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine
contractions, gush of blood, and perineal pain.
(C) The transition stage is characterized by strong uterine contractions and cervical dilation.
Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting.
(D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal
bulge, pushing with contractions, great irritability, and leg cramps.
QUESTION 233
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is
to:
A. Assess the client's respirations
B. Notify the physician
C. Auscultate fetal heart rate
D. Transfer to delivery suite
Answer: C
Explanation:
(A) Immediately following membrane rupture, the fetus is at risk for complications, not
necessarily the mother.

(B) The physician is notified after the nurse completes an assessment of the mother's and
fetus's conditions.
(C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse,
which is assessed by auscultating fetal heart rate.
(D) Rupture of membranes does not necessarily indicate readiness to deliver.
QUESTION 234
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous
delivery is to:
A. Control the delivery by guiding expulsion of fetus
B. Leave the room to call the physician
C. Push against the perineum to stop delivery
D. Cross client's legs tightly
Answer: A
Explanation:
(A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations.
(B) The nurse should always remain with a client experiencing a precipitous delivery.
(C) Pushing against the perineum may cause fetal distress.
(D) Crossing of legs may cause fetal distress and does not stop the delivery process.
QUESTION 235
Following a vaginal delivery, the postpartum nurse should observe for:
A. Dystocia, kraurosis
B. Chadwick's sign
C. Fatigue, hemorrhoids
D. Hemorrhage and infection
Answer: D
Explanation:
(A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of
skin and any mucous membrane (vulva).
(B) Chadwick's sign is a bluish color of vaginal mucosa suggestive of pregnancy.
(C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with
pregnancy.

(D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage
may result from retained placental fragments or soft uterus. Infection may occur from the
introduction of organisms into the uterus during the delivery.
QUESTION 236
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the
physician ordering:
A. Oxytocin
B. Magnesium sulfate (MgSO4)
C. Ampicillin
D. Tetracycline
Answer: C
Explanation:
(A) Oxytocin is prescribed to stimulate uterine contractions.
(B) MgSO4 is a central nervous system depressant prescribed to prevent and control
convulsions related to preeclampsia.
(C) Ampicillin is a penicillin derivative with no known teratogenic effects. This is the safest
antibiotic during pregnancy.
(D) Tetracycline stains teeth yellow and is not as safe as ampicillin during pregnancy.
QUESTION 237
A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking
reflex. The nurse should suspect:
A. Central nervous system damage
B. Hypoglycemia
C. Hyperglycemia
D. These are normal newborn responses to extrauterine life
Answer: B
Explanation:
(A) Central nervous system damage presents as seizures, decreased arousal, and absence of
newborn reflexes.
(B) In a diabetic mother, the infant is exposed to high serum glucose. The fetal pancreas
produces large amounts of insulin, which causes hypoglycemia after birth.

(C) Hypoglycemia is a common newborn problem. Increased insulin production causes
hypoglycemia, not hyperglycemia.
(D) These are not normal adaptive behaviors to extrauterine life.
QUESTION 238
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the
risk of retrolental fibroplasia is to:
A. Maintain O2 at 40%
C. Give moist O2 at>40%
D. Maintain on 100% O2
Answer: A
Explanation:
(A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2 in
premature infants. Complications are hemorrhage and retinal detachment.
(B, C, D) O2 concentration is too high.
QUESTION 239
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe
anxiety disorder. The first nursing action is to:
A. Demand that she relax
B. Ask what is the problem
C. Stand or sit next to her
D. Give her something to do
Answer: C
Explanation:
(A) This nursing action is too controlling and authoritative. It could increase the client's
anxiety level.
(B) In her anxiety state, the client cannot rationally identify a problem.
(C) This nursing action conveys a message of caring and security.
(D) Giving the client a task would increase her anxiety. This would be a late nursing action.
QUESTION 240

A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to
observe?
A. Anger
B. Apathy and flatness
C. Smiling
D. Hostility
Answer: B
Explanation:
(A) Anger is an emotion that is not necessarily present in schizophrenia.
(B) Lack of response to or involvement with environment and distancing are characteristic of
schizophrenia.
(C) Euphoria is more characteristic of manic-depressive disorder (bipolar disorder).
(D) Hostility is an emotion that is not necessarily present in schizophrenia.
QUESTION 241
A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of
food binges followed by self-induced vomiting (purging). The nurse should suspect a
diagnosis of:
A. Anorexia nervosa
B. Anorexia hysteria
C. Bulimia
D. Conversion reaction
Answer: C
Explanation:
(A) Anorexia nervosa is characterized by self-starvation.
(B) Anorexia hysteria is not a known disease or disorder.
(C) Bulimia is characterized by food binges and self-induced vomiting.
(D) Conversion reaction is a defense mechanism.
QUESTION 242
A 24-year-old client presents to the emergency department protesting "I am God." The nurse
identifies this as a:
A. Delusion
B. Illusion

C. Hallucination
D. Conversion
Answer: A
Explanation:
(A) Delusion is a false belief.
(B) Illusion is the misrepresentation of a real, external sensory experience.
(C) Hallucination is a false sensory perception involving any of the senses.
(D) Conversion is the expression of intrapsychic conflict through sensory or motor
manifestations.
QUESTION 243
A 30-year-old client has a history of several recent traumatic experiences. She presents at the
physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal
no organic cause. The nurse recognizes this as:
A. Delusion
B. Illusion
C. Hallucination
D. Conversion
Answer: D
Explanation:
(A) The client's blindness is real. Delusion is a false belief.
(B) Illusion is the misrepresentation of a real, external sensory experience.
(C) Hallucination is a false sensory perception involving any of the senses.
(D) Conversion is the expression of intrapsychic conflict through sensory or motor
manifestations.
QUESTION 244
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his
admission, he has become dependent and demanding to the nursing staff. The nurse identifies
this behavior as which defense mechanism?
A. Denial
B. Displacement
C. Regression
D. Projection

Answer: C
Explanation:
(A) Denial is the disowning of consciously intolerable thoughts.
(B) Displacement is the referring of a feeling or emotion from one person, object, or idea to
another.
(C) Regression is returning to an earlier stage of development.
(D) Projection is attributing one's own thoughts, feelings, or impulses to another person.
QUESTION 245
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.
QUESTION 246
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on
benztropine (Cogentin). What would indicate that benztropine therapy is effective?
A. Smooth, coordinated voluntary movement
B. Tremors
C. Rigidity
D. Muscle weakness
Answer: A
Explanation:

(A) Benztropine is prescribed to decrease or alleviate extrapyramidal side effects of major
tranquilizers. Smooth, coordinated voluntary movement indicates minimal extrapyramidal
side effects.
(B) Tremors are an extrapyramidal side effect.
(C) Rigidity is an extrapyramidal side effect.
(D) Muscle weakness is an extrapyramidal side effect.
QUESTION 247
A client is diagnosed with organic brain disorder. The nursing care should include:
A. Organized, safe environment
B. Long, extended family visits
C. Detailed explanations of procedures
D. Challenging educational programs
Answer: A
Explanation:
(A) A priority nursing goal is attending to the client's safety and well-being. Reorient
frequently, remove dangerous objects, and maintain consistent environment.
(B) Short, frequent visits are recommended to avoid overstimulation and fatigue.
(C) Short, concise, simple explanations are easier to understand.
(D) Mental capability and attention span deficits make learning difficult and frustrating.
QUESTION 248
A 4-year-old child has Down syndrome. The community health nurse has coordinated a
special preschool program. The nurse's primary goal is to:
A. Provide respite care for the mother
B. Facilitate optimal development
C. Provide a demanding and challenging educational program
D. Prepare child to enter mainstream education
Answer: B
Explanation:
(A) Respite care for the family may be needed, but it is not the primary goal of a preschool
program.
(B) Facilitation of optimal growth and development is essential for every child.

(C) A demanding and challenging educational program may predispose the child to failure.
Children with retardation should begin with simple and challenging educational programs.
(D) Mental retardation associated with Down syndrome may not permit mainstream
education. A preschool program’s primary goal is not preparation for mainstream education
but continuation of optimal development.
QUESTION 249
A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the
pain, the nurse should:
A. Place on bed rest; elevate and splint the right knee
B. Apply moist heat to the right knee
C. Administer aspirin for pain
D. Encourage active range of motion to right knee
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.
QUESTION 250
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral
formula. The nurse should feed the infant with:
A. Gavage tube
B. Nipple and bottle
C. A straw and cup
D. Syringe
Answer: D
Explanation:
(A) A gavage tube may damage suture line. It is the most invasive and should be the last
measure.
(B) A nipple and bottle require sucking, which may damage sutures.

(C) A 3-month-old infant is not able to drink from a straw.
(D) A syringe allows for the formula to be placed to the side and back of the mouth. This
minimizes the amount of sucking needed.
QUESTION 251
A 3-year-old child is admitted with a diagnosis of possible noncommunicating
hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
A. Bulging fontanelles
B. Seizure
C. Headache
D. Ataxia
Answer: C
Explanation:
(A) Bulging fontanelles are a symptom of increased intracranial pressure in infants.
(B) Seizure is a late sign of increased intracranial pressure.
(C) Headache is a very early symptom of increased intracranial pressure in the child.
(D) Ataxia is a late sign of increased intracranial pressure.
QUESTION 252
What is the appropriate nursing action for a child with increased intracranial pressure?
A. Head of bed elevated 45 degrees with child's head maintained in a neutral position
B. Child lying flat
C. Head turned to side
D. Frequent visitation for stimulation
Answer: A
Explanation:
(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal
fluid.
(B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage.
(C) Head turned to either side impedes cerebrospinal fluid drainage.
(D) Child should be in a calm, quiet environment with minimal stimulation.
QUESTION 253

A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position
the client?
A. Head of bed elevated 30 degrees on nonoperative side
B. Head of bed elevated 30 degrees on operative side
C. Bed flat on operative side
D. Bed flat on nonoperative side
Answer: D
Explanation:
(A) Elevation of head on nonoperative side would be the position for the late postoperative
period.
(B) Positioning on operative side puts pressure on the suture lines and on the shunt valve.
Elevation of head in immediate postoperative period may cause rapid reduction of
cerebrospinal fluid.
(C) Placement on operative side puts pressure on the suture lines and shunt valve.
(D) Flat position on nonoperative side in the immediate postoperative period prevents
pressure on shunt valve and rapid reduction in cerebrospinal fluid.
QUESTION 254
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the
primary nursing goal in the nursery during the first hours for this newborn?
A. Bonding
B. Maintain normal blood sugar
C. Maintain normal nutrition
D. Monitor intake and output
Answer: B
Explanation:
(A) Bonding is necessary but would not be the priority with this newborn in the nursery.
(B) The infant will be at risk for hypoglycemia because of excess insulin production.
(C) Normal nutrition is a goal for all newborns.
(D) Monitoring intake and output is necessary but is not the most critical nursing goal.
QUESTION 255

A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing
assessment, which lab value should elicit further assessment and requires notification of
physician?
A. pH 7.39
B. White blood cell(WBC) count 10,000 WBCs/mm3
C. Hematocrit 60%
D. Bleeding time of 4 minutes
Answer: C
Explanation:
(A) Normal pH of arterial blood gases for an infant is 7.357.45.
(B) Normal white blood cell count in an infant is 6,00017,500 WBCs/mm3.
(C) Normal hematocrit in infant is 28%42%. A 60% hematocrit may indicate polycythemia, a
common complication of cyanotic heart disease.
(D) Normal bleeding time is 27 minutes.
QUESTION 256
A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this
type of tubing because it:
A. Prevents administration of other drugs
B. Prevents entry of air into tubing
C. Prevents inadvertent administration of a large amount of fluids
D. Prevents phlebitis
Answer: C
Explanation:
(A) A volume control set has a chamber that permits the administration of compatible drugs.
(B) Air may enter a volume control set when tubing is not adequately purged.
(C) A volume control set allows the nurse to control the amount of fluid administered over a
set period.
(D) Contamination of volume control set may cause phlebitis.
QUESTION 257
Which type of insulin can be administered by a continuous IV drip?
A. Humulin N
B. NPH insulin

C. Regular insulin
D. Lente insulin
Answer: C
Explanation:
(A) Humulin N cannot be administered IV.
(B) NPH insulin cannot be administered IV.
(C) Regular insulin is the only insulin that can be administered IV.
(D) Lente insulin cannot be administered IV.
QUESTION 258
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide
bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
A. 5 mg
B. 0.5 mg
C. 0.05 mg
D. 20 mg
Answer: A
Explanation:
(A) 1 mg = 0.1 mL, then 0.5 mL X= 55 mg.
(B) This answer is a miscalculation.
(C) This answer is a miscalculation.
(D) This answer is a miscalculation.
QUESTION 259
A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20
mEq/15 mL. What dosage should the nurse administer to the infant?
A. 1 mEq
B. 1.13 mEq
C. 2 mEq
D. Not enough information to calculate
Answer: C
Explanation:
(A) This answer is a miscalculation.
(B) This answer is a miscalculation.

(C) 1.33 mEq = 1 mL, then 1.5 mL X=1.99, or 2 mEq.
(D) Information is adequate for calculation.
QUESTION 260
A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for
the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?
A. 125 gtt/min
B. 48 gtt/min
C. 20 gtt/min
D. 21 gtt/min
Answer: D
Explanation:
(A) This answer is a miscalculation.
(B) This answer is a miscalculation.
(C) This answer has not been rounded off to an even number.
(D) 20.8, or 21 gtt/min.
QUESTION 261
A 1000-mL dose of D5W 1/2 normal saline is to be infused in 8 hours. The drop factor for the
tubing is 60 gtt/min. How many drops per minute should the nurse administer?
A. 75 gtt/min
B. 100 gtt/min
C. 125 gtt/min
D. 150 gtt/min
Answer: C
Explanation:
(A) This answer is a miscalculation.
(B) This answer is a miscalculation.
(C)125 gtt/min.
(D) This answer is a miscalculation.
QUESTION 262
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is
using a micro drip tubing set. How many drops per minute should the nurse administer?

A. 1 gtt/min
B. 5 gtt/min
C. 50 gtt/min
D. 100 gtt/min
Answer: C
Explanation:
(A) This answer is a miscalculation.
(B) This answer is a miscalculation.
(C) 50 gtt/min.
(D) This answer is a miscalculation.
QUESTION 263
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the
nurse assess for while conducting a vision screening?
A. Hearing test
B. Gait
C. Strabismus
D. Papilledema
Answer: C
Explanation:
(A) Hearing should be assessed separately.
(B) Gait should be assessed separately. Client usually remains in one place for vision
screening. Gait is part of neurological assessment.
(C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or
ambylopia. It is easily assessed during vision screening.
(D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision
screening. It is part of neurological assessment.
QUESTION 264
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the
emergency room approximately 15 minutes after the accident in excruciating pain with
charred clothing to both legs. What is the first nursing action?
A. Apply ice packs to both legs.
B. Begin débridement by removing all charred clothing from wound.

C. Apply Silvadene cream (silver sulfadiazine).
D. Immerse both legs in cool water.
Answer: D
Explanation:
(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal
injury.
(B) Charred clothing should not be removed from wound first. This creates further tissue
damage. Débridement is not the first nursing action.
(C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases
potential for infection.
(D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water
permits gradual temperature change and prevents further thermal damage.
QUESTION 265
A burn victim's immunization history is assessed by the nurse. Which immunization is of
priority concern?
A. Oral poliovirus vaccine
B. Inactivated poliovirus vaccine
C. Tetanus toxoid
D. Hepatitis B vaccine
Answer: C
Explanation:
(A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact
with an infected person.
(B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals.
Polio is transmitted by direct contact with an infected person.
(C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds.
(D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through
contact with infected blood or body fluids.
QUESTION 266
A newborn has been delivered with a meningomyelocele. The nursery nurse should position
the newborn:
A. Prone

B. Supine
C. Side lying
D. Semi-Fowler
Answer: A
Explanation:
(A) The prone position reduces pressure and tension on the sac. Primary nursing goals are to
prevent trauma and infection of the sac.
(B) The supine position exerts pressure on the sac.
(C) Newborns usually cannot maintain side-lying position.
(D) The semi- Fowler position exerts pressure on the sac.
QUESTION 267
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A. Cover sac with dry sterile dressing
B. Cover sac with saline-soaked sterile dressing
C. Do not apply dressing; keep sac open to air
D. Aspirate any fluid from sac
Answer: B
Explanation:
(A) A dry, sterile dressing would adhere to the sac, causing tissue damage.
(B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents
drying.
(C) A sac open to air causes drying and potential for contamination.
(D) This intervention is not an independent nursing action.
QUESTION 268
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial
blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial
blood gases indicate the presence of:
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Answer: D

Explanation:
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2.
(B) Respiratory acidosis is determined by low pH and elevated PaCO2.
(C) Metabolic alkalosis is determined by elevated pH and HCO3.
(D) Metabolic acidosis is determined by low pH and HCO3.
QUESTION 269
A client presents to the emergency room with cyanosis, coughing, tachypnea, and
tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54,
PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence
of:
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Answer: B
Explanation:
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2.
(B) Respiratory acidosis is determined by low pH and elevated PaCO2.
(C) Metabolic alkalosis is determined by elevated pH and HCO3.
(D) Metabolic acidosis is determined by low pH and HCO3.
QUESTION 270
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of
breath. The physician diagnosed an anterior wall myocardial infarction. What tests should the
nurse anticipate?
A. Reticulocyte count, creatinine phosphokinase (CPK)
B. Aspartate transaminase, alanine transaminase
C. Sedimentation rate, WBC count
D. Lactic dehydrogenase, CPK
Answer: D
Explanation:
(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme
released from injured myocardial tissue.

(B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine
transaminase is an enzyme released for general tissue destruction, which is specific for liver
injury.
(C) Sedimentation rate is a nonspecific test for inflammation.
(D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
QUESTION 271
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.
QUESTION 272
A client is being treated for congestive heart failure. His medical regimen consists of digoxin
(Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the
nurse monitor?
A. Intake and output
B. Calcium
C. Potassium
D. Magnesium
Answer: C
Explanation:
(A) Intake and output are not laboratory tests.
(B) Serum calcium levels are not affected by digoxin or furosemide.

(C) Furosemide is a no potassium-sparing loop diuretic. Hypokalemia is a common side
effect of furosemide and may enhance digoxin toxicity.
(D) Serum magnesium levels are not affected by digoxin or furosemide.
QUESTION 273
In the coronary care unit, a client has developed multifocal premature ventricular
contractions. The nurse should anticipate the administration of:
A. Furosemide
B. Nitroglycerin
C. Lidocaine
D. Digoxin
Answer: C
Explanation:
(A) Furosemide is a loop diuretic.
(B) Nitroglycerin is a vasodilator.
(C) Lidocaine is the drug of choice to treat ectopic ventricular beats.
(D) Digoxin slows down the electrical impulses and increases ventricular contractions, but it
does not rapidly correct ventricular ectopy.
QUESTION 274
A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin
levels indicates toxicity?
A. 0.5 ng/mL
B. 1.0 ng/mL
C. 2.0 ng/mL
D. 3.0 ng/mL
Answer: D
Explanation:
(A) 0.5 ng/mL of digoxin is a subtherapeutic level, not a toxic one.
(B) 1.0 ng/mL is a therapeutic level.
(C) 2.0 ng/mL is a therapeutic level.
(D) Digoxin's therapeutic level is 0.82.0 ng/mL. Digoxin's toxic level is >2.0 ng/mL.
QUESTION 275

A client has developed congestive heart failure secondary to his myocardial infarction.
Discharge diet instructions should emphasize the reduction or avoidance of:
A. Fresh vegetables and fruit
B. Canned vegetables and fruit
C. Breads, cereals, and rice
D. Fish
Answer: B
Explanation:
(A) Fresh vegetables and fruits are excellent sources of essential vitamins.
(B) Canned and frozen foods have a high sodium content. Labels of all canned foods should
be read to determine if sodium is used in any form.
(C) Bread, cereal, and rice are excellent sources of carbohydrates.
(D) Fish is an excellent source of protein.
QUESTION 276
A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication's
effectiveness, the nurse should monitor the:
A. prothrombin time (PT)
B. partial thromboplastin time (PTT)
C. PTT-C
D. Fibrin split products
Answer: A
Explanation:
(A) PT evaluates adequacy of extrinsic clotting pathway. Adequacy of warfarin therapy is
monitored by PT.
(B) PTT evaluates adequacy of intrinsic clotting pathway. Adequacy of heparin therapy is
monitored by PTT.
(C) There is no such laboratory test.
(D) Fibrin split products indicate fibrinolysis. This is a screening test for disseminated
intravascular coagulation. Heparin therapy may increase fibrin split products.
QUESTION 277
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to
assess:

A. Respiratory rate for 1 minute
B. Radial pulse for 1 minute
C. Radial pulse for 2 minutes
D. Apical pulse for 1 minute
Answer: D
Explanation:
(A) Respiratory rate is not directly affected by digoxin therapy.
(B) A radial pulse is not as accurate as an apical pulse. Dysrhythmias may not be detected.
(C) A radial pulse is not as accurate as an apical pulse, regardless of assessment time.
(D) Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin
decreases the heart rate. Digoxin should be withheld if apical rates are 120 bpm.
QUESTION 278
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation,
intubated, and receives mechanical ventilation. When performing suctioning, the nurse
should:
A. Suction for a maximum of 20 seconds
B. Hyperoxygenate before and after suctioning
C. Suction for a maximum of 30 seconds
D. Maintain clean technique during suctioning
Answer: B
Explanation:
(A) The maximum time for suctioning is 1015 seconds.
(B) Supplemental O2 should be administered before and after suctioning to reduce hypoxia.
(C) The maximum time for suctioning is 1015 seconds.
(D) Strict sterile technique should be used during suctioning.
QUESTION 279
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.
QUESTION 280
Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?
A. Monitor liver function.
B. Monitor renal function.
C. Assess knowledge of respiratory isolation.
D. Monitor compliance with drug therapy.
Answer: D
Explanation:
(A) Monitoring liver function will not prevent the development of drug-resistant organisms.
(B) Monitoring renal function will not prevent the development of drug resistant organisms.
(C) Knowledge of respiratory isolation will reduce transmission of tuberculosis but will not
prevent development of drug-resistant organisms.
(D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of
drug-resistant organisms. Noncompliance permits the mutation of organisms.
QUESTION 281
To facilitate maximum air exchange, the nurse should position the client in:
A. High Fowler
B. Orthopneic
C. Prone
D. Flat-supine
Answer: B
Explanation:
(A) The high Fowler position does increase air exchange, but not to the extent of orthopneic
position.
(B) The orthopneic position is a sitting position that allows maximum lung expansion.

(C) The prone position places pressure on diaphragm and does not promote maximum air
exchange.
(D) The flat-supine position places pressure on diaphragm by abdominal organs and does not
promote maximum air exchange.
QUESTION 282
A client has been diagnosed with congestive heart failure. His fluid intake and output are
strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake
would be recorded as:
A. 500 mL
B. 540 mL
C. 600 mL
D. 655 mL
Answer: B
Explanation:
(A, C, D) This answer is a miscalculation.
(B) 1 oz = 30 mL; therefore, 18 oz x.
QUESTION 283
The client tells the nurse, "I have pain in my left shoulder." This is considered:
A. Evaluation process
B. Objective information
C. Subjective information
D. Complaining
Answer: C
Explanation:
(A) Evaluation process follows a nursing intervention.
(B) Objective information can be measured.
(C) Subjective information is provided by a person.
(D) Client is reporting a symptom that needs to be assessed.
QUESTION 284
Before completing a nursing diagnosis, the nurse must first:
A. Write goals and objectives

B. Perform an assessment
C. Plan interventions
D. Perform evaluation
Answer: B
Explanation:
(A) Goals and objectives are based on a nursing assessment and diagnosis.
(B) Assessment is the first step of nursing process.
(C) Interventions are nursing actions to meet goals and objectives.
(D) Evaluation process follows nursing interventions.
QUESTION 285
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and
febrile. The physician orders enteral feedings intermittently by nasogastric tube. When
inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will
instruct the client to:
A. Tilt her head backwards
B. Swallow as tube passes
C. Hold breath as tube passes
D. Cough as tube passes
Answer: B
Explanation:
(A) Head should be tilted slightly forward to facilitate insertion.
(B) Swallowing assists with insertion of tube and closes off airway.
(C) Client should be swallowing as tube passes; holding the breath facilitates nothing.
(D) Coughing may expel tube.
QUESTION 286
When assessing residual volume in tube feeding, the feeding should be delayed if the amount
of gastric contents (residual) exceeds:
A. 20 mL
B. 25 mL
C. 30 mL
D. 50 mL
Answer: D

Explanation:
(A) A residual volume of 20 mL is not excessive.
(B) A residual volume of 25 mL is not excessive.
(C) A residual volume of 30 mL is not excessive.
(D) Tube feedings should be withheld and physician notified for residual volumes of 50100
mL.
QUESTION 287
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The
nurse would expect him to be on which type of diet?
A. High protein and high calorie
B. High calorie and high carbohydrate
C. Low-fat 2-g sodium diet
D. High protein and high fat
Answer: B
Explanation:
(A) A high-protein diet is contraindicated in hepatic disease.
(B) High carbohydrates provide high-caloric content to prevent tissue catabolism.
(C) A low-fat 2-g sodium diet is a cardiac diet; however, a low-fat diet would be beneficial.
(D) A high-protein and high-fat diet is contraindicated in hepatic disease.
QUESTION 288
A client has ascites, which is caused by:
A. Decreased plasma proteins
B. Electrolyte imbalance
C. Decreased renal function
D. Portal hypertension
Answer: A
Explanation:
(A) A decrease in plasma proteins causes a decrease in intravascular osmotic pressure
resulting in leakage of fluid into peritoneal cavity.
(B) Fluid and electrolyte imbalance may occur as a result of the ascites.
(C) Ascites is a result of hepatic malfunction, not renal malfunction.
(D) Portal hypertension causes esophageal varices, not ascites.

QUESTION 289
A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be
prepared to administer?
A. Vitamin C
B. Vitamin K
C. Vitamin E
D. Vitamin A
Answer: B
Explanation:
(A) Vitamin C does not directly affect clotting.
(B) Vitamin K is a fat-soluble vitamin that depends on liver function for absorption. Vitamin
K is essential for clotting.
(C) Vitamin E does not directly affect clotting.
(D) Vitamin A does not directly affect clotting.
QUESTION 290
A 45-year-old client has a permanent colostomy. Which of the following foods should he
avoid?
A. Peanut butter and jelly sandwich and milk
B. Corn beef and cabbage and boiled potatoes
C. Oatmeal, whole-wheat toast, and milk
D. Tuna on whole-wheat bread and iced tea
Answer: B
Explanation:
(A, C, D) These foods are allowed with a colostomy.
(B) Gas forming foods such as cabbage should be avoided.
QUESTION 291
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa.
The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse
would suspect that this lesion is:
A. Xerosteromia
B. Candidiasis

C. Leukoplakia
D. Stomatitis
Answer: C
Explanation:
(A) Xerostomia is dry mouth.
(B) Candidiasis can be rubbed off, but it will bleed.
(C) Leukoplakia cannot be rubbed off.
(D) Stomatitis is caused by candidiasis and gram-negative bacteria.
QUESTION 292
A client on the infectious disease unit is discussing transmission of human immunodeficiency
virus (HIV). The nurse would need to provide more client education based on which client
statement?
A. "HIV is a virus transmitted by sexual contact."
B. "Condoms reduce the transmission of HIV."
C. "HIV is a virus that is easily transmitted by casual contact."
D. "HIV can be transmitted to an unborn infant."
Answer: C
Explanation:
(A) HIV is transmitted through unprotected sexual contact.
(B) Condoms are an effective barrier to prevent HIV transmission.
(C) HIV is not easily transmitted by casual contact.
(D) HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.
QUESTION 293
A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse's
knowledge of the central nervous system, the nurse knows that benign tumors:
A. Can be just as dangerous as malignant tumors
B. Grow more rapidly than malignant tumors
C. Do not warrant concern because they do not become malignant tumors
D. Can be removed surgically
Answer: A
Explanation:

(A) Both a benign and a malignant tumor can displace or destroy nearby structures or
increase intracranial pressure.
(B) Benign or malignant brain tumors grow at different rates depending on the type of tumor.
(C) Some benign tumors do become malignant tumors.
(D) Whether or not a tumor is operable depends on its location and the amount of damage its
removal will cause.
QUESTION 294
A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe
right flank pain, nausea, and vomiting. The most important nursing action for him at this time
is:
A. Intake and output measurement
B. Daily weights
C. Straining of all urine
D. Administration of O2 therapy
Answer: C
Explanation:
(A) Intake and output measurements are important but must be accompanied by straining
urine.
(B) Daily weights would not provide for identification of calculi.
(C) Straining urine provides for assessment of calculi and evaluation of calculi descent
through ureters and urethra.
(D) O2 therapy should not be necessary for renal calculi.
QUESTION 295
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 high-calcium 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.
QUESTION 296
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse
should anticipate the administration of:
A. Humulin N
B. Humulin R
C. Humulin U
D. Humulin L
Answer: B
Explanation:
(A) Intermediate-acting insulin is not indicated in an emergency.
(B) Regular insulin is rapid acting and indicated in an emergency situation.
(C) Long-acting insulin is not indicated in an emergency situation.
(D) Intermediate-acting insulin is not indicated in an emergency situation.
QUESTION 297
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer
which of the following IV solutions?
A. D5in normal saline
B. D5W
C. 0.9 normal saline
D. D5in lactated Ringer's
Answer: C
Explanation:
(A) D5in normal saline would increase serum glucose.
(B) D5W would increase serum glucose.
(C) A concentration of 0.9 NS is used to correct extracellular fluid depletion.
(D) D5in Ringer's lactate would increase serum glucose.

QUESTION 298
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 25 breaths/min) is often associated with fever.

(C) Cheyne-Stokes respiratory pattern is most often associated with increased intracranial
pressure secondary to changes in pressure in the cerebral and cerebellar areas.
(D) Biot's breathing is most frequently associated with spinal meningitis.
QUESTION 302
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.
QUESTION 303
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 hemothorax
B. A right hemothorax
C. Intubation of the right mainstem bronchus
D. An inadequate mechanical ventilator
Answer: C
Explanation:

(A) Although a left hemothorax could cause diminished and distant breath sounds, it is
irrelevant to this situation.
(B) A right hemothorax 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.
QUESTION 304
Which of the following blood gas parameters primarily reflects respiratory function?
A. PCO2
B. CO2 content of the blood
C. HCO3
D. Base excess
Answer: A
Explanation:
(A) The lungs are responsible for regulation of CO2, and this parameter primarily reflects
respiratory function.
(B) CO2 content of the blood is an indirect measure of respiratory function.
(C) HCO3 is a measure of kidney function only and is important in acid-base balance.
(D) Base excess represents the excess of HCO3 and is not reflective of respiratory function.
QUESTION 305
Endotracheal tube cuff pressure should never exceed:
A. 10 mm Hg
B. 20 mm Hg
C. 45 mm Hg
D. 60 mm Hg
Answer: B
Explanation:
(A) Pressure<10 mm Hg places the client at risk for aspiration.

(B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher
pressure places the client at risk for tracheal erosion.
(C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This
places the client at great risk for tracheal erosion.
(D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This
places the client at great risk for tracheal erosion.
QUESTION 306
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.
QUESTION 307
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 4872 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.
QUESTION 308
A post-lung surgery client is placed on a chest tube drainage system. When explaining to the
family how the system works, the nurse states that the water-seal bottle of a three-bottle chest
drainage system serves which of the following purposes?
A. Collection bottle for drainage
B. Pressure regulator
C. Preventing accumulation of blood around the heart
D. Preventing air from entering the chest upon inspiration
Answer: D
Explanation:
(A) There is a separate collection bottle for drainage as part of a chest drainage system.
(B) In a three-bottle chest drainage system, one bottle serves only as a pressure regulator.
(C) Mediastinal chest tubes prevent accumulation of blood around the heart immediately
following heart surgery.
(D) The purpose of the water seal bottle in any chest drainage setup is to allow air out of the
chest, but not back in. This negative pressure promotes lung expansion.
QUESTION 309
Which of the following serum laboratory values would the nurse monitor during gentamicin
therapy?
A. Creatinine
B. Sodium
C. Calcium

D. Potassium
Answer: A
Explanation:
(A) A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best
reflects kidney function is serum creatinine.
(B) Serum sodium has no relationship to gentamicin.
(C) Serum calcium has no relationship to gentamicin.
(D) Serum potassium has no relationship to gentamicin. If a client has impaired renal
function secondary to gentamicin administration, he or she may also have hyperkalemia as a
secondary disorder.
QUESTION 310
While changing the dressing on a client's central line, the nurse notices redness and warmth at
the needle insertion site. Which of the following actions would be appropriate to implement
based on this finding?
A. Discontinue the central line.
B. Begin a peripheral IV.
C. Document in the nurse's notes and notify the physician after redressing the site.
D. Clean the site well and redress.
Answer: C
Explanation:
(A) The nurse may never discontinue a central line without a physician's order.
(B) The nurse may never initiate a peripheral IV without a physician's order except in an
emergency situation.
(C) The nurse should always document findings and alert the physician to the findings as
well. The physician may then initiate a new central line and order the current central line to
be discontinued.
(D) Besides cleaning and redressing, the nurse should always document the findings.
QUESTION 311
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started
on a full strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse
confirms placement of the tube in the stomach. The hospital policy states that all tube feeding

must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is
indicative of which of the following?
A. The client aspirated tube feeding.
B. The nurse has placed the suction catheter in the esophagus.
C. This is a normal finding.
D. The feeding is infusing into the trachea.
Answer: A
Explanation:
(A) Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the
client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube
feeding, the client has aspirated the feeding.
(B) Because the trachea provides direct access to a client's airway, it would not be possible to
place the catheter in the esophagus.
(C) Blue-colored sputum is never considered a normal finding and should be reported and
documented.
(D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the
tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the
trachea.
QUESTION 312
The nurse is caring for a client with pancreatitis. Which of the following IV medications
would the nurse expect the physician to prescribe for control of pain in this client?
A. Morphine sulfate
B. Kerolac tromethamine (Toradol)
C. Promethazine (Phenergan)
D. Meperidine (Demerol)
Answer: D
Explanation:
(A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause
spasms of the sphincter of Oddi and increase pancreatic pain.
(B) Ketorolac tromethamine is currently not approved by the Food and Drug Administration
for IV use.
(C) Promethazine is a medication that has no analgesic properties.

(D) Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at
the sphincter of Oddi, which can lead to increased pancreatic pain.
QUESTION 313
The nurse begins morning assessment on a male client and notices that she is unable to
palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after
assessing this finding?
A. Palpate these pulses again in 15 minutes.
B. Use a Doppler to determine presence and strength of these pulses.
C. Document the finding that the pulses are not palpable.
D. Call the physician and notify the physician of this finding.
Answer: B
Explanation:
(A) Palpating these pulses again in 15 minutes may only result in the same findings.
(B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should
then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a
pulse is present.
(C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses
does not indicate absence of blood flow unless pulses cannot be located with a Doppler.
(D) The nurse would only call the physician after determining that the pulses are absent by
both palpation and Doppler.
QUESTION 314
The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse
would expect to find which of the following responses?
A. Increase in gastric secretions
B. Increase in peristalsis
C. Disorientation
D. Drowsiness
Answer: B
Explanation:
(A) Metoclopramide does not stimulate gastric secretions.
(B) This response is expected with metoclopramide, in addition to increasing gastric
emptying.

(C) Disorientation is a symptom of metoclopramide overdose. The drug should be
discontinued.
(D) Drowsiness is a symptom of metoclopramide overdose and the drug should be
discontinued.
QUESTION 315
A 33-year-old client was brought into the emergency room unconscious, and it is determined
that surgery is needed. Informed consent must be obtained from his next of kin. The sequence
in which the next of kin would be asked for the consent would be:
A. Parent, spouse, adult child, sibling
B. Spouse, adult child, parent, sibling
C. Spouse, parent, sibling, adult child
D. Parent, spouse, sibling, adult child
Answer: B
Explanation:
(A) Spouse and adult child would be asked before a parent.
(B) The order of kin relationship for an adult, as determined from legal intestate succession,
is usually spouse, adult child, parent, sibling.
(C) Parent and sibling would be asked after adult child.
(D) Spouse and adult child would be asked before parent. Sibling would be asked last.
QUESTION 316
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.
QUESTION 317
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the
incision, a small part of the abdominal viscera is seen protruding through the incision. This
complication of wound healing is known as:
A. Excoriation
B. Dehiscence
C. Decortication
D. Evisceration
Answer: D
Explanation:
(A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by
trauma, chemicals, burns, or other causes.
(B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of
abdominal tissue.
(C) Decortication is removal of the surface layer of an organ or structure. It is a type of
surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery.
(D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
QUESTION 318
The nurse documents a client's surgical incision as having red granulated tissue. This
indicates that the wound is:
A. Infected
B. Not healing
C. Necrotic
D. Healing
Answer: D
Explanation:
(A) The wound is not infected. An infected wound would contain pus, debris, and exudate.
(B) The wound is healing properly.

(C) A necrotic wound would appear black or brown.
(D) The wound is healing properly and is filled with red granulated tissue and fragile
capillaries.
QUESTION 319
A client has returned to the unit following a left femoral popliteal bypass graft. Six hours
later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse
should:
A. Continue to monitor the foot
B. Notify the physician immediately
C. Reposition and reassess the foot
D. Assure the client that his foot is fine
Answer: B
Explanation:
(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not
help restore the blood supply to the foot.
(B) The physician should be notified immediately because the client is losing blood supply to
his left foot and is in danger of losing the foot and/or leg.
(C) The presenting symptoms are of an emergency nature and require immediate intervention.
(D) This action would be giving the client false assurance.
QUESTION 320
A client is to have a coronary artery bypass graft performed in the morning using a saphenous
vein. He wants to know why the physician does not use the internal mammary artery for his
bypass graft because his friend's physician uses this artery. The nurse tells the client that the
internal mammary artery:
A. Takes more time to remove
B. Has a greater risk of becoming reoccluded
C. Is smaller in diameter
D. Has too many valves
Answer: A
Explanation:
(A) It does take more time to remove the internal mammary artery, and this is one reason why
some physicians do not use it.

(B) There is not a greater risk of reocclusion. In fact, it may actually stay patent longer.
(C) The internal mammary artery is actually larger in diameter than the saphenous vein.
(D) The internal mammary artery does not have too many valves.
QUESTION 321
A client returns to the cardiovascular intensive care unit following his coronary artery bypass
graft. In planning his care, the most important electrolyte the nurse needs to monitor will be:
A. Chloride
B. HCO3
C. Potassium
D. Sodium
Answer: C
Explanation:
(A) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes
is not as important as potassium monitoring.
(B) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes
is not as important as potassium monitoring.
(C) Potassium will need to be closely monitored because of its effects on the heart.
Hypokalemia could result in supraventricular tachyarrhythmias.
(D) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes
is not as important as potassium monitoring.
QUESTION 322
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 11/2 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.
QUESTION 323
A client is being discharged from the hospital tomorrow following a colon resection with a
left colostomy. The nurse knows that the client understands the discharge teaching about care
of her colostomy when she says:
A. "I know that I am not supposed to irrigate my colostomy."
B. "My stool will be soft like paste."
C. "My stoma should be red and slightly raised."
D. "The skin around my stoma may become irritated from the enzymes in my stool."
Answer: C
Explanation:
(A) A left colostomy indicates an ascending colon resection. This type of colostomy can be
irrigated.
(B) The stool from an ascending colon resection should be formed.
(C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the
client should see the physician immediately.
(D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an
ileostomy has more enzymes and is more irritating to the skin.
QUESTION 324
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his
right lower leg. The nurse should:
A. Remind the client that he no longer has that part of his leg and assure him he will be OK
B. Call the physician to request a psychological consultation for the client
C. Turn on the television to distract the client's attention from his amputated leg
D. Give the client his order of Demerol 50 mg IM prn
Answer: D
Explanation:
(A) The nurse is ignoring the client's pain. Telling the client that he will be OK will not
relieve his phantom pain.

(B) The client does not need a psychological consultation. Phantom pain is a normal
sensation experienced by clients with amputations.
(C) Using the television as a distractor will not relieve the client's phantom pain.
(D) Phantom pain is a normal, very real experience for an amputee and should be treated with
pain medication.
QUESTION 325
A client has returned to the unit from the recovery room after having a thyroidectomy. The
nurse knows that a major complication after a thyroidectomy is:
A. Respiratory obstruction
B. Hypercalcemia
C. Fistula formation
D. Myxedema
Answer: A
Explanation:
(A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or
tracheal compression from hemorrhage is a major complication after a thyroidectomy.
(B) Hypocalcemia accompanied by tetany from accidental removal of one or more
parathyroid glands is a major complication, not hypercalcemia.
(C) Fistula formation is not a major complication associated with a thyroidectomy. It is a
major complication with a laryngectomy.
(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a
thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess
production of thyroid hormone.
QUESTION 326
A client had a transurethral resection of the prostate yesterday. He is concerned about the
small amount of blood that is still in his urine. The nurse explains that the blood in his urine:
A. Should not be there on the second day
B. Will stop when the Foley catheter is removed
C. Is normal and he need not be concerned about it
D. Can be removed by irrigating the bladder
Answer: C
Explanation:

(A) Some hematuria is usual for several days after surgery.
(B) The client will continue to have a small amount of hematuria even after the Foley catheter
is removed.
(C) Some hematuria is usual for several days after surgery. The client should not be
concerned about it unless it increases.
(D) Irrigating the bladder will not remove the hematuria. Irrigation is done to remove blood
clots and facilitate urinary drainage.
QUESTION 327
A 72-year-old male client had the Foley catheter that was inserted during the transurethral
resection of his prostate removed today. He is concerned about the urinary incontinence he is
having since removal of the Foley catheter. The nurse explains that:
A. He should not be concerned about it because it will resolve quickly
B. This is usually temporary
C. The nurse will keep him dry, and he should notify the nurse when this happens
D. This is related to the bladder spasms and will soon stop
Answer: B
Explanation:
(A) This problem is temporary, but it may take some time to resolve, especially in an older
man.
(B) This problem is usually temporary, but it may take some time to resolve.
(C) Keeping the client dry will not relieve his anxiety about his incontinence.
(D) The bladder spasms are not the cause of the client's incontinence.
QUESTION 328
A 48-year-old female client is going to have a cholecystectomy in the morning. In planning
for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be
high risk for:
A. Knowledge deficit
B. Urinary retention
C. Impaired physical mobility
D. Ineffective breathing pattern
Answer: D
Explanation:

(A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is
not a priority nursing diagnosis postoperatively.
(B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is
usually not a problem once the Foley catheter is removed.
(C) A client having a cholecystectomy should not be physically impaired. In fact, the client is
encouraged to begin ambulating soon after surgery.
(D) Because of the location of the incision, the client having a cholecystectomy is reluctant to
breathe deeply and is at risk for developing pneumonia. These clients have to be reminded
and encouraged to take deep breaths.
QUESTION 329
A client is having a pneumonectomy done today, and the nurse is planning her postoperative
care. Nursing interventions for a postoperative left pneumonectomy would include:
A. Monitoring the chest tubes
B. Positioning the client on the right side
C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
D. Monitoring the right lung for an increase in rales
Answer: D
Explanation:
(A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to reexpand on the operative side.
(B) The pneumonectomy client should be positioned on the back or operated side because the
sutured bronchial stump may open, allowing fluid to drain into the unoperated side and
drown the client.
(C) The client should not have a pillow under the shoulder and back because of the
subscapular incision.
(D) Rales are commonly heard over the base of the remaining lung, but an increase could
indicate circulatory overload and therefore should be closely monitored.
QUESTION 330
A client returned to the unit following a pneumonectomy. As the nurse is assessing her
incision, she notices fresh blood on the dressing. The nurse should first:
A. Reinforce the dressing.
B. Continue to monitor the dressing.

C. Notify the physician.
D. Note the time and amount of blood.
Answer: C
Explanation:
(A) The dressing should not be reinforced without first notifying the physician. The decision
may be made by the physician to reinforce the dressing after assessing the amount of
bleeding.
(B) Blood on the dressing is unusual and should make the nurse aware that something more
than continuing to monitor the dressing should be done.
(C) The physician should be notified immediately, because if the bleeding persists, the client
may have to be taken back to surgery.
(D) The time and amount of blood do need to be recorded after the physician is notified.
QUESTION 331
A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an
increased white blood cell count, and malaise. The client is experiencing which type of
rejection?
A. Acute
B. Chronic
C. Hyperacute
D. Hyperchronic
Answer: A
Explanation:
(A) The sudden development of fever, graft tenderness, increased white blood count, and
malaise are signs and symptoms of an acute rejection that commonly occurs at 3 months.
(B) Chronic rejection occurs slowly over a period of months to years and mimics chronic
renal failure.
(C) Hyperacute rejection occurs immediately after surgery up to 48 hours postoperatively.
(D) Hyperchronic rejection is not a type of rejection.
QUESTION 332
A client has received preoperative teaching for the vertical partial laryngectomy that he is
scheduled to have in the morning. The nurse determines that the teaching has been effective
when the client states:

A. "I know I will need special swallowing training after my surgery."
B. "The quality of my voice will be excellent after surgery."
C. "I will have very little difficulty swallowing after surgery."
D. "I may also have to have a radical neck dissection done."
Answer: C
Explanation:
(A) A client with a supraglottic (horizontal partial) laryngectomy would require special
swallowing training, not a vertical partial laryngectomy.
(B) The quality of the client's voice will be altered but adequate for communication.
(C) The client will have minimal difficulty swallowing.
(D) A radical neck dissection may be done with a total laryngectomy, but not with a partial
laryngectomy.
QUESTION 333
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative
care. A priority postoperative nursing diagnosis for a client having a vertical partial
laryngectomy would be:
A. Activity intolerance
B. Ineffective airway clearance
C. High risk for infection
D. Altered oral mucous membrane
Answer: B
Explanation:
(A) The laryngectomy client should be able to gradually increase activities without difficulty.
(B) The laryngectomy client may have copious amounts of secretions and require suctioning
for the first 2448 hours. The cannula will require cleaning even after the first 24 hours
because mucus collects in it.
(C) The client does have a potential for infection, but it is not a more important nursing
priority than the ineffective airway clearance.
(D) This problem is not a more important nursing priority than ineffective airway clearance.
The client's mouth may become dry, but good oral care should take care of the dryness.
QUESTION 334

A client is going to have a pneumonectomy in the morning. She had a previous negative
surgical experience, is talking rapidly, and has an increased pulse and respiratory rate.
Nursing interventions for this client should include:
A. Providing opportunities to ask questions and talk about concerns
B. Providing distractors such as reading or watching television
C. Telling her that she should not be so nervous and assuring her that everything will be OK
D. Reminding her that this surgery is not as extensive as her past surgery was
Answer: A
Explanation:
(A) This intervention will help to clarify any misunderstandings about the surgery and give
the client an opportunity to verbalize concerns about the surgery.
(B) Distractors will not alleviate the preoperative anxiety that the client is experiencing. This
response actually denies the client's anxiety.
(C) This intervention is false assurance and denies that anxiety is a normal response to the
threat of surgery.
(D) Psychological responses are not directly related to the extent of the surgery, because they
are influenced by the client's past experiences.
QUESTION 335
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 channeling 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.
QUESTION 336
The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to
know about this medication?
A. Prolonged use of this medication will result in extrapyramidal side effects.
B. When the medication is effective, he will experience no anxiety.
C. The medication should relieve his symptoms of depression.
D. Blood must be drawn weekly to test for toxicity.
Answer: C
Explanation:
(A) Phenothiazines cause extrapyramidal symptoms.
(B) No amount of medication can relieve all anxiety in all cases.
(C) The purpose of amitriptyline is to relieve the symptoms of depression because it is an
antidepressant. It increases the action of norepinephrine and serotonin on nerve cells.
(D) Periodic blood tests are done when lithium is prescribed.
QUESTION 337
The health team needs to realize that the compulsive concern with cleanliness that a client
with severe anxiety exhibits is most likely an attempt to:
A. Reduce his anxiety
B. Avoid going to psychotherapy
C. Manipulate the health team members
D. Increase his self-image by showing higher standards than the fellow clients
Answer: A
Explanation:
(A) These behaviors are attempts to relieve anxiety.
(B) Avoidance is not a pattern in the obsessive client.
(C) Although these behaviors may seem to manipulate others, that is not the purpose behind
the activity.
(D) Inflated self-esteem is not a characteristic of the severely anxious client.
QUESTION 338

A successful executive left her job and became a housewife after her marriage to a plastic
surgeon. She started doing volunteer work for a charity organization. She developed pain in
her legs that advanced to the point of paralysis. Her physicians can find no organic basis for
the paralysis. The client's behavior can be described as:
A. Housework phobia
B. Malingering
C. Conversion reaction
D. Agoraphobia
Answer: C
Explanation:
(A) A typical phobia does not result in physical symptoms (i.e., paralysis).
(B) Malingering is pretending to be ill. This person has a true paralysis.
(C) A conversion reaction is a physical expression of an emotional conflict. It has no organic
basis.
(D) Agoraphobia is fear of public places.
QUESTION 339
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.
QUESTION 340
A 25-year-old lawyer who is married with three young children works long hours in an effort
to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer,
he was referred for therapy to treat this psychophysiological disorder. On meeting with the
therapist, he informed him or her that he was a busy man and did not have much time for this
"psych stuff." When guiding the client to ventilate his feelings, the therapist can expect him
to express feelings of:
A. Guilt
B. Shame
C. Despair
D. Anger
Answer: D
Explanation:
(A) Guilt relates to depression.
(B) Shame is not associated with psychophysiological disorders.
(C) Despair relates to depression.
(D) Repressed anger is associated with psychophysiological disorders.
QUESTION 341
Plans for the care of a client with an ulcer caused by emotional problems need to take into
consideration that:
A. His priority needs are limited to medical management
B. There is no real psychological basis for his illness
C. The disorder is a threat to his physical well-being
D. He is unable to participate in planning his care
Answer: C
Explanation:
(A) There may be a medical emergency that takes top priority; however, the basis of the
problem is emotional.
(B) The problem is a physical manifestation of an emotional conflict.
(C) The bleeding ulcer can be life threatening.

(D) For lifestyle change to occur, the client must participate in the planning of his care so that
he is committed to changes that will have positive results.
QUESTION 342
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.
QUESTION 343
A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who
reported bizarre behavior. Except for going to work, she spends all her time in her room and
expresses concern over neighbors spying on her. She has fears of the telephone being
"bugged." Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the
client. The primary reason for this plan would be to:
A. Protect her from suicide
B. Enable her to develop trust
C. Supervise her medication regimen
D. Involve her in groups for social interaction
Answer: B
Explanation:
(A) Suicide is a greater risk in depression than in schizophrenia.

(B) The client is suspicious and needs help to develop trust, which is basic to her
improvement.
(C) Although she will be taking medication, drug therapy would not necessitate consistency
in the nurses assigned.
(D) A suspicious client should have limited exposure to groups, because group participation
increases discomfort.
QUESTION 344
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia.
She is taking chlorpromazine and has improved to the point of being allowed to go with a
group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep
in mind during this outing is:
A. Hypotension
B. Photosensitivity
C. Excessive appetite
D. Dryness of the mouth
Answer: B
Explanation:
(A) A decrease in blood pressure sometimes occurs with chlorpromazine. It would not be a
factor influenced by a picnic in the park.
(B) Protection from the sun is important in clients taking phenothiazines because they burn
easily and severely.
(C) An appetite increase sometimes occurs with chlorpromazine. It would not be affected by a
picnic.
(D) Dryness of the mouth may occur at any time and is not affected by the picnic outing.
QUESTION 345
Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in
her room. She continues to believe other people are out to get her. A nursing intervention
basic to improving withdrawn behavior is:
A. Assigning her to occupational therapy
B. Having her sit with the nurses while they chart
C. Helping her to make friends
D. Facilitating communication

Answer: D
Explanation:
(A) The nurse does not make this assignment.
(B) One-to-one observation is not appropriate. It does not focus on the client or encourage
communication.
(C) The client is too suspicious to accomplish this goal.
(D) The withdrawn individual must learn to communicate on a one-to-one level before
moving on to more threatening situations.
QUESTION 346
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his
wife could no longer manage the house and children. She does not sleep and talks day and
night. She has purchased some very expensive clothes. The nurse noted that the client speaks
rapidly and changes the subject irrationally. This is an example of:
A. Flight of ideas
B. Delusions
C. Hallucinations
D. Echolalia
Answer: A
Explanation:
(A) Rapidly moving from one topic to another without following any logical sequence is
called flight of ideas.
(B) False beliefs are delusions.
(C) False sensory perceptions are hallucinations ("hearing voices").
(D) Repeating words is called echolalia.
QUESTION 347
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.
QUESTION 348
A client's behavior is annoying other clients on the unit. He is meddling with their belongings
and dominating the group. The best approach by the nurse is to:
A. Seclude him in his room.
B. Set limits on his behavior.
C. Have his medication increased.
D. Ignore him and tell the other clients that these behaviors are due to his illness and that they
should understand.
Answer: B
Explanation:
(A) This action by the nurse would be punitive.
(B) Consistent limit setting will help the client to know what is acceptable behavior.
(C) This action is not within the nurse's scope of practice.
(D) This could be dangerous to the client and to others and violates other clients' rights.
QUESTION 349
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She
is getting very limited calories and is using a lot of energy in her hyperactive state. The most
therapeutic nursing action is to:
A. Insist that she remain at the table and eat a balanced diet.
B. Order a high-calorie diet with supplements.
C. Provide nutritious finger foods several times a day.
D. Offer to go to the dining room with her and allow her to open the food and inspect what
she eats.
Answer: C

Explanation:
(A) The client is not able to sit for long periods. Forcing her to remain at the table will
increase her anxiety and cause her to become hostile.
(B) This action will not ensure that the client eats what is ordered. Dietary orders are not
within the nurse's scope of practice.
(C) Providing finger foods increases the likelihood of eating for hyperactive persons. They
may be eating "on the run."
(D) These clients are not suspicious of the food or insecure in moving about the unit alone.
QUESTION 350
A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him
would be:
A. Doing crafts in occupational therapy
B. Working a 1000-piece puzzle
C. Playing bridge with three other clients
D. Playing basketball in the gym
Answer: D
Explanation:
(A) This activity requires motor skills and therefore would be difficult for a hyperactive
client.
(B) This activity would take too long, and the client would have difficulty concentrating
owing to a limited attention span.
(C) This client would not be able to concentrate enough to play card games. He would
respond to all the stimuli in the area, become distracted, and leave the table.
(D) This activity would allow the client to channel his energy in a positive way.
QUESTION 351
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.
QUESTION 352
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.
QUESTION 353
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during
pregnancy that needs to be reported immediately to a healthcare provider is:
A. Constipation
B. Urinary frequency
C. Breast tenderness
D. Abdominal pain
Answer: D
Explanation:
(A) Constipation is a result of decreased peristalsis due to smooth muscle relaxation related to
changing progesterone levels that occur during pregnancy.

(B) Urinary frequency is a common result of the increasing size of the uterus and the
resulting pressure it places on the bladder.
(C) With the increased vascularity and hypertrophy of the mammary alveoli due to estrogen
and progesterone level changes, the breasts will increase in size and may become tender.
(D) Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or
a placental abruption.
QUESTION 354
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at
32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol
use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's
intrauterine growth retardation is:
A. The client's young age
B. The client's previous abortion
C. The client's history of drug, ethyl alcohol, and tobacco use
D. The client's late prenatal care
Answer: C
Explanation:
(A) Although adolescents frequently have a higher incidence of low-birth-weight infants, this
client is 21 years old.
(B) Uncomplicated induced abortions have not been proved to influence the growth of infants
of subsequent pregnancies.
(C) Compounds in cigarettes and some illicit drugs cause maternal vasoconstriction and a
subsequent reduction in O2 availability for the fetus owing to the resulting reduction in
uteroplacental blood flow. As few as one or two drinks of alcohol per day will decrease birth
weight.
(D) Although early prenatal care has been shown to improve pregnancy outcomes, not
seeking care until the second week of gestation does not, in and of itself, cause intrauterine
growth retardation.
QUESTION 355
When teaching a class of nursing students, the nurse asks why the embryonic period (weeks
48) of pregnancy is so critical.
A. Duplication of genetic information takes place.

B. Organogenesis occurs.
C. Subcutaneous fat builds up steadily.
D. Kidneys begin to secrete urine.
Answer: B
Explanation:
(A) Duplication of genetic material occurs during the preembryonic period (weeks 13)
following conception. The exact duplication of genetic material is essential for cell
differentiation, growth, and biological maintenance of the organism.
(B) Weeks 48, known as the embryonic period, are the time organogenesis occurs and pose
the greatest potential for major congenital malformations. All major internal and external
organs and systems are formed.
(C) Subcutaneous fat does not develop until the latter weeks of gestation.
(D) Kidneys begin to secrete urine during the 13th16th week.
QUESTION 356
What specific hormone must be present in serum or urine laboratory tests used to diagnose
pregnancy?
A. Human chorionic gonadotropin
B. Estrogen
C. -fetoprotein
D. Sphingomyelin
Answer: A
Explanation:
(A) Human chorionic gonadotropin is the biochemical basis for pregnancy tests. It is
produced by the placenta to help maintain the corpus luteum. Its levels climb rapidly
following conception, peaking at about 8 weeks and then gradually decreasing to low levels
after 16 weeks.
(B) Estrogen does steadily rise throughout pregnancy, increasing to 30 times that of prepreg
Nancy levels. Although estrogen levels do change during pregnancy, it is not used as the main
hormone of evaluation in pregnancy tests.
(C) -Fetoprotein is the major protein in the serum of the embryo. It is initially produced by
the yolk sac.
(D) Lecithin and sphingomyelin are two phospholipids of which fetal lung surfactant is
composed. Levels are evaluated to determine fetal lung maturity.

QUESTION 357
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test
was positive, she has two living children, she had one spontaneous abortion, and one infant
died at the age of 3 months. Which of the following best describes the client at the present?
A. Gravida 4, para 2, ab 1
B. Gravida 5, para 3, ab 1
C. Gravida 5, para 4, ab 0
D. Gravida 4, para 3, ab 0
Answer: B
Explanation:
(A) This individual has been pregnant four times, delivered two children, and had one
abortion.
(B) Your client has been pregnant five times, delivered three children, and had one abortion.
(C) This individual has been pregnant five times, delivered four children, and has not had an
abortion.
(D) This individual has been pregnant four times, delivered three children, and has not had an
abortion.
QUESTION 358
A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The
client's glucose tolerance test shows elevated blood sugar levels. Because she only shows
signs of diabetes when she is pregnant, she is classified as having:
A. Insulin-dependent diabetes
B. Type II diabetes mellitus
C. Type I diabetes mellitus
D. Gestational diabetes mellitus
Answer: D
Explanation:
(A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before
the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is
not related to onset during pregnancy.
(B) Non-insulin dependent diabetes (type II diabetes) usually appears in older adults. It has a
slow onset and progression of symptoms.

(C) This type of diabetes is the same as insulin-dependent diabetes.
(D) Gestational diabetes mellitus has its onset of symptoms during pregnancy and usually
disappears after delivery. These symptoms are usually mild and not life threatening, although
they are associated with increased fetal morbidity and other fetal complications.
QUESTION 359
Prior to an amniocentesis, a fetal ultrasound is done in order to:
A. Evaluate fetal lung maturity
B. Evaluate the amount of amniotic fluid
C. Locate the position of the placenta and fetus
D. Ensure that the fetus is mature enough to perform the amniocentesis
Answer: C
Explanation:
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used
for gestational dating, although it does not separately determine lung maturity.
(B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine
congenital anomalies.
(C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted
through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates
the position of the placenta and the fetus.
(D) Amniocentesis can be performed as early as the 15th17th week of pregnancy.
QUESTION 360
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the
nurse's knowledge of the maternal physiological changes in pregnancy, which of these
findings would be of concern?
A. Complaints of dyspnea
B. Edema of face and hands
C. Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks
D. Hematocrit 39%
Answer: B
Explanation:
(A) Dyspnea is a common complaint during the third trimester owing to the increasing size of
the uterus and the resulting pressure against the diaphragm.

(B) Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of
preeclampsia and would be of great concern to the healthcare provider.
(C) An increase in heart rate of 1015 bpm is a normal physiological change in pregnancy due
to the multiple hemodynamic changes.
(D) A hematocrit value of 39% is within the normal range. A value <35% would indicate
anemia.
QUESTION 361
Based on your knowledge of genetic inheritance, which of these statements is true for
autosomal recessive genetic disorders?
A. Heterozygotes are affected.
B. The disorder is always carried on the X chromosome.
C. Only females are affected.
D. Two affected parents always have affected children.
Answer: D
Explanation:
(A) The term heterozygote refers to an individual with one normal and one mutant allele at a
given locus on a pair of homologous chromosomes. An individual who is heterozygous for
the abnormal gene does not manifest obvious symptoms.
(B) Disorders carried on either the X or Y sex chromosome are referred to as sex-linked
recessive.
(C) Either sex may be affected by autosomal recessive genetic disorders because the
responsible allele can be on any one of the 46 chromosomes.
(D) If both parents are affected by the disorder and are not just carriers, then all their children
would manifest the same disorder.
QUESTION 362
Chorioamnionitis is a maternal infection that is usually associated with:
A. Prolonged rupture of membranes
B. Post term deliveries
C. Maternal pyelonephritis
D. Maternal dehydration
Answer: A
Explanation:

(A) Chorioamnionitis is an inflammation of the chorion and amnion that is generally
associated with premature or prolonged rupture of membranes.
(B) Post term deliveries have not been shown to increase the risk of chorioamnionitis unless
there has been prolonged rupture of membranes.
(C) Pyelonephritis is a kidney infection that develops in 20%40% of untreated maternal UTIs.
(D) Maternal dehydration, though of great concern, is not related to chorioamnionitis.
QUESTION 363
A client has been diagnosed with thrombophlebitis. She asks, "What is the most likely cause
of thrombophlebitis during my pregnancy?" The nurse explains:
A. Increased levels of the coagulation factors and a decrease in fibrinolysis
B. An inadequate production of platelets
C. An inadequate intake of folic acid during pregnancy
D. An increase in fibrinolysis and a decrease in coagulation factors
Answer: A
Explanation:
(A) During pregnancy, the potential for thromboses increases owing to the increased levels of
coagulation factors and a decrease in the breakdown of fibrin.
(B) An inadequate production of platelets would result in thrombocytopenia with resulting
signs and symptoms of bleeding such as petechiae, hematuria, or hematemesis.
(C) A deficiency of folic acid during pregnancy produces a megaloblastic anemia. It is
usually found in combination with iron deficiency.
(D) This combination would result in bleeding disorders because more fibrin would be
broken down and fewer clotting factors would be available.
QUESTION 364
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.
QUESTION 365
A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms
of mastitis include:
A. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red
and hardened
B. Marked engorgement and breast pain
C. Elevated temperature and general malaise
D. Cracked nipple with complaints of soreness
Answer: A
Explanation:
(A) Mastitis is a bacterial inflammation of the breast tissue found primarily in breast-feeding
mothers. The bacteria usually enter the breast through a cracked nipple, or the infection
results from stasis of milk behind a blocked duct.
(B) With breast engorgement during breast-feeding, there may be marked breast pain. This is
not necessarily a sign of infection.
(C) Women may become ill during breast-feeding with other bacterial or viral infections that
are not related to mastitis.
(D) Improper care of the nipples or improper positioning of the infant during breastfeeding
may result in cracked or sore nipples.
QUESTION 366
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this
pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets.
She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam
reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine

contractions every 78 minutes after the nurse has placed her on the fetal monitor. Her
condition should indicate that:
A. Her cervix shows she will likely deliver soon
B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks'
gestation
C. She may be in preterm labor because this is more common with multiple pregnancies
D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
Answer: C
Explanation:
(A) Her cervical exam is normal. There are no cervical changes at this time.
(B) Braxton Hicks contractions may be common throughout pregnancy, but they are not
regular.
(C) Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32
weeks in a woman carrying triplets are of great concern. She may be in preterm labor.
(D) UTIs are common in pregnancy due to the enlarging uterus compressing the ureters and
the stasis of urine. The woman would be more likely to complain of urinary frequency and
urgency, fever or chills, and malodorous urine with a UTI.
QUESTION 367
The most frequent cause of early postpartum hemorrhage is:
A. Hematoma
B. Coagulation disorders
C. Uterine atony
D. Retained placental fragments
Answer: C
Explanation:
(A) Hematomas, which are the result of damage to a vessel wall without laceration of the
tissue, are a cause, though not the most frequent cause.
(B) Coagulation disorders are among the causes of postpartal hemorrhage, but they are less
common.
(C) The most frequent causes of hemorrhage in the postpartal period are related to an
interference with involution of the uterus. Uterine atony is the most frequent cause, occurring
in the first 24 hours after delivery.

(D) Retained placental fragments are also a cause, although these bleeds usually occur 714
days after delivery.
QUESTION 368
A client has just been transferred to the floor from the labor and delivery unit following
delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take
her vital signs, she responds in anger, stating, "You leave me alone. You don't care anything
about me. It's people like you who let my baby die." The nurse's best course of action is to:
A. Quietly leave her room, allowing her more private time to deal with her loss.
B. Tell her that what happened was for the best and that she is still young and can have other
children.
C. Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
D. Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being
a normal stage of grief. Assure her that you are there to help her in any way you can.
Answer: D
Explanation:
(A) Parents do need their privacy following a loss, but the nurse still has a responsibility to
provide postpartum physical care.
(B) This is a negative statement, which is not therapeutic. The client is not concerned about
future children but is in the first stages of grief, denial, and anger.
(C) This is a negative statement, which is not therapeutic. The client does not want to hear
about her baby in heaven. She cannot believe that God could love or want her child more than
she could.
(D) Acknowledging that anger is normal and beneficial will help the client to understand the
normal stages of grief. Expressing sorrow over her loss and assuring her that the support is
there to take care of her physical and emotional needs will help to promote a trusting
relationship.
QUESTION 369
When a client arrives on the labor and delivery unit, she informs the nurse that she has been
having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was
earlier. The nurse considers the possibility of uterine rupture. Which of the following
symptoms would be consistent with a uterine rupture?
A. A large gush of clear fluid from the vagina

B. Systolic hypertension
C. Abdominal rigidity
D. Increased fetal movements
Answer: C
Explanation:
(A) This symptom would indicate a rupture of the membranes, which would be expected
during labor. There would be no cause for alarm if the fluid were clear.
(B) With uterine rupture and the risk of maternal shock secondary to blood loss, the most
likely sign would be hypotension indicating hypovolemic shock.
(C) In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or
tenderness.
(D) The most likely finding would be a decrease in fetal movement related to fetal distress
due to impaired uteroplacental blood flow. Maintaining the client on her left side would help
to maximize uterine blood flow.
QUESTION 370
A mother called the physician's office to ask if it would help relieve her small daughter's
abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter
has a fever and has vomited twice. The nurse's response is based on the knowledge that:
A. The symptoms could easily have been caused by constipation, which an enema would
relieve
B. Heat would help to relax the abdominal muscles and relieve her pain
C. Both heat and enemas stimulate intestinal motility and could increase the risk of
perforation
D. Complaints of stomach ache are common in young children and are generally best ignored
Answer: C
Explanation:
(A) Constipation does not cause fever or vomiting but may cause anorexia. Risk of
perforation outweighs the possible benefits of an enema.
(B) Heat will not relieve her symptoms but will increase intestinal motility and increase the
risk of perforation.
(C) Heat and enemas are contraindicated where severe abdominal pain is suspected because
they increase intestinal motility and the risk of perforation.

(D) Complaints accompanied by physical symptoms such as pain, anorexia, and fever should
never be ignored.
QUESTION 371
An 8-year-old child is admitted to the hospital for surgery. She has had no previous
hospitalizations, and both she and her family appear anxious and fearful. It will be most
helpful for the nurse to:
A. Take the child to her room and calmly and matter-offactly begin to get her ready to go to
the operating room
B. Take time to orient the child and her family to the hospital and the forthcoming events
C. Explain that as soon as the child goes to the operating room she will have time to answer
any questions the family has
D. Tell the child and her family that there is nothing to worry about, that the operation will
not take long, and she will soon be as "good as new"
Answer: B
Explanation:
(A) This action does nothing to prepare the child and her family for what will happen or to
relieve their anxiety and fear.
(B) This action provides security by preparing the child and the family for what will happen
and will help to relieve fear and anxiety.
(C) This action does nothing to help prepare the child for what will happen and does not give
the parents’ permission to ask questions until later.
(D) This action provides possibly false reassurance and may prevent the child and/or the
family from asking pressing questions.
QUESTION 372
Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left
femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to
achieve realignment and immobilization of the left femur. When providing nursing care, it is
important for the nurse to remember that:
A. The nurse may lift only the weights that are applying traction in order to reposition him in
bed
B. The client will need special skin care at the pin site according to hospital policy or the
physician's preference

C. The traction pull should result in an immediate increase in comfort and reduce the need for
pain medication
D. The client should be discouraged from participating in self-care activities to avoid the risk
of disrupting the traction
Answer: B
Explanation:
(A) Skeletal traction, including the weights that are applying the traction, is never released by
the nurse.
(B) It is necessary to keep the pin site clean and free from infection.
(C) When first placed in traction, the client may experience increased discomfort as a result
of the traction pull fatiguing the muscle.
(D) When the child in traction is allowed to participate in his care, it gives him a measure of
control and helps him to cope with the situation.
QUESTION 373
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting
behavioral changes including restlessness, difficulty with problem solving, inability to
concentrate on activities, and monotony. Which of the following nursing implementations
would be most effective in helping him cope with immobility?
A. Providing him with books, challenging puzzles, and games as diversionary activities
B. Allowing him to do as much for himself as he is able, including learning to do pin-site care
under supervision
C. Having a volunteer come in to sit with the client and to read him stories
D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's
position frequently
Answer: B
Explanation:
(A) These activities could be frustrating for the client if he is having difficulty with problem
solving and concentration.
(B) Selfcare is usually well received by the child, and it is one of the most useful
interventions to help the child cope with immobility.
(C) This may be helpful to the client if he has no visitors, but it does little to help him
develop coping skills.

(D) This will help to prevent skin irritation or breakdown related to immobility but will not
help to prevent behavioral changes related to immobility.
QUESTION 374
Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During
the acute phase of osteomyelitis, nursing care is directed toward:
A. Moving or turning the client's left leg carefully to minimize pain and discomfort
B. Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing
on the left leg
C. Providing the client with a high-protein, high-fiber diet to promote healing
D. Instituting physical therapy to ensure restoration of optimal functioning of the leg
Answer: A
Explanation:
(A) Any movement of his affected limb will cause discomfort to the child.
(B) No weight bearing will be allowed until healing is well underway to avoid pathological
fractures.
(C) The child will be anorexic and may experience vomiting. Diet should be simple and high
caloric until appetite returns and symptoms subside.
(D) Physical therapy is instituted only after infection subsides.
QUESTION 375
Several months after antibiotic therapy, a child is readmitted to the hospital with an
exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious
and asks what she could have done to prevent the exacerbation. The nurse's response is based
on the knowledge that chronic osteomyelitis:
A. Is caused by poor physical conditions or poor nutrition
B. Often results from unhygienic conditions or an unclean environment
C. Is directly related to sluggish circulation in the affected limb
D. May develop from sinuses in the involved bone that retain infectious material
Answer: D
Explanation:
(A) Poor nutrition and/or poor physical conditions are factors that predispose to the
development of osteomyelitis but do not cause it.

(B) An unclean or unhygienic environment may predispose to the development of chronic
osteomyelitis, but it does not cause an exacerbation of the previous infection.
(C) Sluggish circulation through the medullary cavity during acute osteomyelitis may delay
healing, but it does not cause the disease to become chronic.
(D) Areas of sequestrum may be surrounded by dense bone, become honeycombed with
sinuses, and retain infectious organisms for a long time.
QUESTION 376
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is
hospitalized for additional tests and to begin a course of chemotherapy designed to induce a
remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone
marrow test previously and is apprehensive about having another. Which of the following
interventions will be most effective in relieving her anxiety?
A. Explain what will take place and what she will see, feel, and hear.
B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
C. Tell her not to worry about it, that it will be over soon and she can join her friends in the
playroom.
D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
Answer: A
Explanation:
(A) Even though the child has had the procedure before, she will probably need additional
explanations and emotional support.
(B) The fact that the child has had the procedure before and possibly found it painful or
uncomfortable may increase, not relieve, her stress.
(C) This intervention does nothing to reassure the child and may well prevent her from
expressing her feelings.
(D) This does not prepare the child for the test and burdens her with the expectation that she
act bigger and braver than she is.
QUESTION 377
Parents of children receiving chemotherapy should be warned that alopecia is a side effect
and that:
A. Children seldom show concern about losing their hair
B. The hair will come out gradually, and the loss will not be noticeable for some time

C. It is best for girls to choose a wig similar to their hair style and color before the hair falls
out
D. The parents will soon get used to seeing their children without hair, and it will no longer
bother them
Answer: C
Explanation:
(A) Children may become depressed with a changed appearance and not want to look at
themselves or have others see them.
(B) The hair will fall out in clumps, causing patchy baldness that is quite noticeable and
traumatic to children and their families.
(C) Having a wig that looks like a girl's own hair can be a psychological boost to children and
is helpful in fostering later adjustments to hair loss.
(D) Families may become accustomed to seeing their children without hair, but the loss is
traumatic to them and will continue to bother them.
QUESTION 378
A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the
therapy. Which of the following strategies should be most effective in encouraging the child
to eat?
A. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well.
B. Schedule procedures immediately after eating so that the child will not be tired or in pain
at mealtime.
C. Offer the child a diet with a wider variety of foods and with more seasoning than her usual
diet.
D. Offer the child smaller meals more frequently than usual, and include as many of her
favorite foods as possible.
Answer: D
Explanation:
(A) Because the child's appetite is capricious at best, regular servings may be overwhelming.
Praise the child for what is eaten.
(B) The child will soon learn that procedures follow meals and may play with food rather
than eat it to avoid or delay the procedure.
(C) Young children usually do not like highly seasoned foods and may need the security of
usual foods. Such a change may actually increase anorexia.

(D) Small servings appear more achievable to the child, and the inclusion of favorite foods
can add a sense of security.
QUESTION 379
A child becomes neutropenic and is placed on protective isolation. The purpose of protective
isolation is to:
A. Protect the child from infection
B. Provide the child with privacy
C. Protect the family from curious visitors
D. Isolate the child from other clients and the nursing staff
Answer: A
Explanation:
(A) The child no longer has normal white blood cells and is extremely susceptible to
infection.
(B) There are more appropriate ways to provide privacy, and there is no need to protect the
child from healthy visitors.
(C) Visitors and visiting hours may be at the client's and/or family's request without regard to
the isolation precaution.
(D) The child may have strong positive relationships with other clients or staff. As long as
proper precautions are observed, there is no reason to isolate her from them.
QUESTION 380
A client is experiencing mucosal cell damage secondary to chemotherapy. Because of
mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the
following interventions would be most effective in getting her to eat?
A. Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals
B. A bland, moist, soft diet
C. Staying with the client and providing distraction during meals
D. Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before
meals
Answer: B
Explanation:
(A) Local anesthetics do temporarily relieve the pain but leave an unpleasant taste and numb
feeling that are not conductive to eating.

(B) Such a diet is less irritating to the damaged mucosa and is easier for the child to tolerate.
(C) This intervention is helpful if the child has only anorexia. It does not work if the type and
texture of the food increase oral discomfort.
(D) Lemon glycerin swabs and milk of magnesia dry the oral mucosa and should be avoided.
QUESTION 381
A 15-year-old client was diagnosed as having cystic fibrosis at 8 months of age. He is in the
hospital for a course of IV antibiotic therapy and vigorous chest physiotherapy. He has a poor
appetite. The nurse can best help him to meet the desired outcome of consuming a prescribed
number of calories by:
A. Including the client in planning sessions to select the type of meal plan and foods for his
diet
B. Working with the nutritionist to devise a diet with significantly increased calories
C. Selecting foods for the client's diet that are high in calories and instituting a strict calorie
count
D. Constantly providing him with chips, dips, and candies, because the number of calories
consumed is more important than the quality of foods
Answer: A
Explanation:
(A) The adolescent knows what he likes and will be more likely to eat if he has some control
over his diet.
(B) The nurses and nutritionist can plan an excellent diet, but it will not help the adolescent
unless he eats it.
(C) Eating is already a chore for this client. Adding a strict calorie count could make it even
more burdensome.
(D) Fats are particularly difficult for the cystic fibrosis client to digest. He does need a
healthful diet, not just more calories.
QUESTION 382
The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is
meeting his caloric needs is:
A. Careful monitoring of weight loss or gain
B. Carefully recording amounts and types of foods ingested
C. Keeping a strict account of the number of calories ingested

D. Keeping a careful account of the amount of pancreatic enzymes ingested
Answer: A
Explanation:
(A) Consistent weight gain, even if it is slow, is an indication that the child is eating and
digesting sufficient calories.
(B) Recording how much the child eats is useful, but it is not an indicator of how well his
body is using the foods consumed.
(C) Counting calories will indicate how much he is eating, but it will not reflect whether or
not the foods are properly digested.
(D) Keeping track of the enzyme intake will indicate compliance with medication but not
whether the child is getting sufficient calories.
QUESTION 383
A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems
associated with his disease. However, he needs to be encouraged to participate in daily
physical exercise. The ultimate aim of exercise is to:
A. Create a sense of well-being and self-worth
B. Help him overcome respiratory infections
C. Establish an effective, habitual breathing pattern
D. Promote normal growth and development
Answer: C
Explanation:
(A) Regular exercise does promote a sense of well-being and self-worth, but this is not the
ultimate goal of exercise for this client.
(B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections.
(C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus
secretion, promotes a feeling of well-being, and helps to establish a habitual breathing
pattern.
(D) Along with adequate nutrition and minimization of pulmonary complications, exercise
does help promote normal growth and development. However, exercise is promoted primarily
to help establish a habitual breathing pattern.
QUESTION 384

As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he
appears depressed and talks about suicide and feelings of worthlessness. This is an important
factor to consider in planning for his care because:
A. It may be a bid for attention and an indication that more diversionary activity should be
planned for him
B. No threat of suicide should be ignored or challenged in any way
C. He needs to be observed carefully for signs that his depression has been relieved
D. He needs to be confronted with his feelings and forced to work through them
Answer: B
Explanation:
(A) Threats of suicide should always be taken seriously.
(B) This client has a life-threatening chronic illness. He may be concerned about dying or he
may actually be contemplating suicide.
(C) Sometimes clients who have made the decision to commit suicide appear to be less
depressed.
(D) Forcing him to look at his feelings may cause him to build a defense against the
depression with behavioral or psychosomatic disturbances.
QUESTION 385
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child
checkup. His immunizations are up to date, and his mother reports that he has had no
significant illnesses or injuries. Which of the following signs would lead the nurse to believe
that he has had a cerebral injury?
A. Hyperextension of the neck with evidence of pain on flexion
B. Holding the head to one side and pointing the chin toward the other side
C. Holding the head erect and in the midline when in a vertical position
D. Significant head lag when raised to a sitting position
Answer: D
Explanation:
(A) This position is indicative of a possible meningeal irritation or infection such as
meningitis.
(B) This position is seen most frequently in infants who have had an injury to the
sternocleidomastoid muscle.
(C) Most infants aged 4 months and older are able to maintain this position.

(D) Infants older than 6 months of age should not have significant head lag. This is a sign of
cerebral injury and should be referred for further evaluation.
QUESTION 386
During an examination, the nurse notes that an infant has diaper rash on the convex surfaces
of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will
be most effective in resolving the condition?
A. Coating the inflamed areas with zinc oxide
B. Using talcum powder on the inflamed areas to promote drying
C. Removing the diaper entirely for extended periods of time
D. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change
Answer: C
Explanation:
(A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat
retention.
(B) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation.
(C) Removing the diaper and exposing the area to air and light facilitate drying and healing.
(D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply
clean with a wet cloth.
QUESTION 387
A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she
offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has
gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's
response is based on the knowledge that:
A. Milk intake should be limited to no more than four 8-oz bottles per day and should be
followed by iron-enriched cereal or other solid foods or juices
B. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to
eat solid foods
C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long
as he takes a vitamin supplement daily
D. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to
bottle feeds. Milk intake should be limited to 1 qt/day
Answer: D

Explanation:
(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the
solid foods.
(B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate
diet.
(C) The vitamin supplement will help, but the infant needs an iron supplement.
(D) Giving the solid food when the infant is hungriest will increase the likelihood that he will
eat. The more solid food he takes, the less milk he will desire.
QUESTION 388
A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her
hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's
parents question why they cannot feed their own child. Which of the following responses
would be most appropriate by the nurse?
A. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues
and feeding behaviors.
B. The same nurses will prevent parental fatigue and frustration.
C. The same nurses will prevent infant fatigue and frustration.
D. Primary nurses will ensure privacy.
Answer: A
Explanation:
(A) Consistent primary care nurses can better interpret infant cues and note feeding
behaviors.
(B) In nonorganic failure to thrive the parent-infant dyad has already experienced difficulties
in the relationship. These parents may already feel dissatisfied and frustrated. The primary
nurse would be unable to prevent this.
(C) Assigning a primary nurse does not ensure that infant fatigue and frustration will not
occur or can be prevented.
(D) Providing privacy does not ensure a change in feeding behavior.
QUESTION 389
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.
QUESTION 390
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to
bring her favorite objects from home. What is the nurse's rationale?
A. To reduce fear of the unknown
B. To keep the child calm
C. To establish a trusting relationship
D. To prevent or minimize separation anxiety
Answer: D
Explanation:
(A) Objects from home do not reduce fear of the unknown. Children need explanations,
reassurance, and preparation for the unknown. Also, parental presence can promote comfort
and feelings of security.
(B) A calm, relaxed, and reassuring manner will assist in calming the child. The child's
objects from home will not assist in calming the child.
(C) A trusting relationship is based on the quality of the nurse-client relationship. Objects
from home have no impact.
(D) Favorite objects from home assist in creating a familiar setting. Also, these objects may
prevent or minimize separation from the child's usual routine and family support.
QUESTION 391
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.
QUESTION 392
A school-age child with asthma is ready for discharge from the hospital. His physician has
written an order to continue the theophylline given in the hospital as an oral home
medication. Immediately prior to discharge, he complains of nausea and becomes irritable.
His vital signs were normal except for tachycardia. What first nursing actions would be
essential in this situation?
A. Hold the child's discharge for 1 hour.
B. Notify the physician immediately.
C. Discharge the child as the physician ordered.
D. Administer an antiemetic as necessary.
Answer: B
Explanation:
(A) Holding the child's discharge alone does not address the client's problem.
(B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The
physician should be notified immediately so that a serum theophylline level can be ordered.
Theophylline dose should be withheld until the physician is notified.
(C) The child must be evaluated for theophylline toxicity before any discharge.
(D) Cause of the nausea should be investigated before the administration of an antiemetic.

QUESTION 393
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the
baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis
of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor,
sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing
diagnosis.
A. Fluid volume deficit
B. Altered nutrition
C. Altered bowel elimination
D. Anxiety
Answer: A
Explanation:
(A) Fluid volume deficit is the major problem. Symptoms of dehydration are evident. The
effects of fluid and electrolyte balance may be life threatening. Rehydration can be
accomplished effectively through IV fluids and electrolytes.
(B) Vomiting may also signal a nutritional problem. However, the nutritional problem would
be secondary to fluid and electrolyte disturbances. The infant may also be placed on NPO
status.
(C) With vomiting, a decrease in the size and number of stools is expected.
(D) The infant cannot verbalize feelings of anxiety. Anxiety would not be an appropriate
diagnosis.
QUESTION 394
A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting.
With prolonged vomiting, the infant is prone to:
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: D
Explanation:
(A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while
plasma PCO2 and plasma HCO3 increase.

(B) Respiratory alkalosis results from increased respiratory rate and depth. Plasma pH
increases, while plasma PCO2 and plasma HCO3 decrease.
(C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2,
and HCO3 decrease.
(D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of
potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2
increase; plasma HCO3 may decrease and then increase to compensate.
QUESTION 395
Parents of young children often need anticipatory guidance from the nurse. Parents may have
little knowledge regarding growth and development. Which of the following toys and
activities would the nurse suggest as appropriate for a toddler?
A. Cutting, pasting, string beads, music, dolls
B. Mobiles, rattle, squeeze toys
C. Pull-toys, large ball, dolls, sand and water play, music
D. Simple card games, puzzles, bicycle, television
Answer: C
Explanation:
(A) These activities are suited for the preschool-age child (35 years old). The activities are
not safe for a toddler.
(B) Infants (01 year) like these toys.
(C) These activities provide the toddler (13 years old) with a variety of physical activities for
play.
(D) The toddler lacks the physical and cognitive abilities for these activities. The tasks are far
better suited for the school-age child.
QUESTION 396
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in
assisting her in expressing her feelings. Which activity should the nurse provide the child to
assist her in expressing her feelings?
A. Books with colorful pictures
B. Music
C. Riding toys
D. Puppets

Answer: D
Explanation:
(A) Books increase cognition, assist with fine motor skills, and augment language
development.
(B) Music provides auditory stimulation and large-muscle activity.
(C) Riding toys provide large-muscle activity.
(D) Puppets allow expression of feelings and fears that otherwise could not be directly
communicated.
QUESTION 397
During his hospitalization, a 3-year-old child has become unusually aggressive in his play
activities. His parents report this change in behavior to the primary nurse. How could the
nurse explain the child's change in behavior?
A. Deep-seated feelings of hostility
B. A lack of interest in socializing
C. Usual behavior for this child
D. A coping response
Answer: D
Explanation:
(A) Unusually aggressive behavior does not indicate a deep-seated problem.
(B) A lack of social interest results in poor participation in play activities with peers.
Aggression would not be an expected behavior.
(C) The aggressive behavior was newly developed and not a routine behavior.
(D) Play provides the child with opportunities for coping and adaptation. Aggression during
the play activities would indicate a coping response.
QUESTION 398
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast.
She experienced a supracondylar fracture of the humerus near the elbow. Which nursing
action is most essential during the first 24 hours after surgery and cast application?
A. Mobilization of the child
B. Discharge teaching
C. Pain management
D. Assessment of neurovascular status

Answer: D
Explanation:
(A) Mobilization is important but not absolutely essential.
(B) Discharge teaching should be initiated prior to surgery as well as during the postoperative
period.
(C) Assessment and management of pain are necessary and high in priority.
(D) Neurovascular status of the extremity is of primary importance. The risk of circulatory
impairment exists with any cast application. This type of fracture is common in children. A
high incidence of neurovascular complications exists with fractures near the elbow.
QUESTION 399
A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment
was initiated by the nurse. Which skill would cause the nurse to be concerned about the
infant's developmental progression?
A. She sits briefly alone with assistance.
B. She creeps and crawls.
C. She pulls herself to her feet with help.
D. She stands while holding onto furniture.
Answer: A
Explanation:
(A) The 9-month-old infant can sit alone for long periods. By the age of 6 months, many
infants can pull themselves to a sitting position.
(B, C, D) This skill represents normal development.
QUESTION 400
Children often experience visual impairments. Refractive errors affect the child's visual
activity. The main refractive error seen in children is myopia. The nurse explains to the child's
parents that myopia may also be described as:
A. Cataracts
B. Farsightedness
C. Near-sightedness
D. Lazy eye
Answer: C
Explanation:

(A) Cataracts are not considered refractive errors. Cataracts cane described as opacity of the
lens.
(B) Hyperopiais the term for farsightedness. One can see objects at a distance more clearly
than close objects.
(C) Myopiais the term for near-sightedness. Objects that are close in distance are more clearly
seen.
(D) Lazy eye refers to strabismus or misalignment of the eyes.