Power Practice Provides the Concentrated Practice Students NCLEX-RN: Need to Earn a Top Score

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All the Practice You Need NCLEX-RN to Succeed on the NCLEX-RN! COMPLETE TEST PREPARATION ® Success on the NCLEX-RN is mandatory to become a registered nurse. NCLEX-RN: Power Practice provides the concentrated practice students NCLEX-RN: need to earn a top score. Inside, you will have access to three full-length practice exams—two in the book, one online—based on the official test, with detailed answer explanations for each answer choice. In addition, this : POWER PRACTICE

indispensible study guide provides: POWER PRACTICE Powerful Practice to Help You Pass the NCLEX-RN Exam n THREE NCLEX-RN practice exams for effective test preparation n THREE full-length practice NCLEX-RN exams with n Important information about the exam—what’s on it, when it’s given, detailed answer explanations how to register, and how it’s scored n The perfect supplement to any NCLEX-RN review guide n A customized online score report with comprehensive answer Alicia Culleiton explanations Dr. Yvonne Weideman n The LearningExpress Test Preparation System, which includes stress- reducing and time-budgeting tips NCLEX-RN exam instantly scored Added value—Access to an

FREE NCLEX-RN Practice Online Visit LearningExpress’s Online Practice Center to: n Access an NLCEX-RN practice exam—FREE n Receive immediate scoring and detailed answer explanations for all questions n Focus your study with a customized diagnostic report and boost your score to guarantee success

® Boost Your Score! Prepare for a Brighter Future FREE ACCESS to an Instantly Scored Online Practice Exam IT’S LIKE HAVING THE TEST IN ADVANCE! NCLEX-RN is a registered trademark of the National Council of State Boards of Nursing (NCSBN), which neither sponsors nor endorses this product. NCLEX-RN®: PowER PRaCtiCE

NEW YORK

Library of Congress Cataloging-in-Publication Data:

NCLEX-RN : power practice.—1st ed. p. ; cm. ISBN 978-1-57685-908-7 I. LearningExpress (Organization) [DNLM: 1. Nursing Care—Examination Questions. 2. Test-Taking Skills—Examination Questions. WY 18.2] 610.73076—dc23 2012032761

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ISBN-13: 978-1-57685-908-7

For more information or to place an order, contact LearningExpress at: 2 Rector Street 26th Floor New York, NY 10006

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NCLEX-RN is a registered trademark of the National Council of State Boards of Nursing (NCSBN), which neither sponsors nor endorses this product.

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CoNtRibutoRS vii

ChaPtER 1 Introduction to the NCLEX-RN® 1 Overview of NCLEX-RN Registering for the Exam What to Expect at the Test Center During the Test What Skills Are Tested? A Note on Guessing Exam Results

ChaPtER 2 The LearningExpress Test Preparation System 7 Step 1: Get Information Step 2: Conquer Test Anxiety Step 3: Make a Plan Step 4: Learn to Manage Your Time Step 5: Learn to Use the Process of Elimination Step 6: Reach Your Peak Performance Zone Step 7: Make Final Preparations Step 8: Make Your Preparations Count

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ChaPtER 3 NCLEX-RN Practice Test 1 21 Questions Answers

ChaPtER 4 NCLEX-RN Practice Test 2 93 Questions Answers

aDDitioNaL oNLiNE PRaCtiCE 167

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Dr. Yvonne Weideman is an Assistant Professor of Nursing at Duquesne University School of Nursing. Her areas of interest are the preparation of students for the NCLEX exam and the use of innovative technology in the classroom to enhance learning. Dr. Weideman has recently developed a model for integrating theory and content through the use of virtual technology entitled “The Virtual Pregnancy Model.”

Dr. Alicia Culleiton is an Assistant Clinical Professor at Duquesne University School of Nursing. She currently teaches doctoral-level nursing courses as well as undergraduate NCLEX-RN preparation courses. Dr. Culleiton earned her BSN from the Catholic University of America, her MSN in nursing administration and nursing education from Indiana University of Pennsylvania, and her doctorate from Chatham University. Her work has been published in nursing and educational journals. Her clinical expertise is in emergency/trauma and critical care nursing, with research interests that include student remediation and NCLEX-RN preparation.

Karen Paraska, PhD, CRNP, is assistant professor of nursing at Duquesne University. She has taught a range of graduate nursing courses that include offerings in advanced practice nursing and research methods, as well as undergraduate courses, including NCLEX-RN preparation courses. She is coauthor of several referred articles, including “Cognitive Impairment Associated with Adjuvant Therapy in Breast Cancer” for the journal Psycho-Oncology.

vii

NCLEX-RN_00_FM_i-viii.indd 7 11/30/12 9:24 AM NCLEX-RN_00_FM_i-viii.indd 8 11/30/12 9:24 AM INtrODUctION tO the NcLeX-rN® chapter 1

ongratulations! If you are reading this book, it means that you have graduated or are about to graduate from an accredited registered nurse (RN) program and are interested in preparing for the National CCouncil Licensure Examination for Registered Nurses (NCLEX-RN®) , which will enable you to gain a license as a registered professional nurse. One of the most important ways to begin preparing for the NCLEX-RN is to become familiar with the format of the exam, the process of registering for the exam, what to expect on test day, the subjects the exam covers, and so on. This chapter will help you get started. While the information in this chapter is current as of the date of publication, some details may change as time goes by. For the most recent information, refer to the official National Council of State Boards of Nursing (NCSBN) NCLEX website at https://www.ncsbn.org/nclex.htm.

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Overview of NcLeX-rN .htm.) The nursing board will certify to Pearson VUE that you are eligible to sit for the exam. This results in The NCLEX-RN is a computer-based exam that tests your Authorization to Test (ATT) letter, which must the knowledge, skills, and abilities you’ll need to prac- be shown the day of the exam. The ATT is valid for a tice safely and effectively as an entry-level RN. The time period—from 60 to 365 days—determined by test is administered in a computerized adaptive test- your board of nursing, and the validity time frame ing (CAT) format, which, by adapting to each indi- cannot be extended. For this reason, it is important vidual’s abilities, allows the computer testing program that you schedule your appointment for the exam as to evaluate your abilities more effectively and effi- soon as possible after receiving your ATT. ciently than do more traditional approaches to test- Step-by-step, the registration process looks like ing. While the procedure the program uses is this, as outlined in the “2012 NCLEX® Examination complex, the general principle is fairly simple. With Bulletin”: each answer you record, the computer reassesses your competencies and continues to ask additional ques- 1. Submit an application for licensure to the tions until it is virtually certain about whether your board of nursing where you wish to be licensed. abilities are above or below the level required. 2. Meet all of the board of nursing’s eligibility Given the test’s adaptability, the number of requirements to take the NCLEX. questions it asks—anywhere from 75 to 265 items— 3. Register for the NCLEX with Pearson VUE. is different for each individual. Of this number, 15 are 4. Receive Acknowledgement of Receipt of Regis- pretest questions designed to help test producers tration from Pearson VUE. develop new types of questions; these are not consid- 5. The board of nursing makes you eligible to take ered in your assessment. The exam is not divided into the NCLEX. sections corresponding to content areas, though it is 6. Receive Authorization to Test (ATT) letter from important that you understand what content areas Pearson VUE. are covered to help you prepare (see section “What 7. Schedule your exam with Pearson VUE. Skills Are Tested?”). There is a time limit of six hours, no matter what number of questions you are given. Source: Taken from “2012 NCLEX® Examination Bulletin,” page 2; available at https://www.ncsbn.org/ 2012_NCLEX_Candidate_Bulletin.pdf. registering for the exam The fee to register for the exam is $200, which is Registration for the NCLEX-RN is a two-part pro- nonrefundable. You must also pay a fee associated cess: applying for licensure with the board of nursing with the licensure application required by your nurs- in the state or territory from which you are seeking ing board. The registration is valid for a 365-day your license, and registering for the exam with Pear- period, during which the nursing board will establish son VUE, which administers the test. It is advisable to your eligibility. If a candidate doesn’t meet the board’s start both phases at once, so that both can proceed eligibility requirements within that time period, the simultaneously. registration fee is forfeited. You must meet all of your nursing board’s Failing to appear at the scheduled examination requirements for taking the NCLEX-RN. (For a com- time will also result in both the forfeiture of your reg- plete list of the boards of nursing and links to their istration fee and the invalidation of your ATT, unless websites, go to https://www.ncsbn.org/contactbon you reschedule one full business day before your

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scheduled time. If you don’t pass the exam on your working on. As you enter the testing room, the test first try, you can retest based on a minimum waiting administrator (TA) will give you an erasable note period—45 or 90 days—determined by your state board with a marker, to be used for calculations and nursing board. note taking. You cannot write on the note board until More specific information about registration after the tutorial is finished; writing on it before is and scheduling can be found in the “2012 NCLEX® considered a serious violation and can result in an Examination Bulletin,” available at https://www.ncsbn incident report and your results being placed on hold. .org/2012_NCLEX_Candidate_Bulletin.pdf. This doc- If you need another note board during the test, you ument and others found at the NCSBN’s website can raise your hand and ask the TA to provide you should be checked to confirm details, which may with one. change after publication of this book. As mentioned, the time limit for the test is six hours. During that period there are two programmed optional breaks, one at two hours and another at What to expect three and one-half hours; the computer will inform at the test center you when these breaks start. You will also be allowed unscheduled breaks, such as those to use the rest- The NCLEX-RN is administered at one of the Pear- room, but all breaks, including those that are sched- son Professional Centers (PPCs); there are over 200 uled, count against test time. of them in the United States and 18 at locations out- The testing environment is as standardized as side the United States. possible to ensure that all candidates complete the Plan to arrive at least 30 minutes before your exam under the same conditions. Strict controls, test is scheduled to begin. Make sure to bring—in therefore, are in effect, such as the audio and video addition to your ATT letter—an acceptable personal monitoring and recording and the restriction against form of identification (ID). The only IDs considered cell phones, pagers, and other electronic devices in acceptable are a U.S. driver’s license or U.S. state iden- the testing room, as well as other personal items such tification (both issued by your state’s Department of as coats, hats, scarves, gloves, bags, purses, wallets, Motor Vehicles), U.S. passport, and U.S. military and watches. See page 8 in the “2012 NCLEX® Exam- identification. For test centers outside of the United ination Bulletin,” available at https://www.ncsbn.org/ States, only a U. S. passport is acceptable. 2012_NCLEX_Candidate_Bulletin.pdf, for more In addition to the ID you bring with you, other information. secure forms of identification will be taken during the check-in process, such as a digital signature and a palm vein scan. For further information on security What Skills are tested? procedures at the test site, refer to the “2012 NCLEX® Examination Bulletin,” available at https://www.ncsbn During the nursing program you have completed, .org/2012_NCLEX_Candidate_Bulletin.pdf. much of your study was focused on specific areas of knowledge—such as anatomy and physiology, diseases and pathologies, and pharmaceuticals—needed During the test to work as a registered nurse. The key to being an effective RN, however, is the application of that The test begins with a brief tutorial, during which knowledge. Therefore, the questions—mostly multi- you are instructed on how to use the computer you’re ple choice, though some in other formats—are

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designed to test whether you can apply that knowl- which nursing care should enhance the safety and edge in the safe and effective care of clients as an effectiveness of the setting in which care is deliv- entry-level RN. The exam, therefore, measures your ered and the ways that RNs must work to protect understanding of the needs of clients you may clients and healthcare personnel. The skills mea- encounter in practice, as well as your comprehension sured in this content area include, but are not of the integrated processes critical in nursing to limited to, advance directives, advocacy, case address these needs. management, informed consent, and ethical practice. Client Needs n Safe and Effective Care Environment: Safety and As mentioned, client needs compose the basic frame- Infection Control. This content area addresses the work for the test plan. The client needs are broken ways in which RNs should work to protect both down into four main categories, two of which have clients and healthcare workers from health and subcategories, as shown in the table. environmental hazards. The skills measured in this content area relate to, but are not limited to, Percentage of Items emergency response plans, handling hazardous Client Needs Categories in Each Category and infectious materials, safe use of equipment, Safe and Effective Care and use of restraints and safety devices. Environment n Health Promotion and Maintenance. This content Management of Care 16–22% area addresses the ways in which RNs should Safety and Infection 8–14% work to incorporate knowledge of growth and Control development principles, optimal health, and pre- Health Promotion and 6–12% vention and early detection strategies into the Maintenance care of their clients. The skills measured in this Psychosocial Integrity 6–12% content area relate to, but are not limited to, ante/ Physiological Integrity intra/postpartum and newborn care, developmental stages and transitions, health promotion, Basic Care and Comfort 6–12% disease prevention, lifestyle choices, and tech- Pharmacological and 13–19% niques of physical assessment. Parenteral Therapies n Psychosocial Integrity. This content area addresses Reduction of Risk 10–16% the ways in which RNs should work to sustain Potential and enhance the emotional, mental, and social Physiological 11–17% well-being of clients as they undergo events caus- Adaptation ing stress as well as of clients dealing with acute ® Source: Taken from “2012 NCLEX Examination Bulletin,” or long-term mental illness. The skills measured page 13; available at https://www.ncsbn.org/2012_NCLEX_ Candidate_Bulletin.pdf. in this content area relate to, but are not limited to, abuse and neglect, behavioral interventions, As explained next, these content areas cover the crisis intervention, end-of-life care, grief and loss, full range of ways that RNs are expected to attend to mental health concepts, and therapeutic commu- their clients’ needs. nication and environment. n Physiological Integrity: Basic Care and Comfort. n Safe and Effective Care Environment: Management This content area addresses the ways in which of Care. This content area addresses the ways in RNs should work to provide comfort to clients

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and assist clients in performing activities and For a more complete explanation and list of meeting expectations of daily living. The skills examples in each client need category, refer to the measured in this content area relate to, but are “2010 NCLEX-RN Detailed Test Plan, Candidate Ver- not limited to, assistive devices, elimination, sion” (available at https://www.ncsbn.org/1287.htm). mobility and immobility, nutrition and oral hydration, and rest and sleep. Integrated Processes n Physiological Integrity: Pharmacological and Par- Integrated processes critical to the practice of nursing enteral Therapies. This content area addresses the are also addressed in the questions on the NCLEX- ways in which RNs work to provide safe and RN exam. These processes include all the methodolo- effective care in the administration of medication gies employed by RNs in entry-level positions to and parenteral therapies. The skills measured in address their clients’ needs. As described in the “2010 this content area relate to, but are not limited to, NCLEX-RN Detailed Test Plan, Candidate Version” adverse effects, contraindications, side effects, (available at https://www.ncsbn.org/1287.htm), they interactions, blood and blood products, dosage include: calculation, expected actions or outcomes, medication administration, and parenteral/intrave- n Nursing process: a scientific, clinical reasoning nous therapies. approach to client care that includes assessment, n Physiological Integrity: Reduction of Risk Potential. analysis, planning, implementation, and This content area addresses the ways in which evaluation. RNs work to reduce the likelihood of complica- n Caring: interaction of the nurse and client in an tions or problems that arise due to existing condi- atmosphere of mutual respect and trust. In this tions, procedures, and treatments. The skills collaborative environment, the nurse provides measured in this content area relate to, but are encouragement, hope, support, and compassion not limited to, vital signs, diagnostic tests, labora- to help achieve desired outcomes. tory values, potential for complications of n Communication and documentation: verbal and diagnostic procedures, and potential for compli- nonverbal interactions between the nurse and the cations from surgical procedures and health client, the client’s significant others, and the other alterations, as well as system-specific (such as car- members of the healthcare team. Events and diovascular, endocrine, gastroenterological, integ- activities associated with client care are validated umentary, musculoskeletal, and neurological) in written and/or electronic records that reflect assessments. standards of practice and accountability in the n Physiological Integrity: Physiological Adaptation. provision of care. This content area addresses the ways in which n Teaching/learning: facilitation of the acquisition RNs work to provide care, and to manage that of knowledge, skills, and attitudes promoting a care, for patients with acute, chronic, or life- change in behavior. threatening conditions. The skills measured in this content area relate to, but are not limited to, alterations in body systems, fluid and electrolyte a Note on Guessing imbalances, hemodynamics, medical emergen- cies, pathophysiology, and unexpected response Fast guessing may result in a drastically lowered score. to therapies. In typical paper-and-pencil tests, and even some administered by a computer, unanswered items are

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marked wrong. But due to the nature of computer- To ensure quality and accuracy, the results are ized adaptive testing, this strategy is ill-advised, since scored twice—once by the computer and a second it will result in the computer program giving candi- time after the computer results are transmitted to dates easier items, which they may also get wrong if Pearson VUE’s central office. And even though the they are guessing and running short on time. computer obtains the candidate’s result, this informa- In short, rapid guessing should be avoided. You tion is not available to the test center’s staff. should simply maintain a steady pace, allotting approx- If you fail the exam, you will receive a Candidate imately one to two minutes to each item; stay focused; Performance Report (CPR) from your nursing board. and carefully read each item before answering. In addition to notifying the candidate of the unacceptable performance on the test, the CPR includes information about the number of items administered exam results and the candidate’s relative strengths and weaknesses vis-à-vis the test plan. With this information, the can- Examination results are mailed—by the board of didate will be guided in preparation for a re-exami- nursing—to the candidate approximately one month nation. As mentioned, the retake waiting period after the test. If you haven’t heard after five weeks, depends on your board of nursing, and there will be a you should contact your board of nursing, not Pear- minimum of 45 or 90 days between exams. son VUE. Unofficial results are available within 48 hours through Quick Results Service for a small fee, if your board of nursing participates in the program.

NCLEX-RN_01_1-6.indd 6 11/30/12 9:25 AM the Learningexpress test preparation chapter 2 system

t takes significant preparation to score well on any exam, and the NCLEX-RN® is no exception. The LearningExpress Test Preparation System, developed by experts exclusively for LearningExpress, offers a Inumber of strategies designed to facilitate the development of the skills, disciplines, and attitudes necessary for success. Preparing for and attaining a passing score on the NCLEX-RN exam requires surmounting an assortment of obstacles. While some may prove more troublesome than others, all of them carry the potential to hinder your performance and negatively affect your scores. Here are some examples:

n lack of familiarity with the exam format n paralyzing test anxiety n leaving preparation to the last minute n not preparing

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n failure to develop vital test-taking skills like: Step 1. Get information 1 hour n how to effectively pace through an exam Step 2. Conquer test anxiety 20 minutes n how to use the process of elimination to answer Step 3. Make a plan 20 minutes questions accurately Step 4. Learn to manage your time 10 minutes n when and how to guess Step 5. Learn to use the process n mental and/or physical fatigue of elimination 20 minutes n test day blunders like: Step 6. Reach your peak n arriving late at the testing facility performance zone 10 minutes n taking the exam on an empty stomach Step 7. Make final preparations 10 minutes n not accounting for fluctuations in temperature Step 8. Make your at the testing facility preparations count 10 minutes Total 2 hours, 40 minutes The common thread among these obstacles is control. Although a host of pressing, unanticipated, We estimate that working through the entire and sometimes unavoidable difficulties may frustrate system will take you approximately three hours. It’s your preparation, there remain some proven, effective perfectly okay if you work at a faster or slower pace. strategies for placing yourself in the best possible posi- It’s up to you to decide whether you should set aside a tion on exam day. These strategies can significantly whole afternoon or evening to work through the improve your level of comfort with the exam, offering LearningExpress Test Preparation System in one sit- you not only the confidence you’ll need, but also, and ting, or break it up and do just one or two steps a day perhaps most importantly, a higher test score. for the next several days. The LearningExpress Test Preparation System helps to put you in greater control. Here’s how it works. Separated into eight steps, the system height- step 1: get information ens your confidence level by helping you understand both the exam and your own particular set of test- Time to complete: 1 hour taking strengths and weaknesses. It will help you Activities: Read Chapter 1, “Introduction to the structure a study plan, practice a number of effective NCLEX-RN” test-taking skills, and avoid mental and physical fatigue on exam day. Each step is accompanied by an Knowing more about an exam can often make it activity. appear less daunting. The first step in the Learning- While the following list suggests an approxi- Express Test Preparation System is to determine mate time for the completion of each step, these are everything you can about the type of information only guidelines for your initial introduction. The reg- you will be expected to know on the NCLEX-RN, as ular practice of a number of them may require a more well as how your knowledge will be assessed. substantial time commitment. It may also be necessary and helpful to return to one or more of them throughout the course of your preparation.

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What You Should Find Out peak. Stop here and answer the questions on the “Test Knowing the details will help you study efficiently Stress Quiz” to determine your level of test anxiety. and help you feel a sense of control. Here’s a list of things you might want to find out: Stress Management before the Exam If you feel your level of anxiety is getting the best of n What skills are tested? you in the weeks before the exam, here are things you n How many sections are on the exam? can do to bring the level down: n How many questions are in each section? n How much time is allotted for each section? n Prepare. There’s nothing like knowing what to n How is the exam scored, and is there a penalty for expect to put you in control of test anxiety. That’s guessing and wrong answers? why you’re reading this book. Use it faithfully, n Is the test a computerized test or will you have an and you will be ready on test day. exam booklet? n Practice self-confidence. A positive attitude is a n Will you be given scratch paper to write on? great way to combat test anxiety. Stand in front of the mirror and say to your reflection, “I’m pre- Answers to these questions are in Chapter 1 of pared. I’m confident. I’m going to ace this exam. I this book and on the NCSBN’s NCLEX-RN website. know I can do it.” Record these messages on a recorder as well. As soon as negative thoughts creep in, drown them out with these positive step 2: conquer test anxiety affirmations. If you hear them often enough and you use the LearningExpress method to study for Time to complete: 20 minutes the NCLEX-RN, they will be true. Activity: Take the “Test Stress Quiz” n Fight negative messages. Every time someone talks to you about how hard the exam is or how it Now that you know what’s on the test, the next step is is difficult to pass, think about your self-confidence to address one of the biggest obstacles to success: test messages. If the someone with the negative mes- anxiety. Test anxiety may not only impair your per- sages is you—telling yourself you don’t do well formance on the exam itself, but also keep you from on exams, that you just can’t do this—don’t lis- preparing properly. In Step 2, you will learn stress ten. Turn on your recorder and listen to your self- management techniques that will help you succeed confidence messages. on your exam. Practicing these techniques as you n Visualize. Visualizing success can help make it work through the activities in this book will help happen—and it reminds you of why you’re doing them become second nature to you by exam day. all this work in preparing for the exam. Imagine yourself beginning the first day of your dream Combating Test Anxiety job. A little test anxiety is a good thing. Everyone gets ner- n Exercise. Physical activity helps calm your body vous before a big exam—and if that nervousness and focus your mind. Besides, being in good motivates you to prepare thoroughly, so much the physical shape can actually help you do well better. Many athletes report pregame jitters that they on the exam. Go for a run, lift weights, go are able to harness to help them perform at their swimming—and exercise regularly.

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You need to worry about test anxiety only if it is extreme enough to impair your performance. The following questionnaire will provide a diagnosis of your level of test anxiety. In the blank before each statement, write the number that most accurately describes your experience.

0 = Never 1 = Once or twice 2 = Sometimes 3 = Often

I have gotten so nervous before an exam that I simply put down the books and didn’t study for it. I have experienced disabling physical symptoms such as vomiting and severe headaches because I was nervous about an exam. I have simply not showed up for an exam because I was scared to take it. I have experienced dizziness and disorientation while taking an exam. I have had trouble filling in the little circles because my hands were shaking too hard. I have failed an exam because I was too nervous to complete it. Total: Add up the numbers in the blanks.

Your Test Stress Score Here are the steps you should take, depending on your score. If you scored:

n Below 3, your level of test anxiety is nothing to worry about; it’s probably just enough to give you that little extra edge. n Between 3 and 6, your test anxiety may be enough to impair your performance, and you should practice the stress management techniques in this section to try to bring your test anxiety down to manageable levels. n Above 6, your level of test anxiety is a serious concern. In addition to practicing the stress management techniques listed in this section, you may want to seek additional, personal help. Call your community college and ask for the academic counselor or ask the counselor at your nursing school. Tell the counselor that you have a level of test anxiety that sometimes keeps you from being able to take the exam. The counselor may be will- ing to help you or may suggest someone else you should talk to.

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Stress Management on Test Day n Take a mental break. Everyone loses concentra- There are several ways you can bring down your level tion once in a while during a long exam. It’s nor- of stress and anxiety on test day. They’ll work best if mal, so you shouldn’t worry about it. Instead, you practice them in the weeks before the exam, so accept what has happened. Say to yourself, “Hey, I you know which ones work best for you. lost it there for a minute. My brain is taking a break.” Close your eyes, and do some deep n Breathe deeply. Take a deep breath while you breathing for a few seconds. Then go back to count to five. Hold it in for a count of one, and work. then let it out on a count of five. Repeat several times. Try these techniques ahead of time and see if n Move your body. Try rolling your head in a circle. they work for you! Rotate your shoulders. Shake your hands from the wrist. n Visualize again. Think of the place where you are step 3: make a plan most relaxed: lying on the beach in the sun, walking through the park, or wherever relaxes you. Time to complete: 20 minutes Now, close your eyes and imagine you’re actually Activity: Construct a study plan there. If you practice in advance, you will find that you need only a few seconds of this exercise There is no substitute for careful preparation and to experience a significant increase in your sense practice over time. So the most important thing you of relaxation and well-being. can do to better prepare yourself for your exam is to create a study plan or schedule and then follow it. When anxiety threatens to overwhelm you dur- This will help you avoid cramming at the last minute, ing the test, there are still things you can do to man- which is an ineffective study technique that will only age your stress level: add to your anxiety. Once you have your plan, make a commitment n Repeat your self-confidence messages. You to follow it. Set aside at least 30 minutes every day should have them memorized by now. Say them for studying and practice. This will do more good quietly to yourself, and believe them! than two hours crammed into a Saturday. If you n Visualize one more time. This time, visualize have months before the test, you’re lucky. Don’t put yourself moving smoothly and quickly through off your studying until the week before. Start now. the exam, answering every question correctly, and Even 10 minutes a weekday, with half an hour or finishing just before time is up. Like most visual- more on weekends, can make a big difference in ization techniques, this one works best if you’ve your score. practiced it ahead of time. n Find an easy question. Skim over the questions until you find an easy one, and then answer it. Getting even one question answered correctly gets you into the test-taking groove.

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step 4: Learn to step 5: Learn to use manage your time the process of elimination

Time to complete: 10 minutes to read; many hours Time to complete: 20 minutes of practice Activity: Complete worksheet on “Using the Process Activities: Practice these strategies as you take the of Elimination” sample exams After time management, the next most important Steps 4, 5, and 6 of the LearningExpress Test Prepara- tool for taking control of your test is using the pro- tion System put you in charge of your NCLEX-RN cess of elimination wisely. It’s standard test-taking experience by showing you test-taking strategies that wisdom that you should always read all the answer work. Practice these strategies as you take the practice choices before choosing your answer. This helps you exams in this book and online. Then, you will be find the right answer by eliminating wrong answer ready to use them on test day. choices. Consider the following question. Although it First, you will take control of your time on the is not the type of question you will see on NCLEX-RN, NCLEX-RN. Start by understanding the format of the mental process that you use will be the same. the test. Refer to Chapter 1 to review this information; in particular, make sure you understand the way 9. Sentence 6: I would like to be considered for the computerized adaptive testing (CAT) works. the assistant manager position in your com- You will want to practice using your time wisely pany my previous work experience is a good on the practice tests, while trying to avoid making match for the job requirements posted. mistakes at the same time as working quickly. Which correction should be made to sentence 6? n Listen carefully to directions. By the time you a. Insert Although before I. get to the test, you should know how it works. But b. Insert a question mark after company. listen carefully in case something has changed. c. Insert a semicolon and However before my. n Pace yourself. Glance at your watch every few d. Insert a period after company and capitalize minutes to ensure that you are not taking much my. more than one to two minutes on each item. e. No corrections are necessary. n Keep moving. Don’t spend too much time on one question. If you don’t know the answer, skip If you happen to know that sentence 6 is a run-on the question and move on. Mark the question for sentence and you know how to correct it, you don’t review, and come back to it later. need to use the process of elimination. But let’s n Don’t rush. You should keep moving; but rushing assume that, like some people, you don’t. So, you look won’t help. Try to keep calm and work methodi- at the answer choices. Although surely doesn’t sound cally and quickly. like a good choice, because it would change the meaning of the sentence. So, you eliminate choice a—and now you have only four answer choices to deal with. Write a on your note board with an X through or beside it. Move on to the other answer choices.

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If you know that the first part of the sentence If you don’t like these marks, devise your own system. does not ask a question, you can eliminate choice b as Just make sure you do it long before exam day—while a possible answer. Write b on your note board with an you’re working through the practice tests in this book X through or beside it. Choice c, inserting a semico- and online—so you won’t have to worry about it dur- lon, could create a pause in an otherwise long sen- ing the exam. tence, but inserting the capitalized word However Even when you think you’re absolutely clueless might not be correct. If you’re not sure whether this about a question, you can use the process of elimina- answer is correct, write c on your note board with a tion to get rid of one answer choice. By doing so, question mark beside it, meaning “well, maybe.” you’re better prepared to make an educated guess, as Answer choice d would separate a very long you will see next. More often, the process of elimina- sentence into two shorter sentences, and it would not tion allows you to get down to only two possible right change the meaning. It could work, so write d on answers. Nevertheless, as explained in Chapter 1, your note board with a check mark beside it, meaning rapid guessing is a strategy that should be avoided in “good answer.” Answer choice e means that the sen- the NCLEX-RN. It will result in the computer pro- tence is fine like it is and doesn’t need any changes. gram giving candidates easier items, which you may The sentence could make sense as it is, but it is defi- also get wrong if you are guessing and running short nitely long. Is this the best way to write the sentence? on time. If you’re not sure, write e on your note board with a Try using your powers of elimination on the question mark beside it. questions starting on page 14. The answer explana- Now, your note board looks like this: tions show one possible way you might use the pro- X a. cess to arrive at the right answer. X b. ? c. 3 d. step 6: reach your ? e. peak performance zone

You’ve got just one check mark, for a good Time to complete: 10 minutes to read; weeks to answer, d. If you’re pressed for time, you should sim- complete! ply select choice d. If you’ve got the time to be extra Activity: Complete the “Physical Preparation careful, you could compare your check mark answer Record” to your question mark answers to make sure that it’s better. (It is: Sentence 6 is a run-on, and should be Physical and mental fatigue can significantly hinder separated into two shorter, complete sentences.) your ability to perform as you prepare and also on It’s good to have a system for marking good, the day of the exam. Poor diet choices can, as well. bad, and maybe answers. We recommend using this Drastic changes to your existing daily routine may one: cause a disruption too great to be helpful, but mod- X = bad est, calculated alterations in your level of physical 3 = good activity, the quality of your diet, and the amount and ? = maybe regularity of your rest can enhance your studies and your performance on the exam.

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Use the process of elimination to answer the following questions. 1. Ilsa is as old as Meghan will be in five years. The 3. Smoking tobacco has been linked to difference between Ed’s age and Meghan’s age a. increased risk of stroke and heart attack. is twice the difference between Ilsa’s age and b. all forms of respiratory disease. Meghan’s age. Ed is 29. How old is Ilsa? c. increasing mortality rates over the past a. 4 10 years. b. 10 d. juvenile delinquency. c. 19 d. 24 4. Which of the following words is spelled correctly? 2. “All drivers of commercial vehicles must carry a. incorrigible a valid commercial driver’s license whenever b. outragous operating a commercial vehicle.” c. domestickated According to this sentence, which of the d. understandible following people need NOT carry a commercial driver’s license? a. a truck driver idling his engine while waiting to be directed to a loading dock b. a bus operator backing her bus out of the way of another bus in the bus lot c. a taxi driver driving his personal car to the grocery store d. a limousine driver taking the limousine to her home after dropping off her last passenger of the evening

Answers Here are the answers, as well as some suggestions as to how you might have used the process of elimination to find them.

1. d. You should have eliminated choice a right off 2. c. Note the word not in the question, and go the bat. Ilsa can’t be four years old if Meghan through the answers one by one. Is the truck is going to be Ilsa’s age in five years. The driver in choice a “operating a commercial best way to eliminate other answer choices is vehicle”? Yes, idling counts as “operating,” to try plugging them into the information so he needs to have a commercial driver’s given in the problem. For instance, for license. Likewise, the bus operator in choice b choice b, if Ilsa is 10, then Meghan must be is operating a commercial vehicle; the ques- 5. The difference between their ages is 5. tion doesn’t say the operator has to be on the The difference between Ed’s age, 29, and street. The limo driver in choice d is operating Meghan’s age, 5, is 24. Is 24 two times 5? a commercial vehicle, even if it doesn’t have No. Then choice b is wrong. You could elimi- a passenger in it. However, the driver in nate choice c in the same way and be left choice c is not operating a commercial vehi- with choice d. cle, but his own private car.

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3. a. You could eliminate choice b simply because plain silly, so you could eliminate that one, of the presence of the word all. Such abso- too. You are left with the correct choice, a. lutes hardly ever appear in correct answer 4. a. How you used the process of elimination here choices. Choice c looks attractive until you depends on which words you recognized as think a little about what you know—aren’t being spelled incorrectly. If you knew that the fewer people smoking these days, rather correct spellings were outrageous, domesti- than more? So how could smoking be cated, and understandable, then you would responsible for a higher mortality rate? (If be home free. Surely you knew that at least you didn’t know that mortality rate means one of those words was wrong in the question! the rate at which people die, you might keep this choice as a possibility, but you would still be able to eliminate two answers and have only two to choose from.) And choice d is

your guessing abiLity

The following are ten really hard questions. You are not supposed to know the answers. Rather, this is an assessment of your ability to guess when you don’t have a clue. Read each question carefully, as if you were expected to answer it. If you have any knowledge of the subject, use that knowledge to help you eliminate wrong answer choices. 1. September 7 is Independence Day in 4. American author Gertrude Stein was born in a. India. a. 1713. b. Costa Rica. b. 1830. c. Brazil. c. 1874. d. Australia. d. 1901.

2. Which of the following is the formula for 5. Which of the following is NOT one of the Five determining the momentum of an object? Classics attributed to Confucius? a. p = MV a. I Ching b. F = ma b. Book of Holiness c. P = IV c. Spring and Autumn Annals d. E = mc2 d. Book of History

3. Because of the expansion of the universe, the 6. The religious and philosophical doctrine that stars and other celestial bodies are all moving holds that the universe is constantly in a away from each other. This phenomenon is struggle between good and evil is known as known as a. Pelagianism. a. Newton’s first law. b. Manichaeanism. b. the big bang. c. neo-Hegelianism. c. gravitational collapse. d. Epicureanism. d. Hubble flow.

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7. The third Chief Justice of the U.S. Supreme How Did You Do? Court was You may have simply gotten lucky and actually a. John Blair. known the answer to one or two questions. In addi- b. William Cushing. tion, your guessing was probably more successful if c. James Wilson. you were able to use the process of elimination on d. John Jay. any of the questions. Maybe you didn’t know who the third Chief Justice was (question 7), but you knew 8. Which of the following is the poisonous that John Jay was the first. In that case, you would portion of a daffodil? have eliminated choice d and, therefore, improved a. the bulb your odds of guessing right from one in four to one b. the leaves in three. c. the stem According to probability, you should get two- d. the flowers and-a-half answers correct, so getting either two or 9. The winner of the Masters golf tournament in three right would be average. If you got four or more 1953 was right, you may be a really terrific guesser. If you got a. Sam Snead. one or none right, you may be a really bad guesser. b. Cary Middlecoff. Keep in mind, though, that this is only a small c. Arnold Palmer. sample. You should continue to keep track of your d. Ben Hogan. guessing ability as you work through the sample 10. The state with the highest per capita personal questions in this book. Circle the numbers of ques- income in 1980 was tions you guess on as you make your guess; or, if you a. Alaska. don’t have time while you take the practice tests, go b. Connecticut. back afterward and try to remember which questions c. New York. you guessed at. Remember, on a test with four d. Texas. answer choices, your chance of guessing correctly is one in four. So keep a separate “guessing” score for Answers each exam. How many questions did you guess on? Check your answers against the following correct How many did you get right? If the number you got answers. right is at least one-fourth of the number of ques- 1. c. tions you guessed on, you are at least an average 2. a. guesser—maybe better—and you should always go 3. d. ahead and guess on the real exam. If the number you 4. c. got right is significantly lower than one-fourth of the 5. b. number you guessed on, you would be safe in guess- 6. b. ing anyway, but maybe you would feel more comfort- 7. b. able if you guessed only selectively, when you can 8. a. eliminate a wrong answer or at least have a good 9. d. feeling about one of the answer choices. 10. a. Remember, even if you are a play-it-safe person with lousy intuition, you are still safe guessing every time.

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Exercise Physical Preparation Record If you are already engaged in a regular program of In the week leading up to the test, you may be so physical activity, resist allowing the pressure of the involved with studying (and, unfortunately, stress) approaching exam to alter this routine. If you have that you neglect to treat your body kindly. This work- not been engaged in regular physical activity, it may sheet will help you stay on track. be helpful to begin during your test preparations. For each day of the week before the test, write Speak with someone knowledgeable about such mat- down what physical exercise you engaged in and for ters to design a regimen suited to your particular cir- how long and what you ate for each meal. Remember, cumstances and needs. Whatever its form, try to keep you’re trying for at least half an hour of exercise every it a regular part of your preparation as the exam other day (preferably every day) and a balanced diet approaches. that is light on junk food. These practices are key to your body and brain working at their peaks. Diet A balanced diet will help you achieve peak performance. Limit your caffeine and junk food intake as step 7: make final preparations you continue on your preparation journey. Eat plenty of fruits and vegetables, along with lean proteins and Time to complete: 10 minutes to read; time to com- complex carbohydrates. Foods that are high in leci- plete will vary thin (an amino acid), such as fish and beans, are espe- Activity: Complete the “Final Preparations” cially good brain foods. worksheet Your diet is also a matter that is particular to you, so any major alterations to it should be discussed You’re in control of your mind and body; you’re in with a person with expert knowledge of nutrition. charge of test anxiety, your preparation, and your test-taking strategies. Now, it’s time to take charge of Rest external factors, like the testing site and the materials For your brain and body to function at optimal lev- you need for taking the test. els, they must have an adequate amount of rest. It will be important to determine what an adequate Find Out Where the Exam Is and amount of rest is for you. Determine how much rest Make a Trial Run you must have to feel at your sharpest and most alert, Make sure you know exactly when and where your and make an effort to get that amount regularly as test is being held. Do you know how to get to the the exam approaches and particularly on the night exam site? Do you know how long it will take to get before the exam. there? If not, make a trial run if possible, preferably It may help to record your efforts. On page 18 is on the same day of the week at the same time of day. a “Physical Preparation Record” for the week prior to On the “Final Preparations” worksheet, make note of the exam; you may find its use helpful for staying on the amount of time it will take you to get to the test track. site. Plan on arriving at least 30 to 45 minutes early so

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For the week before the test, record (1) the type and duration of your physical exercise, (2) your food consumption for each day, and (3) the number of hours you slept.

Exam minus 7 days Exam minus 3 days Exercise: ______for ______minutes Exercise: ______for ______minutes Breakfast: Breakfast: Lunch: Lunch: Dinner: Dinner: Snacks: Snacks:

Exam minus 6 days Exam minus 2 days Exercise: ______for ______minutes Exercise: ______for ______minutes Breakfast: Breakfast: Lunch: Lunch: Dinner: Dinner: Snacks: Snacks:

Exam minus 5 days Exam minus 1 day Exercise: ______for ______minutes Exercise: ______for ______minutes Breakfast: Breakfast: Lunch: Lunch: Dinner: Dinner: Snacks: Snacks:

Exam minus 4 days Exercise: ______for ______minutes Breakfast: Lunch: Dinner: Snacks:

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you can get the lay of the land, use the bathroom, and step 8: make your calm down. Then figure out how early you will have preparations count to get up that morning, and make sure you get up that early every day for a week before the test. Time to complete: 10 minutes, plus test-taking time Activity: Ace the NCLEX-RN! Gather Your Materials Make sure you have all the materials that will be Fast-forward to test day. You’re ready. You made a required at the testing facility. Whether it’s an admis- study plan and followed through. You practiced your sion ticket, an ID, a second form of ID, pencils, pens, test-taking strategies while working through this or any other item that may be necessary, make sure book. You’re in control of your physical, mental, and you have put it aside. It’s preferable to put them all emotional state. You know when and where to show aside together. up and what to bring with you. In other words, you’re Arrange your clothes the evening before the well prepared! exam. Dress in layers so that you can adjust readily to When you’re done with the test you will have the temperature of the exam room. earned a reward. Plan a celebration. Call up your friends and plan a party, have a nice dinner with your Fuel Appropriately family, or pick out a movie to see—whatever your Decide on a meal to eat in the time before your exam. heart desires. Taking the exam on an empty stomach is something And then do it. Go into the test, full of confi- to avoid, particularly if it is an exam that spans sev- dence, armed with test-taking strategies you’ve prac- eral hours. Eating poorly and feeling lethargic are also ticed until they’re second nature. You’re in control of to be avoided. Decide on a meal that will sate your yourself, your environment, and your performance hunger without adverse effect. on the exam. You’re ready to succeed. So do it, and look forward to your future as someone who has Final Preparations passed the NCLEX-RN! To help organize your final preparations, a “Final Preparations” worksheet is provided on page 20.

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Getting to the exam site:

Exam date: ______

Location of exam site:______

Do I know how to get to the exam site? Yes No (If no, make a trial run.)

Time it will take to get to the exam site: ______

Departure time: ______

Things to Lay Out the Night Before

Clothes I will wear

Sweater/jacket

Watch

Photo ID

Four #2 pencils

Other Things to Bring/Remember

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his examination has been designed to test your understanding of the content included on the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which you must pass to become Ta registered nurse, and also to allow you to experience the format in which the exam is administered. Becoming comfortable with the examination format and logistics will help you be more relaxed when it comes to actually sitting for the test, enabling you to perform at your best. The actual NCLEX-RN examination is computer adaptive, which means all examinees will have a different number of test questions depending on how many and what types of questions they answer correctly and how many they answer incorrectly. All test takers must answer a minimum of 75 items, and the maximum number of items that the candidate may answer is 265 during the allotted six-hour time period. This Learning- Express practice exam has 165 questions, and you should allow yourself four hours to complete it. Then, after you have completed the exam, look at the answer key to read the rationales for both the correct and the incorrect choices, as well as the sources of the information. It is recommended that you utilize the

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sources to thoroughly review information that was Completion of this examination represents the problematic for you. Because the NCLEX-RN exami- culmination of extensive test preparation. You have nation is graded on a sliding scale that is based on the worked very hard to review the information from difficulty of each particular exam, we are unable to your NCLEX-RN curriculum, and now it is your time predict how many correct answers would equate to to shine. Good luck! an actual passing grade on this practice exam.

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practice test 1 answer sheet

1. 56. 111. 2. 57. 112. 3. 58. 113. 4. 59. 114. 5. 60. 115. 6. 61. 116. 7. 62. 117. 8. 63. 118. 9. 64. 119. 10. 65. 120. 11. 66. 121. 12. 67. 122. 13. 68. 123. 14. 69. 124. 15. 70. 125. 16. 71. 126. 17. 72. 127. 18. 73. 128. 19. 74. 129. 20. 75. 130. 21. 76. 131. 22. 77. 132. 23. 78. 133. 24. 79. 134. 25. 80. 135. 26. 81. 136. 27. 82. 137. 28. 83. 138. 29. 84. 139. 30. 85. 140. 31. 86. 141. 32. 87. 142. 33. 88. 143. 34. 89. 144. 35. 90. 145. 36. 91. 146. 37. 92. 147. 38. 93. 148. 39. 94. 149. 40. 95. 150. 41. 96. 151. 42. 97. 152. 43. 98. 153. 44. 99. 154. 45. 100. 155. 46. 101. 156. 47. 102. 157. 48. 103. 158. 49. 104. 159. 50. 105. 160. 51. 106. 161. 52. 107. 162. 53. 108. 163. 54. 109. 164. 55. 110. 165. 23

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Questions 4. Upon examining the mouth and throat of a seven-year-old, the nurse observes the 1. The nurse on a medical-surgical unit is caring following: for a client with an extensive wound infection. The physician has ordered contact precautions based on the wound culture results. The nurse recognizes when caring for this client that she should wear disposable medical examination gloves a. upon entering the client’s room to provide care. b. when providing care within five feet of the client. c. when anticipating a dressing change. d. when the potential of contamination from body fluids exists.

2. When administering magnesium to a preeclampsic pregnant woman, the nurse assesses The mother asks the nurse if the child’s tonsils for signs and symptoms of magnesium toxic- should be removed as they are so large. The ity. These include all of the following EXCEpT nurse knows that the tonsils reach their maxi- a. absent reflexes. mum size between the ages of b. fetal heart rate of 120. a. 4 and 6. c. respirations < 12 per minute. b. 6 and 8. d. urine output < 30cc/hour. c. 8 and 10. d. 10 and 12. 3. The nurse is caring for a client diagnosed with glaucoma. Which of the following medica- 5. The nurse is preparing to complete a neuro- tions, if prescribed for the client, should the logical assessment on a client. The nurse is nurse question? aware that which of the following are included a. atropine sulfate (Isopto Atropine) when assessing a client using the Glasgow b. betaxolol (Betoptic) Coma Scale? Select all that apply. c. pilocarpine (Ocusert pilo-20) 1. eye opening d. pilocarpine hydrochloride (Isopto Carpine) 2. motor response 3. pupil reaction 4. verbal performance a. 1, 2, 3, 4 b. 1, 2, 4 c. 1, 4 d. 2, 3

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6. When the nurse is able to take the client’s per- 9. A nurse has asked an unlicensed nursing assis- spective into consideration and communicate tant to feed a client who is ordered a full liquid this understanding back to the client, the nurse diet. The nurse will instruct the nursing assis- is using tant that which of the following items are per- a. assertiveness. mitted on this type of diet? Select all that b. empathy. apply. c. sympathy. 1. ice cream d. transference. 2. oatmeal 3. pudding 7. A nurse administers 12 U of regular insulin 4. yogurt mixed with 34 U of NpH insulin to a diabetic a. 1, 4 client at 7:00 a.m. At 12 noon the client is off b. 2, 3 the unit at radiology when lunch trays arrive. c. 1, 3, 4 Which of the following is the most appropriate d. 1, 2, 4 action for the nurse to complete? a. Contact the radiology department and ask 10. The nurse is teaching a class to new mothers the RN to start an IV of 5% dextrose. about safe infant sleeping environments. The b. Request that the client be returned to the nurse teaches that which of the following unit to eat lunch if the testing is not increase the infant’s risk for sudden infant complete. death syndrome (SIDS)? Select all that apply. c. Save the lunch tray and have client eat when 1. sleeping with a pacifier he or she returns to the unit. 2. low birth weight d. Take a glass of orange juice or milk to the 3. maternal smoking during pregnancy radiology department for the client at 12 4. being placed on back for sleep noon. a. 1, 2 b. 2, 3 8. A woman in preterm labor is admitted to the c. 3, 4 hospital and given an intramuscular (IM) d. 1, 4 injection of betamethasone. The nurse explains to the client that betamethasone a. lowers maternal blood pressure. b. prevents fetal seizures. c. promotes fetal lung maturation. d. stops maternal contractions.

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11. The nurse is caring for a client in the intensive, 12. The first intervention that a nurse should per- care unit (ICU) who has suffered a stroke. The form when caring for a woman experiencing client is diagnosed with a left homonymous postpartum hemorrhage due to uterine atony hemianopsia. Which of the following illustra- is to tions demonstrates the nurse’s interpretation a. administer packed red blood cells. of the visual field defect that this client is b. administer pitocin. experiencing? c. insert a urinary catheter. d. massage the fundus. STOP STOP 13. A client on a medical surgical unit is extremely restless and agitated. It is decided that the cli- a. ent will begin chemical restraints with IV sedatives. The nurse recognizes it is important to monitor the client for which of the following common side effects associated with chemical sedations and restraints? a. ability to remove the restraints STOP b. pain c. hypertension d. respiratory depression b. 14. A nurse goes into a client’s room to start an IV. The client tells the nurse in a hostile voice, “I am sick of being poked at and stuck with nee- dles. Go away and leave me alone.” Which is the best response by the nurse? a. “I will leave you alone.” STO STO b. “This won’t hurt.” c. “You have had a lot of tests and treatments.” c. d. “You have to have this IV.”

15. A client is being prepared for cardioversion. The client is fearful and anxious about the pain associated with the countershock to be delivered. Conscious sedation is provided for the client. The nurse will monitor the client for which of the following associated with conscious sedation? d. a. allergic reaction b. alteration in level of consciousness c. hypertension d. respiratory distress

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16. The nurse is working with a client on the one- 19. The nurse is assisting a client to the bathroom. year anniversary of a stillborn baby’s birth. During the interaction, the client tells the The client expresses that for the past month nurse, “I might as well be dead; I can’t even go she has been experiencing episodes of sadness to the bathroom on my own.” Which response and crying. The nurse knows that most likely by the nurse would be most therapeutic and this client is in which of the following phases appropriate? of grief? a. “Stay positive. Things will look better a. anticipatory tomorrow.” b. bittersweet b. “You are progressing well. A week ago, you c. intense couldn’t even get out of bed.” d. reorganization c. “You sound really discouraged and frustrated today.” 17. A client with positive cultures for methicillin- d. “Why are you feeling so bad today? This resistant Staphylococcus aureus (MRSA) is isn’t like you.” being treated on a medical-surgical unit. The nurses on the unit implement contact precau- 20. The nurse is trying to teach an eight-year-old tions when interacting with the client. Which girl how to administer her insulin injections. of the following are components of contact The girl is accompanied by her mother and precautions? her sister, who is a toddler. The toddler keeps a. placing the client in a negative air pressure interrupting the nurse. What strategy might room the nurse use to facilitate communication? b. placing the client in a private or semiprivate a. Distract the toddler with a book. room b. Ignore the toddler and continue. c. wearing an N-95 respirator when c. Tell the toddler to behave. interacting with the client d. Tell the mother to control the toddler. d. wearing a mask when interacting with the client 21. The nurse is caring for a client diagnosed with Alzheimer’s who is being treated for pneumo- 18. The nurse is assessing a six-month-old with nia. During a.m. care, the client becomes agi- hydrocephalus. The nurse would expect to find tated and states, “Where am I? I’m afraid. Who which of the following upon assessment? are you? Where is my family?” Which of the a. bulging fontanel following is the nurse’s best response? b. firm fontanel a. “I just told you four times that you’re in the c. increased pulse hospital and your family will be here later.” d. sunken fontanel b. “The name of the hospital is on the sign over the door. Let’s go out into the hall and read it again.” c. “You are in the hospital and you’re safe. Your family will be here at 10 o’clock, which is half an hour from now.” d. “You know where you are. You were admitted here one week ago for pneumonia. Don’t worry; your family will be here soon.”

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22. The nurse anticipates administering metho- 24. A nurse working in a child development clinic trexate for which of the following complica- notices that a child consistently plays alone, tions in the antepartum period? even when other children are present. While a. complete abortion the child enjoys the presence of others, she b. ruptured tubal pregnancy focuses on her own activity. The nurse recog- c. threatened abortion nizes that solitary play is appropriate for which d. unruptured tubal pregnancy age child? a. an infant 23. The nurse is caring for a client with a pleur- b. a toddler Evac chest tube following open heart surgery. c. a preschooler On the illustration, which area should the d. a school age child nurse check when assessing for the presence of an air leak? 25. The nurse identifies a client as being at risk for developing thromboembolic disease. Antiem- bolism stockings have been ordered for the cli- 3 ent. Which of the following directions should genzyme REF A-8000-08 the nurse include in teaching the client about 2500 650 © 1600 200 the correct use of the stockings? 180 600 2400 1500 160 a. If ambulating at least 10 times daily, it is 2 20 4 550 2300 1400 140 unnecessary to wear the stockings.

120 15 2200 1300 500 b. If the skin becomes painful underneath the

100

PLEUR-EVAC 1200 450 2100 stockings, notify the nurse and request pain 10 1100 400 2000 medication.

1000 5 350 c. Cross the legs only while wearing the 1900 50 900 stockings; otherwise keep the legs 1800 300

1 800 uncrossed. 1700 250 d. The most appropriate time to apply the 700 10 hose is before standing first thing in the morning.

a. 1 26. A woman comes into the office for her initial b. 2 prenatal visit. She states the first day of her last c. 3 menstrual period was April 9, 2012. Using d. 4 Naegele’s rule, the nurse determines the client’s correct due date to be a. January 9, 2013 b. January 16, 2013 c. January 23, 2013 d. January 26, 2013

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27. A client has undergone emergency treatment 30. The nurse is teaching the parent of a child related to acute coronary syndrome. The client with eczema (atopic dermatitis). The nurse has had minimal periods of sleep over the past determines that the parent understands the 24 hours. Which of the following assessment instructions when the parent states that when findings is consistent with sleep deprivation? bathing the child she will a. cool extremities a. ensure the child’s skin is completely dry b. confusion after bathing. c. depression b. use a mild soap or cleansing agent. d. periods of apnea c. use hot water. d. vigorously rub the child with a towel. 28. The nurse has been asked by the manager to work an overtime shift. She does not want the 31. The nurse is caring for a client who is hyper- overtime because of an evening appointment. thermic. The physician orders the application The manager tells her to think of her cowork- of a hypothermic blanket. Which of the fol- ers, who will have a “bad” evening if the “hole” lowing findings should lead the nurse to is not filled. The best assertive response from suspect the client may be experiencing hypo- the nurse is, thermia following the application of the a. “I cannot work the shift tonight.” blanket? Select all that apply. b. “Okay, I will this time but not the next.” 1. bradycardia c. “You are making me feel guilty.” 2. drowsiness d. “You don’t understand.” 3. hypertension 4. hypotension 29. The nurse is completing her morning assess- 5. increased urine output ment on her assigned client. The nurse notes 6. tachycardia that the client’s blood pressure is 85/55 mm a. 1, 2, 4 Hg with a pulse rate of 62 bpm. Which of the b. 2, 4, 5 following actions should the nurse complete c. 2, 3, 6 first? d. 3, 5, 6 a. Assess the client for dizziness and the skin of the extremities for warmth. 32. A laboring client’s station is documented as b. Elevate the head of the client’s bed. −1. The nurse assuming care for this client c. Retake the client’s blood pressure. would expect the fetal head to be d. Review the client’s chart and determine the a. crowning. client’s normal blood pressure range. b. level with the ischial spines. c. one centimeter above the ischial spines. d. one centimeter below the ischial spines.

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33. A nurse is assessing the pupil size of a client 35. A seasoned nurse is passing medications with diagnosed with an epidural hematoma. Fol- a graduate nurse. The graduate nurse is pre- lowing the assessment, the nurse immediately paring to apply a clonidine (Catapres) trans- notifies the physician that the client may be dermal patch to a client. Which of the experiencing increased intracranial pressure following actions by the graduate nurse would with compression of the oculomotor nerve. cause the seasoned nurse to intervene? Which of the following pupil sizes on the illus- a. The graduate nurse applies a bioclusive seal tration best supports the nurse’s conclusion? over the patch after application. b. The graduate nurse applies the patch to a dry, hairless area of subcutaneous tissue. c. The graduate nurse performs hand hygiene after the application of the patch.

9 d. The graduate nurse removes any previously 8 7 applied transdermal patch. PUPIL GAUGE 4 6 5 4 36. The nurse is caring for a postpartum woman 3 2 experiencing hemorrhagic shock. The nurse 3 recognizes that the most objective and least invasive assessment of adequate organ perfu-

2 sion and oxygenation is 1 a. cool, dry skin. b. cyanosis in the buccal mucosa. a. 1 c. diminished restlessness. b. 2 d. urinary output at least 30 ml/hour. c. 3 d. 4

34. A 13-year-old enters a hospital for a surgical procedure. The nurse planning care for the adolescent knows that a. development ends in adolescence. b. growth is proximocaudal. c. growth is cephalodistal. d. developmental tasks are age-related.

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37. The nurse is preparing to administer an intra- 39. The nurse is caring for a client who is receiving muscular (IM) injection into the left dorsoglu- IV gentamicin. The nurse recognizes that gen- teal muscle of an adult client. On the tamicin is known to be nephrotoxic. Given illustration, in which area should the nurse these circumstances, the nurse should inde- plan to administer the injection? pendently evaluate the client’s a. BUN level. b. creatinine clearance level. c. fluid intake. d. urinary output. 1 40. A six-year-old boy is being seen at an urgent- 2 care clinic. Upon assessing the respiratory rate, the nurse determines it to be 24 breaths per 3 minute. The most appropriate action by the

4 nurse is to a. document the respiratory rate. b. have another nurse recheck the rate. c. notify the physician. d. recheck the respiratory rate. a. 1 b. 2 41. The nurse is caring for a client diagnosed with c. 3 cirrhosis. Which of the following information d. 4 obtained by the nurse during the assessment will be of most concern? 38. The nurse has just completed reading a client’s a. The client has ascites and a 3 kg weight gain biopsy report, which shows that the client has from the previous day. cancer. As the nurse enters the room to per- b. The client complains of right upper- form an assessment, the client states: “I know quadrant pain with abdominal palpation. that the biopsies will show I have cancer.” The c. The client’s skin has multiple spider-shaped nurse’s best response is, blood vessels on the abdomen. a. “I do not know what the biopsies will show.” d. The client’s hands flap back and forth when b. “I am not allowed to discuss the results.” the arms are extended. c. “Maybe you don’t have cancer.” d. “You think the biopsies will be positive?” 42. When assessing for fetal presentation on a pregnant client, the nurse should use which of the following? a. Chadwick’s sign b. Hegar’s sign c. Leopold’s maneuver d. McMurray’s test

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43. The nurse is working with a dying client who 46. A 56-year-old female client asks the nurse how states that he told God that if he could just live to calculate her body mass index (BMI). The to see his son’s graduation, he could die in client weighs 160 pounds and is 5 feet 6 inches peace. The nurse should document that the tall (66˝). Together, the client and the nurse client is in which of the following stages of calculate the client’s BMI to the nearest tenth death and dying, according to Dr. Elisabeth of a point as which of the following? Kübler-Ross’s theories? a. 25.8 a. anger b. 24.7 b. bargaining c. 24.9 c. denial d. 23.9 d. depression 47. The nurse is conducting a parenting class for 44. A client on a medical-surgical unit diagnosed new parents. The nurse correctly instructs the with hypertension is receiving the diuretic spi- parents that infant social development ronolactone (Aldactone). Which of the follow- includes smiling at their mirror image during ing statements by the client indicates that the which of the following ages? teaching about this medication has been a. zero to three months effective? b. four to six months a. “I can only have low-fat cheese.” c. seven to nine months b. “I can use a salt substitute at dinner.” d. 10 to 12 months c. “I will have apple juice instead of orange juice.” d. “I will drink at least six glasses of water every day.”

45. The nurse is preparing to care for a pregnant client whose medical record documents that the client has +1 protein in her urine and a blood pressure reading of 152/92. The nurse plans care for a client most likely experiencing a. eclampsia. b. gestational hypertension. c. preeclampsia. d. severe preeclampsia.

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48. The nurse is caring for a client with a stage 3 50. The nurse is completing an admission assess- pressure ulcer. The client’s daughter asks the ment on a client who is having a same-day nurse which layer of her mother’s tissue is procedure. The client states she has been tak- actually damaged. Using the illustration, the ing ginkgo daily for the past year. To monitor nurse indicates which circled area is indicative the effectiveness of ginkgo, the nurse evaluates of a stage 3 pressure ulcer? which of the following? 4 a. blood pressure b. motivation c. attention span d. red blood cells

Epidermis 51. When assessing the cervix of a client thought to be about four weeks pregnant, the nurse 3 Dermis determines that the lower portion of the client’s cervix is beginning to soften. The nurse should document this as

Subcutaneous a. Chadwick’s sign. tissue (fat) b. Hegar’s sign. c. Homan’s sign. 1 2 d. Murphy’s sign.

a. 1 52. A client diagnosed with terminal brain cancer b. 2 is admitted into a hospice program. The client c. 3 is experiencing continuous, increasing d. 4 amounts of pain. The nurse caring for the client will administer opioid pain medications to 49. The nurse makes a phone call to the physician provide which of the following? regarding a 79-year-old client with chest pains. a. around-the-clock routine administration of The client has a history of anxiety. The nurse analgesics correctly communicates the information indi- b. enough pain medication to keep the client cated in the “B” of the SBAR communication comfortable technique in which of the following c. pain relief with pro re nata (pRN) statements? medications at the client’s request a. “A 79-year-old client with a history of d. sedation and pain relief at the family’s anxiety.” request b. “He is complaining of chest pain.” c. “Do you want to start an EKG?” d. “I am concerned about a panic attack.”

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53. The nurse is assessing the skin of a six-year- 56. The nurse enters the room of a client who has old boy with severe cerebral palsy and notes just returned from surgery. The client had a that the child has a pressure ulcer on the right total laryngectomy and radical neck dissection. buttock measuring 2 cm by 2 cm with partial- Upon assessment, the nurse notes the follow- thickness loss of the dermis. She also observes ing problems. In which order should the nurse that the wound base is red. The nurse should address them? document this pressure ulcer as 1. The client is coughing blood-tinged a. stage 1. secretions from the tracheostomy. b. stage 2. 2. The client is lying in a lateral position c. stage 3. with the head of the bed flat. d. stage 4. 3. The Hemovac in the neck incision con- tains 250 mL of bloody drainage. 54. A client arrives in the emergency department 4. The NG tube is disconnected from suc- with a swollen right ankle after an injury while tion and clamped off. playing football. Which of the following initial a. 1, 2, 3, 4 actions by the nurse is most appropriate? b. 2, 1, 3, 4 a. appling a moist, warm compress to the c. 4, 2, 1, 3 ankle. d. 4, 3, 2, 1 b. assessing ROM of the right ankle c. removing the client’s cleat and sock 57. The nurse is working with a client who has d. wrapping the ankle in a compression depression. The client exhibits some signs of bandage regressing and mourning over an impending loss but demonstrates satisfaction and compe- 55. The nurse is assessing a newborn infant. tence. The nurse and client are in which phase Which of the following is a sign of potential of the therapeutic relationship? distress? a. initiating a. closed posterior fontanel b. orienting b. heart rate of 130 c. termination c. palpable anterior fontanel d. working d. respiratory rate of 40 58. The nurse is caring for a client receiving chemotherapy. Which of the following laboratory results is most important to report to the healthcare provider? a. hemoglobin of 11 g/L b. platelets of 66,000/µl c. serum creatinine level of 1.0 mg/dl d. WBC count of 1,800/µl

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59. A nurse at an urgent-care clinic is assessing a 62. The nurse is developing a plan of care for a cli- 13-month-old child with diarrhea. The nurse ent diagnosed with syndrome of inappropriate checks for signs of dehydration by assessing antidiuretic hormone (SIADH). Which of the the child for a following interventions would be most impor- a. bulging fontanel. tant for the nurse to include in the care of this b. closed fontanel. client? c. firm fontanel. a. ambulating the client once a shift d. sunken fontanel. b. instructing the client to use incentive spirometry every two hours 60. A bone marrow transplant is being planned c. monitoring hourly intake and output for a client with acute leukemia who has not d. restricting free water oral intake responded to chemotherapy. In discussing this treatment with the client, the nurse will 63. The nurse is admitting a male client with bor- explain which of the following? derline personality disorder. When conducting a. The donor bone marrow cells are the client’s health history, the nurse would transplanted immediately after an infusion NOT expect to find which of the following? of chemotherapy. a. impulsive behavior b. The transplantation of the donated cells is b. persistent mistrust of others considered painful by many clients. c. low self-esteem c. The transplant procedure takes place in a d. substance abuse sterile operating room to minimize the risk for infection. 64. A client in the ICU is ordered to receive IV d. Several weeks of hospitalization will be potassium chloride (KCL) 40 mEq for the required after the hematopoietic stem cell treatment of hypokalemia. When administer- transplant (HSCT). ing the potassium solution via a central line, the nurse is aware that which of the following 61. The nurse is determining a neonate’s Apgar is true? score one minute after birth. The neonate’s a. The amount of KCL added to IV fluids central skin color is pink but all extremities are should not exceed 20 mEq/L to prevent the blue. The nurse should score the infant’s color development of hyperkalemia. as which of the following? b. The KCL should be administered as an IV a. 0 bolus in order to correct the hypokalemia b. 1 quickly before complications occur. c. 2 c. The KCL should be given very slowly to d. 3 avoid venospasm and inflammation at the IV insertion site. d. To reduce the risk for cardiac dysrhythmia, the maximum amount of KCL to be administered in one hour should not exceed 20 mEq.

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65. The nurse begins the assessment process of a 68. A client with Ménière’s disease is admitted to child during a well-baby visit. The nurse the hospital with vertigo, nausea, and vomit- notices the infant using the pincer grasp to ing. Which of the following nursing interven- pick up pieces of cereal and eat them unas- tions is appropriate for the nurse to sisted. Based on the infant’s fine motor devel- implement? opment, the nurse should recognize an infant a. Encourage oral fluids up to 2,000 mL daily. who is approximately how many months old? b. Change the client’s position every four hours. a. one c. Keep the head of the bed elevated at 30 b. four degrees. c. eight d. Keep the client’s room darkened and quiet. d. 11 69. The nurse working with preadolescent and 66. A client has undergone a cataract extraction adolescent girls knows that females should and intraocular lens implantation. On the receive three doses of the HpV vaccine, third postoperative day the client contacts the according to Centers for Disease Control and eye clinic and gives the nurse all of the follow- prevention (CDC) recommendations, between ing information. Which information is most the ages of concerning to the nurse? a. 7 and 9. a. The client complains that the vision has b. 10 and 12. “not improved much.” c. 13 and 18. b. The client complains of eye pain rated at a 6 d. 18 and 21. (on a 0–10 scale). c. The client has poor depth perception when 70. A client is brought to the trauma center by a wearing the eye patch. coworker after suffering a burn injury while d. The client has questions about the working on an electrical power line. Which of prescribed eyedrops. the following actions should the nurse complete first? 67. The nurse is assessing the head and chest cir- a. Assess for the contact points. cumference of a one-week-old infant. The b. Obtain the client’s vital signs. nurse expects the head circumference to be c. place a cervical collar on the client. a. larger than the chest by 2–3 cm. d. place the client on a cardiac monitor. b. larger than the chest by 4–5 cm. c. smaller than the chest by 2–3 cm. 71. The nurse is caring for a client with a history d. smaller than the chest by 4–5 cm. of drinking a case of beer per day. The client underwent an emergency appendectomy. Knowing that the client is at risk for withdrawal symptoms, the nurse’s plan of care includes an assessment for all of the following EXCEpT a. agitation. b. decreased heart rate. c. hyperalertness. d. seizures.

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72. A male client diagnosed with sleep apnea has 74. The nurse is reviewing orders written by the been using a Continuous positive Airway pres- physician after making client rounds. After sure (CpAp) machine for two weeks. When the reviewing the orders, the nurse determines client returns to the sleep clinic, he tells the which of the following require the nurse to nurse, “I still am not sleeping well.” Which of contact the physician to clarify the order? the following responses by the nurse is most Select all that apply. appropriate? 1. aspirin 325 mg orally qd a. “CpAp takes a month or so to achieve the 2. furosemide (Lasix) 20 mg IV now maximum effect.” 3. D5W with 40 mEq KCL IV at 150 mL/hr. b. “Do you want to talk to the physician about 4. heparin 5,000 u subcutaneously b.id. possible surgery?” 5. MS 2 mg IV q 1hr pRN c. “Have you been using the CpAp every night a. 1, 2, 3, 4 as instructed?” b. 1, 4, 5 d. “It is possible the CpAp pressure should be c. 2, 3, 5 increased.” d. 1, 2

73. A nurse is precepting a nursing student who is 75. A nurse is working at the emergency depart- caring for a pregnant client with a low-lying ment when a young child is admitted with placenta previa. The nurse determines that the poisoning. The nurse suspects that the poison- student is able to differentiate between the ing agent was a corrosive substance when types of placenta previa when the student which of the following is assessed? identifies which of the following as a low-lying a. drooling placenta previa? b. jaundice c. oliguria d. tinnitus

76. The nurse is assessing a female client after surgery. The client states that she has been utilizing aromatherapy. The nurse will evaluate the 123 4 effects of aromatherapy on the client by completing which of the following? a. 1 a. auscultating the client’s breath sounds b. 2 b. assessing the client’s blood pressure and c. 3 heart rate d. 4 c. checking the incision for signs of infection d. monitoring the client’s intake and output

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77. A client in labor has the following fetal heart 79. A client is admitted into the emergency room monitor tracing: with a suspected cocaine overdose. The nurse

240 240 knows that this client is at risk for 210 210 a. cardiac arrest. 180 180

150 150 b. panic. 120 120 c. psychosis. 90 90

60 60 d. respiratory arrest.

30 30 100 100 80. The nurse has administered lactulose (Cephu- 80 80 60 60 lac) 30 mL QID over the course of the hospi- 40 40 talization of a client diagnosed with advanced 20 20 0 0 cirrhosis. The client is now complaining of diarrhea. The nurse explains to the client that Which intervention should the nurse imple- it is still important to take the lactulose ment first? because it a. Continue to monitor client. a. prevents constipation. b. Notify the physician. b. prevents gastrointestinal bleeding. c. place client in left lateral position. c. improves nervous system function. d. prepare for an emergency cesarean section. d. promotes fluid loss.

78. A client who is recovering from orthopedic 81. A child is admitted to the acute-care facility surgery is seen in the clinic two weeks later. due to pyloric stenosis. The nurse’s plan of The client has been instructed to use a walker care should include all EXCEpT which of the to ambulate with partial weight bearing. following? Which of the following observations would 1. assessment for dehydration lead the nurse to conclude the client is using 2. administration of blood products the correct technique? 3. administration of chelation therapy a. The client’s elbows are bent at a 30° angle 4. document intake and output while using the walker. a. 1 and 2 b. The client is bent over the walker. b. 1 and 3 c. The client holds the walker about two c. 2 and 3 inches above the floor while walking. d. 1 and 4 d. The client is utilizing a walker that has four wheels in place.

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82. A nurse is preparing to care for a client who 84. A nurse is inserting a nasogastric (NG) tube had a lobectomy for the treatment of lung can- for a client diagnosed with a small bowel cer. Which of the following illustrations obstruction. While inserting the tube, resis- reflects the nurse’s knowledge about the extent tance is met. Which of the following actions is of surgery performed? most appropriate for the nurse to take next? a. Ask the client to swallow some water. 1 2 b. Check for the correct placement of the tube with 30 cc of air. c. Continue to advance or push the tube into the nares. d. Remove the tube and try the other nares.

85. A client prescribed donepezil (Aricept) for 3 4 treatment of Alzheimer’s disease is being admitted into the hospital. During the review of medications, the nurse assesses for which class of medications that are contraindicated with Aricept? a. anticholinergics b. diuretics a. 1 c. narcotics b. 2 d. antipsychotics c. 3 d. 4 86. A nurse is caring for a client who is receiving IV heparin after suffering a stroke. Which of 83. A nurse is providing nutritional education to a the following laboratory results indicates that pregnant client. Which of the following foods the client is receiving a therapeutic dosage? should the nurse instruct the client to avoid? a. phosphorus: 3.9 mg/dL a. hard-boiled eggs b. platelets: 275,000/mm3 b. morning cup of coffee c. pT: 22 seconds c. cooked shrimp d. pTT: 60 seconds d. feta cheese 87. The nurse is planning to provide education on safe infant sleeping practices to a new mother. The nurse realizes that the client will be most receptive to learning infant care during which of Rubin’s phases of bonding? a. letting-go phase b. letting-in phase c. taking-in phase d. taking-hold phase

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88. A nurse is caring for all of the following clients 92. An elderly female client with an extensive on a medical-surgical unit. Which of the fol- medical history is being treated in the CVICU lowing is at risk for developing respiratory for her third myocardial infarction. The cli- acidosis? ent’s family has encouraged her to complete a a. a 30-year-old with Guillain-Barré syndrome living will and a durable power of attorney. b. a 40-year-old with a large amount of The client asks the nurse, “Why do I need to pancreatic drainage complete both?” The nurse explains to the cli- c. a 52-year-old who has received a massive ent that a living will differs from a durable blood transfusion power of attorney in that the living will d. a 65-year-old with chronic congestive heart a. authorizes a designated representative to act failure on the client’s behalf in private affairs— medical, business, or some other legal 89. The nurse is working on a neurologic pediatric matter. unit. The nurse would suspect increased b. provides a legal medical directive that intercranial pressure in the child exhibiting specifies what types of medical treatment which of the following symptoms? the client desires when or if she becomes a. decreased pulse and decreased blood unable to express her wishes. pressure c. provides the client with an advance health b. decreased pulse and increased blood care directive (AHCD). pressure d. does not provide legal documentation of the c. increased pulse and increased blood client’s wishes, but will make her family and pressure healthcare providers quickly aware of her d. increased pulse and decreased blood medical wishes. pressure 93. A client has been prescribed Thorazine for 90. A client had a splenectomy performed after relief of psychotic symptoms. The client later experiencing a lacerated spleen from a motor- comes to the emergency room with symptoms cycle accident. The nurse will anticipate teach- of neuroleptic malignant syndrome. Upon ing the client about the increased risk for assessment the nurse expects to find developing which of the following related to a. dyskinesia. this surgical procedure? b. gait shuffling. a. anemia c. rigidity. b. bleeding tendencies d. toe tapping. c. infection d. lymphedema

91. A client has just delivered a newborn. The client begins to tremble as the placenta is delivered. The nurse recognizes that trembling a. has no clinical significance. b. indicates fear of becoming a mother. c. indicates fear of fetal death. d. indicates abruptio placentae.

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94. A client diagnosed with hypertensive crisis is 97. A client comes to the clinic due to suspected admitted to the cardiac care unit (CCU). The pregnancy. Upon sonographic exam, there is client has no past medical history. Upon evidence of a fetus. The nurse knows this is a arrival to the unit, the client’s blood pressure is a. positive sign of pregnancy. 212/142 mm Hg. Which of the following find- b. potential sign of pregnancy. ings during the nurse’s reassessment will c. presumptive sign of pregnancy. require immediate attention? d. probable sign of pregnancy. a. The client complains of a headache with a pain score of 8 on a scale of 1 to 10. 98. A graduate nurse is caring for a client who is b. The client is unable to move the right leg ordered soft wrist restraints. The graduate when instructed. nurse asks the charge nurse how often she c. The client’s urine output is 85 mL over the should plan to assess the placement of the past two hours. restraints and the condition of the restrained d. Tremors are present in the fingers when the area. Which of the following is the nurse’s best arms are extended. response? a. every half hour 95. A preceptor is working with a new nurse in the b. every hour urgent-care clinic on the care of children with c. every three hours fevers. The preceptor determines that the new d. every eight hours nurse has understood the related concepts when the new nurse instructs a mother NOT 99. A client who is taking an antipsychotic is doc- to give a child with a fever umented to have tardive dyskinesia. The nurse a. acetaminophen. plans care for a client with b. acetylsalicylic acid. a. drooling, dystonia, and permanent gait c. ibuprofen. shuffling. d. tepid baths. b. pill-rolling movements, dyskinesia, and a flat affect. 96. A client who weighs 155 pounds asks the nurse c. spasms of the neck and limbs. how much protein should be included in the d. toe tapping and uncontrolled restlessness. daily diet. The nurse recommends that the diet should include which of the following minimums? a. 38 grams of protein daily b. 65 grams of protein daily c. 53 grams of protein daily d. 56 grams of protein daily

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100. The nurse is caring for a client who is coma- 103. The nurse is conducting a prenatal class and tose following a head injury. The client is explaining cardinal movements of labor. The receiving continuous tube feedings via a soft nurse determines that the class has understood nasogastric (NG) tube. During the nurse’s the concepts when clients correctly identify reassessment of the client, new crackles in the the phase where the fetal head bends to the client’s lungs are noted. In which order will the chest as nurse take the following actions? a. extension. 1. Check the tube feeding residual volume. b. external rotation. 2. Notify the client’s physician. c. flexion. 3. Obtain the client’s oxygen saturation. d. internal rotation. 4. Turn off the tube feeding. a. 1, 3, 2, 4 104. The nurse is caring for a client in the ICU with b. 3, 1, 4, 2 a central venous pressure (CVp) line. Which of c. 3, 4, 1, 2 the following is an appropriate practice guide- d. 4, 3, 1, 2 line for the nurse to be aware of when CVp is being monitored? 101. The nurse is caring for a child admitted with a. A CVp of 2 to 5 mm Hg requires immediate acute glomerulonephritis. The nurse should intervention to prevent the development of incorporate which of the following into the pulmonary edema. plan of care? b. A CVp of 15 mm Hg or greater requires the a. decreased carbohydrates need for immediate fluid replacement. b. decreased fluid c. A pressure greater than 6 mm Hg must be c. decreased protein reported to the physician immediately. d. increased sodium d. Overall trended measurements are more important than any individual measures. 102. The nurse is caring for a client with an extensive burn injury. The nurse has calculated that 105. A client’s blood lithium level comes back as the client needs 1,800 mL of fluid in the first 0.9 mEq/L. The nurse’s first intervention 24 hours in order to maintain blood volume should be to and urinary output. How many mL will the a. contact the physician with toxic level. nurse plan to infuse in the first eight hours b. contact physician with therapeutic level. based on the parkland formula? c. continue to monitor the client. a. 500 d. prepare to administer mannitol. b. 700 c. 900 d. 1,200

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106. A graduate nurse is following an RN during 109. The nurse is providing teaching to a breast- her nursing shift in the CCU. A client is to feeding mother of a 12-month-old infant with have an intra-arterial blood pressure monitor- an egg, milk, wheat, and soy allergy. The nurse ing initiated. The graduate nurse observes the should explain that the allergens that can be nurse performing the Allen’s test and asks why transmitted through breast milk include which this test is completed. Which of the following of the following? Select all that apply. is the best response by the nurse? 1. eggs a. “To check for abnormal clotting because of 2. milk the risk of thromboembolism formation. 3. wheat b. “To check if the volume of blood flow is 4. soy sufficient to the extremity to provide an a. 1, 2, 4 accurate measurement.” b. 2, 3, 4 c. “To determine if the artery has a diameter c. 1, 3, 4 large enough to permit passage of the d. all of the above monitoring catheter.” d. “To make sure that collateral circulation is 110. A client diagnosed with acute renal failure sufficient to keep the tissue supplied with (ARF) has a serum potassium level of oxygenated blood.” 6.5 mEq/L. The client is ordered IV glucose and insulin. Which of the following will the 107. A laboring client’s water breaks. The nurse sus- nurse evaluate to best determine the effective- pects infection when the amniotic fluid is ness of the medications? a. clear with white flecks. a. blood glucose level b. green in color. b. BUN and creatinine levels c. port-wine color. c. electrocardiograph (ECG) d. yellow. d. serum potassium level

108. The nurse is assessing a client experiencing the 111. The nurse is caring for a client experiencing onset of symptoms of type 1 diabetes. Which delirium due to a metabolic imbalance. The of the following questions should the nurse nurse plans care for the client knowing that ask the client? delirium a. “Do you crave sugary drinks?” 1. causes permanent impairment. b. “Has your weight decreased?” 2. causes reversible cognitive deficits. c. “How long have you felt anorexic?” 3. is precipitated by a defined event. d. “Is your urine dark in color?” 4. is self-limiting. a. 1 and 3 b. 2 and 3 c. 2 and 4 d. 1 and 4

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112. A client presents to the emergency department 114. A client diagnosed with atrial fibrillation is (ED) with a sudden onset of jaundice, nausea, receiving warfarin (Coumadin) 5 mg each day. and vomiting. Further assessment and labora- The client’s international normalized ratio tory results reveal hepatomegaly, abnormal (INR) is 1.8. Which of the following is the liver function studies, and negative serologic expected nursing action regarding changing testing for viral causes of hepatitis. Which of the dosage of medication? the following questions is most appropriate for a. The INR level is too low. The warfarin the nurse to ask the client? dosage should be increased. a. “Are you taking corticosteroids for any b. The INR level is too high. The warfarin reason?” dosage needs to be decreased. b. “Do any of your family members have c. The INR level is too high. The warfarin jaundice?” dosage needs to be increased. c. “Do you use any over-the-counter d. The INR level is within the expected range. medications?” The warfarin dosage does not need to be d. “Have you ever used IV drugs in the past?” adjusted.

113. The nurse is helping a client prepare a birthing 115. The nurse is caring for a child admitted with a plan. The nurse explains that which of the fol- sickle-cell anemia sequestration crisis. The lowing are risk factors that might indicate a nurse plans care for a child with need for a cesarean birth? Select all that apply. a. decreased red blood cell production. 1. placenta previa b. petechia and bruising. 2. anemia c. pooling of blood in the spleen. 3. genital herpes d. swollen hands and feet. 4. puerpera a. 1, 2 116. The nurse assesses a client’s gag reflex. When b. 2, 3 doing so, which of the following cranial nerves c. 2, 4 is the nurse assessing? d. 1, 3 a. Abducens (sixth) b. Glossopharyngeal (ninth) c. Hypoglossal (12th) d. Trigeminal (fifth).

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117. When timing a client’s contractions, the nurse 120. The nurse is caring for a client in the intensive measures the frequency of the contractions by care unit (ICU) with a basal skull fracture. measuring from Upon assessment, the nurse notes clear drain-

100 100 age from the client’s right nares. Which of the

75 75 following admission orders should the nurse question? 50 50

25 25 a. cold packs for facial bruising b. head of bed elevated 30 degrees 0 0 c. insertion of a nasogastric tube 12 3456 d. turning the client every two hours a. point 1 to 3. b. point 2 to 5. 121. The nurse assessing a young child observes the c. point 1 to 4. following. The nurse correctly documents d. point 3 to 4. this as

118. A nurse is caring for a client who has just Uneven begun therapy with theophylline (Theo-24). shoulders The nurse will teach the client to limit the intake of which of the following while taking this medication? Curve in spine

a. cola, coffee, and chocolate Uneven hips b. cream cheese, dairy creamer, and cottage cheese c. lobster, shrimp, and crawfish d. pineapple, oranges, and watermelon

a. kyphosis 119. The nurse is working with a client with a b. lordosis depersonalization disorder. The nurse plans c. scoliosis care for a client with d. Scheuermann’s disease a. fixed, lifelike, false beliefs. b. loss of personal reality. c. loss of recall of personal memories. d. two or more distinctive personalities.

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122. The nurse is making rounds on a nursing unit 125. The nurse is admitting a client with an antiso- and notices that smoke is coming from a cli- cial personality disorder. The highest-priority ent’s room. Upon entering the client’s room, assessment for this client includes the client’s the nurse notes the client is standing in the risk for bathroom with his hospital gown on fire. a. delirium. Which of the following actions should the b. hallucinations. nurse take immediately? c. harming self or others. a. Call a medical code. d. substance abuse. b. Find the closest fire alarm box and activate it. 126. A client is scheduled for a Schilling’s test. The c. Obtain water from the client’s bathroom nurse will instruct the client to complete and douse the client. which of the following? d. Tell the client to drop and roll on the floor. a. Administer a Fleets Enema the evening before the test. 123. Beractant was administered to a preterm b. Collect urine for 12 hours prior to the test. infant. The nurse caring for the infant should c. Empty the bladder prior to the test. monitor for which of the following adverse d. Have nothing by mouth for eight hours reactions? prior to the test. a. bradycardia b. necrotizing enterocolitis 127. The nurse is developing a teaching plan for a c. retinopathy seven-year-old child on the administration of d. tachycardia insulin. The child seems unable to concentrate, fidgets, and interrupts the nurse during the 124. A nurse is caring for a terminally ill client. The teaching sessions. The nurse should client’s family is called to the hospital because a. assess for history of ADHD. the client’s death is imminent. Which of the b. check the child’s blood sugar. following assessment findings would lead the c. instruct the parents, not the child. nurse to conclude that the client’s death is d. rely on written instructions. near? Select all that apply. 1. Blood pressure is 80/60 mm Hg. 128. The nurse is preparing to administer a blood 2. Body is rigid, and lack of change in posi- transfusion. Which of the following nursing tion is noted. interventions is appropriate for the nurse to 3. Cheyne-Stokes respirations are take when setting up the supplies for the documented. transfusion? 4. The client’s extremities are warm to the a. Ensure the blood is left at room temperature touch. for one hour prior to the infusion. 5. The client states he is dying. b. Add any required IV medication to the 6. The client reports seeing family members blood bag within a half hour of the planned who have passed on. infusion. a. 1, 2, 3, 4, 5, 6 c. prime the blood tubing set with 0.9% b. 1, 2, 4, 6 normal saline, completely filling the filter. c. 2, 3, 5, 6 d. Use a small-bore catheter to prevent rapid d. 2, 4, 5 infusion of blood products.

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129. A nurse is planning care for a teenage pregnant 133. The nurse is assessing a client with dementia. girl. The nurse plans for the client’s care know- To facilitate the assessment of cognition, the ing that teenage pregnancy places the client at nurse should use which of the following? risk for which of the following complications? a. CAGE a. anemia b. HITS b. gestational diabetes c. MMS c. placenta previa d. pSA d. preterm delivery 134. A telemetry nurse is analyzing the ECG 130. The nurse is caring for a client who is sus- rhythm strip of a client she is caring for. The pected of experiencing an abdominal aortic nurse notes that there are nine QRS complexes aneurysm. Which of the following assessment in a six-second strip. The nurse calculates the findings will aid in confirming this diagnosis? client’s heart rate as which of the following? a. boardlike, rigid abdomen a. 54 bpm b. knifelike pain in the back area b. 80 bpm c. pulsating mass in the abdomen c. 88 bpm d. unequal femoral pulses d. 90 bpm

131. A child with cerebral palsy has involuntary 135. During a newborn assessment, the nurse writhing motions. The nurse documents observes that one half of the infant’s skin is this as dark pink and the other is pale. The nurse a. athetosis. documents this finding as b. ataxia. a. acrocyanosis. c. hypertonia. b. harlequin changes. d. hypotonia. c. lanugo. d. milia. 132. A client is admitted to a medical-surgical unit with thrombophlebitis in the right leg. Five 136. The nurse is caring for a client with a head hours after admission to the unit, the client injury. The client has clear drainage from the becomes confused and diaphoretic. Upon fur- nose and ears. How can the nurse determine if ther assessment, the client is coughing up the drainage is cerebrospinal fluid (CSF)? blood-streaked sputum and is complaining of a. Measure the pH of the fluid. severe chest pain on inspiration. Which of the b. Measure the specific gravity of the fluid. following should the nurse do first? c. Test the fluid for glucose. a. Administer oxygen via nasal cannula. d. Test the fluid for chloride. b. perform the Heimlich maneuver. c. position the client in a Fowler’s position. d. place the client in the Trendelenburg position.

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137. The nurse is examining a teenager with 139. A client’s labor is being augmented with oxy- anorexia nervosa. What might the nurse find tocin. The fetal monitor shows the fetal heart during the history and assessment? rate to be 170 with late decelerations. The a. binge eating and purging nurse’s first intervention should be: b. BMI less than 25 a. Administer oxygen. c. increased sodium levels b. Contact the physician. d. early onset of menses c. place client in left lateral position. d. Stop the oxytocin. 138. An elderly female client presents to the community clinic stating foot pain. Upon further 140. A client is admitted to the hospital with a assessment, the client complains of “improp- detached retina of the right eye. The nurse erly fitting shoes and sore feet.” The client patches both eyes. The client’s family member additionally relays that her primary physician asks, “Why are you patching both eyes?” has referred her to a podiatrist. Based on the The nurse’s best response is: illustration, the nurse accurately identifies the a. “To decrease eye movement.” client’s bunion at which location? b. “To prevent eye infections.” c. “To prevent photophobia.” d. “To prevent nystagmus.”

141. A client with a delusional disorder believes that her face has become disfigured even though it has not. The nurse knows that this belief is representative of which subtype of delusional disorder? a. conjugal 4 b. erotomania c. persecutory d. somatic 1

3 142. The nurse is caring for a client diagnosed with 2 liver failure. Which of the following laboratory values would the nurse expect to find? a. 1 a. decreased serum creatinine b. 2 b. decreased serum sodium c. 3 c. increased ammonia level d. 4 d. increased serum calcium

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143. A father reports that his child’s temperature is 145. The nurse is completing a newborn assessment 102.5 Fahrenheit. This equates to how many when a swelling such as the following is noted: degrees Celsius? a. 29.17 b. 39.17 c. 40.94 d. 56.94

144. A 50-year-old male client is diagnosed with Laennec’s cirrhosis. The client has extensive ascites and his respirations are rapid and shallow. The physician has decided to perform a paracentesis. The nurse caring for the client during this procedure will give highest priority to which of the following? a. frequently obtaining the client’s blood pressure (Bp) and pulse during the procedure

b. gathering all the appropriate sterile The nurse should document this as: equipment a. anencephaly c. positioning the client upright on the edge of b. caput succedaneum the bed c. cephalohematoma d. properly labeling the abdominal fluid and d. hydrocephalus sending it to the laboratory 146. An emergency department nurse is caring for a male client injured in a motor vehicle colli- sion (MVC). The nurse observes use of acces- sory muscles, severe chest pain, shortness of breath, and agitation. The nurse also notices one side of the client’s chest moving differently from the other. The nurse suspects a flail chest. Based on these observations, which of the following is the nurse’s best initial action? a. Administer pain medication as prescribed. b. Apply a sandbag to the flail side of the chest. c. prepare for intubation and mechanical ventilation. d. prepare for chest tube insertion.

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147. The order for a teenage girl with asthma reads, 150. A client has just returned to the unit after hav- “120 mg aminophylline (theophylline) p.o. ing a femoral arteriogram completed. Which b.i.d.” The nurse has 80 mg per 15 ml solution of the following assessments is essential for the of aminophylline available. How many tea- nurse to complete initially? spoons should the nurse administer? a. auscultating the client’s lung sounds a. 3 b. inspecting the client’s groin area b. 3.5 c. palpating the client’s carotid pulse c. 4 d. taking the client’s blood pressure d. 4.5 151. The nurse is preparing to give a woman in pre- 148. A client is being treated in the emergency term labor betamethasone (Celestone). The department (ED) after sustaining a fracture of nurse plans to administer the medication as the left tibia four hours ago. A long leg cast has two intramuscular (IM) injections given been applied. Upon assessment, the client is a. six hours apart. complaining of increasing pain. The pain is b. 12 hours apart. more intense with passive flexion of the toes. c. 24 hours apart. The nurse suspects the client is developing d. 48 hours apart. compartment syndrome. Which of the following actions should the nurse take initially? 152. The nurse is caring for a client in the (ICU) a. Administer the client’s pRN narcotic following a craniotomy. The client has an medications for pain and reassess the client intracranial pressure monitoring device in in 15 minutes. place. The client is becoming lethargic, and the b. Elevate the casted leg to the heart level, notify nurse notes that the intracranial pressure read- the physician, and prepare to split the cast. ing is high. How should the nurse position c. Notify the physician and prepare the client the client? for an emergency fasciotomy. a. Elevate the head of the bed (HOB) to a d. Raise the left leg above the heart, apply ice, position that promotes optimal venous and notify the physician. outflow for the client. b. Elevate the head of the bed 90°. position the 149. A teenager was prescribed percocet after client upright with pillows supporting the arthroscopic knee surgery. The client takes the client’s head. medication every four to six hours as pre- c. place the client flat in bed with his or her scribed. Two months later, the client is con- legs elevated 15 degrees on pillows. tinuing to take the percocet. The nurse d. place the client in the left side lying position documents the client’s with pillows to support the client’s back. a. dependency. b. substance use. c. tolerance. d. withdrawal.

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153. The nurse is examining a six-month-old 156. The nurse is caring for a client who had a cen- infant. The nurse recommends to the physi- tral line placed for IV fluid administration. cian that the infant may need further neuro- When the nurse enters the client’s room to logical screening based on the presence of reassess the client, the IV bag is empty, the IV which of the following findings? line is full of air, and the client is dyspneic. a. palmar grasp Which of the following is the best initial action b. plantar grasp by the nurse? c. sucking reflex a. Disconnect the IV tubing and place the d. tonic neck reflex client on the left side with the head down. b. Call a code and begin CpR immediately. 154. A client had a cast applied to the left leg in the c. Hang another IV bag as soon as possible, ED. The nurse has provided the client with disconnect the IV tubing, and prime the discharge instructions. Which of the following line. statements indicates that the client under- d. Notify the physician and administer oxygen stands the instructions? via nasal cannula immediately. a. “I will pack the left leg in ice for 24 hours to help the cast dry.” 157. A client is prescribed disulfiram (Antabuse). b. “I will place the casted leg on a fabric- The nurse knows that this medication is used covered pillow to help it dry.” to treat c. “If my leg gets itchy, I can use a knitting a. alcohol abuse. needle to gently itch under the cast.” b. anxiety. d. “When I get home, I will use my hair drier c. delirium. to help my cast dry faster.” d. depression.

155. The nurse is administering an ergot alkaloid to 158. A nurse is caring for a client in the ICU who is a client who had a postpartum hemorrhage. It receiving mechanical ventilation. The high- is important for the nurse to monitor the cli- pressure alarm begins to sound repeatedly. The ent for client is sleeping quietly. Which of the follow- a. elevated blood pressure. ing is the most appropriate initial response by b. edema. the nurse? c. increased heart rate. a. Call the respiratory therapist to assess the d. increased respirations. ventilator. b. Check the ventilator tubing. c. Obtain an arterial blood gas. d. Reposition the client to stimulate coughing.

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159. The nurse is assessing a child admitted to the 162. A 70-year-old male is admitted to the hospital emergency room for suspected appendicitis. with a diagnosis of gout. During the nurse’s Which of the following would the nurse expect admission assessment to the unit, which of the to find? Select all that apply. following is the client most likely to report to 1. decreased white blood cells the nurse? 2. periumbilical area pain a. a gradual onset of pain, swelling, redness, 3. lower left quadrant abdominal pain and warmth of the affected joint 4. rebound tenderness b. a gradual onset of pain, swelling, redness, a. 1, 2 and warmth of the affected joint when b. 1, 3 walking c. 2, 4 c. a recent history of trauma, alcohol d. 3, 4 ingestion, surgical stress, or illness d. no recent alcohol consumption or dietary 160. The nurse is caring for a client with a past changes medical history of seizures. While the nurse is performing morning care, the client begins to 163. The nurse administering magnesium sulfate have a seizure. What is the priority assessment determines that the client might be experienc- of the nurse at this time? ing magnesium toxicity when which of the fol- a. the length of the seizure activity lowing is observed? b. presence or absence of an aura a. depressed patellar reflex c. type and progression of seizure activity b. elevated blood pressure d. events that precipitated the seizure activity c. increased respiratory rate d. increased urinary output 161. A client with anxiety states to the nurse that she knows something bad is going to happen. The client seems unable to focus on anything else. The nurse documents the client’s anxiety as a. mild. b. moderate. c. severe. d. panic.

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164. An adult client is to receive Tazicef (ceftazi- answers dime) 500 mg IM (intramuscularly) q8 hours for diagnosis of pneumonia. A vial of the med- 1. a. The nurse should wear gloves upon entering ication supplies 1 gram that needs to be recon- the client’s room. This is standard procedure stituted with 5 mL of diluent (sterile water). when a client is ordered contact precau- After the medication has been reconstituted, tions. Choice b is incorrect. Gloves should how much medication should the nurse with- also be worn in this instance; however, con- draw into the syringe based on the illustration? tact precautions require the nurse to wear

gloves upon entering the room, not only

3 when providing care within five feet of the

2 2

2 client. Choice c is incorrect. Gloves should 1 1 1 MONOJECT also be worn in this instance; however, contact precautions require the nurse to wear

4 gloves upon entering the room, not only 3 2 when anticipating a dressing change. Choice 1 d is incorrect. Gloves should also be worn in

this instance; however, contact precautions a. 1 require the nurse to wear gloves upon enter- b. 2 ing the room, not only when the potential c. 3 of contamination from body fluids exists. d. 4 Category: Safe and Effective Care Environ- ment: Safety and Infection Control 165. The nurse is planning to perform the Guthrie Subcategory: Adult: Miscellaneous test on a child. The nurse knows that this test 2. b. A fetal heart rate of 120 per minute is screens for within normal limits and therefore is not a a. Down syndrome sign of magnesium toxicity. Choice a is b. Hip dysplasia incorrect. Hypotonic and/or absent reflexes c. Lead toxicity are signs of magnesium toxicity. Choice c is d. phenylketonuria incorrect. One sign of magnesium toxicity is respiratory depression of < 12 per minute. Choice d is incorrect. Decreased urinary output such as < 30 cc/hour is a sign of magnesium toxicity. Category: physiological Integrity: pharma- cology and parenteral Therapies Subcategory: Maternal Infant: Maternal Medications

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3. a. Atropine is a mydriatic and cycloplegic 6. b. Empathy is the ability to take another’s per- medication and is contraindicated in clients spective into consideration and communi- with glaucoma. This medication will dilate cate the understanding back to the person. the pupil and can increase intraocular pres- Choice a is incorrect. Assertiveness involves sure in the eye. Choice b is incorrect. Betax- stating your thoughts and feelings even olol (Betoptic) is a miotic agent that is used when others may disagree. Choice c is incor- to treat glaucoma. Choice c is incorrect. rect. Sympathy involves harmony or agree- pilocarpine (Ocusert pilo-20) is a miotic ment in the sharing of feelings of another. agent that is used to treat glaucoma. Choice Choice d is incorrect. Transference involves d is incorrect. pilocarpine Hydrochloride the redirection of feelings from one person (Isopto Carpine) is a miotic agent that is to another. used to treat glaucoma. Category: psychosocial Integrity Category: physiological Integrity: physio- Subcategory: Mental Health: Therapeutic logical Adaptation Communication Subcategory: Adult: Endocrine Disorders 7. b. Consistency for mealtimes assists with regu- 4. d. The tonsils reach their maximum size lation of blood glucose, so the best option is between the ages of 10 and 12. Choices a, b, for the client to be returned to the unit to and c are incorrect. The tonsils do not reach have lunch at the usual time. Choice a is their maximum size before the age of 10. incorrect. This is an intervention that is Category: Health promotion and invasive, unnecessary, and not accompanied Maintenance by a physician’s order. Choice c is incorrect. Subcategory: pediatrics: Assessment This delay in eating may cause the client to 5. b. The Glasgow Coma Scale assesses eye open- experience hypoglycemia. Choice d is incor- ing (1), motor response (2), and verbal per- rect. A glass of milk or juice will keep the formance (4). Choice a is incorrect. pupil client from becoming hypoglycemic but will reaction (3) is not part of the Glasgow cause a sudden rise in blood glucose because Coma Scale. Choice c is incorrect. Motor of the rapid absorption of the simple response (2) is also part of the Glasgow carbohydrate in these items. Coma Scale. Choice d is incorrect. pupil Category: physiological Integrity: pharma- reaction (3) is not part of the Glasgow cology and parenteral Therapies Coma Scale; eye opening (1) and verbal per- Subcategory: Adult: Endocrine Disorders formance (4) are. Category: physiological Integrity: physiological Adaptation Subcategory: Adult: Neurological Disorders

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8. c. Betamethasone is an antenatal glucocorti- 10. b. Low birth rate and maternal smoking dur- coid and is used to promote maturation of ing pregnancy increase an infant’s risk for the fetal lungs. Choice a is incorrect. Beta- SIDS. Choice a is incorrect. A low birth rate methasone is used to promote fetal lung increases the infant’s risk for SIDS, but maturation. Examples of medications used sleeping with a pacifier reduces the risk for to lower maternal blood pressure when the SIDS. Choice c is incorrect. Smoking during client is preeclampsic include labetalol and pregnancy does increase an infant’s risk for magnesium sulfate. Choice b is incorrect. SIDS. However, it is recommended that Betamethasone is used to promote fetal lung infants are placed on their back for sleep. maturation. Magnesium sulfate is used to Choice d is incorrect. It is recommended prevent maternal seizures, but there are no that infants be offered a pacifier for sleep as medications to prevent fetal seizures. Choice well as being placed on their back for sleep d is incorrect. Betamethasone are used to to decrease the incidence of SIDS. promote fetal lung maturation. Tocolytic Category: physiological Integrity medications such as Brethine is used to stop Subcategory: pediatrics: Respiratory premature maternal contractions. Disorders Category: physiological Integrity: pharma- 11. a. Hemianopsia is the loss of half of the visual cology and parenteral Therapies field and is classified by the location of the Subcategory: Maternal Infant: Maternal missing visual field: the outer half (bitem- Medications poral), the same half (homonymous), the 9. c. These foods are all permitted on a full liquid right half (right homonymous), the left half diet, but oatmeal is not. Choices a, b, and d (left homonymous), the upper half (supe- is incorrect. All these foods are permitted on rior), or the lower half (inferior) of each a full liquid diet. visual field. This illustration demonstrates Category: physiological Integrity: Basic left homonymous hemianopsia, which is Care and Comfort blindness in the temporal half of one eye Subcategory: Adult: Gastrointestinal and the nasal half of the other eye, occur- Disorders ring on the left side of each eye. Choice b is incorrect. This illustration demonstrates a normal visual field. Choice c is incorrect. Hemianopsia is the loss of half of the visual field and is classified by the location of the missing visual field. This illustration demonstrates right homonymous hemianopsia. Choice d is incorrect. This illustration demonstrates a visual field of a client diagnosed with glaucoma. Category: physiological Integrity: Reduc- tion of Risk Subcategory: Adult: Neurological Disorders

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12. d. The first intervention by the nurse when a 14. c. This statement encourages the client to clar- client experiences uterine atony in the post- ify and verbalize his or her feelings. Choice a partum period is to massage the fundus. is incorrect. The nurse should not leave the Choice a is incorrect. To determine whether client alone, and this statement does not packed red blood cell administration is enable the client to verbalize feelings. needed, the client’s hemoglobin and hema- Choice b is incorrect. This statement invali- tocrit levels would first need to be assessed. dates the client’s feelings; additionally, inser- Choice b is incorrect. The nurse should first tion of an IV can be perceived as painful. massage the fundus. Then if the client is still Choice d is incorrect. This statement facili- experiencing uterine atony, pitocin might be tates a power struggle between the client ordered. Choice c is incorrect. If the client and the nurse. The client does have the right is experiencing uterine atony due to an to refuse the insertion of an IV. overdistended bladder, insertion of a uri- Category: psychosocial Integrity nary catheter may assist in resolving the Subcategory: Mental Health: Therapeutic atony. However, the first intervention by the Communications nurse for urine atony is always to massage 15. d. The client must be able to maintain a patent the fundus. Category: Safe and Effective airway during the use of conscious sedation. Care Management Oversedation may result in loss of airway Subcategory: Maternal Infant: postpartum and resultant respiratory distress. Choice a 13. d. When clients are receiving chemical seda- is incorrect. The client may experience an tion or restraints, they should be monitored allergic reaction due to sedation used; closely for excessive drowsiness and/or however, the loss of airway, resulting in res- respiratory depression. In situations when piratory distress, is a more common com- long-acting sedation is utilized, care must be plication. Choice b is incorrect. A change or taken as the effects of these medications are alteration in level of consciousness is not an not seen for up to one hour after adminis- expected side effect of conscious sedation. tration. Choice a is incorrect. The client may Choice c is incorrect. Hypertension is not a require physical restraints if the client is sig- side effect associated with the use of con- nificantly agitated. However, in this sce- scious sedation. nario, there is no mention of additional Category: physiological Integrity: Reduc- restraints. Choice b is incorrect. The client tion of Risk may experience pain, and pain may also Subcategory: Adult: Cardiovascular accompany restlessness. However, pain is Disorders not a side effect of chemical restraints. Choice c is incorrect. The client may experience an increase in blood pressure; however, hypertension should not occur from the administration of IV sedatives and thus is not considered a common side effect of chemical sedations and restraints. Category: Safe and Effective Care Environ- ment: Safety and Infection Control Subcategory: Adult: Miscellaneous

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16. b. The bittersweet phase of grief occurs with 18. a. The nurse should expect the fontanels to be reminders of the loss such as an anniversary bulging due to an increased retention of date. During this time, the client typically cerebral spinal fluid in the ventricles of the experiences episodic bouts of sadness and brain. Choice b is incorrect. A firm fontanel crying. Choice a is incorrect. During the is the expected finding in a healthy six- anticipatory stage of grief there is knowl- month-old. Hydrocephalus is an increased edge of the impending loss; the fetus is still retention of cerebral spinal fluid within the alive but the prognosis is poor. Choice c is ventricles of the brain. The increased pres- incorrect. During the intense phase of grief, sure from the fluid would cause the fontanel there is deep sadness and symptoms of to bulge. Choice c is incorrect. Hydrocepha- fatigue, headaches, dizziness, backaches, and lus would cause increased intracranial pres- insomnia. Guilt and anger may also be sure; therefore, the pulse would be expected expressed. Choice d is incorrect. During the to decrease while the blood pressure reorganization phase of grief, the client increased. Choice d is incorrect. A sunken attempts to understand why the loss fontanel would be expected in an infant occurred. The client returns to daily activi- who was dehydrated. ties at work and at home. Category: physiological Integrity: physio- Category: psychosocial Integrity logical Adaptation Subcategory: Maternal Infant: Maternal Subcategory: pediatrics Complications 19. c. This is a therapeutic and appropriate com- 17. b. The client who is MRSA positive should be ment for the nurse to make. Sharing an placed in a private room or a semiprivate observation with the client conveys aware- room with a client with an active infection ness of the client’s feelings and promotes caused by the same organism. Choice a is further communication between the client incorrect. It is not necessary to place the cli- and nurse. Choices a, and b are incorrect. ent in a negative air pressure room; this They are not therapeutic and appropriate intervention is included in airborne precau- comments for the nurse to make. They don’t tions and is not necessary for contact pre- recognize the feelings the client is undergo- cautions. Choice c is incorrect. It is not ing. Choice d is incorrect. This is not a ther- necessary for nurses or other healthcare apeutic and appropriate comment for the providers interacting with the client to wear nurse to make. Asking why the client feels a an N-95 respirator. This intervention is certain way doesn’t promote therapeutic associated with airborne precautions and is communication. not necessary for contact precautions. Category: psychosocial Integrity Choice d is incorrect. It is not necessary for Subcategory: Adult: Miscellaneous nursing staff or other healthcare providers interacting with the client to wear a mask. This intervention is associated with airborne precautions and is not necessary for contact precautions. Category: Safe and Effective Care Environ- ment: Safety and Infection Control Subcategory: Adult: Miscellaneous

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20. a. By distracting the toddler with a book, the 22. d. Methotrexate is administered as a single nurse gives the toddler attention and pro- injection for unruptured ectopic pregnan- vides the toddler with an activity. The nurse cies when the blastocyte is less than 3.5 cm will then be able to continue educating the in diameter. Choice a is incorrect. After a eight-year-old without interruptions from complete abortion, the nurse monitors for the toddler. Choice b is incorrect. Toddlers the client’s serum HCG levels to return to are egocentric and demand attention. If prepregnancy levels, but would not admin- ignored, the toddler will continue to seek ister methotrexate. Choice b is incorrect. attention through interruptions. Choice c is Although methotrexate is a recommended incorrect. The mother may not approve of treatment for ectopic pregnancies, it is con- the nurse reprimanding the child. Addition- traindicated for ruptured tubal pregnancies. ally, this may encourage the child to con- Choice c is incorrect. For threatened abor- tinue to interrupt for attention. Choice d is tions, the client’s treatment plan might incorrect. This statement may offend the include bed rest, avoidance of stress, and mother and does not offer any assistance to sedation, but not the administration of facilitate the toddler behaving in an appro- methotrexate. priate manner. Category: Safe and Effective Management Category: psychosocial Integrity of Care: Management of Care Subcategory: Mental Health: Therapeutic Subcategory: Maternal Infant: Maternal Communications Complications 21. c. providing the specific information requested by the client comforts and reas- sures the client, who feels lost and confused, and promotes orientation. Choice a is incorrect. The nurse should not scold or infantilize the client. Choice b is incorrect. The nurse should not assume that the client will remember the name of the hospital after seeing the sign in the hallway. Choice d is incorrect. The nurse should not assume that a client with Alzheimer’s disease will remember being admitted to the hospital, and should provide specific information about when the client’s family will arrive. Category: psychosocial Integrity Subcategory: Adult: Neurological Disorders

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23. a. The nurse should assess the second chamber 25. d. The client should be instructed that the of the chest tube drainage system. The sec- most appropriate time to apply the antiem- ond chamber is the water-seal chamber. bolism stockings is before the client rises Continuous bubbling in this chamber is from bed in the morning. This will maxi- unexpected and indicates a leak between the mize the compression effect, thus lessening client and the water seal. The air leak could venous distention and development of also be inside the client’s thorax, at the chest edema. Choice a is incorrect. Even though tube insertion site, between tubing connec- the client is ambulating frequently, the anti- tions, or within the system. The nurse also embolism stockings should also be worn in needs to be aware that in a wet suction, con- an effort to prevent the development of stant gentle bubbling should occur in the thromboembolic disease. Choice b is incor- first chamber (the suction-control chamber) rect. If the stockings begin to cause skin dis- when using suction. Choice b is incorrect. comfort to the client, the stockings should This area of the chest tube, the suction con- be removed and the skin underneath must trol, would not be assessed to determine if be assessed by the nursing staff. The nursing an air leak was present. Choice c is incor- staff must ensure that the stockings are rect. This area of the chest tube, the actual reapplied without twisting or wrinkles. tube itself, would not be assessed to deter- Choice c is incorrect. The client should be mine if an air leak was present. Choice d is instructed not to cross his or her legs. Cross- incorrect. This area of the chest tube, the ing the legs impedes circulation and should fluid collection chamber, would not be be avoided with or without elastic stockings assessed to determine if an air leak was being in place. present. Category: physiological Integrity: Basic Category: physiological Integrity: Reduc- Care and Comfort tion of Risk Subcategory: Adult: Cardiovascular Subcategory: Adult: Neurological Disorders Disorders 24. a. Solitary play is appropriate for an infant, 26. b. Using Naegele’s rule, the nurse adds one that is, a child aged 1 to 12 months. Choice year, subtracts three months, and adds seven b is incorrect. parallel play (playing along- days to the first day of the last menstrual side but not with another) is appropriate for period. Choice a is incorrect. To obtain a a toddler. Choice c is incorrect. A pre- due date of January 9, 2013, the client’s first schooler engages in associative play (playing day of the last menstrual period would have together but without group goals). Choice d been April 2, 2012 (add one year; subtract is incorrect. School age children engage in three months and add seven days). Choice c cooperative play (play that follows orga- is incorrect. To obtain a due date of January nized rules with defined leaders and 23, 2013, the client’s first day of the last followers). menstrual period would have been April 16, Category: physiological Integrity: Basic 2012. Choice d is incorrect. To obtain a due Care and Comfort date of January 26, 2013, the client’s first day Subcategory: pediatrics: Developmental of the last menstrual period would have Milestones been April 19, 2012. Category: physiological Adaptation Subcategory: Maternal Infant: Antepartum

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27. b. Clients who are experiencing sleep depriva- 29. a. The first action the nurse should complete tion often show signs of impaired cognitive is assess the client to ascertain if there are functioning such as confusion. Choice a is physical signs consistent with hypotension incorrect. Cool extremities are not a sign or resulting in decreased perfusion of the brain symptom associated with sleep deprivation. and peripheral circulation. Choice b is Choice c is incorrect. Depression is not a incorrect. This nursing intervention is sign or symptom associated with sleep incorrect. The nurse should not elevate the deprivation, but rather a cause. Choice d is head of the client’s bed, as this action would incorrect. A period of apnea is not a sign or further decrease the blood pressure. Choice symptom associated with sleep deprivation. c is incorrect. Only after assessing the cli- Category: physiological Integrity: Basic ent’s present condition should the nurse Care and Comfort recheck the blood pressure for accuracy of Subcategory: Adult: Cardiovascular the reading. Choice d is incorrect. Deter- Disorders mining the normal range of blood pressure 28. a. This is the best assertive response. The nurse is indicated after the assessment and verifi- stands up for herself. Choice b is incorrect. cation of the reading is completed. In this statement the nurse is negotiating or Category: physiological Integrity: Reduc- compromising what she wants with what tion of Risk potential the unit needs. It is not an assertive state- Subcategory: Adult: Cardiovascular ment. Choice c is incorrect. Assertive state- Disorders ments do not begin with “you,” as these 30. b. Only mild soaps or cleansing agents should statements put the emphasis on the other be used to decrease irritation to the skin. person’s actions versus the nurse’s feeling/ Choice a is incorrect. The child’s skin wants/beliefs. Choice d is incorrect. This should be left moist to increase the effec- statement doesn’t allow the nurse to stand tiveness of ointments and/or creams to be up for herself, as assertive statements applied after bathing. Choice c is incorrect. should. The nurse should stand up for her- Warm, not hot, water should be used to self by stating, “I cannot work the shift promote and maintain hydration of the tonight.” skin. Choice d is incorrect. The child should Category: Safe and Effective Care Environ- be lightly patted down with the towel to ment: Management of Care promote and maintain skin hydration and Subcategory: Mental Health: Therapeutic integrity. Communications Category: Health promotion and Maintenance Subcategory: pediatrics: Assessment

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31. a. The purpose of using a hypothermic blan- 33. d. Compression of the oculomotor nerve will ket is to reduce the client’s temperature, so result in pupil dilation from the shifting of the nurse should monitor the client for the brain and paralyzing the muscles con- signs of hypothermia. Signs of hypothermia trolling the pupillary size and shape. This is include bradycardia, hypotension, and a neurological emergency, as herniation of drowsiness. The low cardiac output from the brain can occur; the physician should be hypotension (decrease in blood pressure) notified immediately. Choice a is incorrect. and bradycardia (slowing of the heart rate) A pupil size of 1, generally not included on affects the central nervous system, produc- the gauge, would not indicate increased ing drowsiness. The client’s urine output (5) intracranial pressure with compression of is decreased in hypothermia as a result of the oculomotor nerve. Choices b and c are decreased perfusion. Hypertension (3) (high incorrect. These pupil gauge sizes would not blood pressure) and tachycardia (6) (an indicate increased intracranial pressure with abnormally high heart rate) are not indi- compression of the oculomotor nerve. cated in hypothermia. Choices b, c, and d Category: physiological Integrity: physio- are incorrect. logical Adaptation Category: physiological Integrity: physio- Subcategory: Adult: Neurological Disorders logical Adaptation 34. d. Developmental tasks are age-related. Choice Subcategory: Adult: Miscellaneous a is incorrect. Development is a lifelong 32. c. When the fetal head is one centimeter above process; therefore development does not the ischial spines, the client’s station is doc- end in adolescence. Choices b and c are umented as −1. Choice a is incorrect. incorrect. Growth is cephalocaudal (head to Crowning occurs when the fetal head is at feet) and proximodistal (center of the body the opening of the fully effaced and dilated outward). cervix. Choice b is incorrect. When the fetal Category: physiological Integrity: Basic head is level with the ischial spines, the cli- Care and Comfort ent’s station is documented as 0. Choice d is Subcategory: pediatric Growth and incorrect. When the fetal head is one centi- Development meter below the ischial spines, the client’s 35. a. Clonidine is used to treat hypertension. The station is documented as +1. nurse should not apply a bioclusive, tega- Category: Safe and Effective Management derm, or tape to seal the patch, as it can of Care: Management of Care affect the absorption of the medication. Subcategory: Maternal Infant: Intrapartum Choices b, c, and d are incorrect. These options follow correct procedure for applying a transdermal patch. Category: physiological Integrity: pharma- cology and parenteral Therapies Subcategory: Adult: Cardiovascular Disorders

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36. d. Urinary output of at least 30 ml/hour is the 39. d. The nurse should be concerned with renal most objective and least invasive assessment function, and urinary output provides of adequate organ perfusion and oxygen- information about renal functioning. ation. Choice a is incorrect. A client experi- Choices a and b are incorrect. The blood encing hemorrhagic shock would have cool, urea nitrogen (BUN) level and the creati- clammy skin. Choice b is incorrect. Cyano- nine clearance level also evaluate renal func- sis in the buccal mucosa would be an indi- tioning, but they both require a physician cator of inadequate organ and tissue order so may not be available for monitor- oxygenation. Choice c is incorrect. Dimin- ing. Choice c is incorrect. Evaluating the ished restlessness is a subjective measure of client’s fluid intake will not help determine organ perfusion and oxygenation. whether the client is experiencing Category: Safe and Effective Management nephrotoxicity. of Care: Management of Care Category: physiological Integrity: pharma- Subcategory: Maternal Infant: Maternal cology and parenteral Therapies Complications Subcategory: Adult: Renal Disorders 37. b. The left dorsogluteal muscle is best located 40. a. A respiratory rate of 24 breaths per minute at position 2; above and outside a line is within the normal range for a six-year-old drawn from the left posterior superior iliac boy; therefore, the nurse should document spine to the left greater trochanter of the the apical rate. Choice b is incorrect. A femur. The needle should be inserted at a respiratory rate of 24 breaths per minute in 90-degree angle. Choices a, c, and d are a six-year-old boy is considered within the incorrect. These locations are not correct. normal limits; therefore, there is no need for Category: physiological Integrity: pharma- another nurse to recheck the respirations. cology and parenteral Therapies Choice c is incorrect. As the respiratory rate Subcategory: Adult: Miscellaneous is within the normal limits for a six-year-old 38. d. This statement allows the client to express his boy, the physician does not need to be noti- feelings, thoughts, and fears, an integral com- fied. Choice d is incorrect. As the respiratory ponent of the therapeutic relationship. Choice rate is within the normal limits for a six- a is incorrect. The nurse is not communicat- year-old boy, the nurse does not need to ing honestly by stating the he or she does not recheck it. know the results when the results are known. Category: Health promotion and Trust is an integral component of the thera- Maintenance peutic relationship. Choice b is incorrect. This Subcategory: pediatrics: Assessment statement is untrue and disrupts trust within the therapeutic relationship. It also does not allow the client to discuss his feelings and fears. Choice c is incorrect. This is a false statement, as the nurse knows that the client has cancer. Trust is an integral component of the therapeutic relationship. Category: psychosocial Integrity Subcategory: Mental Health: Therapeutic Communications

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41. d. The asterixis, a condition indicating this 43. b. The client is asking for more time to see his type of hand movement, indicates that the son’s graduation, an example of a typical client has hepatic encephalopathy, and strategy in the bargaining phase. Choice a is hepatic coma may occur. Choice a is incor- incorrect. In the anger phase, the client may rect. The ascites and weight gain do indicate express anger at God or at healthcare pro- the need for treatment but not as urgently fessionals that he has cancer. Choice c is as the changes in neurologic status. Choice incorrect. In the denial phase, the client b is incorrect. The upper right quadrant rejects the terminal diagnosis. Choice d is abdominal pain is not unusual for the client incorrect. While the client may exhibit with cirrhosis, and does not require a symptoms of depression due to the terminal change in treatment. Choice c is incorrect. diagnosis, depression is not a phase of Spider angiomas, such as described in this Kübler-Ross’s stages of death and dying. response, are not unusual for the client with Category: physiological Integrity: Basic cirrhosis, and do not require a change in Care and Comfort treatment. Subcategory: Mental Health Category: physiological Integrity: physio- 44. c. Spironolactone is a potassium-sparing logical Adaptation diuretic. Clients should be instructed to Subcategory: Adult: Gastrointestinal choose low-potassium foods such as apple Disorders juice rather than foods that have higher lev- 42. c. Leopold’s maneuver is used to assess the els of potassium, such as citrus fruits. fetal presentation on a pregnant client. Choice a is incorrect. The fat content of the Choice a is incorrect. Chadwick’s sign is a cheese is not relevant; thus the client does bluish discoloration of the uterus during not have to consume only low-fat cheese. pregnancy. Choice b is incorrect. Hegar’s Choice b is incorrect. Clients should be sign is a softening of the pregnant client’s taught to avoid salt substitutes, which are cervix that is noted during bimanual exam. high in potassium. Choice d is incorrect. Choice d is incorrect. McMurray’s test is Because the client is using spironolactone used to assess for a meniscal tear. as a diuretic, the nurse will encourage the Category: physiological Integrity: Basic client to increase fluid intake. Six glasses of Care and Comfort water are not sufficient; the client should Subcategory: Maternal Infant: Antepartum drink eight or more glasses of water each day. Category: physiological Integrity: pharma- cology and parenteral Therapy Subcategory: Adult: Cardiovascular Disorders

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45. c. Symptoms of preeclampsia include +1 pro- 48. a. A stage 3 ulcer involves full-thickness dam- tein in the urine and blood pressure of age. This includes skin loss of the dermis 140/90 to 160/110. Choice a is incorrect. and epidermis and penetration as far down Eclampsia is characterized by the onset of as the subcutaneous tissue. Choices b and c seizure activity in a woman diagnosed with are incorrect. This area, the dermis, does not preeclampsia who did not have a history of indicate a stage 3 pressure ulcer. Choice d is seizures prior to pregnancy. Choice b is incorrect. This area, the epidermis, does not incorrect. Gestational hypertension is char- indicate a stage 3 pressure ulcer. acterized by onset of hypertension without Category: Safe and Effective Care Environ- proteinuria that occurs after 20 weeks of ment: Management of Care pregnancy. Choice d is incorrect. Severe Subcategory: Adult: Integumentary preeclampsia is characterized by the pres- Disorders ence of any of the following in a woman 49. a. The “B” in the SBAR communication tech- diagnosed with preeclampsia: systolic blood nique stands for “background information.” pressure > 160, diastolic blood pressure In this example the background is that the > 110, +2 or +3 proteinuria, oliguria, epi- client is 79 years old and has a history of gastric pain, and elevated liver enzymes. anxiety. Choice b is incorrect. This state- Category: Safe and Effective Care Manage- ment represents the “S,” which stands for ment: Management of Care “situation” in the SBAR technique. Choice c Subcategory: Maternal Infant: Maternal is incorrect. This statement represents the Complications “R,” which stands for “recommendations” in 46. a. The BMI calculation is: the SBAR technique. Choice d is incorrect. BMI = (Weight ÷ Height2) × 703 This statement represents the “A” for “assess- = (160 ÷ 662) × 703 ment” in the SBAR technique. = 25.8 Category: Safe and Effective Care Environ- Choices b, c, and d are incorrect. ment: Safety and Infection Control Category: Safe and Effective Care Environ- Subcategory: Mental Health: Anxiety ment: Health promotion and Maintenance Disorders Subcategory: Adult: Miscellaneous 47. c. At seven to nine months of age, infants are able to smile at their mirror image. Choice a incorrect. At zero to three months infants are able to smile socially at another person. Choice b is incorrect. At four to six months of age, infants are able to discriminate strangers from parents. Choice d is incorrect. At 10 to 12 months of age, infants are increasingly aware of strangers. Category: Health promotion and Mainte- nance Subcategory: pediatrics: Growth and Development

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50. c. Ginkgo is useful in the prevention and treat- 52. a. The nurse will administer pain medication ment of dementia and cerebral insuffi- based on the principles of beneficence and ciency; thus, monitoring attention span nonmaleficence. Under these principles, the would be appropriate. Choice a is incorrect. goal of pain management in a terminally ill Assessing the client’s blood pressure would client is adequate pain relief even if the not be helpful in determining the effective- effect of pain medications could hasten ness of the ginkgo. Choice b is incorrect. death. Choice b is incorrect. The client Assessing the client’s level of motivation requires around-the-clock administration of would not be helpful in determining the pain medication to ensure that the client effectiveness of the ginkgo. Choice d is does not experience breakthrough pain and incorrect. Evaluating the client’s red blood discomfort. Choice c is incorrect. Adminis- cell count would not be helpful in deter- tration of analgesics on a pRN basis will not mining the effectiveness of the ginkgo. provide the consistent level of analgesia the Category: physiological Integrity: pharma- client requires. Choice d is incorrect. The cology and parenteral Therapy nurse should not rely on the client’s family Subcategory: Adult: Neurological Disorders to request pain medication. Clients usually 51. b. Hegar’s sign is the softening of the cervix in do not require so much pain medication pregnant women. Choice a is incorrect. that they are oversedated and unaware of Chadwick’s sign is a bluish discoloration of stimuli. the uterus in pregnant women. Choice c is Category: Safe and Effective Care Environ- incorrect. Homan’s sign is pain elicited in ment: Management of Care the calf when the healthcare professional Subcategory: Adult: Oncology Disorders flexes the client’s foot. Choice d is incorrect. 53. b. In stage 2 pressure ulcers, there is partial- Murphy’s sign tests for gallbladder disease. thickness loss of the dermis presenting as a It is elicited by asking the client to breathe shallow wound with a red or pink wound deeply while palpating the costal margin of bed. Choice a is incorrect. A stage 1 pressure the upper right abdominal quadrant. If the ulcer is an area of intact erythema that does gallbladder is inflamed, the client will expe- not blanch with pressure. Choice c is rience pain. incorrect. A stage 3 pressure ulcer has full- Category: Health promotion and thickness loss of the dermis. Subcutaneous Maintenance tissue may be visible but not bone, tendon, Subcategory: Maternal Infant: Antepartum or muscle. Choice d is incorrect. In stage 4 pressure ulcers, there is muscle, tendon, or bone visible. Category: physiological Integrity Subcategory: pediatrics

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54. d. The nurse should implement the RICE 56. b. The client should first be placed in a semi- treatment (rest, ice, compression, elevation) Fowler’s position to maintain a patent air- for soft tissue injuries. Use of a compression way and reduce incisional swelling. The bandage around the ankle will decrease tis- blood-tinged secretions may obstruct the sue swelling. Choice a is incorrect. The airway, so suctioning the client is the next nurse should apply a cold compress, not a appropriate action. Then the Hemovac warm compress. Cold packs should be should be drained because the 250 mL of applied for the first 24 hours to reduce drainage will decrease the amount of suc- swelling. Choice b is incorrect. Moving the tion in the Hemovac and could lead to inci- ankle through range of motion (ROM) sional swelling and poor healing. Last, the activities will increase swelling and risk fur- nasogastric (NG) tube should be recon- ther injury. Choice c is incorrect. The foot- nected to suction to prevent gastric dilation, ball cleat does not need to be removed nausea, and vomiting. Choices a, c, and d immediately and will help to compress the are incorrect. These sequences of events are injury if it is left in place. not correct. See answer choice b for the cor- Category: physiological Integrity: Reduc- rect sequence. tion of Risk Category: physiological Integrity: physio- Subcategory: Adult: Musculoskeletal logical Adaptation Disorders Subcategory: Adult: Respiratory Disorders 55. a. A closed posterior fontanel on a newborn 57. c. During the termination phase, the client infant is a sign of potential distress. Choice may exhibit signs of anxiety or regression b is incorrect. The normal heart rate for a but is able to demonstrate satisfaction and newborn is 120 to 160. Choice c is incorrect. competence. Choices a and b are incorrect. The anterior fontanel of a newborn should During the initiating/orienting phase the be palpable. Choice d is incorrect. The nurse begins to build trust and rapport. normal respiratory rate for a newborn is Choice d is incorrect. During the working 30 to 50. phase, the focus is on mutually reaching set Category: physiological Integrity: Risk goals; coping mechanisms are identified and Reduction alternative behaviors are explored. Subcategory: Maternal Infant: Neonate Category: physiological Integrity: Basic Assessment Care and Comfort Subcategory: Mental Health: Therapeutic Communications

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58. d. The nurse should report the low white 60. d. The client will be required to stay in the blood cell (WBC) count to the healthcare hospital for several weeks following the pro- provider. Neutropenia places the client at cedure. The client requires strict protective risk for severe infection and is an indication isolation to prevent infection for two to four that the chemotherapy dose may need to be weeks after HSCT while waiting for the lower or that WBC growth factors such as transplanted marrow to start generating filgrastim (Neupogen) are needed. Neupo- cells. Choice a is incorrect. The HSCT takes gen is a prescription medication used to place one or two days after chemotherapy to reduce the risk of infection in clients with prevent damage to the transplanted cells by some tumors who are receiving strong che- the chemotherapy drugs. Choice b is incor- motherapy, which decreases the number of rect. This is inaccurate information. The infection-fighting white blood cells. Choices transplanted cells are infused through an IV a, b, and c are incorrect. These laboratory line; thus the transplant is not painful. data do not indicate an immediate life- Choice c is incorrect. This is inaccurate threatening adverse effect of the information. The procedure does not need chemotherapy. to occur in an operating room. Category: physiological Integrity: Reduc- Category: physiological Integrity: physio- tion of Risk logical Adaptation Subcategory: Adult: Oncology Disorders Subcategory: Adult: Oncology Disorders 59. d. A sunken or depressed fontanel is a sign of 61. b. A score of 1 would indicate the neonate’s dehydration. Choice a is incorrect. If the central skin color was pink while the child’s fontanel was bulging, it would indi- extremities were blue. Choice a is incorrect. cate increased intercranial pressure. Choice A score of 0 would indicate the neonate’s b is incorrect. A closed fontanel in a color was pale. Choice c is incorrect. A score 13-month-old child would be a part of nor- of 2 would indicate that the neonate’s skin mal growth and development, as the fonta- color was pink both centrally and in the nel closes between 7 and 19 months of age, extremities. Choice d is incorrect. Scores for and therefore would not assist the nurse is skin color on the Apgar scale range from determining whether the child was dehy- 0 to 2, with 0 indicating a pale color, 1 indi- drated. Choice c is incorrect. A firm anterior cating pink central color and blue extremi- fontanel would be considered within the ties, and 2 indicating the skin color as pink normal limits; a depressed or sunken fonta- throughout. nel would indicate dehydration. Category: physiological Integrity: physio- Category: physiological Integrity: Reduc- logical Adaptation tion of Risk Subcategory: Maternal Infant: Neonate Subcategory: pediatrics Assessment

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62. d. The nurse should be certain that the client 64. d. Correct administration of KCL IV includes: restricts free water intake. SIADH causes peripheral line: Usual concentration: 20 to water retention, which leads to hyponatre- 40 mEq/L; maximum: 80 mEq/L, infused at mia, so water intake is restricted. Choice a a maximum rate of 10 mEq/hour. Central is incorrect. Ambulating the client may be line: Usual concentration: 20 to 60 mEq/L, included in the plan of care for any hospi- infused at a maximum rate of 20 mEq/hour. talized client, but is not specifically indi- Choice a is incorrect. The rate of adminis- cated for the diagnosis of SIADH. Choice b tration, not the amount of KCL added to IV is incorrect. Instructing the client to utilize fluids, must be considered by the nurse. incentive spirometry may be included in the Choice b is incorrect. Rapid IV administra- plan of care for any hospitalized client, but tion of KCL can cause cardiac arrest; KCL is is not specifically indicated for the diagnosis administered at a maximal rate of 20 mEq/ of SIADH. Choice c is incorrect. The nurse hr. Choice c is incorrect. KCL can cause should monitor intake and output, but inflammation of peripheral veins when hourly monitoring is not required. administered peripherally, but it can be Category: physiological Integrity: physio- administered by this route. logical Adaptation Category: physiological Integrity: pharma- Subcategory: Adult: Endocrine Disorders cology and parenteral Therapies 63. b. Clients with borderline personality disorder Subcategory: Adult: Fluid and Electrolyte generally do not exhibit persistent feelings Imbalances of mistrust toward others; rather, they tend 65. c. Fine motor expectations for an eight-month- to fluctuate in their emotions about other old include utilization of the pincer grasp, people. Choice a is incorrect. Clients with which involves the thumb and forefinger. borderline personality disorder do exhibit Choice a is incorrect. Fine motor expecta- impulsive behavior. Choice c is incorrect. tions for a one-month-old include opening Clients with borderline personality disorder and closing hands. Choice b is incorrect. often exhibit low self-esteem. Choice d is Fine motor expectations for a four-month- incorrect. Clients with borderline personal- old include transferring objects from one ity disorder often also have an issue with hand to the other. Choice d is incorrect. substance abuse. Fine motor expectations for an 11-month- Category: psychosocial Integrity old include scribbling. Subcategory: Mental Health: personality Category: Health promotion and Disorders Maintenance Subcategory: pediatrics: Developmental Milestones

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66. b. postoperative cataract surgery clients usu- 69. b. The HpV vaccine is approved for females ally experience little or no pain, so a pain ages 9 to 25, but the CDC recommends that score of 6 out of 10 may indicate complica- girls receive the vaccine between the ages of tions such as hemorrhage, infection, or 10 and 12. Choice a is incorrect. The HpV increased intraocular pressure. Choices a, c, vaccine is approved for use in females and d are incorrect. The information given between the ages of 9 and 25. Choice c is by the client indicates a need for client incorrect. While the HpV vaccine is teaching, but does not indicate that compli- approved for females between the ages of 9 cations of the surgery may be occurring. and 25, it is recommended that they receive Category: physiological Integrity: physio- it between the ages of 10 and 12. Choice d is logical Adaptation incorrect. While the HpV vaccine is Subcategory: Adult: Eye and Ear Disorders approved for females between the ages of 9 67. a. The head circumference of a one-week-old and 25, it is recommended that they receive infant is expected to be 2 to 3 cm larger than the vaccine before becoming sexually active. the chest circumference. Choice b is incor- Category: physiological Integrity: Reduc- rect. If the head circumference is larger than tion of Risk the chest circumference by 4 to 5 cm, this Subcategory: pediatrics: Assessment could be an indication of hydrocephalus. 70. c. Cervical spine injuries are commonly asso- Choices c and d are incorrect. If the head ciated with electrical burns; therefore, stabi- circumference is smaller than the chest cir- lization of the cervical spine takes cumference by 2 cm or more, this could be precedence after airway management. an indication of an underdeveloped brain. Choices a, b, and d are incorrect. These Category: physiological Integrity: Health actions are included in the emergent care promotion and Maintenance after electrical burns, but the most impor- Subcategory: Maternal Infant: Neonate tant priority is to avoid spinal cord injury. Assessment Category: physiological Integrity: physio- 68. d. A darkened, quiet room will decrease the logical Adaptation symptoms of the acute attack of Ménière’s Subcategory: Adult: Integumentary disease. Choice a is incorrect. Fluids are Disorders administered intravenously during an acute 71. b. Alcohol withdrawal symptoms include an attack; thus the need to encourage an elevated, not decreased, heart rate. Choice a increase in oral fluids is not necessary. is incorrect. Agitation is an early symptom Choices b and c are incorrect. The client of alcohol withdrawal. Choice c is incorrect. should be positioned for comfort. Hyperalertness is an early symptom of alco- Category: physiological Integrity: physio- hol withdrawal. Choice d is incorrect. Sei- logical Adaptation zures can occur during alcohol withdrawal, Subcategory: Adult: Eye and Ear Disorders especially in the first 7 to 48 hours. Category: physiological Integrity: Reduc- tion of Risk Subcategory: Mental Health: Alcohol Withdrawal

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72. c. CpAp therapy is very effective in improving 75. a. Drooling can result from the ingestion of a sleep quality in clients with sleep apnea; corrosive substance. Choice b is incorrect. however, many clients are noncompliant Jaundice is associated with acetaminophen with the therapy. The nurse should be sure overdose/poisoning. Choice c is incorrect. that the client is actually using the CpAp Oliguria is associated with acetylsalicylic machine as prescribed. Choice a is incorrect. overdose/poisoning. Choice d is incorrect. When CpAp is used as prescribed, the Tinnitus is associated with acetylsalicylic effects on sleep quality are seen immedi- toxicity/poisoning. ately. Choice b is incorrect. Surgery may be Category: physiological Integrity: pharma- an appropriate therapy for the client; how- cologic and parenteral Therapies ever, suggesting surgery would not be an Subcategory: pediatrics: Gastrointestinal appropriate first action by the nurse in this Disorders situation. Choice d is incorrect. Utilizing a 76. b. Aromatherapy is used for stress reduction, higher pressure setting will make it more and a decrease in the client’s blood pressure difficult for the client to exhale and is likely and pulse would indicate that the aroma- to decrease client compliance with therapy. therapy was effective. Choice a is incorrect. Category: physiological Integrity: physio- Auscultating the client’s breath sounds logical Adaptation would not be used to determine the effec- Subcategory: Adult: Respiratory Disorders tiveness of aromatherapy. Choice c is incor- 73. c. This is a picture of a low-lying placenta pre- rect. Checking the incision for signs of via. Choice a is incorrect. This is a picture of infection would not be used to determine a marginal placenta previa. Choice b is incor- the effectiveness of aromatherapy. Choice d rect. This is a picture of a complete placenta is incorrect. Monitoring the client’s intake previa. Choice d is incorrect. This is a picture and output would not be used to determine of a normally implanted placenta. the effectiveness of aromatherapy. Category: Safe and Effective Management Category: psychosocial Integrity of Care: Management of Care Subcategory: Adult: Miscellaneous Subcategory: Maternal Infant: Maternal Complications 74. b. The abbreviations “qd” (daily)(order 1), “u”(units)(order 4), and “MS” (morphine sulfate)(order 5) are inappropriate abbreviations for a physician to use when writing a medication order. These abbreviations are prohibited by the Joint Commission. Orders 2 and 3 contain essential components of the medication order (i.e., medication name, dose, frequency, and route) and use acceptable abbreviations. Choices a, c, and d are incorrect. See answer choice b. Category: physiological Integrity: pharma- cology and parenteral Therapies Subcategory: Adult: Miscellaneous

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77. a. The monitor strip shows that the fetal heart 79. a. Symptoms of cocaine overdose include car- rate is within the normal range in response diac arrhythmias, which can lead to cardiac to maternal contractions. The nurse should arrest. Choice b is incorrect. panic is associ- continue to monitor the client. Choice b is ated with overdoses of hallucinogens such incorrect. There is no need to notify the as LSD and pCp but not cocaine. Choice c physician at this point in time as the moni- is incorrect. psychosis is associated with tor strip does not indicate fetal distress. overdoses of hallucinogens such as LSD and Choice c is incorrect. While the left lateral pCp but not cocaine. Choice d is incorrect. position promotes fetal blood flow and oxy- Overdoses of opioids such as morphine genation, the monitor strip does not indi- and heroin place the client at risk for cate fetal distress; therefore, the client does respiratory arrest. not need to be placed in the left lateral posi- Category: physiological Integrity: Reduc- tion. Choice d is incorrect. There is no indi- tion of Risk cation of fetal distress on the monitor strip; Subcategory: Mental Health: Substance therefore, the client will not need a cesarean Abuse section at this time. 80. c. The purpose of using lactulose in a client Category: physiological Integrity: Basic with cirrhosis is to lower ammonia levels Care and Comfort and prevent encephalopathy. Symptoms of a Subcategory: Maternal: Fetal Assessment high ammonia level include confusion or 78. a. The client is demonstrating proper tech- extreme sleepiness. Hepatic encephalopathy nique when elbows are bent at a 30° angle, is the occurrence of confusion, altered level indicating the use of the walker at the of consciousness, and coma as a result of proper height for the client. Choice b is liver failure. In the advanced stages it is incorrect. This demonstrates improper tech- called hepatic coma. Choice a is incorrect. nique: the client should stand erect while Although administration of lactulose may using the walker. Choice c is incorrect. This prevent constipation, the medication is not demonstrates improper technique: the client ordered for this purpose for this client. cannot be ambulating with partial weight Choice b is incorrect. The medication is not bearing if the client lifts the walker off the ordered for this purpose for this client. floor. Choice d is incorrect. This demon- Choice d is incorrect. Although administra- strates improper technique: the client can- tion of lactulose may prevent fluid loss via not be ambulating with partial weight stool, the medication is not ordered for this bearing while using a walker with four purpose for this client. wheels. Category: physiological Integrity: pharma- Category: physiological Integrity: Basic cology and parenteral Therapies Care and Comfort Subcategory: Adult: Gastrointestinal Subcategory: Adult: Musculoskeletal Disorders Disorders

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81. d. Due to the risk for dehydration from vomit- 83. d. pregnant women should avoid soft cheeses ing, the nurse should include assessment for such as feta and brie due to the potential for dehydration and documentation of intake contracting listeria. Choice a is incorrect. and output in the client’s plan of care. Only undercooked eggs such as those with a Choice a is incorrect. The child with pyloric running yolk need to be avoided during stenosis is at risk for dehydration from vom- pregnancy. Choice b is incorrect. As long as iting, so an assessment of dehydration the client does not consume more than 300 should be included in the plan of care. mg of caffeine per day, a cup of coffee in the However, administration of blood products morning is allowed. Choice c is incorrect. As is not indicated. Choice b is incorrect. While long as the shrimp is cooked, it is safe to eat an assessment for dehydration due to vom- during pregnancy. Swordfish, shark, tilefish, iting should be made, chelation therapy, and king mackerel should be avoided due to which is utilized for lead poisoning, should high levels of mercury they contain. not be administered. Choice c is incorrect. Category: physiological Integrity: Administration of blood products is not Risk Reduction indicated, and chelation therapy is used to Subcategory: Maternal Infant: Antepartum treat lead poisoning. 84. d. If the nurse experiences resistance during Category: physiological Integrity: physio- the insertion of the nasogastric tube, the logical Adaptation nurse should remove the tube and try the Subcategory: pediatrics: Gastrointestinal other nares to prevent damage to nasal Disorders mucosa and internal structures. Choice a is 82. a. This image represents a lobectomy, in which incorrect. Asking the client to swallow water only a lobe of the lung is removed. Choice b may help advance the tube, but will not pre- is incorrect. This image demonstrates a vent injury to the client. Choice b is incor- pneumonectomy, in which the entire lung is rect. The tube has met resistance as it was removed. Choice c is incorrect. This image being inserted; therefore checking for place- demonstrates a wedge resection, in which a ment is inappropriate since it hasn’t reached small, well-circumscribed lesion is removed the stomach yet. Choice c is incorrect. The without regard for the location of the inter- nurse should not continue to advance or segmental planes. Choice d is incorrect. This push the tube into the nares, as this may image demonstrates a segmentectomy. injure the client. Bronchopulmonary segments are subdivi- Category: physiological Integrity: Basic sions of the lung that function as individual Care and Comfort units. Subcategory: Adult: Gastrointestinal Category: physiological Integrity: physio- Disorders logical Adaptation Subcategory: Adult: Oncology Disorders

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85. a. Anticholinergic medications, which affect 87. d. During the taking-hold phase, the mother the central and peripheral nervous systems, feels in control; she is ready to begin caring are contraindicated with donepezil (Ari- for the infant and is receptive to learning cept). Choice b is incorrect. Diuretics may infant care. Choice a is incorrect. During the be contraindicated with certain types of letting-go phase the mother may feel role kidney diseases, but not with acetylcholines- conflict about being a mother. Therefore, terase inhibitors, an example of which is she may not be receptive to learning infant Aricept. Choice c is incorrect. Narcotics care. Choice b is incorrect. There is not a should be use with caution for clients with “letting-in” phase in Rubin’s phases of respiratory conditions, but are not contrain- bonding. Choice c is incorrect. During the dicated for use with acetylcholinesterase taking-in phase, the mother is focused on inhibitors, an example of which is Aricept. her own needs and on her delivery experi- Choice d is incorrect. Antipsychotic medica- ence and may not be receptive to learning tions may cause neuroleptic malignant syn- infant care. drome as an adverse reaction but are not Category: psychosocial Integrity contraindicated with alcetylcholinesterase Subcategory: Maternal Infant: postpartum inhibitors, an example of which is Aricept. 88. a. Guillain-Barré syndrome can cause respira- Category: physiological Integrity: pharma- tory acidosis, because the syndrome can cology and parenteral Therapies affect the muscles of respiration, which Subcategory: Mental Health: Medications might decrease alveolar ventilation and 86. d. A partial thromboplastin time (pTT) of 60 result in the retention of carbon dioxide. seconds is therapeutic for a client receiving Choice b is incorrect. This client is at risk heparin. The 60 seconds value falls within for developing metabolic acidosis. Choice c the therapeutic range of 1.5 to 2.5 times the is incorrect. This client is at risk for devel- control when a client is on heparin. The oping metabolic alkalosis. Choice d is incor- normal range of a pTT is 25 to 38 seconds. rect. This client is at risk for developing Choice a is incorrect. A phosphorus level is respiratory alkalosis. not used to measure the therapeutic effects Category: physiological Integrity: physio- of heparin therapy. The normal phosphorus logical Adaptation level is 2.5 to 4.5 mg/dL. Choice b is incor- Subcategory: Adult: Fluid and Electrolyte rect. A platelet count is not used to measure Imbalances the therapeutic effects of heparin therapy. The normal platelet level is 150,000 to 450,000/mm3. Choice c is incorrect. A prothrombin time (pT) level is not used to measure the therapeutic effects of heparin therapy. The normal pT level is 11 to 13.5 seconds. A pT level is utilized to evaluate the effects of warfarin (Coumadin). Category: physiological Integrity: Reduc- tion of Risk Subcategory: Adult: Neurological Disorders

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89. b. A decreased pulse coupled with increased 92. b. A living will is a legal document that out- blood pressure can be indications of lines a client’s wishes about life-sustaining increased intercranial pressure. Choice a is medical treatment if the client becomes ter- incorrect. A decreased pulse can indicate minally ill or permanently unconscious. increased intercranial pressure, but the Choice a is incorrect. This statement defines blood pressure would be increased, not a durable power of attorney. Choice c is decreased. Choice c is incorrect. Signs of incorrect. Both a living will and a durable increased intercranial pressure include power of attorney are considered AHCDs. increased blood pressure but the pulse Choice d is incorrect. A living will is consid- would be decreased, not increased. Choice d ered a legal document. is incorrect. Neither increased pulse nor Category: Safe and Effective Care Environ- decreased blood pressure is a symptom of ment: Management of Care increased intercranial pressure. Subcategory: Adult: Cardiovascular Category: Safe and Effective Care Environ- Disorders ment: Management of Care 93. c. Rigidity, along with irregular or erratic Subcategory: pediatrics: Neurologic pulse, changes in mental status, and elevated Conditions creatinine are signs of neuroleptic malig- 90. c. Removing a client’s spleen predisposes the nant syndrome. Choice a is incorrect. Dys- client to an increased risk of developing an kinesia, although an adverse reaction to infection. Choice a is incorrect. There is not Thorazine, is not a symptom of neuroleptic an increased risk of developing anemia fol- malignant syndrome, which can cause irreg- lowing a splenectomy. Choice b is incorrect. ular or erratic pulse, changes in mental sta- There is not an increased risk of developing tus, and elevated creatinine. Choice b is not bleeding tendencies following a splenec- correct. Gait shuffling is an extrapyramidal tomy. Choice d is incorrect. There is not an symptom that can occur as an adverse reac- increased risk of developing lymphedema tion to Thorazine, but it is not a symptom following a splenectomy. of neuroleptic malignant syndrome, which Category: physiological Integrity: Reduc- can cause rigidity, irregular or erratic pulse, tion of Risk changes in mental status, and elevated creat- Subcategory: Adult: Hematological inine. Choice d is incorrect. Toe tapping Disorders may be a symptom of hyperactivity in cli- 91. a. There is no clinical significance to a client ents with attention deficit hyperactivity dis- trembling during or after the third stage of order (ADHD), but it is not a symptom of delivery. Choices b and c are incorrect. neuroleptic malignant syndrome. While trembling can indicate fear in some Category: physiological Integrity: pharma- situations, it does not have clinical signifi- cology and parenteral Therapies cance when it occurs during or after the Subcategory: Mental Health: Medications third stage of delivery. Choice d is incorrect. Abruptio placentae is a rupturing of the placenta prior to delivery. Category: physiological Integrity: physiological Adaptation Subcategory: Maternal Infant: Intrapartum

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94. b. The client’s inability to move the right leg 96. d. The recommended daily protein intake is when instructed may indicate that a hemor- 0.8 to 1 g/kg of body weight, which for this rhagic stroke is occurring. Immediate inter- client is 70.4 kg × 0.8 g = 56.3 or 56 g/day. vention by the nurse is required to prevent Choices a, b, and c are incorrect. They are further neurologic damage. Choice a is not the daily minimum requirement of pro- incorrect. The client’s headache is most tein for a client who weighs 155 pounds. likely caused by the hypertension and will Category: Health promotion require rapid nursing actions, but does not Subcategory: Adult: Miscellaneous require action as urgently as the neurologic 97. a. Evidence of a fetus during sonogram exam changes. Choice c is incorrect. The client’s is a positive sign of pregnancy. Choice b is decreased urine output is most likely caused incorrect. The categories for signs of preg- by the hypertension and will require rapid nancy include positive, presumptive, and nursing actions, but does not require action probable, not potential. Choice c is incor- as urgently as the neurologic changes. rect. presumptive signs of pregnancy Choice d is incorrect. The client’s tremors include breast tenderness, fatigue, morning are most likely caused by the hypertension sickness, and quickening. Choice d is incor- and will require rapid nursing actions, but rect. probable signs of pregnancy include do not require action as urgently as the neu- Goodell’s sign, Hegar’s sign, Chadwick’s rologic changes. sign, and ballottement. Category: physiological Integrity: Reduc- Category: physiological Integrity: Basic tion of Risk Care and Comfort Subcategory: Adult: Cardiovascular Subcategory: Maternal Infant: Antenatal Disorders 98. b. The placement of restraints as well as skin 95. b. Acetylsalicylic acid should not be given to a condition, color, temperature, and sensation child with a fever due to the risk for Reye’s of restraint area must be checked at least syndrome. Choice a is incorrect. Acetamino- every hour. Choice a is incorrect. This may phen can be given to a child with a fever. provide more frequent assessment, but the Choice c is incorrect. Ibuprofen is safe to standard is every hour. Choices c and d are give to a child with a fever. Choice d is incorrect. These intervals are too long and incorrect. Tepid baths can provide comfort may increase the risk of injury. to the child as well as assist in lowering the Category: Safe and Effective Care Environ- child’s temperature. ment: Safety and Infection Control Category: Safe and Effective Care Environ- Subcategory: Adult: Miscellaneous ment: Management of Care Subcategory: pediatrics: Endocrine Disorders

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99. a. Drooling, dystonia, and permanent gait 101. c. Decreased protein intake should be incor- shuffling are symptoms of tardive dyskine- porated into the child’s plan of care to sia, an adverse reaction to antipsychotic decrease the workload of the kidneys. medications. Choice b is incorrect. Choice a is incorrect. The amount of carbo- pill-rolling movements, dyskinesia, and a hydrates in the diet does not need to be flat affect are symptoms of drug-induced restricted, as the kidneys are not impacted parkinsons. Drooling, dystonia, and perma- by carbohydrates. Choice b is incorrect. Flu- nent gait shuffling are symptoms of tardive ids should be increased in a child with glo- dyskinesia, an adverse reaction to antipsy- merulonephritis. Choice d is incorrect. The chotic medications. Choice c is incorrect. child with glomerulonephritis should Repetitive hand motions are not a sign of restrict sodium intake to decrease the tardive dyskinesia. Choice d is incorrect. Toe workload of the kidneys. tapping and uncontrolled restlessness are Category: Safe and Effective Care Environ- symptoms of akathesia. Drooling, dystonia, ment: Management of Care and permanent gait shuffling are symptoms Subcategory: pediatrics: Genitourinary of tardive dyskinesia, an adverse reaction to Disorders antipsychotic medications. 102. c. The client needs to receive 1,800 mL of fluid Category: physiological Integrity: pharma- in the first 24 hours following the burn cology and parenteral Therapies injury. Using the parkland formula, half Subcategory: Mental Health: Medications of the total amount is to be infused in the 100. d. This situation indicates the client may be first eight hours, which in this instance is aspirating. The nurse’s first action should be 900 mL. The remaining half of the total to turn off the tube feeding (4) to avoid fur- amount is infused over the remaining 16 ther aspiration. The next action should be hours. Choices a, b, and d are incorrect. to check the client’s oxygen saturation (3) Category: physiological Integrity: physio- because this may indicate the need for logical Adaptation immediate respiratory suctioning and/or Subcategory: Adult: Integumentary oxygen administration. The tube feeding Disorders residual volume should be checked next (1). This will provide data about the possible causes of aspiration. Last, the physician should be notified (2) and informed of all the assessment data the nurse has just obtained. Choices a, b, and c are incorrect. They are not the proper sequences of events. Category: physiological Integrity: Reduction of Risk Subcategory: Adult: Neurological Disorders

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103. c. During flexion, the fetal head bends to the 105. c. The nurse should continue to monitor the chest to present the smallest diameter for client, as the lithium level is within the ther- delivery. Choice a is incorrect. During apeutic range. Choice a is incorrect. A lith- extension, upward resistance from the pelvic ium level of 0.9 mEq/L is within the floor after the head has passed through the therapeutic range. Choice b is incorrect. The symphysis pubis causes the head to extend, lithium level of 0.9 mEq/L is within thera- which allows the occiput to emerge. Choice peutic range, so there is no need to contact b is incorrect. During external rotation, the the physician at this time. Choice d is incor- shoulders turn to allow for delivery of the rect. Mannitol is administered to manage anterior then posterior shoulder. Choice d is toxicity. A blood level of 0.9 mEq/L is not incorrect. During internal rotation, the head toxic; it is within the therapeutic range. enters into the pelvis and then rotates 90 Category: physiological Integrity: pharma- degrees so that the back of the neck can cology and parenteral Therapies proceed under the symphysis pubis. Subcategory: Mental Health: Medications Category: physiological Integrity: physio- 106. d. The Allen’s test is used to test blood supply logical Adaptation to the hand, specifically, the patency of the Subcategory: Maternal Infant: Intrapartum radial and ulnar arteries. It is performed 104. d. Trended changes in CVp are more signifi- prior to radial arterial blood sampling or cant than any individual measurement. cannulation. Choices a, b, and c are incor- Choice a is incorrect. The risk of developing rect. These are not the reasons why the pulmonary edema is associated with an ele- Allen’s test is performed. vated CVp. Choice b is incorrect. A CVp of Category: physiological Integrity: physio- 15 mm Hg indicates hypervolemia, and logical Adaptation fluid replacement would be contraindicated. Subcategory: Adult: Cardiovascular Choice c is incorrect. The normal range for Disorders

CVp is 0 to 8 mm Hg or 5 to 10 cm H2O, 107. d. Amniotic fluid that is yellow in color may depending on what type of equipment is indicate an infection. Choice a is incorrect. used. A pressure greater than 6 mm Hg Amniotic fluid that is clear but with white would fall within the normal range and flecks is within normal limits. Choice b is therefore would not need to be reported to incorrect. Amniotic fluid that is green in the physician. color indicates fetal distress. Choice c is Category: physiological Integrity: physio- incorrect. Amniotic fluid that is the color logical Adaptation of port wine is indicative of abruptio pla- Subcategory: Adult: Cardiovascular centae. Disorders Category: Safe and Effective Care Manage- ment: Safety and Infection Control Subcategory: Maternal Infant: Intrapartum

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108. b. An early symptom of type 1 diabetes is 110. d. The nurse should expect to recheck the weight loss. Weight loss occurs because the serum potassium level during the infusion body is no longer able to absorb glucose and of glucose and insulin to determine the starts to break down protein and fat for effectiveness of the therapy. Choice a is energy. Choice a is incorrect. The client may incorrect. The blood glucose level should be experience increased thirst, but will not monitored during the infusion to assess for crave fluids containing sugar. Choice c is hypoglycemia or hyperglycemia; however, incorrect. The client will experience an the serum potassium level shows the effec- increased appetite; a question about tiveness of the therapy. Choice b is incor- anorexia is inappropriate. Choice d is incorrect. The BUN and creatinine levels will not rect. The client will experience polyuria, the change with the administration of glucose excessive passage of urine (at least 2.5 liters and insulin. Choice c is incorrect. Changes per day for an adult), resulting in profuse in serum potassium level will impact the urination and urinary frequency. ECG and muscle strength; however, the Category: physiological Integrity: physio- nurse should recheck the serum potassium logical Adaptation level to best evaluate the effects of the Subcategory: Adult: Endocrine Disorders medications. 109. d. Eggs, milk, wheat, and soy can all be trans- Category: physiological Integrity: physio- mitted through breast milk and cause an logical Adaptation allergic reaction in the child. Choice a is Subcategory: Adult: Renal Disorders incorrect. Eggs, milk, and soy can all be 111. b. Delirium is precipitated by a defined event. transmitted through breast milk, as well as Cognitive impairments caused by delirium wheat, causing an allergic reaction in the are reversible once the underlying cause of child. Choice b is incorrect. Milk, wheat, the delirium is treated. Choice a is incorrect. and soy can all be transmitted through The impairments caused by delirium are breast milk, as well as eggs, causing an aller- reversible and are precipitated by a defined gic reaction in the child. Choice c is incor- event. This underlying cause of the delirium rect. Eggs, wheat, and soy can all be must be treated, as delirium is not a self- transmitted through breast milk, as well as limiting disease. Choice c is incorrect. The milk, causing an allergic reaction in the impairments caused by delirium are not child. permanent, and delirium is not a self- Category: Safe and Effective Care Environ- limiting disease; the underlying cause of the ment: Safety and Infection Control delirium must be treated. Choice d is incor- Subcategory: pediatrics: Hematological/ rect. The impairment caused by delirium is Immune System reversible and delirium is not a self-limiting disease; the underlying cause if the delirium must be treated. Category: physiological Integrity: physiological Adaptation Subcategory: Mental Health: Cognitive Disorders

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112. c. The client’s symptoms, lack of antibodies 115. c. The child with sickle-cell anemia who is in a for hepatitis, and the abrupt onset of symp- sequestration crisis experiences pooling of toms suggest toxic hepatitis can be caused the blood in the spleen. Choice a is incor- by commonly used OTC drugs such as acet- rect. Decreased red blood cell production aminophen (Tylenol). Choice a is incorrect. occurs when the child with sickle-cell ane- Corticosteroid use is not associated with the mia is in an aplastic crisis. Choice b is incor- symptoms listed. Choice b is incorrect. rect. petechia, tiny hemorrhagic spots on the Jaundice is a sign of viral hepatitis, which is skin, and bruising occur with a decrease in not indicated by the serologic testing. white blood cells in diseases such as leuke- Choice d is incorrect. IV drug use is associ- mia. Choice d is incorrect. Swollen hands ated with viral hepatitis, which is not indi- and feet occur when the child with sickle- cated by the serologic testing. cell anemia is in a vaso-occlusive crisis. Category: physiological Integrity: physio- Category: physiological Integrity: physiological Adaptation logical Adaptation Subcategory: Adult: Gastrointestinal Subcategory: pediatrics: Hematologic and Disorders Immune Disorders 113. d. placenta previa and active genital herpes 116. b. Cranial nerve number nine is responsible present a risk that might indicate a need for for the pharyngeal gag reflex as well as for a cesarean birth. Choice a is incorrect. pla- movement of the phonation muscles of the centa previa is a risk factor that might indi- pharynx. It is also responsible for taste of cate a need for a cesarean birth but anemia the posterior third of the tongue and sensa- is not. Choice b is incorrect. Active genital tion from the eardrum to the ear canal. The herpes is a risk factor that might indicate a gag reflex is tested by touching the posterior need for a cesarean birth but anemia is not. pharyngeal wall with the tongue blade and Choice c is incorrect. puerpera occurs in the observing for gagging. Choice a is incorrect. postpartum period and is therefore not a Cranial nerve number six is responsible for risk factor that might indicate a need for lateral movement. Choice c is incorrect. a cesarean birth. Anemia is also not a risk Cranial nerve 12 is responsible for tongue factor. movement. Choice d is incorrect. Cranial Category: Safe and Effective Care Manage- nerve five has both motor and sensory comment: Safety and Infection Control ponents. It is responsible for sensation in Subcategory: Maternal Infant: Intrapartum the face, scalp, oral and nasal mucosa mem- 114. a. The target INR for clients with atrial fibril- branes, and the cornea, and it allows chew- lation is 2.0 to 3.0. The client’s INR is below ing movement of the jaw. this range, and the dosage of warfarin Category: Health promotion and should be increased. Choices b and c are Maintenance incorrect. The INR level is not too high. Subcategory: Adult: Neurological Disorders Choice d is incorrect. The INR is not within the desired range. Category: physiological Integrity: pharma- cology and parenteral Therapies Subcategory: Adult: Cardiovascular Disorders

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117. c. Timing from the beginning of one contrac- 120. c. Rhinorrhea may indicate a dural tear with tion to the beginning of the next measures cerebrospinal fluid (CSF) leakage; insertion the frequency of the contractions. Choice a of a nasogastric tube will increase the risk is incorrect. Timing from the beginning of for infections such as meningitis, and thus is one contraction to the end of the contrac- contraindicated. Choices a, b, and d are tion measures the duration of the contrac- incorrect. These orders are appropriate. tion. Choice b is incorrect. From point 2 to Category: physiological Integrity: physio- point 5 measures the peak of one contrac- logical Adaptation tion to the peak of the next. Choice d is Subcategory: Adult: Neurological Disorders incorrect. Timing from the end of one con- 121. c. Scoliosis is a lateral curvature of the spine traction to the beginning of the next con- resulting in uneven shoulders and hips and traction measures the interval between prominent scapulae. Choice a is incorrect. contractions. Kyphosis is an abnormal or excessive for- Category: Health promotion and ward rounding of the upper shoulders from Maintenance developmental or degenerative diseases. Subcategory: Maternal Infant: Intrapartum Choice b is incorrect. Lordosis is an abnor- 118. a. Theophylline is a methylxanthine broncho- mal curvature in the lumbar area of the dilator. The client needs to be taught to spine resulting in a swayback posture. avoid or limit intake of foods that contain Choice d is incorrect. Scheuermann’s disease xanthine. These foods include cola, coffee, is a kyphosis or forward rounding of the and chocolate. Choices b, c, and d are incor- upper shoulders during adolescence. rect. These foods are not high in xanthine, Category: physiological Integrity: physio- which should be avoided when theophylline logical Adaptation therapy is being administered. Subcategory: pediatrics: Musculoskeletal Category: physiological Integrity: pharma- Disorders cology and parenteral Therapies 122. d. The most appropriate action is to tell the Subcategory: Adult: Respiratory Disorders client to drop and roll on the ground. This 119. b. Clients with depersonalization disorders will smother the flames and put out the fire. have a loss of their personal reality and feel The client’s safety is the priority. Choice a is like things are not real. Choice a is incorrect. incorrect. This is not warranted in the Fixed, lifelike, false beliefs are associated instance of a fire. Choice b is incorrect. It is with delusional disorders. Choice c is incor- not necessary for the responding nurse to rect. Loss of recall of personal memories is locate the fire alarm box. The other nurses associated with dissociative amnesia. Choice who respond to the emergency can activate d is incorrect. Having two or more distinc- the fire alarm. The priority is the client’s tive personalities is associated with dissocia- safety. Choice c is incorrect. Obtaining tive identity disorder. water may take too long, given where the Category: physiological Integrity: physio- client is in the bathroom. The priority inter- logical Adaptation vention is to have the client drop to the Subcategory: Mental Health: Dissociation floor and roll. Disorders Category: Safe and Effective Care Environ- ment: Safety and Infection Control Subcategory: Adult: Miscellaneous

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123. a. Bradycardia, a slower than normal heart 125. c. Clients with an antisocial personality disor- rate, is a possible adverse reaction to berac- der are at risk for harming themselves or tant. Choice b is incorrect. Necrotizing others. Choice a is incorrect. Delirium can enterocolitis is a complication experienced be caused by substance abuse withdrawal, by preterm infants, but it is not an adverse metabolic imbalances, or infectious diseases reaction to beractant. Choice c is incorrect. but is not associated with antisocial person- Retinopathy is a complication of prematu- ality disorders. Choice b is incorrect. Hallu- rity, but it is not an adverse reaction to ber- cinations are associated with paranoid actant. Choice d is incorrect. An adverse schizophrenia and substance abuse but not reaction to beractant is bradycardia, a with antisocial personality disorder. Choice slower than normal heart rate, not tachycar- d is incorrect. Substance abuse can be a dia, a faster than normal heart rate. form of self-medication for clients with Category: physiological Integrity: pharma- antisocial personality disorder, but the cology and parenteral Therapies highest-priority assessment is the client’s Subcategory: Maternal Infant: Intrapartum risk for harming self or others. 124. c. The nurse must be aware of the physical and Category: physiological Integrity: physio- physiological signs of death. This is con- logical Adaptation firmed in the rigidity of the client’s body Subcategory: Mental Health: Dissociation and lack of change in position (2), Cheyne- Disorders Stokes respirations (3), the client’s state- 126. d. The Schilling’s test is used to determine

ments that he is dying (5) and is seeing whether the body absorbs vitamin B12 nor- family members who have already passed on mally. The client should be instructed to fast (6). Findings within the normal range for eight hours prior to the test. No food or include blood pressure of 80/60 mm Hg (1) drink is permitted. Following the adminis-

and extremities that are warm to the touch tration of the vitamin B12 dose, food is then (4). Choices a, b, and d are incorrect. delayed for three hours. Choice a is incor- Category: psychosocial Integrity rect. The client is not required to administer Subcategory: Adult: Miscellaneous a Fleets Enema prior to the procedure. Choice b is incorrect. It is not necessary for the client to collect his or her urine for 12 hours prior to the test. The client will be instructed to collect his or her urine after

the B12 is administered. Choice c is incorrect. It is not necessary to empty the bladder prior to the test. Category: physiological Integrity: physiological Adaptation Subcategory: Adult: Hematological Disorders

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127. a. Signs of ADHD include difficulty concen- 129. d. pregnancy during the teen years places the trating, fidgeting, and interrupting others. client at risk for preterm labor and delivery. Choice b is incorrect. Hypoglycemia and Choice a is incorrect. Risk factors for ane- hyperglycemia can cause difficulty concen- mia include multiple pregnancies, smoking, trating, but fidgeting and interrupting are poor nutrition, and excess alcohol con- not usually associated with changes in blood sumption. Choice b is incorrect. Risk factors sugars. Therefore, assessing the child’s blood for gestational diabetes include maternal age sugar would not be indicated. Choice c is older than 35, obesity, and a family history incorrect. While it is appropriate for the of diabetes. Choice c is incorrect. Risk fac- nurse to teach the parents how to adminis- tors for placenta previa include advanced ter the child’s insulin, it is important to maternal age, previous uterine surgeries, include the child in the teaching. Choice d is multiple pregnancies, and multiparity. incorrect. While written information should Category: physiological Integrity: Reduc- be given to the child and family, children tion of Risk with ADHD-like symptoms often have diffi- Subcategory: Maternal Infant: culty focusing on written information; Complications therefore, it would be inappropriate to rely 130. c. A pulsating abdominal mass is a common on written instructions as the primary finding of abdominal aortic aneurysm. teaching method. Choice a is incorrect. A boardlike, rigid Category: physiological Integrity: psycho- abdomen may indicate internal bleeding. social Integrity Choice b is incorrect. Knifelike pain in the Subcategory: pediatrics: Neurological/ back area may indicate a ruptured abdomi- Cognitive Disorders nal aneurysm. Choice d is incorrect. 128. c. The tubing is primed with 0.9% normal Unequal femoral pulses are not associated saline solution. If the filter is not completely with an abdominal aortic aneurysm. primed, debris will quickly enter the filter Category: physiological Integrity: physio- and the infusion will be slowed. Choice a is logical Adaptation incorrect. It is neither necessary nor recom- Subcategory: Adult: Cardiovascular mended that the blood be left at room tem- Disorders perature for one hour prior to the infusion. Choice b is incorrect. No medication should be added to the blood products. Choice d is incorrect. The client should have a large- bore catheter inserted for the blood transfusion. Category: physiological Integrity: physiological Adaptation Subcategory: Adult: Miscellaneous

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131. a. Athetosis refers to involuntary writhing 133. c. The MMS is the Mini Mental Status exam, motions in clients with cerebral palsy. which is a set of questions designed to eval- Choice b is incorrect. Ataxia refers to unco- uate cognitive function. Choice a is incor- ordinated muscle movements and a wide- rect. The CAGE exam is a screening tool for based gait in clients with cerebral palsy. alcoholism that consists of four questions. Choice c is incorrect. Hypertonia refers to Choice b is incorrect. The HITS exam is a rigidity or spasticity of the muscles in a cli- screening tool for domestic violence. Choice ent with cerebral palsy. Choice d is incor- d is incorrect. The pSA is a blood test that rect. Hypotonia refers to diminished reflexes measures levels of prostate-specific antigen or floppiness in a client with cerebral palsy. in the blood as a screening tool for prostate Category: physiological Integrity: physio- cancer. logical Adaptation Category: Health promotion and Subcategory: Neurological/Cognitive Maintenance Disorders Subcategory: Mental Health: Cognitive 132. c. The symptoms suggest that the client is Disorders experiencing a pulmonary embolus. The cli- 134. d. A regular heart rate is calculated by multi- ent should be placed in the Fowler’s posi- plying the number of QRS complexes in a tion (semi-upright sitting position—45–60 six-second strip by 10. In this scenario there degrees—with knees either bent or straight) are nine QRS complexes; thus, the heart rate to promote lung expansion and ease dys- is calculated at 90 bpm. This method is not pnea. Choice a is incorrect. The nurse accurate if the client’s heart rate is irregular. should apply oxygen via nasal cannula, but Choices a, b, and c are incorrect. The heart after the client is placed in a Fowler’s posi- rate is 90 bpm. tion. Choice b is incorrect. The client is not Category: physiological Integrity: physio- choking; thus the Heimlich maneuver is not logical Adaptation required. Choice d is incorrect. The Tren- Subcategory: Adult: Cardiovascular delenburg position (supine, or flat on the Disorders back, with the feet higher than the head by 135. b. Harlequin changes are benign changes in 15–30 degrees) is contraindicated in this sit- the neonate’s skin where one half turns dark uation. pink or red and the other half turns pale. Category: physiological Integrity: physio- Choice a is incorrect. Acrocyanosis is cyano- logical Adaptation sis of the hands and feet in neonates. Choice Subcategory: Adult: Respiratory Disorders c is incorrect. Lanugo is a fine, downy hair on the body of the neonate. Choice d is incorrect. Milia are small, white bumps appearing over the neonate’s nose, chin, and/or cheeks. Category: Health promotion and Maintenance Subcategory: Maternal Infant: Neonate Assessment

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136. c. CSF is positive for glucose; thus the drain- 139. d. The nurse should stop the oxytocin prior to age should be tested for the presence of glu- administering oxygen, placing the woman in cose. Choice a is incorrect. Testing the fluid’s the left lateral position, or contacting the pH will not confirm CSF. Choices b and d physician. Choice a is incorrect. Although are incorrect. The fluid should be tested for oxygen therapy is appropriate, the nurse glucose. should first stop the oxytocin. Choice b is Category: physiological Integrity: physio- incorrect. Although the physician should be logical Adaptation contacted, the nurse should first stop the Subcategory: Adult: Neurological Disorders oxytocin, place the client in the left lateral 137. a. Teenagers with anorexia nervosa can have a position, and administer oxygen per proto- history of binge eating and purging and/or col. Choice c is incorrect. Although the left severely restricting food intake. Choice b is lateral position will promote maternal and incorrect. Teenagers with anorexia nervosa fetal circulation and oxygenation, the nurse would have a BMI of less than 18.5. Choice should first stop the oxytocin. c is incorrect. A symptom of anorexia ner- Category: Safe and Effective Care Manage- vosa is decreased sodium levels. Choice d is ment: Safety and Infection Control incorrect. A symptom of anorexia nervosa is Subcategory: Maternal Infant: Intrapartum absence of menorrhea. 140. a. Both eyes are patched to decrease eye move- Category: psychosocial Integrity ment. This is done because increased eye Subcategory: pediatrics movement can increase the amount of 138. d. This area correctly identifies the client’s detachment. Choice b is incorrect. patching bunion. A bunion results from inflamma- both eyes is not done to prevent eye infection and thickening of the first metatarsal tions. Choice c is incorrect. patching both joint of the great toe, usually with marked eyes is not done to prevent photophobia. enlargement of the joint and the lateral dis- Choice d is incorrect. patching both eyes is placement of the toe. Choices a, b, and c are not done to prevent nystagmus. incorrect. These areas do not identify a Category: physiological Integrity: physio- bunion. logical Adaptation Category: physiological Integrity: Basic Subcategory: Adult: Eye Disorders Care and Comfort Subcategory: Adult: Musculoskeletal Disorders

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141. d. A client with a somatic subtype of delu- 143. b. The formula for converting from Fahrenheit sional disorder has an irrational belief that to Celsius is: 5 the body is disfigured or nonfunctional. C = (F − 32) × –9. 5 Choice a is incorrect. A client with a conju- C = (102.5 – 32) × –9 = 39.17 gal delusional subtype has an irrational Choices a, c, and d are incorrect. belief that a significant other has been Category: physiological Integrity: pharma- unfaithful. Choice b is incorrect. A client cology and parenteral Therapies with an erotomania delusional subtype has Subcategory: pediatrics: Medication an irrational belief of emotional or spiritual 144. a. A serious complication of a paracentesis is love from a person with an elevated social hypovolemic shock or vascular collapse. The status. Choice c is incorrect. A client with a nursing priority is monitoring the client’s persecutory subtype of delusional disorder Bp and pulse to watch for this complication. has an irrational belief that there is a con- Choices b, c, and d are incorrect. spiracy against him or her. Category: physiological Integrity: physio- Category: physiological Integrity: physiological Adaptation logical Adaptation Subcategory: Adult: Gastrointestinal Subcategory: Mental Health: Delusional Disorders Disorders 145. c. In cephalohematoma, the bulge, or edema, 142. c. The client with liver failure will have an is between the bone and periosteum and increased ammonia level. Ammonia is a by- does not cross the suture lines. Choice a is product of protein metabolism, and a dis- incorrect. Anencephaly would not present as eased liver is unable to convert ammonia a bulge, or edema, of the soft tissues, but the into urea to be excreted in the urine. Choice head circumference might present as either a is incorrect. The nurse would expect to see equal to or smaller than the chest circumfer- an elevated ammonia level, not decreased ence. Choice b is incorrect. In caput succe- serum creatinine. Choice b is incorrect. daneum, the bulge, or edema, of the soft The nurse would expect to see an elevated tissue of the head crosses over the suture ammonia level, not decreased serum lines (where the borders of the bony plates sodium. Choice d is incorrect. The nurse of the skull intersect). Choice d is incorrect. would expect to see an elevated ammonia Hydrocephalus would present as significant level, not increased serum calcium. swelling of the entire head, not as a bulge or Category: physiological Integrity: physio- swelling in a particular area of the head. logical Adaptation Category: Health promotion and Subcategory: Adult: Gastrointestinal Maintenance Disorders Subcategory: Maternal Infant: Neonate Assessment

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146. c. The client’s symptoms indicate potential 148. b. To decrease the pressure within the com- respiratory distress; therefore, the nurse partment, the nurse should elevate the should prepare for intubation and mechani- affected extremity to the level of the heart cal ventilation. Choice a is incorrect. pain and prepare to remove/split the cast. If this medications should be administered, but intervention does not resolve the pressure, the need to address the client’s respiratory the client may require fasciotomy. Choice a distress is the priority. Choice b is incorrect. is incorrect. Administering pain medication Applying a sandbag to the flail side is con- in this scenario is not the action to take ini- traindicated. Choice d is incorrect. A chest tially. The pain from compartment syn- tube is not indicated for the treatment of a drome does not respond well to pain flail chest. medication. Choice c is incorrect. Interven- Category: physiological Integrity: physio- tion b should be implemented initially by logical Adaptation the nurse. The physician may complete a Subcategory: Adult: Respiratory Disorders fasciotomy if intervention b is unsuccessful. 147. d. The correct answer is 4.5 teaspoons, deter- Choice d is incorrect. This position should mined as follows: be avoided. placing the extremity above the ______120 mg _____15 ml ______1 teaspoon level of the heart will actually increase the x teaspoons = 1 × 80 mg × 5 ml 1,800 pressure in the compartment. = ____ 400 Category: physiological Integrity: physio- = 4.5 teaspoons logical Adaptation Choices a, b, and c are incorrect. Subcategory: Adult: Musculoskeletal Category: physiological Integrity: pharma- Disorders cology and parenteral Therapies Subcategory: pediatrics: Medication

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149. a. Dependency refers to intermittent or continu- 151. c. Betamethasone (Celestone) is administered ous cravings for a medication or substance in two doses 24 hours apart. Choices a and d that leads to its repeated misuse. It would be are incorrect. Betamethasone (Celestone) is expected that the client would no longer need administered as two IM injections 24 hours to take the medication every four to six hours apart. Choice b is incorrect. Dexamethasone two months after surgery. Choice b is incor- is administered in doses 12 hours apart, but rect. Substance use refers to ingestion of a betamethasone is administered in two doses prescription or over-the-counter medication, 24 hours apart. alcohol, nicotine, or illicit drug. The client is Category: physiological Integrity: pharma- using the percocet as it was prescribed; how- cology and parenteral Therapies ever, it would not be expected that the client Subcategory: Maternal Infant: Maternal would need to take the medication every four Medication to six hours two months after surgery. Choice 152. a. Elevating the client’s HOB to a position that c is incorrect. Tolerance refers to the need for will promote optimum venous outflow is the increasing amounts of a medication to priority. The benefit of this position will be achieve the desired effect. Choice d is incor- evident by a decrease in the intracranial rect. Withdrawal refers to clinical symptoms pressure reading. Choice b is incorrect. produced from cessation in the user of a med- Ninety degrees is too much elevation for a ication or substance. lethargic postoperative craniotomy with an Category: physiological Integrity: Basic Care intracranial pressure monitoring device in and Comfort place. Choice c is incorrect. This position is Subcategory: Mental Health: Substance contraindicated because elevating the client’s Abuse legs will increase blood flow to the brain, 150. b. The client is at risk for bleeding. Bleeding at which will further increase the client’s intra- the site of the arterial puncture site is a seri- cranial pressure reading. Choice d is incor- ous potential problem for several hours fol- rect. The side lying position is not effective lowing the completion of the procedure. in decreasing or increasing intracranial Choice a is incorrect. The completion of a pressure. femoral arteriogram does not predispose the Category: physiological Integrity: physiolog- client to respiratory complications; general ical Adaptation anesthetic is not used during the procedure. Subcategory: Adult: Neurological Disorders Choice c is incorrect. The client’s femoral pulse should be assessed if thrombus formation at the puncture site is suspected. There is no need to assess the client’s carotid pulse. Choice d is incorrect. The client may experience a drop in Bp if bleeding is occurring. However, assessing for obvious bleeding would be the correct initial action. Category: physiological Integrity: physiological Adaptation Subcategory: Adult: Cardiovascular Disorders

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153. a. The palmar grasp should disappear around 155. a. When administering ergot alkaloids, the three to four months of age. Choice b is nurse should closely monitor the client’s incorrect. The plantar grasp does not disap- blood pressure and hold the medication if pear until eight to 10 months of age. Choice the Bp becomes elevated. Choice b is incor- c is incorrect. The sucking reflex does not rect. Administration of ergot alkaloids does disappear until 10 to 12 months of age. not cause edema as an adverse reaction. Choice d is incorrect. The tonic neck reflex Choice c is incorrect. Ergot alkaloid admin- disappears between four and six months of istration may cause bradycardia, a slower age, so it is not considered an abnormal than normal heart rate, not an increased finding in a six-month-old. heart rate (tachycardia). Choice d is incor- Category: physiological Integrity: Reduc- rect. An adverse reaction to ergot alkaloids tion of Risk is respiratory depression, not an increase in Subcategory: pediatrics: Assessment the respiration rate. 154. b. The nurse should have instructed the client Category: physiological Integrity: pharma- that it is appropriate to place the casted leg cology and parenteral Therapies on a cloth-covered pillow or blanket. These Subcategory: Maternal Infant: Maternal are both breathable materials that allow the Medications cast to air-dry. No plastic should be used. 156. a. The nurse suspects that the client is experi- Choice a is incorrect. Ice should be applied encing an air embolism. An air embolism for 20 minutes, then removed for 20 min- occurs frequently with central lines with utes to help prevent edema of the casted sudden onset of dyspnea, hypotension, ste- extremity. Choice c is incorrect. Nothing nosis, and chest pain. The best initial nurs- should be inserted underneath the cast. ing action is to clamp the IV line and turn Choice d is incorrect. Hair driers, fans, and the client to the left side to trap the air in heat lamps should not be used to help dry the right side of the heart so it does not the cast. If used, the inside of the cast would enter the pulmonary artery. Then call the remain damp while the outside would dry. physician and administer oxygen via nasal Category: physiological Integrity: Reduc- cannula. Choice b is incorrect. CpR is not tion of Risk necessary at this point, but should be antici- Subcategory: Adult: Musculoskeletal pated if the client’s condition deteriorates. Disorders Choice c is incorrect. Discontinuing and clamping the IV are the priority actions. It is not appropriate to hang another bag of IV fluids at this time. Choice d is incorrect. The second action the nurse should take is to notify the physician and administer oxygen via nasal cannula. Category: physiological Integrity: physiological Adaptation Subcategory: Adult: Respiratory Disorders

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157. a. Disulfiram is used to assist clients to stop 159. c. pain that starts in the periumbilical area and drinking by causing negative symptoms if rebound tenderness are common findings in alcohol is consumed while on the medica- children with appendicitis. Choice a is tion. Choice b is incorrect. Disulfiram is incorrect. pain that starts in the periumbili- used to assist clients to stop drinking. Medi- cal area is common in children with appen- cations to treat anxiety include Xanax, dicitis, but the white blood cells would be Valium, and Ativan. Choice c is incorrect. expected to increase. Choice b is incorrect. Disulfiram is used to assist clients to stop Common assessment findings of appendici- drinking. Delirium is treated by first treat- tis include increased, not decreased, white ing the underlying pathology causing the blood cells and pain in the periumbilical delirium. Choice d is incorrect. Disulfiram area, progressing to the lower right, not left, is used to assist clients to stop drinking. quadrant of the abdomen. Choice d is Medications used to treat depression include incorrect. While rebound tenderness is a Wellbutrin, Celexa, paxil, and Zoloft. finding associated with appendicitis, the Category: physiological Integrity: pharma- abdominal pain is usually in the periumbili- cology and parenteral Therapies cal area, progressing to the lower right Subcategory: Mental Health: Medications quadrant of the abdomen. 158. b. The ventilator tubing should be checked Category: Safe and Effective Care Environ- first. Unless the client is coughing or has ment: Safety and Infection Control decreased airway compliance, or there is a Subcategory: pediatrics: Gastrointestinal hazard airway instruction, a high-pressure Disorders alarm usually indicates water collection in 160. c. The priority is for the nurse to observe the the ventilator tubing. Choice a is incorrect. type and progression of the seizure activity. The respiratory therapist does not need to It is very important to ensure the client is be contacted. The RN should be able to safe and does not harm himself or herself check the ventilator tubing and can correct during the seizure. Choice a is incorrect. It the problem. Choice c is incorrect. There is is important to record the length of the sei- no indication that an arterial blood gas zure, but this can be done only after the sei- analysis is needed. Choice d is incorrect. zure. Choice b is incorrect. An aura is a There is no evidence of airway obstruction warning sign that some clients experience or excess mucus; therefore, there is no prior to a seizure. It may include dizziness, need to reposition the client to stimulate visual or auditory disturbances, or numb- coughing. ness. This is not a priority assessment dur- Category: physiological Integrity: Reduc- ing the actual seizure. Choice d is incorrect. tion of Risk It is important to report what precipitated Subcategory: Adult: Respiratory Disorders the seizure, but this is done only after the seizure. Category: physiological Integrity: physiological Adaptation Subcategory: Adult: Neurological Disorders

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161. c. A client with a belief that something bad is 163. a. Depressed reflexes are a sign of magnesium going to happen and is unable to focus on toxicity. Choice b is incorrect. Magnesium anything else is experiencing severe anxiety. sulfate is administered to decrease the blood Choice a is incorrect. A client with mild pressure in women with sever preeclampsia anxiety has a worry or fear that is a part of and eclampsia. Choice c is incorrect. living and does not prevent the client from Decreased, not increased, respiration is a focusing on other things. Choice b is incor- sign of magnesium sulfate toxicity. Choice d rect. A client with moderate anxiety focuses is incorrect. Decreased urinary output of on the immediate concern and is selectively less than 30 ml per hour, not increased out- inattentive to other concerns. Choice d is put, is a sign of magnesium sulfate toxicity. incorrect. A client experiencing panic has a Category: physiological Integrity: pharma- sense of dread, terror, and/or impending cology and parenteral Therapies doom and rational thought becomes lost. Subcategory: Maternal Infant: Maternal Category: physiological Integrity: physio- Medication logical Adaptation 164. c. 1,000 mg:5 mL = 500 mg:x mL Subcategory: Mental Health: Anxiety 1,000x = 2,500 _____2,500 Disorders 1,000 = 2.5 mL 162. c. The client is most likely to report a recent Choices a, b, and d are incorrect. history of trauma, alcohol ingestion, surgi- Category: physiological Integrity: pharma- cal stress, or illness. All of these events are cology and parenteral Therapies known to trigger an acute gout attack. Subcategory: Adult: Miscellaneous Choice a is incorrect. The onset of pain, 165. d. The Guthrie test is a screening test for phe- swelling, redness, and warmth is usually nylketonuria. Choice a is incorrect. The abrupt in nature when gout is diagnosed. screening test for Down syndrome is the Choice b is incorrect. The abrupt onset of maternal serum alpha-fetoprotein (MSAFp) symptoms of a client experiencing gout and ultrasound. Choice b is incorrect. usually occurs at night with the client awak- Screening tests for hip dysplasia include ening to severe pain, swelling, redness, and Ortolani’s and Barlow’s maneuvers. Choice warmth in the affected joint. Choice d is c is incorrect. Lead toxocity screening is incorrect. Recent alcohol consumption or conducted via blood analysis. dietary changes can precipitate an event Category: physiological Integrity: Reduc- of gout. tion of Risk Category: physiological Integrity: Reduc- Subcategory: pediatrics: Endocrine tion of Risk Disorders Subcategory: Adult: Musculoskeletal Disorders

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his examination has been designed to test your understanding of the content included on the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which you must pass to become Ta registered nurse, and also to allow you to experience the format in which the exam is administered. Becoming comfortable with the examination format and logistics will help you be more relaxed when it comes to actually sitting for the test, enabling you to perform at your best. The actual NCLEX-RN exam is computer adaptive, which means all examinees will have a different number of test questions depending on how many and what types of questions they answer correctly and how many they answer incorrectly. All test takers must answer a minimum of 75 items, and the maximum number of items that the candidate may answer is 265 during the allotted six-hour time period. This LearningExpress practice exam has 165 questions, and you should allow yourself four hours to complete it. Then, after you have completed the exam, look at the answer key to read the rationales for both the correct and the incorrect choices, as well as the sources of the information. It is recommended that you utilize the sources to thoroughly review information that was problematic for you. Because the NCLEX-RN examination

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is graded on a sliding scale that is based on the difficulty of each particular exam, we are unable to predict how many correct answers would equate to an actual passing grade on this practice exam. Completion of this examination represents the culmination of extensive test preparation. You have worked very hard to review the information from your NCLEX-RN curriculum, and now it is your time to shine. Good luck!

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practice test 2 answer sheet

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Questions 3. A graduate nurse is completing a critical-care nursing course. The nurse will identify which 1. A client is prescribed lisinopril (Zestril) for the of the following as the QRS complex? treatment of hypertension. The client asks the nurse about possible side effects of the medication. The nurse will relay that which of the following are common adverse effects of 1 angiotensin-converting enzyme (ACE) inhibitors? Select all that apply. 1. constipation 32 4

2. dizziness a. 1 3. headache b. 2 4. hyperglycemia c. 3 5. hypotension d. 4 6. impotence a. 1, 4, 6 4. A nurse is preparing to administer an intra- b. 2, 3, 5 muscular (IM) injection to a four-year-old c. 1, 3, 4, 6 girl. Where should the nurse plan to adminis- d. 2, 4, 5, 6 ter the injection?

2. A woman comes to the labor and delivery triage area stating that she is in labor. The nurse determines that the client is in true labor due to which of the following? a. cervical dilation of 4 cm b. contractions that decrease when sitting c. contractions that decrease with ambulation d. lightening

a b c d

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5. A client is being treated in a medical-surgical 8. A nurse is preparing to administer prostaglan- unit following an ileostomy placement. The din E to a pregnant woman who is at 40 weeks nurse is teaching the client about diet follow- gestation. Which intervention should the ing the surgery. It is important for the nurse to nurse implement first? include which of the following in the dietary a. Assess for patency of IV access. instructions? b. Have the client void prior to initiating the a. “Chewing your food thoroughly will aid in therapy. digestion.” c. Monitor for stomach cramping. b. “Eating six small meals a day will prevent d. Position the client so that she is lying on her abdominal distention.” left side. c. “It is necessary to limit your fluid intake to 100 mL per day.” 9. A client diagnosed with renal failure has just d. “You can eat anything you want; monitoring started peritoneal dialysis treatments. During your diet is not necessary.” the infusion of the dialysate, the client begins to complain of abdominal pain. Which of the 6. A young male client is admitted to the hospital following actions is most appropriate for the with Hodgkin’s disease. The client has been nurse to complete? unresponsive to multiple therapeutic interven- a. Decrease the amount of dialysate solution tions. Death appears imminent. A priority goal being infused. in the treatment of this client is which of the b. Explain to the client that the pain will following? decrease after more exchanges. a. Reduce the client’s fear of more aggressive c. Slow down with the infusion rate. treatment. d. Stop the dialysis session immediately. b. Reduce the client’s fear of pain. c. Reduce the client’s feelings of fear. 10. A nurse is assessing an infant for hip dysplasia. d. Reduce the client’s feelings of isolation. The maneuver pictured is called what?

7. A nurse is completing the medication- reconciliation list on a client admitted with pneumonia. One of the medications is Rem- eron. The nurse knows that this medication is used in clients with which of the following? a. anxiety b. bipolar disorder c. depression d. sleep disorders a. Barlow’s maneuver b. Chadwick’s sign c. Hegar’s sign d. Ortolani’s maneuver

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11. A nurse in the neonatal intensive care unit 14. A nurse suspects benzodiazepine toxicity in a (NICU) is planning to administer the pre- client taking Tranxene. Expected assessment scribed lung surfactant, beractant, to a neonate findings would include which of the following? via endotracheal tube. She knows that berac- Select all that apply. tant is administered to preterm infants for pre- 1. hyperactivity vention and treatment of 2. confusion a. asthma. 3. increased reflexes b. neonatal croup. 4. somnolence c. respiratory distress syndrome. a. 1, 4 d. sudden infant death syndrome. b. 2, 3 c. 2, 4 12. A nurse is caring for a client with metastatic d. 1, 3 breast cancer on the oncology unit. The client is to receive tamoxifen (Nolvadex). The nurse 15. A client at 38 weeks gestation comes into the must specifically monitor which of the follow- labor and delivery triage area. The client has ing laboratory values while the client is taking been experiencing contractions that are irreg- this medication? ular in frequency, are localized in the abdo- a. calcium level men, and decrease when the client ambulates. b. glucose level The client has no cervical changes. The nurse c. potassium level should d. prothrombin time a. instruct the client to ambulate in the halls. b. instruct the client to return home. 13. A client is admitted to the hospital to rule out c. prepare the client for admission. colon cancer. A diagnostic study of the colon is d. prepare the client for cesarean section. ordered. The nurse teaches the client how to self-administer a prepackaged enema. Which 16. A client is being discharged from a cardiac of the following statements by the client indi- step-down unit following the insertion of a cates effective teaching? permanent pacemaker in the upper left chest a. “I will administer the enema while lying on area. Upon discharge, the nurse should include my back with both knees flexed.” which of the following instructions? Select all b. “I will administer the enema while lying on that apply. my left side with my right knee flexed.” 1. Avoid air travel because of security c. “I will administer the enema while lying on alarms. my right side with my left knee flexed.” 2. Avoid lifting objects heavier than three d. “I will administer the enema while sitting pounds. on the bathroom toilet.” 3. A microwave cannot be used. 4. Immobilize the affected arm for four to six weeks. 5. Take and record your daily pulse rate. a. 1, 3, 4 b. 3, 4, 5 c. 1, 2 d. 2, 5

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17. A nurse is caring for a child with tetralogy of 20. A nurse is working on a mental health unit Fallot. The nurse knows that this disorder with a client. The nurse is trying to help the involves which four of the following defects? client understand that his frequent loud, angry Select all that apply. outbursts are disruptive and cause others to 1. left ventricular hypertrophy avoid him. This is an example of which type of 2. overriding aorta therapy? 3. patent ductus arteriosus a. behavioral 4. pulmonary stenosis b. cognitive 5. right ventricular hypertrophy c. crisis 6. ventral septal defect d. milieu a. 1, 2, 3, 4 b. 2, 4, 5, 6 21. A nurse has just completed a neurological c. 3, 4, 5, 6 exam on a client. The client is exhibiting d. 1, 3, 5, 6 decerebrate posturing. Which of the following correctly describes the decerebrate posturing? 18. A nurse is working in the child development a. back arched, rigid extension of all four unit. In which child should the nurse consider extremities that a developmental delay exists? b. back hunched over, rigid flexion of all four a. a two-month-old who is unable to transfer extremities with supination of arms and objects from hand to hand palmar flexion of the feet b. a six-month-old who is unable to play c. internal rotation and abduction of arms peekaboo with flexion of the elbows, wrists, and c. a 14-month-old who is unable to pull up fingers into a standing position d. supination of the arms with dorsal flexion d. a 16-month-old who is unable to use a fork of the feet

19. A client is being treated in the hospital for chronic renal failure. The client has been placed on a 500 mL per day fluid restriction. During the nurse’s late evening assessment, the client is requesting additional fluids. Which of the following is the most appropriate nursing intervention? a. Explain to the client the importance of the fluid restriction. b. Disregard the client’s request. c. Give the client a piece of hard candy. d. Tell the client that you will speak to the physician about the request.

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22. A nurse is assessing the growth and height of a 23. A nurse is caring for clients in a postpartum five-year-old boy. The boy’s height is 115 cm unit. Which client should the nurse attend to and his weight is 15 kg. After documenting the first? child’s growth on the following growth chart, a. the breast-feeding client with sore nipples the nurse should include which of the follow- b. the client with a first-degree perineal ing interventions into the child’s plan of care? laceration c. the client with lochia rubra 2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles NAME ______d. the client with a soft, boggy uterus 12 13 14 15 16 17 18 19 20 Mother’s Stature Father’s Stature cm in Date Age Weight Stature BMI* AGE (YEARS) 76 190 95 74 90 185 24. A graduate nurse is participating in a basic 72 75 180 health-assessment course. The nurse correctly 50 70 175 68 *To calculate BMI: Weight (kg) Ϭ Stature (cm) ϫ Stature (cm) 25 identifies Erb’s point at which location? ϫ Ϭ ϫ ϫ 170 10,000 or Weight (Ib.) Stature (in.) St ature (in.) 703 10 66 in cm 34567891011 5 165 64 160 160 62 62 155 155 60 60 150 S 150 58 T 145 56 A 140 T 105 230 54 U 135 100 220 52 R 130 E 95 95 210 50 200 125 90 48 90 190 120 85 46 180 115 80 44 75 170 110 75 42 160 105 50 70 40 150 100 65 140 38 25 95 60 130 36 10 90 5 55 120 34 85 50 110 32 80 45 100 30 40 90 80 80 35 35 70 W 70 30 30 ab cd 60 E 60 25 I 25 50 50 20 G 20 40 H 40 15 15 T 30 30 10 AGE (YEARS) 10 Ib kg kg Ib 2 345678910 11 12 13 14 15 16 17 18 19 20

a. increased nutritious snacks b. increased physical activity c. decreased caloric intake d. television viewing limits

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25. A client is admitted to the ICU following a 28. A child is admitted to the pediatric unit due to mitral valve replacement. The client has persis- patent ductus arteriosus. Where on the picture tent bleeding from the sternal incision during is this defect located? the early postoperative period. It is imperative that the nurse complete which of the following? Select all that apply. 1. Administer warfarin (Coumadin). c b 2. Begin intravenous dopamine (Inotropin) for a systolic BP ≤ 100. d a 3. Confirm the availability of blood products. 4. Evaluate postoperative laboratory reports, including complete blood count (CBC), international normalized ratio (INR), partial thromboplastin time (PTT), and platelet levels. 5. Monitor the mediastinal chest-tube drainage. 29. A nurse is assessing a client for probable signs a. 1, 3 of pregnancy during the first prenatal visit. b. 2, 5 Which of the following signs would the nurse c. 1, 2, 4 expect to find? d. 3, 4, 5 a. breast tenderness b. missed period 26. A nurse is caring for a client and notes that the c. Chadwick’s sign parenteral nutrition (PN) bag is empty. Which d. fetal heartbeat of the following solutions should the nurse hang until another PN solution is mixed and 30. A nurse is caring for a client recently diag- delivered to the nursing unit? nosed with glaucoma. The client is prescribed a. 5% dextrose in Ringer’s lactate miotic medication. When teaching the client b. 5% dextrose in water about medication effects, the nurse will inform c. 5% dextrose in 0.9% sodium chloride the client that this medication will produce d. 10% dextrose in water which of the following effects? a. dilated pupil to reduce intraocular pressure 27. A nurse’s goal with group therapy is to b. interrupted drainage of aqueous humor a. assess family functioning. from the eye b. identify immediate coping patterns. c. lowered intraocular pressure and enhanced c. replace negative attitudes and behaviors. blood flow to the retina d. resolve emotional and self-esteem issues. d. reshaped lines of the eye to eliminate blurred vision

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31. A nurse has received a nursing report. Which 35. A nurse is providing discharge instructions to of the following client data is assessed as the the parents of a 10-year-old child with rheu- highest priority? matic heart disease. The nurse determines that a. hemoglobin level: 14.6 gm/dL the parents have understood the discharge b. pulse oximetry reading: 85% instructions when the mother states, c. urine output: 250 mL/8 hours a. “I hold digoxin if the heart rate is greater d. serum potassium level: 3.8 mEq/L than 60 bpm.” b. “I give the antibiotic once a month.” 32. A nurse is caring for a client who obsessively c. “I should not give my child Tylenol.” washes his hands. The nurse should d. “I should not give my child aspirin.” a. focus the client’s attention on the behavior. b. ignore the compulsive behavior. 36. A male client receives hemodialysis treatments c. prevent the client from washing his hands. three times a week. The home health nurse is d. set defined times for hand washing. assessing the client’s ability to self-monitor between the dialysis treatments. The nurse 33. A client is being educated about the complica- determines the client is fully informed when tions of peritoneal dialysis. Which of the fol- he states that he records which of the follow- lowing should the nurse teach the client about ing on a daily basis? preventing peritonitis? Select all that apply. a. blood urea nitrogen (BUN) and creatinine 1. Antibiotics may be added to the dialysate levels to treat peritonitis. b. daily living activities and periods of 2. Broad-spectrum antibiotics can be weakness administered to prevent infection. c. intake and output and weight 3. Peritonitis is characterized by cloudy d. respiratory and heart rates dialysate drainage and abdominal pain. 4. Peritonitis is the most serious and com- 37. A client who is 32 weeks pregnant and experi- mon complication of peritoneal dialysis. encing a healthy pregnancy is in the office for a 5. Utilizing clean technique is permissible routine prenatal visit. She asks when she for the prevention of peritonitis. should return for her next prenatal visit. The a. 1, 5 nurse should schedule the client’s next prena- b. 2, 4 tal visit for when? c. 1, 2, 3, 4 a. in one week d. 1, 2, 3, 4, 5 b. in two weeks c. in three weeks 34. A client is in her second trimester of preg- d. in four weeks nancy. She tells the nurse that she is always thirsty and that she has been voiding more than usual. Based on this information, the nurse should check for a. edema. b. glycosuria. c. proteinuria. d. tinnitus.

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38. A client with the following cardiac telemetry 40. A nurse is completing a physical assessment on reading is being discharged home after an a healthy five-year-old during a well child visit. unsuccessful cardioversion attempt. Which of the following would the nurse expect to find during the respiratory assessment? Select all that apply. 1. abdominal breathing 2. anterior-to-posterior ratio 1:1 3. hyperresonant lung sounds

4. respiratory rate of 14 breaths per minute The nurse understands the client will be a. 1, 2 instructed to take which of the following med- b. 1, 3 ications in order to prevent thromboembolic c. 2, 3 complications of this dysrhythmia? d. 2, 4 a. aspirin (acetylsalicylic acid) b. Coumadin (warfarin sodium) 41. A nurse is caring for a client diagnosed with c. heparin ulcerative colitis. The nurse recognizes that an d. Ticlid (ticlopidine) expected outcome of the medical regimen has been achieved when which of the following 39. A nurse is caring for a client with Alzheimer’s occurs? disease who frequently repeats statements and a. The client verbalizes acceptance of an questions. The nurse knows that the part of ileostomy. the client’s brain that is being affected by the b. The client’s episodes of constipation disease is which of the following areas? decrease. c. The client maintains an ideal body weight. d. The client states the importance of decreasing fluid intake. a c 42. A nurse is caring for a client diagnosed with diabetes. The nurse is assessing the client for common complications related to this disor- b d der. In doing so, the nurse should include an examination of which of the following? a. abdomen b. eyes c. lymph glands d. pharynx

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43. A client has been seen and treated for gastroin- 46. A client is admitted to the emergency depart- testinal reflux in the emergency department. ment with second-degree burns to the anterior Which of the following client statements indi- portion of the right leg and to the anterior and cates to the nurse that the client understands posterior portions of the right arm. Based on how to prevent reflux? the rule of nines, the triage nurse will docu- a. “It is important for me to lie down and rest ment what percentage of total body surface for 35 minutes after meals.” area (TBSA) burned? b. “I will eat smaller meals more frequently a. 18% throughout the day.” b. 27% c. “I will increase my fluids with meals to help c. 36% with digestion.” d. 45% d. “I will sleep on my left side to empty my stomach contents.” 47. A nurse is caring for a client who has been ordered a dose of iron by the parenteral route. 44. A nurse is working with a client who has a his- The nurse is aware that which of the following tory of early Alzheimer’s disease. The nurse actions should be taken to decrease pain at the wants the client to take her medications and injection site? then get dressed. The nurse should tell the a. changing the needle used to draw up the client, medication prior to injection to prevent a. “Don’t get dressed until you take your bruising at the site medications.” b. gently massaging the injection site to b. “Take your medications and then get increase absorption of the prescribed dressed.” medication c. “Get dressed.” (This is said after the client c. using a Z-track method for intramuscular has taken her medications.) injection of the prescribed medication d. “Take your medications.” (This is said after d. utilizing an air lock when drawing up the the client has eaten breakfast.) prescribed medication

45. A nurse is providing nutritional counseling for a client at 12 weeks gestation. The nurse should teach the client to do which of the following? a. Avoid undercooked eggs and meats. b. Decrease sodium intake. c. Limit caffeine intake to 800 mg per day. d. Limit folic-acid-fortified breads and cereals.

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48. A charge nurse on a medical-surgical unit is 51. A nurse is admitting a client who is 28 weeks preparing to make morning assignments for pregnant and is experiencing uterine contrac- the nursing staff. Which of the following nurs- tions every 10 minutes that are not relieved by ing activities may be delegated to the licensed changing position. Her cervix is dilated to 4 practical nurse or licensed vocational nurse cm and her blood pressure is 122/72 mm Hg. (LPN/LVN)? Select all that apply. The client’s pulse is 78 beats per minutes and 1. endotracheal suctioning her respirations are 20 breaths per minute. 2. client admission assessments Based on this information, the client might be 3. intravenous medication administration experiencing which complication of 4. intramuscular medication pregnancy? administration a. cervical incompetence 5. subcutaneous medication administration b. placenta previa 6. urinary catheterization c. preeclampsia a. 1, 2, 3, 5 d. preterm labor b. 1, 4, 5, 6 c. 2, 4 52. A graduate nurse needs to administer potas- d. 3, 5 sium chloride intravenously to a client with hypokalemia. The nursing preceptor deter- 49. A father brings his two-month-old child to the mines that the graduate nurse is unprepared clinic for a well child exam. The nurse knows for this procedure if the graduate states that that according to Centers for Disease Control which of the following is part of the plan for and Prevention (CDC) immunization recom- the preparation and administration of potas- mendations, the child will be due for which of sium chloride intravenously? the following vaccinations? a. diluting the potassium chloride in the a. DTaP (diphtheria, tetanus, pertussis) appropriate amount of normal saline b. influenza b. monitoring the client’s urine output during c. MMR (measles, mumps, rubella) the infusion process d. varicella c. obtaining a controlled electronic IV pump for infusion 50. A client diagnosed with post-traumatic stress d. preparing the potassium chloride for disorder is having difficulty falling asleep at intravenous bolus injection night. To promote sleeping, the nurse should a. administer amitriptyline. 53. A 37-year-old client, who has four children b. have the client watch television. and is a waitress by occupation, is seen in the c. help the client establish a routine. outpatient clinic for a routine checkup. The d. sit in the room with the client. nurse caring for this client realizes she is at risk for developing which of the following peripheral vascular disorders? a. acute arterial embolism b. arterial insufficiency c. thrombophlebitis d. varicose veins

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54. When communicating with a client who 57. A nurse is providing education to the parents speaks a different language, the nurse is aware of an 11-year-old girl regarding the CDC rec- that it is the best practice to complete which of ommendations for immunizations for the following? 11-year-old girls. The nurse realizes additional a. Arrange for an interpreter when education is needed when the mother states communicating with the client. that her daughter needs which vaccination? b. Speak loudly and clearly when a. HPV (human papillomavirus) communicating with the client. b. inactivated polio virus c. Speak to the client only when family is c. influenza present to enhance communication. d. MCV4 (meningococcal conjugate vaccine) d. Stand close to the client and speak loudly during interactions. 58. An elderly woman is brought to the emergency department by her son for treatment of a frac- 55. A client with premature rupture of the mem- tured left arm. On assessment, the nurse notes branes is in labor. Suddenly, the client experi- old and new areas of ecchymosis on the client’s ences an acute onset of respiratory distress, legs and chest. The nurse asks the client how chest pain, and hypotension. The fetal monitor she sustained these injuries. The client, indicates a decrease in the fetal heart rate. The although reluctant, tells the nurse in confi- nurse should immediately place the client in dence that her live-in boyfriend frequently hits which of the following positions? her when the house is not clean. Which of the a. left lateral following is the most appropriate nursing b. right lateral response? c. semi-Fowler’s a. “Do you have any friends that you can stay d. Trendelenburg with until you get these issues resolved with your boyfriend?” 56. A client presents to the emergency room with b. “Let’s talk about specific ways you can complaints of chest pain that began five hours manage your time to help prevent this from ago. A troponin-T blood-serum analysis is happening again.” obtained, the results of which reveal a level of c. “This is a legal issue, and it’s important for 0.7 ng/mL. The nurse recognizes that this you to recognize that I will have to report it result indicates which of the following? to the proper authorities.” a. a level that is in the normal range d. “This is unacceptable behavior by your b. a level that indicates the presence of angina boyfriend; I will need to speak to him and c. a level that indicates myocardial infarction your son immediately about the situation.” d. a level that indicates possible gastritis

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59. For a client with bulimia nervosa, the nurse’s 62. A newborn infant was circumcised earlier in plan of care should include which of the fol- the day. The manager of the nurse caring for lowing? Select all that apply. the infant recognizes that the nurse under- 1. providing calorie-dense foods stands the infant’s nursing care needs when the 2. establishing a client food contract manager observes the nurse performing which 3. staying with the client two hours after of the following interventions? she eats a. assessing the circumcision site for signs of 4. limiting time in the bathroom bleeding and/or infection a. 1, 2 b. cleansing the circumcision site with a baby b. 2, 3 wipe c. 3, 4 c. placing a petroleum gauze around the d. 1, 4 circumcision site and then placing the infant in the radiant warmer 60. A nurse is reviewing laboratory results for a d. securing the infant’s diaper tightly to apply client for whom she is assigned care. The cli- pressure to the circumcision site ent’s potassium level is recorded at 3.1 mEq/L. The nurse recognizes this would explain the 63. A client is admitted to the medical-surgical presence of which of the following on the unit with a diagnosis of diabetes mellitus. The electrocardiogram? client received NPH insulin at 7 a.m. The a. absent P-waves nurse must carefully monitor the client for b. elevated ST segments hypoglycemia between which of the following c. elevated T-waves time periods? d. U-waves a. 9 a.m.–11 a.m. b. 1 p.m.–7 p.m. 61. A nurse is caring for a client in the neurologi- c. 7 p.m.–11 p.m. cal intensive care unit. The client has a history d. midnight–6 a.m. of a seizure disorder and is receiving dilantin (Phenytoin). Which of the following is a thera- 64. The hospital’s standing orders for newborns peutic serum dilantin level for a client with a include eye prophylaxis medication to be history of seizures? administered within the first hour of birth. a. 9 µg/mL The nurse understands that this is to protect b. 16 µg/mL the infant’s eyes from which of the following c. 28 µg/mL infections? d. 37 µg/mL a. candidiasis b. genital herpes c. gonorrhea d. B strep

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65. A nurse is preparing to change the parenteral 68. A nurse is caring for a client in the manic nutrition (PN) solution bag and tubing. The phase of bipolar disorder. The nurse’s plan of client’s central venous line is located in the care should include interventions that address right subclavian vein. The nurse will ask the which of the following symptoms? client to take which of the following actions a. impulsiveness during the tubing change? b. feelings of hopelessness a. Breathe as normally as possible. c. suicidal thoughts b. Exhale evenly and slowly. d. anxiety c. Take a deep breath, hold it, and bear down. d. Turn the head to the right side. 69. A client is admitted to the emergency department complaining of burning on urination. 66. A nurse in a pediatric unit is caring for a child Upon assessment, it is apparent that the client with congestive heart failure. The nurse should has a low-grade fever. The physical examina- perform which of the following interventions? tion also reveals right-sided costovertebral ten- a. administer morphine sulfate derness. Identify the area the nurse percussed b. lower the head of the bed to elicit this sign. c. offer small meals frequently d. provide a stimulating environment

67. A client is complaining of chest pain. The

graduate nurse is performing a 12-lead elec- 2 trocardiogram (ECG). Identify the area where 3 lead V6 should be placed. 4 1

12 3 4

a. 1 b. 2 a. 1 c. 3 b. 2 d. 4 c. 3 d. 4

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70. A nurse on orientation is completing umbilical- 73. A nurse is instructing a client diagnosed with cord care on a newborn who is six hours old. pneumonia on how to use an incentive spi- The nurse is preparing to unclamp the cord. rometer properly. The nurse should instruct Which action by the unit nursing educator the client to implement the following steps. observing the nurse is best? Place the following steps in order from first a. Distract the newborn with a brightly to last. colored object. 1. The client should exhale fully. b. Instruct the nurse that the cord should 2. The client should inhale on the mouth- shrivel and fall off within 7 to 10 days. piece and hold the breath for three c. Encourage the nurse to unclamp the cord. seconds. d. Stop the nurse from unclamping the cord. 3. The client should passively exhale. 4. The client should take a deep breath and 71. A nurse is caring for a client with complica- cough. tions related to rheumatoid arthritis. Which of a. 1, 2, 3, 4 the following statements might indicate a vio- b. 2, 1, 4, 3 lation of client confidentiality? c. 3, 2, 1, 4 a. The nurse discussed the client’s condition d. 4, 1, 2, 3 and diagnosis with a family friend over the telephone. 74. A nurse is caring for a child with aortic steno- b. The nurse discussed the client’s condition sis. Which of the following would the nurse and diagnosis with another nurse at shift NOT expect to find upon assessment? report. a. congestive cough c. The nurse discussed the client’s medication b. cyanosis therapy with the hospital pharmacist. c. fatigue d. The nurse discussed the client’s medication d. tachycardia therapy with the physician. 75. A nurse is caring for a client admitted with 72. A client in the cardiovascular step-down unit severe depression who has lost 25 pounds in is having a chest tube removed following open the past three months. To ensure adequate heart surgery. During the chest tube removal, nutritional intake, the nurse should the nurse instructs the client to complete a. allow the client to select meals. which of the following activities? b. attractively present large meals. a. Exhale slowly. c. offer finger foods frequently. b. Inhale and exhale quickly. d. provide calorie-dense foods. c. Perform the Valsalva maneuver. d. Stay very still during the procedure.

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76. A nurse is caring for a client with an infant 80. A client who is eight weeks pregnant is experi- daughter who is seven hours old. The client is encing morning sickness. The nurse instructs wondering why the infant has downy hair on the patient to her chest and face. Which of the following is a. eat dry crackers prior to getting out of bed the best response by the nurse? in the morning. a. “That is unusual; I have not seen this b. eat three large meals per day. before.” c. increase the amount of fatty foods in her b. “That is lanugo and it will disappear on its diet. own.” d. increase the amount of fluids she has with c. “That is milia and it will disappear on its her meals. own.” d. “That is lanugo and it will need to be 81. A client is admitted to the neurological ICU surgically removed.” following a craniotomy. The nurse and the medical staff have established a goal to main- 77. A client in the ICU is diagnosed with a myo- tain the client’s intracranial pressure (ICP) cardial infarction. The client develops cardio- within normal range. Which of the following genic shock. Which of the following should the nurse do? Select all that apply. characteristic signs should the nurse expect to 1. Assure the head of the bed is elevated 15 observe in this client? to 30 degrees. a. bradycardia 2. Encourage the client to cough and b. elevated blood pressure breathe deeply often. c. fever 3. Monitor the client’s neurological status d. oliguria using the Glasgow Coma Scale (GCS). 4. Notify the healthcare provider if the ICP 78. A nurse is administering Pitocin to a client to is greater than 20 mm Hg. induce labor. The nurse realizes that because 5. Stimulate the client with the use of active of this, the client will need close monitoring in range-of-motion exercises. the postpartum period for a. 2, 5 a. hemorrhage. b. 1, 3, 4 b. hyperglycemia. c. 3, 4, 5 c. hypoglycemia. d. 2, 3, 4, 5 d. orthostatic hypotension. 82. A nurse and graduate nurse are caring for a 79. A client is being treated in the ICU for a client diagnosed with Parkinson’s disease. The hypertensive crisis. The nurse is to administer graduate nurse asks the nurse what the initial sodium nitroprusside (Nipride). The medica- sign of Parkinson’s disease is. Which of the fol- tion comes in a dilution of 50 mg/250 mL. lowing is a correct response by the nurse? How many micrograms of Nipride are in a. akinesia each milliliter? b. bradykinesia a. 10 mcg c. rigidity b. 20 mcg d. tremors c. 100 mcg d. 200 mcg

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83. A nurse is admitting a child diagnosed with 87. A nurse is caring for a client with a head rheumatic fever to the pediatric unit. The injury. Upon assessment, the nurse finds the nurse should assess for which of the following? client in the position pictured. a. decreased sedimentation rate b. history of viral throat infection c. pain in the joints d. inspiratory pain The nurse will correctly document this as 84. A nurse is caring for a client with pulmonary which of the following? congestion. The physician orders chest physio- a. decerebrate therapy. When should the nurse plan to per- b. decorticate form chest physiotherapy? c. opisthotonus a. after meals d. prone b. before meals c. when the client has time 88. A nurse is caring for a client who is diagnosed d. when the nurse has time with gout. Which of the following foods should the nurse instruct the client NOT to 85. A client diagnosed with depression is taking eat? Select all that apply. the medication Celexa. The client is beginning 1. chocolate to experience increased energy and improved 2. cod affect. When planning the client’s care, the 3. eggs nurse’s priority is to 4. green, leafy vegetables a. allow the client to verbalize feelings. 5. liver b. assess for thoughts of suicide. 6. sardines c. ensure adequate nutritional intake. a. 1, 3, 4 d. monitor the client’s blood pressure. b. 2, 5, 6 c. 2, 3, 4, 5 86. A client is breast-feeding her two-week-old d. 1, 2, 3, 5 infant. The client complains of sore, cracked nipples. The nurse realizes that cracked nipples 89. The Apgar score of a neonate at one minute a. are a normal occurrence for clients who are after birth is 6. The nurse should prepare to breast-feeding. perform which nursing intervention? b. are often caused by the infant’s latching on a. Administer oxygen to the infant. incorrectly. b. Begin resuscitation measures. c. can be prevented by having the client guide c. Give the infant its first bath. only the nipple into the infant’s mouth. d. Place the infant on the mother’s chest to d. can be prevented by washing the nipples promote bonding. after each feeding with soap and water.

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90. A mother asks a nurse how she should take the 93. A 24-year-old female client presents to the temperature of her three-year-old daughter. community medical clinic complaining of a Which of the following should be the nurse’s 20-pound weight loss over the prior month response? Select all that apply. even though she has felt “famished” and hasn’t 1. axillary changed her activity level. After further assess- 2. oral ment, the nurse learns the client has a diagno- 3. tympanic sis of Graves’ disease. Which other signs and 4. rectal symptoms support the diagnosis of Graves’ a. 1, 2 disease? Select all that apply. b. 1, 3 1. bounding, rapid pulses c. 1, 4 2. bradycardia d. 2, 4 3. constipation 4. heat intolerance 91. A nurse is completing a dressing change for a 5. mild tremors client in the burn unit. The client is prescribed 6. nervousness mafenide acetate (Sulfamylon). While applying a. 1, 4, 5, 6 the medication to the burned area, the client b. 2, 3, 5 complains of local discomfort and burning. c. 3, 6 Which of the following is the most appropriate d. 4, 5 action for the nurse to take in this situation? a. Apply a thinner layer of the medication. 94. During the first day after delivery, a nurse b. Discontinue using the medication. assesses a client’s fundus and notices that it c. Notify the healthcare provider. feels boggy. Which is the first action that the d. Tell the client this is normal. nurse should perform? a. Document the “boggy” fundus. 92. A nurse is caring for a client experiencing b. Have the client void. acute respiratory failure. The nurse will focus c. Massage the fundus. on resolving which of the following? d. Notify the physician. a. hypoventilation, hypoxemia, and hypercapnia 95. A client is diagnosed with antisocial personal- b. hyperoxemia, hypocapnia, and ity disorder. The nurse should assess the client hyperventilation for which of the following? Select all that c. hyperventilation, hypertension, and apply. hypocapnia 1. anxiety d. hypotension, hyperoxemia, and 2. risk for harming self hypercapnia 3. risk for harming others 4. substance abuse a. 1, 2, 3 b. 2, 3, 4 c. 1, 3, 4 d. 1, 2, 4

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96. A nurse is assessing a client’s Babinski reflex. 98. A nurse is caring for a client who is to receive On the illustration, which location indicates eyedrops as well as eye ointment in the left eye. the point where the nurse should place the Which of the following demonstrates appro- tongue blade to begin the stroke of the foot? priate administration of these medications? a. Administer the eyedrops first, followed by 3 the eye ointment. b. Administer the eyedrops, wait 10 minutes, and then administer the eye ointment. 2 c. Administer the eye ointment first, followed by the eyedrops. d. Administer the eye ointment, wait 10 minutes, and then administer the eyedrops.

1 4 99. A primigravida comes to the office for a routine prenatal visit. The nurse assesses the fetal a. 1 heart rate as 130 beats per minute. The nurse b. 2 should c. 3 a. anticipate that the woman will need an d. 4 ultrasound. b. document the fetal heart rate as 130 beats 97. During a nurse’s morning assessment of a cli- per minute. ent, the nurse notes that the client’s abdominal c. reassess the fetal heart rate. girth has increased since the previous shift. d. turn the mother on her left side. The nurse also recognizes that the client has increased ascites. The client’s vital signs are a 100. A physician orders a Guthrie test for an infant. temperature of 37.3°C, a heart rate of 118 The child’s mother asks the nurse about the bpm, shallow respirations of 26 breaths per test. The nurse should answer that it is a minute, a blood pressure of 130/77 mm Hg, screening test for

and an SpO2 of 89% on room air. Given these a. cystic fibrosis. assessment findings, which of the following b. Down syndrome. actions should receive priority by the nurse? c. phenylketonuria. a. Perform assessment of heart sounds. d. spina bifida. b. Elevate the head of the bed. c. Obtain an order for blood cultures. d. Prepare for a paracentesis.

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101. A client is being cared for in a burn unit after 104. A primigravida is in the active phase of labor. suffering partial-thickness burns. The client’s When the nurse performs Leopold’s maneuver, laboratory work reveals a positive wound cul- the fetal head is palpated at position 4, as illus- ture for gram-negative bacteria. The physician trated. The nurse then concludes that the fetus orders silver sulfadiazine (Silvadene) to be is in which of the following positions? applied to the client’s burns. The nurse provides information to the client about the medication. Which of the following statements made by the client indicates a lack of understanding about this treatment? a. “This medication is an antibacterial.” b. “This medication will be applied directly to the wounds.” c. “This medication will stain my skin permanently.” d. “This medication will help my burns heal.”

102. A client is being released from the same-day surgery center following glaucoma surgery. 1234

Which of the following is correct for the nurse a. breech to include in the discharge instructions related b. horizontal to home care? c. transverse a. Add extra lighting in the home. d. vertex b. Decrease daily fluid intake. c. Decrease the amount of active exercise. 105. A nurse is caring for a 40-year-old male client d. Wear dark sunglasses in the sunlight. diagnosed with essential hypertension. To diagnose essential hypertension, the nurse 103. A nurse is performing the admission assess- understands that the client’s blood pressure ment on a client diagnosed with schizophre- readings were consistently at or above which nia. Upon assessment, the client imitates the of the following? nurse’s movements. The nurse should docu- a. 125/90 mm Hg ment this as b. 132/85 mm Hg a. aphasia. c. 140/90 mm Hg b. ataxia. d. 168/80 mm Hg c. echolalia. d. echopraxia.

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106. A nurse is caring for a client with a right-arm 109. The nurse correctly identifies the following arteriovenous fistula. The nurse recognizes rhythm strip as which of the following? that the client is at risk for developing arterial steal syndrome. The nurse assesses the client for which of the following manifestations that will confirm the diagnosis of this syndrome? a. aching pain, pallor, and edema of the right arm b. edema and reddish discoloration of the a. sinus rhythm with premature atrial right arm contractions (PACs) c. pain in the right arm, arm pallor, and b. sinus rhythm with second-degree diminished pulse atrioventricular (AV) block—Mobitz I d. warmth, pain in the right hand, and redness c. sinus rhythm with premature ventricular contractions (PVCs) 107. A nurse is caring for a client who has a newly d. ventricular pacing performed colostomy. After participating in colostomy-care sessions with the nurse and 110. A pregnant client who is five weeks gestation receiving support from his spouse, the client comes to the emergency room with a sus- has decided to change the colostomy pouch pected ectopic pregnancy. Based on this, what alone. Which of the following behaviors indi- would the nurse expect to find upon cates that the client is beginning to accept the assessment? change in body image? a. cervical dilation a. The client rarely speaks about the recent b. hemorrhage surgery. c. nausea and vomiting b. The client requests that his spouse leave the d. unilateral pelvic pain room. c. The client tightly closes his eyes when the 111. A laboring client asks for pain medication and abdomen is exposed. an order is written for Stadol. Prior to admin- d. The client touches the affected body part. istering the medication, the nurse should assess the client’s 108. The father of a toddler admitted for a colos- a. fundal height. tomy due to Hirschsprung’s disease is afraid b. heart rate. that he will not be able to manage the ostomy. c. lochia. An appropriate response by the nurse is d. respirations. a. “The home care nurse will help.” b. “Everyone is a little afraid at first.” c. “You can do it. I have watched you do it.” d. “You are worried about managing the ostomy.”

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112. A nurse is caring for a client on the oncology 115. A client has just completed delivering a still- unit. The client states, “I am so itchy.” The born infant. What intervention should the nurse relays to the client that the pruritus is nurse complete first? probably caused by the cancer or the treat- a. Provide the mother with an opportunity to ments. Which of the following nursing inter- hold the infant. ventions is most appropriate for the nurse to b. Put a discrete sign or symbol on the door implement? alerting healthcare personnel of the fetal a. administration of antihistamines death. b. administration of topical steroids c. Remove the infant from the room. c. dressing the bed with silk sheets d. Refer the mother to a support group. d. medicated baths pro re nata (PRN) 116. A nurse is planning care for a client who is 113. A client is admitted to a psychiatric hospital exhibiting pain in the left lower extremity with a conversion disorder. The client is expe- eight weeks after fracturing the tibia, even riencing an inability to move his right arm. though the fracture is completely healed and However, the client does not seem to be appro- all other complications have been ruled out. priately concerned about this, nor does the cli- The client rates the pain at a level 6 on a ent display any symptoms of anxiety. The 10-point scale. The nurse’s plan of care should nurse knows that the client is exhibiting include interventions for a client with a. catatonic excitement. a. hypochondria. b. catonic stupor. b. pain disorder. c. la belle indifference. c. conversion disorder. d. pseudoneurologic manifestation. d. body dysmorphic disorder.

114. A client presents to the community health cen- 117. A nurse is supervising a graduate nurse during ter 48 hours after receiving a Mantoux skin the insertion of a urinary catheter in a female test for evaluation with a positive response to client diagnosed with fluid overload. The the test. The nurse understands that the find- graduate nurse should advance the catheter ing indicates that the client how far into the urethra? _1 a. is actively immune to tuberculosis. a. 2˝ (1 cm) b. has produced an immune response. b. 2˝ (5 cm) c. has an active case of tuberculosis. c. 3.6˝ (15 cm) d. will develop full-blown tuberculosis. d. 3.8˝ (20 cm)

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118. A nurse is caring for a client complaining of 120. A nurse just received the morning laboratory abdominal pain. While assessing the client’s results for a client with chronic renal failure. abdomen, where should the nurse place his The client’s serum calcium level is 8.4 mg/dL, hand to palpate the liver? and the client’s serum phosphorus level is 4.0 mg/dL. Given these laboratory results, the nurse should monitor the client for the development of which the following? Select all 2 that apply. 1. cardiac arrhythmias 2. constipation 1 3. decreased clotting times 3 4. drowsiness and lethargy 5. fractures 6. Trousseau sign 4 a. 3, 4 b. 2, 3, 5

c. 4, 5, 6 a. 1 d. 1, 4, 5, 6 b. 2 c. 3 121. A client who is breast-feeding her infant was d. 4 discharged from the hospital two days ago after a healthy vaginal delivery. The client calls 119. A nurse is providing education to a caregiver the clinic nurse and states that her right breast on management of a child’s pinworms. The is swollen, painful, and warm to the touch, and nurse should include instructions for which of that she has a temperature of 101°F. The nurse the following? should instruct the client to a. administration of tinidazole (Tindamax) a. discontinue breast-feeding and use warm b. monitoring for abdominal cramping compresses on the breast. c. prevention of dehydration b. go to the emergency room. d. proper hand washing technique c. make a clinic appointment for next week. d. make a clinic appointment for today.

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122. A nurse is caring for a female client who is 125. A child comes to the emergency room after diagnosed with a sexual pain disorder. The drinking turpentine. Assessment findings nurse should assess for which of the following? include burning sensation in the throat and Select all that apply. drooling. The priority intervention for the 1. aversion nurse is to 2. dyspareunia a. administer activated charcoal. 3. hypoactive desire b. administer a cathartic. 4. vaginisimus c. dilute the corrosive with milk. a. 1, 4 d. induce vomiting. b. 2, 3 c. 2, 4 126. A graduate nurse is reviewing ECG rhythm d. 3, 4 tracings with her preceptor. The graduate nurse would correctly identify the following 123. A client is in for her first prenatal visit. She rhythm as asks the nurse when she will be able to hear her baby’s heartbeat. The nurse knows that the fetal heart rate can be detected by a. Doppler in the second month. b. Doppler in the third month. c. stethoscope in the third month. a. artifact. d. stethoscope in the fourth month. b. asystole. c. coarse ventricular fibrillation. 124. A nurse is assessing the level of consciousness d. fine ventricular fibrillation. of a client who has suffered a head injury. The client’s Glasgow Coma Scale score is 15. Which 127. A client is being treated in the ICU after expe- of the following responses did the nurse assess riencing premature ventricular contractions. in this client to arrive at a score of 15? Select The nurse has initiated an IV infusion of lido- all that apply. caine hydrochloride. Upon assessment, the cli- 1. bradycardia and hypotension ent is experiencing periods of excitation. 2. incomprehensible sounds Which of the following is also considered a 3. motor response to localized pain side effect of IV lidocaine administration? 4. orientation to person, place, and time a. lethargy 5. spontaneous eye opening b. palpitations 6. unequal pupil size c. tinnitus a. 1, 2 d. urinary frequency b. 4, 5 c. 1, 3, 6 d. 2, 3, 5

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128. A nurse is caring for a client at 38 weeks gesta- 131. A nurse is caring for a client whose status is tion who has been diagnosed with eclampsia. post–total laryngectomy. The nurse should The client begins to complain of upper right include which of the following in the client’s quadrant abdominal pain and begins to vomit. plan of care? The client’s blood work reveals that the liver a. Ensure the tracheostomy cuff is fully enzymes are elevated. Which action should inflated. NOT be performed by the nurse at this time? b. Develop an alternative form of a. administration of magnesium sulfate per communication. order c. Encourage oral feedings as soon as possible. b. fetal monitoring d. Keep the client flat in bed. c. palpation of the client’s abdomen d. preparation of the client for delivery 132. A child is admitted to the pediatric unit with decreased white blood cells. The father asks 129. A client is being treated in the emergency the nurse if she thinks that the child has leuke- department for an ischemic stroke. The client mia. An appropriate response by the nurse is is ordered to receive a tissue plasminogen acti- a. “I am not sure.” vator (t-PA). In preparation to give this medi- b. “The test results are not back yet.” cation, the nurse should complete which of the c. “Are you concerned that your child has following first? leukemia?” a. Ask what medications the client is taking at d. “Ask your doctor when he comes in.” present. b. Complete a history and physical assessment. 133. A nurse has just assessed a client’s blood pres- c. Determine the onset time of the stroke. sure one day postdelivery. After obtaining a d. Identify if the client is scheduled for surgery. reading of 120/72 mm Hg, the nurse removes the blood pressure cuff and notices that the 130. A nurse is providing nutritional education for client’s arm is ecchymotic in the area where an alcoholic client. The nurse knows that alco- the blood pressure cuff was located. The nurse hol inhibits the absorption of thiamine. Which should of the following foods is a good source of a. monitor the client’s intake and output. thiamine? b. notify the physician. a. apples c. place the cuff on the client more loosely b. fish next time. c. green beans d. retake the blood pressure on the other arm. d. nuts

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134. A client is admitted to a nursing unit with a 137. A nurse receives the laboratory results for a cli- diagnosis of pneumonia. Upon assessment, the ent who is receiving IV antineoplastic medica- client has a productive cough and is diapho- tions. Which of the following serum retic with a temperature of 103.2°F. Which of laboratory results would necessitate that the the following actions should the nurse include nurse implement bleeding precautions? in the care for this client? a. ammonia level: 30 mcg/dL a. frequent linen changes b. clotting time: 15 minutes b. providing a bedpan for the client frequently c. platelet count: 50,000/mm3 c. nasotracheal suctioning d. white blood cell count: 7,000/mm3 d. repositioning the client every four hours 138. A nurse is providing discharge instructions for 135. A nurse is assessing a client who overdosed on a client who is receiving sulfisoxazole. Which cocaine. The nurse assesses for which of the of the following should be included in the following? Select all that apply. instructions? 1. cardiac arrhythmias a. Decrease the dose of medication when 2. increased blood pressure symptoms are improving. 3. diarrhea b. Maintain a high fluid intake. 4. pupil constriction c. Notify the physician immediately if urine a. 1, 2, 3 turns dark brown. b. 1, 2, 4 d. Restrict fluid intake. c. 2, 3, 4 d. 1, 3, 4 139. A nurse is planning a health-education semi- nar to teenagers on acne. The nurse’s teaching 136. A client being cared for on a medical-surgical should include which of the following? Select unit has had a colectomy nine hours ago. The all that apply. client has just used a patient-controlled anal- 1. avoidance of popping an acne pimple gesia (PCA) pump to administer morphine for 2. application of topical creams pain. Additionally, the client has been reposi- 3. sebum production decreases in teen years tioned for comfort and has stable vital signs. 4. use of birth control with Accutane What should the nurse do next? a. 1, 2, 3 a. Apply 2L oxygen via nasal cannula. b. 1, 3, 4 b. Dim the room lights. c. 1, 2, 4 c. Check on the client’s family. d. 2, 3, 4 d. Reassess the client’s vital signs.

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140. A nurse is caring for a client with myasthenia 143. A nursing manager is conducting rounds on gravis. The client has become increasingly the labor and delivery unit. Currently, there weaker since the nurse’s earlier assessment. are four clients in labor. One client is at station The physician prepares to identify whether the 0, the second client is at station −1, the third client is reacting to an overdose of medication client is at station +3, and the fourth client is (cholinergic crisis) or an increasing severity of at station −3. Based only on this information, the disease (myasthenic crisis). An injection of the manager anticipates which client to edrophonium (Tensilon) is administered. deliver first? Which of the following would indicate the a. client at station 0 client is in cholinergic crisis? b. client at station −1 a. complaints of muscle spasms c. client at station +3 b. improvement of the client’s weakness d. client at station −3 c. no change in the client’s condition d. temporary worsening of the condition 144. A nurse is caring for a client who is ordered for a magnetic resonance imaging (MRI). The 141. A nurse is caring for a client with a history of nurse should advise the client that which of diabetes and vascular dementia. To assist in the the following actions would pose a threat to prevention of further cognitive changes, the the client during the MRI? nurse’s plan of care should include which of a. the client asking questions during the scan the following? Select all that apply. b. the client lying still during the scan 1. administration of Aricept c. the client hearing a thumping sound during 2. a diet high in thiamine the scan 3. increased exercise d. the client wearing a ring and bracelet during 4. monitoring client’s glucose the scan a. 1, 2 b. 2, 3 145. A child with a history of hydrocephalus is c. 3, 4 admitted to the pediatric unit for a shunt d. 1, 4 replacement. Postoperatively, the child becomes irritable and combative, and com-

142. A nurse is reviewing histamine (H2)-receptor plains of a headache. The nurse’s first inter- antagonist medications with a graduate nurse. vention is to The graduate nurse correctly identifies which a. document the findings.

of the following medications as H2-receptor b. administer Tylenol. antagonists? Select all that apply. c. notify the physician. 1. cimetidine (Tagamet) d. utilize restraints. 2. famotidine (Pepcid) 3. lansoprazole (Prevacid) 4. nizatidine (Axid) 5. ranitidine (Zantac) a. 1, 5 b. 2, 4 c. 1, 2, 4, 5 d. 2, 3, 4, 5

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146. A nurse for the evening shift has just received 149. A nurse is preparing to administer eardrops to report on her clients. After making initial a child who is three years old. The nurse rounds, which of the following clients will the should administer the eardrops by gently pull- nurse plan to care for first? ing the pinna a. a client requiring colostomy irrigation a. down and back. b. a client requiring a chest X-ray b. down and outward. c. a client with a fever who is diaphoretic c. up and back. d. a client who just received pain medication d. up and outward.

147. A charge nurse is preparing nursing assign- 150. A nurse is caring for a toddler with a history of ments for the daylight shift. Which of the fol- bronchopulmonary dysplasia who was admit- lowing clients are appropriate for the nurse to ted due to respiratory infection. The nurse assign to a licensed practical nurse (LPN) to should anticipate physician orders for all of provide client care? Select all that apply. the following EXCEPT 1. a client receiving total parenteral nutri- a. antibiotics. tion (TPN) b. steroids. 2. a client who had an appendectomy two c. bronchodilators. days ago d. a surfactant. 3. a client with diverticulitis who requires teaching about medications 151. A nurse is preparing to document a child’s 4. a client who is experiencing an exacerba- weight in kilograms. The child weighs tion of ulcerative colitis 62 pounds. The nurse should document the 5. a client with an intestinal obstruction child’s weight as who needs a nasogastric (NG) tube a. 26.96 kg inserted b. 28.18 kg a. 1, 5 c. 136.40 kg b. 2, 4 d. 138 kg c. 1, 2, 5 d. 2, 3, 4

148. A nurse is caring for a client with multiple past admissions to the hospital for hypoglycemia. Which of the following instructions should the nurse reinforce with the client to help decrease the episodes of hypoglycemia? a. Consume a candy bar when lightheadedness occurs. b. Eat a high-protein, low-carbohydrate diet, and avoid fasting. c. Increase foods high in saturated fats and fast in the afternoon. d. Take iron supplements while increasing foods high in vitamins B and D.

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152. A nurse is assigned to care for a client whose 155. A client is admitted to the medical-surgical cultural background is different from her own. unit with a diagnosis of Addison’s disease. The To address the situation, the nurse should do nurse assigned to this client’s care should which of the following? Select all that apply. review laboratory reports for which of the fol- 1. Ask the client if there are cultural or reli- lowing conditions? gious requirements that should be con- a. decreased BUN level sidered in the plan of care. b. hypernatremia 2. Explain the nurse’s beliefs so that the cli- c. hypoglycemia ent will understand the differences. d. hypocalcemia 3. Recognize that all cultures experience pain in the same way. 156. During a home visit to a Hispanic client and 4. Respect the client’s cultural beliefs. her infant one week after delivery, the nurse 5. Understand that nonverbal cues, such as notices dark blue marks on the neonate’s but- eye contact, may have a different mean- tocks. The nurse should ing in different cultures. a. document these as Mongolian spots. a. 1, 5 b. document these as Montgomery spots. b. 1, 4, 5 c. notify the physician. c. 2, 3, 4 d. suspect abuse. d. 1, 2, 3, 4, 5 157. A client in the active phase of labor is at 153. A nurse is caring for a client with depersonali- 38 weeks gestation and has a history of zation disorder. Which of the following would preeclampsia. As she is ambulating to the the nurse expect to find? bathroom, the client experiences severe a. hallucinations abdominal pain and a gush of dark red vaginal b. feeling detached from the body bleeding. The nurse should implement appro- c. loss of memories priate nursing interventions for d. anxiety a. placental abruption. b. eclampsia. 154. A client diagnosed with lung cancer has c. HELLP syndrome. received external beam radiation therapy. The d. placenta previa. nurse caring for the client should assess for which of the following? 158. A nurse is caring for a client with delirium. a. diarrhea Which of the following should the nurse’s plan b. dysphasia of care include? Select all that apply. c. improved energy level 1. chemical restraint d. normal white blood cell count 2. cognition assessment 3. environmental stimulation 4. relaxation techniques a. 1, 2 b. 2, 3 c. 3, 4 d. 2, 4

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159. A child with cerebral palsy is documented to 163. A nurse is caring for a client who had an have diplegia. The nurse prepares to care for a abdominal perineal resection three days ago. child whose dysfunction is Upon assessment, the nurse notes that the a. equal in all four extremities. wound edges are not approximated and half of b. greater in the lower extremities. the incision has separated. The nurse should c. greater in the upper extremities. immediately take which of the following d. involves one side of the body. actions? a. Apply an abdominal binder. 160. A nurse is assigned to a client with a 12-hour- b. Apply a strip of tape to the incision. old male infant. During report, the nurse was c. Cover the wound with a moist sterile told that the client is in the taking-hold phase dressing. of Rubin’s bonding phases. The nurse knows d. Irrigate the wound with sterile water. that during this phase it is appropriate to perform which intervention? 164. Growth and development principles set forth a. Assess for symptoms of depression in the that growth occurs in a proximodistal direc- mother. tion. The nurse knows this means that a child b. Contact the physician to perform a will gain control of circumcision on the infant. a. arm then finger movement. c. Encourage the mother to verbalize her b. arm then leg movement. birthing experience. c. finger then arm movement. d. Teach the mother basic infant care. d. leg then arm movement.

161. A client diagnosed with acute pancreatitis is 165. A nurse is working with a three-year-old child. being treated on a medical-surgical unit. The child states that his stuffed animal told Which of the following complications should him to put his toys away. The nurse knows the nurse look for in this client? that this is a normal occurrence in which of a. cirrhosis Piaget’s stages of development? b. duodenal ulcer a. concrete operational thought c. heart failure b. formal operational thought d. pneumonia c. preoperational thought d. sensorimotor period 162. A client has been recently diagnosed with Raynaud’s phenomenon. To prevent recurrent vasospastic episodes, the nurse should instruct the client to complete which the following? a. Elevate the hands and feet as much as possible. b. Increase coffee intake to three cups per day. c. Utilize a vibrating massage device on the hands. d. Wear gloves while obtaining food from the freezer.

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answers 4. a. The deltoid is an appropriate site to administer an IM injection to a toddler. Choice b 1. b. The nurse should relay to the client that diz- is incorrect. This site is appropriate to ziness (2), headache (3), and hypotension administer a subcutaneous injection but not (5) are all common adverse effects of lisino- an IM injection. Choice c is incorrect. The pril and other ACE inhibitors. Choices a and dorsogluteal site is an appropriate site to c are incorrect. Lisinopril may cause diar- administer an IM injection for children pre- rhea, not constipation (1). Lisinopril does school age and older but not for toddlers. not cause hyperglycemia (4) or impotence Choice d is incorrect. The ventrogluteal site (6). Choice d is incorrect. Lisinopril is an appropriate site to administer an IM does not cause hyperglycemia (4) or injection for children preschool age and impotence (6). older but not for toddlers. Category: Physiological Integrity: Pharma- Category: Physiological Integrity: Pharma- cological and Parenteral Therapies cological and Parenteral Therapies Subcategory: Adult: Cardiovascular Subcategory: Pediatrics: Medication Disorders Administration 2. a. During true labor, the cervix dilates and 5. a. The nurse should instruct the client to chew effaces. Choice b is incorrect. True labor his or her food thoroughly. This will aid in contractions will continue to increase in digestion as well as prevent obstruction. strength and frequency when sitting. Choice Choice b is incorrect. It is unnecessary for c is incorrect. Braxton-Hicks contractions, the nurse to instruct the client to eat six not true labor contractions, will decrease small meals a day. Choice c is incorrect. It is with ambulation. Choice d is incorrect. unnecessary for the client to restrict fluid Lightening refers to the dropping of the intake. The client should remain adequately fetus into the pelvic cavity. It is not a sign of hydrated. Choice d is incorrect. The client is true labor. usually placed on a regular diet, but is Category: Health Promotion and encouraged to use caution about eating Maintenance high-fiber, high-cellulose foods (e.g., nuts, Subcategory: Maternal Infant: Intrapartum popcorn, corn, peas, tomatoes), as these 3. c. Area 3 is considered the QRS complex. foods may swell in the intestine and cause Choice a is incorrect. Area 1 is considered an obstruction. the ST segment. Choice b is incorrect. Area Category: Physiological Integrity: Basic 2 is considered the PR interval. Choice d Care and Comfort is incorrect. Area 4 is considered the ST Subcategory: Adult: Gastrointestinal interval. Disorders Category: Physiological Integrity: Physio- logical Adaptation Subcategory: Adult: Cardiovascular Disorders

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6. d. Terminally ill clients often describe feelings 9. b. Pain is common during the first few of isolation because they feel ignored. The exchanges because of peritoneal irritation; terminally ill client may also sense any dis- however, the pain usually disappears after comfort that family and friends feel in the one to two weeks of regular treatments. client’s presence. Appropriate nursing inter- Choice a incorrect. The amount of solution ventions include spending time with the cli- being infused should not be decreased. It ent, encouraging discussion about feelings, should be explained to client that the pain and answering questions openly and hon- will decrease after more exchanges. Choice c estly. Choices a, b, and c are incorrect. is incorrect. The infusion rate or infusion Reducing the client’s fears is secondary to amounts should not be slowed down; pain lessening the client’s feelings of isolation. during the first one to two sessions is com- Category: Psychosocial Integrity mon. Choice d is incorrect. The dialysis ses- Subcategory: Adult: Oncology Disorders sion should not be immediately 7. c. Remeron is used to treat clients with depres- discontinued. It should be explained to cli- sion. Choice a is incorrect. Medications for ent that the pain will decrease after more anxiety disorders include benzodiazepines, exchanges. barbiturates, and sedatives. Choice b is Category: Physiological Integrity: Physio- incorrect. Medications for bipolar disorder logical Adaptation include lithium. Choice d is incorrect. Medi- Subcategory: Adult: Renal Disorders cations for sleep disorders include barbitu- 10. a. To perform Barlow’s maneuver, the nurse rates and sedatives. places the index and middle fingers on the Category: Physiological Integrity: Pharma- greater trochanters and the thumbs at the cological and Parenteral Therapies inner thigh inguinal creases. The hip is then Subcategory: Mental Health: Medications gently adducted, or moved inward. Choice b 8. b. The client should void prior to initiating the is incorrect. Chadwick’s sign refers to a blu- therapy so that she is able to maintain a ish discoloration of the vagina, cervix, and supine position for up to two hours after the labia during pregnancy. Choice c is incor- medication is administered. Choice a is rect. Hegar’s sign refers to a softening of the incorrect. Prostaglandin E is administered cervix during pregnancy. Choice d is incor- vaginally, not intravenously. Choice c is rect. While Ortolani’s maneuver is also used incorrect. Stomach cramping is an adverse to assess for hip dysplasia, the nurse per- reaction to the medication and therefore forms the maneuver by abducting the new- would not occur until the medication is born’s hips, not adducting, which is administered. Choice d is incorrect. The cli- performed in Barlow’s maneuver. ent should be positioned in a supine posi- Category: Health Promotion and tion after the medication is administered. Maintenance Category: Physiological Integrity: Pharma- Subcategory: Pediatrics: Musculoskeletal cological and Parenteral Therapies Disorders Subcategory: Maternal Infant: Maternal Medications

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11. c. Beractant is a lung surfactant administered 13. b. Lying on the left side allows the enema solu- to infants to prevent or treat respiratory dis- tion to flow downward by gravity into the tress syndrome in preterm infants. Choice a rectum and sigmoid colon. Choices a, c, and is incorrect. Asthma is treated with bron- d are incorrect. These are not appropriate chodilators or steroids. Beractant is a lung positions for self-administration of an surfactant. Choice b is incorrect. Neonatal enema. croup is treated with bronchodilators and Category: Safe and Effective Care Environ- steroids. Beractant is a lung surfactant. ment: Safety and Infection Control Choice d is incorrect. While there are ways Subcategory: Adult: Oncology Disorders to reduce the risk for Sudden Infant Death 14. c. The expected assessment findings would Syndrome, there is no medication available include confusion (2) and somnolence (4). at this time to prevent it. Choice a is incorrect. The expected assess- Category: Physiological Integrity: Pharma- ment findings would include somnolence cological and Parenteral Therapies (4) but not hyperactivity (1). Choice b is Subcategory: Maternal Infant: Neonatal incorrect. The expected assessment findings Complications would include confusion (2) and decreased, 12. a. Tamoxifen can increase calcium, cholesterol, not increased, reflexes (3). Choice d is incor- and triglyceride levels. Prior to the adminis- rect. The client with benzodiazepine toxicity tration of this drug, the nurse should obtain would not exhibit hyperactivity (1) or a complete blood count and platelet count. increased reflexes (3). Serum calcium levels should also be assessed Category: Physiological Integrity: Pharma- and monitored periodically during the ther- cological and Parenteral Therapies apy. The nurse should assess for signs and Subcategory: Mental Health: Medications symptoms of hypercalcemia, which include 15. b. The client is in false labor and should return increased urine volume, excessive thirst, home. Choice a is incorrect. The client is in constipation, vomiting, nausea, hypotonic- false labor; therefore, instructing the client ity of muscles, flank pain, and deep bone to ambulate in the halls is inappropriate. pain. Choice b is incorrect. The glucose level Choice c is incorrect. The client is in false does not need to be monitored in relation to labor and should not be admitted at this the administration of this medication. time. Choice d is incorrect. The client is in Choice c is incorrect. The potassium level false labor; therefore, preparing for a cesar- does not need to be monitored related to ean section is not appropriate. the administration of this medication. Category: Health Promotion and Choice d is incorrect. The prothrombin time Maintenance does not need to be monitored in relation to Subcategory: Maternal Infant: Intrapartum the administration of this medication. Category: Physiological Integrity: Pharma- cological and Parenteral Therapies Subcategory: Adult: Oncology Disorders

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16. d. In addition to not lifting heavy objects (2), 18. c. The gross motor ability to pull up into a the client should also be instructed to avoid standing position usually develops around lifting the arm on the operative side above 10 to 12 months of age. Choice a is incor- shoulder level for one week postinsertion; rect. The fine motor skill to transfer objects prolonged immobilization is not required. from hand to hand develops around four to Upon discharge, it is important for the six months of age. Choice b is incorrect. The nurse to teach the client how to take and cognitive skill to play peekaboo usually record his or her pulse daily (5). Choices a, develops around 10 to 12 months of age. b, and c are incorrect. The pacemaker metal Choice d is incorrect. The social/adaptive casing does not set off airport security skill to use a fork usually develops around alarms, so there is no need to avoid air travel 18 to 24 months of age. (1). Microwave ovens are safe to use and do Category: Safe and Effective Care Environ- not alter pacemaker function (3). It gener- ment: Management of Care ally takes up to two months for the incision Subcategory: Pediatrics: Growth and site to heal and for the patient to regain full Development range of motion, but prolonged immobili- 19. c. Providing the client with a piece of hard zation (4) is not required. candy will aid in eliminating thirst and Category: Physiological Integrity: Reduc- maintain the fluid restriction. Choice a is tion of Risk Potential incorrect. Reinforcing the need for main- Subcategory: Adult: Cardiovascular taining the fluid restriction does not address Disorders the client’s needs. Choice b is incorrect. It is 17. b. An overriding aorta (2), pulmonary stenosis nontherapeutic to ignore the client’s request (4), right ventricular hypertrophy (5), and for fluids. Choice d is incorrect. The nurse is ventral septal defect (6) are the four defects aware that the client must adhere to the associated with tetralogy of Fallot. Choices a ordered fluid restriction and that the physi- and d are incorrect. Left ventricular hyper- cian will not alter the order. It would be trophy (1) occurs with congestive heart fail- inappropriate for the nurse to provide the ure, and patent ductus arteriosus (3) occurs client with more fluids than prescribed. This when the ductus arteriosus fails to close may result in fluid overload, which could after birth. Choice c is incorrect. Patent duc- lead to an emergency hemodialysis session. tus arteriosus (3) occurs when the ductus Category: Physiological Integrity: Basic arteriosus fails to close after birth. Care and Comfort Category: Physiological Integrity: Physio- Subcategory: Adult: Renal Disorders logical Adaptation Subcategory: Pediatrics: Cardiovascular Disorders

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20. a. Behavioral therapy uses learning principles 22. a. The child’s weight is in the 5th percentile to effect changes in behavior by focusing on and his height in the 90th percentile. The the consequences of actions. Choice b is child needs to increase his caloric intake, incorrect. Cognitive therapy focuses on and an appropriate intervention for this is replacing clients’ negative or irrational to increase nutritious snacking. Choice b is beliefs. Choice c is incorrect. Crisis therapy incorrect. The child’s weight is in the 5th focuses on identification of immediate cop- percentile and his height is in the 90th per- ing patterns. Choice d is incorrect. Milieu centile. This does not indicate a need for therapy incorporates a planned use of the increased physical activity. Choice c is incor- treatment environment as part of the rect. Decreased caloric intake would cause therapy. the child’s weight to drop even further and Category: Psychosocial Integrity cause further disproportion between the Subcategory: Mental Health: Therapy child’s height and weight. Choice d is incor- 21. a. Decerebrate posturing occurs in clients with rect. The child’s weight is in the 5th percen- damage to the upper brain stem, midbrain, tile while his height is in the 90th percentile. or pons, and is demonstrated clinically by While setting limits on television viewing is arching of the back, rigid extension of the important for all children, it would not extremities, pronation of the arms, and help the child to increase his weight plantar flexion of the feet. Choices b and d appropriately. are incorrect. These answers do not describe Category: Health Promotion and decerebrate posturing. Choice c is incorrect. Maintenance This answer describes decorticate posturing. Subcategory: Pediatrics: Growth and Category: Physiological Integrity: Physio- Development logical Adaptation Subcategory: Adult: Neurological Disorders

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23. d. The client with a soft, boggy uterus is at risk 25. d. The client may require blood products, for postpartum hemorrhage. The nurse depending on laboratory values and severity should attend to this client first by gently of bleeding; therefore, availability of blood massaging the client’s fundus. Choice a is product should be confirmed by calling the incorrect. The soreness is most likely related blood bank (3). The hemoglobin and hema- to incorrect latching on of the infant. The tocrit levels should be assessed to evaluate nurse can work with this client the next blood loss; an elevated INR and PTT and a time she goes to feed the infant. Choice b is decreased platelet count increase the risk for incorrect. A first-degree perineal laceration postoperative bleeding and must be evalu- is usually small and does not involve the ated (4). Close monitoring of blood loss muscles. This type of tear usually heals from the mediastinal chest tube should also quickly and causes little or minimal discom- be completed (5). Choices a, b, and c are fort. Therefore, this client does not need incorrect. Coumadin (1) is an anticoagulant immediate attention. Choice c is incorrect. that will increase bleeding and should be Lochia rubra is the expected finding for the held postoperatively. It is necessary to first two to three days in the postpartum obtain information on the type of valve period. This client does not need to be seen replacement received. For a mechanical first by the nurse. heart valve, the INR is kept at 2 to 3.5. Tis- Category: Safe and Effective Care Environ- sue valves do not require anticoagulation. ment: Management of Care Dopamine should not be initiated if the cli- Subcategory: Maternal Infant: Maternal ent is hypotensive from hypovolemia; a fluid Complications: Postpartum volume assessment should always be com- 24. c. It indicates the location of Erb’s point, pleted first, and fluid resuscitation should where the aortic and pulmonic valve sounds be used prior to initiating an infusion of radiate. Choice a is incorrect. It indicates the dopamine (2). location of the aortic valve sounds. Choice b Category: Physiological Integrity: Physio- is incorrect. It indicates the location of the logical Adaptation pulmonic valve sounds. Choice d is incor- Subcategory: Adult: Cardiovascular rect. It indicates the location of the mitral Disorders valve sounds. Category: Health Promotion and Maintenance Subcategory: Adult: Cardiovascular Disorders

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26. d. Clients receiving PN solutions are at risk for 29. c. Chadwick’s sign, a bluish coloration of the developing hypoglycemia. It is essential that vagina, cervix, and vulva is a probable sign the solution containing the highest amount of pregnancy. Choice a is incorrect. Breast of glucose should be hung until the new PN tenderness is a presumptive sign of preg- solution becomes available. Because PN nancy. Choice b is incorrect. Missing a solutions contain high glucose concentra- period is a presumptive sign of pregnancy. tions, the 10% dextrose in water is the best Choice d is incorrect. Fetal heart tones are a choice. Choices a, b, and c are incorrect. Cli- positive sign of pregnancy. ents receiving PN solutions are at risk for Category: Health Promotion and developing hypoglycemia. These solutions Maintenance will not be as effective in decreasing the risk Subcategory: Maternal Infant: Antepartum of hypoglycemia as 10% dextrose in water. 30. c. Miotic medications are used to lower the Category: Physiological Integrity: Pharma- intraocular pressure, which then increases cological and Parenteral Therapies blood flow to the retina. This decreases reti- Subcategory: Adult: Gastrointestinal nal damage and loss of vision. Miotic medi- Disorders cation also causes a contraction or 27. d. Resolution of emotional and self-esteem constriction of the ciliary muscle and wid- issues is the goal of group therapy. Choice a ens the trabecular meshwork. Choices a, b, is incorrect. Assessment of family function- and d are incorrect. These are not effects of ing is the goal of family therapy. Choice b is miotic medications. incorrect. Identification of immediate cop- Category: Physiological Integrity: Pharma- ing patterns is the goal of crisis intervention. cological and Parenteral Therapies Choice c is incorrect. Replacement of nega- Subcategory: Adult: Eye Disorders tive attitudes and behaviors is the goal of 31. b. Nursing priorities are generally classified as cognitive therapy. high, intermittent, and low. A pulse oxime- Category: Psychosocial Integrity try reading of 85% is well below the normal Subcategory: Mental Health: Therapy level (95% to 100%) and indicates the high- 28. c. A patent ductus arteriosus is an abnormal est priority. Choice a is incorrect. The opening between the aorta and pulmonary hemoglobin level is within the normal artery that causes blood from the aorta to range (male: 14 to 18 gm/dL; female: 12 to be shunted to the pulmonary artery. Choice 16 gm/dL), making this a low priority. a is incorrect. This is a healthy tricuspid Choice c is incorrect. The urine output is valve. Choice b is incorrect. This depicts a adequate, however marginal, which is an portion of the aorta that has developed nor- intermittent priority. Choice d is incorrect. mally. Choice d is incorrect. This is a nor- The potassium level is within the normal mally formed mitral valve. range (3.5 to 5 mEq/L), which is a low Category: Physiological Integrity: Physio- priority. logical Adaptation Category: Safe and Effective Care Environ- Subcategory: Pediatrics: Cardiovascular ment: Management of Care Disorders Subcategory: Adult: Miscellaneous

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32. d. The nurse should set defined times for the 34. b. Increased thirst and urination during preg- client to perform the compulsive action. nancy are symptoms of gestational diabetes. This will assist the client in decreasing the The nurse should assess for additional amount of time spent engaged in the activ- symptoms such as glycosuria. Choices a, c, ity. Choice a is incorrect. Focusing the cli- and d are incorrect. These conditions are ent’s attention on the behavior will not help not symptoms of gestational diabetes. the client understand the underlying cause Category: Physiological Integrity: Reduc- of the behavior or learn how to control the tion of Risk Potential behavior. Choice b is incorrect. Ignoring the Subcategory: Maternal Infant: Maternal compulsive behavior will not help the client Complications: Antepartum to understand the underlying cause of the 35. b. Often, monthly prophylactic antibiotic ther- behavior or learn how to control the behav- apy will be ordered for a child with rheu- ior. Choice c is incorrect. Preventing the cli- matic heart disease. Choice a is incorrect. ent from performing the compulsive action Digoxin is to be given if the heart rate is may cause an increase in the client’s anxiety. greater than 60 bpm. Choice c is incorrect. Category: Psychosocial Integrity Tylenol is not contraindicated for a child Subcategory: Mental Health: Therapy with rheumatic heart disease. Choice d is 33. c. If peritonitis is present, antibiotics may be incorrect. Aspirin is not contraindicated for added to the dialysate (1). Broad-spectrum a child with rheumatic heart disease. antibiotics may be administered to prevent Category: Physiological Integrity: Physio- infection when a peritoneal catheter is logical Adaptation inserted for peritoneal dialysis (2). Peritoni- Subcategory: Pediatrics: Cardiovascular tis, the most serious and common compli- Disorders cation of peritoneal dialysis (4), is 36. c. It is necessary for clients on hemodialysis to characterized by cloudy dialysate drainage, monitor their fluid status between hemodi- diffuse abdominal pain, and rebound ten- alysis treatments or sessions. This is accom- derness (3). Choices a and d are incorrect. plished by recording intake and output and Utilizing septic technique, not simply clean weight on a daily basis. The client on hemo- technique (5), is an imperative measure to dialysis should not gain more than 1.1 prevent peritonitis. Choice b is incorrect. It pounds (0.5 kg) of weight per day. Choice a omits teachings 1 and 3. is incorrect. It is unnecessary for the client Category: Safe and Effective Care Environ- to record blood urea nitrogen and creati- ment: Safety and Infection Control nine levels daily. The physician will order Subcategory: Adult: Renal Disorders these laboratory tests as needed. Choice b is incorrect. It is unnecessary for the client to record daily living activities and periods of weakness. Choice d is incorrect. It is unnecessary for the client to record daily respiratory and heart rates. Category: Health Promotion and Maintenance Subcategory: Adult: Renal Disorders

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37. b. Between 32 and 36 weeks gestation, visits 39. b. The client is having difficulty with short- are scheduled for every other week in a term memory, which is controlled by the healthy pregnancy. Choice a is incorrect. temporal lobe. Choice a is incorrect. The cli- Weekly prenatal visits are scheduled after ent is having difficulty with short-term week 36 in a healthy pregnancy. Choice c is memory. The location indicated by this incorrect. Prenatal visits are usually not choice is the frontal lobe, which regulates scheduled every three weeks in a healthy decision making, problem solving, con- pregnancy. Choice d is incorrect. Monthly sciousness, and emotions. Choice c is incor- prenatal visits are usually scheduled rect. The client is having difficulty with between 4 and 32 weeks gestation. short-term memory. The location indicated Category: Physiological Integrity: Reduc- by this choice is the occipital lobe, which tion of Risk Potential processes information related to vision. Subcategory: Maternal Infant: Antepartum Choice d is incorrect. The client is having 38. b. The cardiac telemetry strip is showing atrial difficulty with short-term memory. The fibrillation. Clients experiencing this location indicated by this choice is the cere- rhythm are at risk for clot formation. The bellum, which controls movement and client will be discharged home on the oral balance. anticoagulant Coumadin. Choice a is incor- Category: Physiological Integrity: Physio- rect. Clients experiencing atrial fibrillation logical Adaptation are at risk for clot formation. The client will Subcategory: Mental Health: Cognitive be discharged home on the oral anticoagu- Disorders lant Coumadin, not aspirin. Choice c is incorrect. The client will be discharged home on the oral anticoagulant Coumadin, not heparin, which is administered intravenously. Choice d is incorrect. The client will be discharged home on the oral anticoagulant Coumadin, not Ticlid. Ticlopidine is used to reduce the risk of stroke in clients who have had a stroke or have had warning signs of a stroke and who cannot be treated with aspirin. Ticlopidine is also used along with aspirin to prevent blood clots from forming in coronary stents. Category: Physiological Integrity: Pharma- cological and Parenteral Therapies Subcategory: Adult: Cardiovascular Disorders

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40. b. It would be normal for a five-year-old child 42. b. Diabetic neuropathy, cataracts, and glau- to have abdominal breathing (1). Due to the coma are common complications in diabe- thinness of the chest wall, it would also be tes, thus necessitating the nurse to complete normal for the child to have hyperresonant an eye assessment and examination. The cli- lung sounds (3). Choice a is incorrect. While ent’s feet should also be examined at each it would be expected for the child to exhibit client encounter, as the nurse will monitor abdominal breathing (1), the anterior-to- for thickening, fissures, ulcers, and thick- posterior ratio would be expected to be 1:2, ened nails. Choices a, c, and d are incorrect. not 1:1 (2). Choice c is incorrect. Due to the Although the nurse should assess these parts thinness of a young child’s chest wall, it is of the body in a thorough examination, they normal to have hyperresonant breath are not pertinent to common diabetic com- sounds (3). However, the expected anterior- plications. to-posterior ratio in a five-year-old child Category: Physiological Integrity: Reduc- would be 1:2, not 1:1 (2). Choice d is incor- tion of Risk Potential rect. The expected anterior-to-posterior Subcategory: Adult: Endocrine Disorders ratio in a five-year-old child is 1:2, not 1:1 43. b. It is important for clients diagnosed with (2). The expected respiratory rate in a gastrointestinal reflux to eat smaller, more healthy five-year-old is 20 to 28 breaths per frequent meals to help prevent recurrence. minute, not 14 breaths per minute (4). Choice a is incorrect. The client should not Category: Physiological Integrity: Basic lie down until two to three hours after food Care and Comfort consumption to prevent reflux from recur- Subcategory: Pediatrics: Cardiovascular ring. Choice c is incorrect. Fluid should be Disorders restricted with meals to decrease gastric dis- 41. c. An expected medical outcome in the treat- tention and prevent reflux from recurring. ment of a client diagnosed with ulcerative Choice d is incorrect. The client should ele- colitis is that the client maintains an ideal vate the head of the bed approximately four body weight. Choice a is incorrect. It is not to six inches when sleeping. This facilitates assumed that a client with the diagnosis of esophageal emptying and decreases episodes ulcerative colitis will need an ileostomy. The of reflux. decision to perform surgery depends on the Category: Physiological Integrity: Reduc- extent of the disease and the severity of the tion of Risk Potential client’s symptoms. Choice b is incorrect. Subcategory: Adult: Gastrointestinal The client diagnosed with ulcerative colitis Disorders will experience episodes of diarrhea, not constipation. Choice d is incorrect. The client should maintain adequate hydration; thus hydration should be encouraged. Category: Physiological Integrity: Basic Care and Comfort Subcategory: Adult: Gastrointestinal Disorders

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44. c. The nurse should give the client one com- 47. c. Parenteral iron is given by intramuscular mand at a time. Choices a and b are incor- route using the Z-track technique, which rect. The client will not be able to follow a will decrease pain and tracking of the medi- two-step command. Choice d is incorrect. cation during needle withdrawal. Choice a Although the nurse is giving the client one is incorrect. Proper technique includes command at a time, the client is not being changing the needle after drawing up the instructed to get dressed. medication and before administering the Category: Safe and Effective Care Environ- injection to prevent staining of the skin. ment: Management of Care Choice b is incorrect. The site should not be Subcategory: Mental Health: Cognitive massaged after the injection, because mas- Disorders saging the area may result in staining of the 45. a. Pregnant women should avoid undercooked skin. Choice d is incorrect. An air lock eggs and meats due to risk of salmonella should be used, but the Z-track method will infection. Choice b is incorrect. Healthy prevent pain. pregnant women do not need to limit their Category: Safe and Effective Care Environ- sodium intake. Choice c is incorrect. Preg- ment: Safety and Infection Control nant women should limit their caffeine Subcategory: Adult: Hematological intake to 300 mg per day. Choice d is incor- Disorders rect. Breads and cereals fortified with folic 48. b. In general, an LPN or LVN can perform the acid should be consumed by pregnant same tasks as a nursing assistant (e.g., skin women. Folic acid can help to prevent care, range of motion exercises, ambulation, neural-tube birth defects. grooming, and hygiene measures) in addi- Category: Safe and Effective Care Environ- tion to dressing changes, endotracheal suc- ment: Safety and Infection Control tioning (1); medication administration Subcategory: Maternal Infant: Antepartum (oral, intramuscular, and subcutaneous) 46. a. The anterior portion of the right leg equals (4 and 5); and urinary catheterization (6). 9% and the anterior plus posterior portions Choices a, c, and d are incorrect. Client of the right arm equal 9% for a total of 18%. admission assessments (2) and administra- Choices b, c, and d are incorrect. tion of intravenous medications (3) are the Category: Physiological Integrity: Physio- responsibility of the registered nurse. logical Adaptation Category: Safe and Effective Care Environ- Subcategory: Adult: Integumentary ment: Management of Care Disorders Subcategory: Adult: Miscellaneous

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49. a. The DTaP vaccine, which includes diphthe- 51. d. Preterm labor occurs between 27 and 36 ria, tetanus, and pertussis, is usually one of weeks of pregnancy. Symptoms include reg- the vaccinations given at the two-month ular contractions occurring at least every well child exam. Choice b is incorrect. The 10 minutes that are not relieved with posi- influenza vaccination should not be admin- tion changes. Cervical dilation is also a istered to children less than six months of symptom of preterm labor. Choice a is age. Choice c is incorrect. The MMR vac- incorrect. Symptoms of cervical incompe- cine, which includes measles, mumps, and tence include cervical dilation but not regu- rubella, should not be administered to chil- lar contractions. Choice b is incorrect. dren less than 12 months of age. Choice d is Symptoms of placenta previa include pain- incorrect. The varicella vaccination should less vaginal bleeding but not cervical dila- not be administered to children less than tion or contractions. Choice c is incorrect. A 12 months of age. symptom of preeclampsia includes elevated Category: Physiological Integrity: Reduc- blood pressure. tion of Risk Potential Category: Physiological Integrity: Physio- Subcategory: Pediatrics: Assessment logical Adaptation 50. c. Establishing a relaxing prebed routine will Subcategory: Maternal Infant: Maternal provide signals for the client’s body that it is Complications: Antepartum time for sleep, and thus will promote sleep. 52. d. Potassium chloride is never given by bolus Choice a is incorrect. Amitriptyline, while (IV push). Administering potassium chlo- having the side effect of drowsiness, is used ride by IV push can result in cardiac arrest. for the treatment of depression, not to help Choice a is incorrect. When administrating clients sleep. Choice b is incorrect. Watching potassium chloride intravenously, it must television is considered to be a stimulating always be diluted in fluid. Normal saline is activity and is therefore contraindicated for recommended. Dextrose solution is avoided promoting sleep. Choice d is incorrect. Sit- because this type of solution increases intra- ting in the room with the client may distract cellular potassium. The IV site is monitored the client from sleeping and will reward the closely because potassium chloride can irri- client for not sleeping. tate the veins and phlebitis can occur. Category: Health Promotion and Choice b is incorrect. The nurse should Maintenance monitor the client’s urine output during Subcategory: Mental Health: Cognitive potassium chloride administration and Disorders must notify the physician if the urine output falls below 30 mL per hour. Choice c is incorrect. Potassium chloride is always administered via an electronic IV pump or controller. Category: Physiological Integrity: Pharma- cological and Parenteral Therapies Subcategory: Adult: Miscellaneous

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53. d. Varicose veins are more common after the 55. a. The woman is most likely experiencing an age of 30, especially in clients whose occu- amniotic fluid embolism and should be pations require prolonged standing. They positioned in the left lateral position to also occur more frequently in pregnant facilitate maternal and fetal circulation and women and those with a positive family his- oxygenation. Choice b is incorrect. While tory of varicose veins and systemic prob- the right lateral position might be consid- lems such as heart disease. Another risk ered, the left lateral position is a better factor is obesity. Choices a, b, and c are choice because oxygenation to both the incorrect. There is no information in this mother and the fetus is facilitated. Choice c client profile to indicate these conditions. is incorrect. Semi-Fowler’s position is when Category: Health Promotion and the client lies supine with the head of the Maintenance bed elevated 30 degrees. Clients receiving Subcategory: Adult: Cardiovascular tubing feedings are placed in the semi- Disorders Fowler’s position. Choice d is incorrect. The 54. a. Arranging for an interpreter would be the Trendelenburg position is when the client’s best practice when communicating with a head is tilted down; it is used for treatment client who speaks a different language. of hemodynamic shock. It would not be Choice b is incorrect. Speaking loudly when used in this scenario because increased communicating with a client is inappropri- blood flow is needed for both the mother ate and an ineffective way to communicate. and the fetus, which is best accomplished Choice c is incorrect. Speaking to a client through the left lateral position. only when the family is present is inappro- Category: Physiological Integrity: Reduc- priate because it violates privacy; addition- tion of Risk Potential ally, it is not certain that information will be Subcategory: Maternal Infant: Intrapartum correctly translated. Choice d is incorrect. Standing close to a client and speaking loudly during interactions is an inappropriate and ineffective way to communicate. Category: Psychosocial Integrity Subcategory: Adult: Miscellaneous

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56. c. Troponin is a regulatory protein found in 58. c. The nurse must report situations not only striated muscle. Troponins function of elder abuse but also child abuse, gunshot together in the contractile apparatus for wounds, criminal acts, and certain infec- striated muscles and skeletal muscles in the tious diseases. The client should be told that myocardium. Increased amounts of tropo- her information is kept confidential unless nins are released into the bloodstream when it places the nurse under a legal obligation an infarction occurs, causing damage to the to report the information to the proper myocardium. A troponin-T value that is authorities. Choices a and b are incorrect. higher than 0.2 ng/mL is consistent with a These options do not address the legal myocardial infarction. Choice a is incorrect. implications of the situation and do not A normal serum troponin-T level is 0.0 to ensure a safe environment for the client. 0.2 ng/mL. Choice b is incorrect. A normal Choice d is incorrect. This option does not serum troponin-T level is lower than 0.2 ng/ address the legal implications of the situa- mL. A level of 0.7 ng/mL is not indicative of tion and does not ensure a safe environment angina but rather a myocardial infarction. for the client. Confidential issues are not to Choice d is incorrect. An elevated troponin be discussed with nonmedical personnel or level is not associated with gastritis. Gastritis the client’s family or friends without the cli- can be confused with chest pain associated ent’s permission. with a myocardial infarction. Category: Safe and Effective Care Environ- Category: Physiological Integrity: Physio- ment: Management of Care logical Adaptation Subcategory: Adult: Miscellaneous Subcategory: Adult: Cardiovascular 59. b. Establishing a client food contract (2) will Disorders help the client to control binging, and stay- 57. b. The inactivated polio virus is not recom- ing with the client for two hours after eating mended at this time, unless the child is (3) will help prevent opportunities for the behind on her inactivated polio immuniza- client to purge. Choice a is incorrect. Estab- tions. Choice a is incorrect. The CDC rec- lishing a client food contract (2) will help ommends that children receive the HPV the client to control binging, but the client (human papillomavirus) vaccine between should be provided with nutrient-dense, not the ages of 11 and 12. Choice c is incorrect. calorie-dense foods (1). Choice c is incor- The CDC recommends yearly influenza vac- rect. Staying with the client for two hours cinations. Choice d is incorrect. The CDC after eating (3) will help prevent opportuni- recommends that children receive the ties for the client to purge, but limiting time meningococcal conjugate vaccine (MCV4) in the bathroom (4) will not. Choice d is between the ages of 11 and 12. incorrect. The client should be provided Category: Physiological Integrity: Reduc- nutrient-dense, not calorie-dense foods (1). tion of Risk Potential Limiting time in the bathroom (4) will not Subcategory: Pediatrics: Assessment prevent opportunities for the client to purge after eating. Category: Safe and Effective Care Environ- ment: Management of Care Subcategory: Mental Health: Eating Disorders

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60. d. A potassium level lower than 3.5 mEq/L 62. a. The circumcision site should be assessed for indicates hypokalemia. Hypokalemia can be signs of bleeding and for signs of infection. a life-threatening occurrence. Specific elec- Choice b is incorrect. Cleansing the site with trocardiogram changes indicative of hypo- a baby wipe is not recommended due to the kalemia include inverted T-waves, alcohol content in baby wipes. Choice c is ST-segment depression, and prominent incorrect. An infant with a petroleum dress- U-waves. Choice a is incorrect. In hypokale- ing should not be placed in a radiant mia, which is indicated by the client’s potas- warmer due to the risk for burns. Choice d sium level, the P waves are not affected. is incorrect. The infant’s diaper should be Absent P-waves are associated with atrial secured loosely and changed every four fibrillation. Choice b is incorrect. In hypo- hours. Securing the diaper tightly will cause kalemia, which is indicated by the client’s discomfort. potassium level, there would be depressed Category: Safe and Effective Care Environ- ST-segments. Choice c is incorrect. In hypo- ment: Safety and Infection Control kalemia, which is indicated by the client’s Subcategory: Maternal Infant: Neonate potassium level, the T waves would be 63. b. NPH insulin is an intermediate-acting insu- inverted. lin. It peaks in 6 to 12 hours after adminis- Category: Physiological Integrity: Physio- tration. Its onset is 1 to 2 hours, and its logical Adaptation duration is 18 to 24 hours. In this scenario, Subcategory: Adult: Electrolyte Imbalances the medication was given at 7 a.m.; there- 61. b. The therapeutic range for serum dilantin fore, the nurse should monitor for hypogly- level is 10 to 20 µg/mL. If the level is below cemia during the peak action of the the therapeutic range, the client would medication, which would be between 1 p.m. experience seizure activity. If the level is too and 7 p.m. Choices a, c, and d are incorrect. high, the client will be at risk for toxicity. NPH insulin peaks in 6 to 12 hours after Choices a, c, and d are incorrect. The thera- administration. peutic range for serum dilantin level is 10 to Category: Physiological Integrity: Physio- 20 µg/mL. logical Adaptation Category: Physiological Integrity: Physio- Subcategory: Adult: Endocrine Disorders logical Adaptation Subcategory: Adult: Neurological Disorders

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64. c. Eye prophylaxis in newborns is for the pre- 66. c. The child with congestive heart failure vention of eye infections caused by gonor- should be offered small meals frequently. rhea and/or trichomoniasis infection. Choice a is incorrect. Morphine sulfate is Choice a is incorrect. Candidiasis or yeast administered for pain. There is no indica- infections are not passed from mother to tion that this child is in pain. Choice b is fetus during the delivery process. Choice b is incorrect. Due to fluid in the lungs, the child incorrect. Prevention of transmission of will most likely not tolerate the head of the active genital herpes from mother to fetus is bed being lowered. Choice d is incorrect. accomplished through cesarean section. The environment should be kept nonstimu- Choice d is incorrect. Prevention of trans- lating for a child admitted with congestive mission of B strep from mother to fetus is heart failure. accomplished through administration of IV Category: Safe and Effective Care Environ- antibiotics to the mother just prior to the ment: Management of Care delivery. Subcategory: Pediatrics: Cardiovascular Category: Safe and Effective Care Manage- Disorders ment: Safety and Infection Control 67. c. The V6 lead is placed at the fifth intercostal Subcategory: Maternal Infant: Neonate space at the midaxillary line (area 3). Cor- Medications rect placement of the leads is essential when 65. c. The nurse will ask the client to take a deep performing a 12-lead ECG to accurately breath, hold it, and bear down during the document the electrical potential of the tubing change. Called the Valsalva maneu- heart. V6 is one of the precordial leads and, ver, this step helps avoid air embolus during in combination with the other leads, records tubing changes. Choices a and b are incor- potential in the horizontal plane. Choices a, rect. These actions are inappropriate and b, and d are incorrect. The V6 lead is placed could potentially cause an air embolism at the fifth intercostal space at the midaxil- during the tubing change. Choice d is incor- lary line (area 3). rect. If the center venous line is located on Category: Physiological Integrity: Reduc- the right side, the client should be tion of Risk Potential instructed to turn his or her head to the left, Subcategory: Adult: Cardiovascular not the right. In this situation, turning the Disorders head to the right will increase intrathoracic 68. a. Impulsiveness occurs during the manic pressure. phase of bipolar disorder. Choice b is incor- Category: Physiological Integrity: Pharma- rect. Feelings of hopelessness occur during cological and Parenteral Therapies the depressive phase of bipolar disorder. Subcategory: Adult: Endocrine Disorders Choice c is incorrect. Suicidal thoughts occur during the depressive phase of bipolar disorder. Choice d is incorrect. Anxiety is not a symptom of either the manic or the depressive phase of bipolar disorder. Category: Safe and Effective Care Environ- ment: Safety and Infection Control Subcategory: Mental Health: Mood Disorders

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69. d. To determine whether costovertebral ten- 71. a. Violations of confidentiality occur when cli- derness (a sign of glomerulonephritis) is ent information is discussed with nonmedi- present, the nurse should percuss the costo- cal persons, such as family or friends, vertebral angle, that is, the angle over each without the client’s permission. Choices b, c, kidney that’s formed by the lateral and and d are incorrect. It is appropriate to dis- downward curve of the lowest rib and the cuss a client’s diagnosis with other members vertebral column. The costovertebral angle of the healthcare team. can be percussed by placing the palm of one Category: Safe and Effective Care Environ- hand over the costovertebral angle and ment: Management of Care striking it with the fist of the other hand. Subcategory: Adult: Musculoskeletal Choices a, b, and c are incorrect. The physi- Disorders cal examination revealed right-sided costo- 72. c. When a chest tube is removed, the client is vertebral tenderness. The areas indicated in instructed to perform the Valsalva maneuver these choices are incorrect. (which is to bear down). The physician then Category: Physiological Integrity: Physio- quickly withdraws the chest tube and, with logical Adaptation the assistance of the nurse, applies an air- Subcategory: Adult: Renal Disorders tight dressing to the site. Alternatively, the 70. d. The nursing educator should stop the nurse client can also be instructed to take a deep from unclamping the cord and remind the breath and hold the breath while the tube is nurse that the clamp should not be removed removed. Choices a, b, and d are incorrect. for the first 24 hours after birth. Choice a is It would be inappropriate as well as inaccu- incorrect. The cord should not be rate to instruct the client to follow any of unclamped for the first 24 hours after birth, these instructions during chest tube so the baby does not need to be distracted. removal. Choice b is incorrect. While it is true that Category: Safe and Effective Care Environ- the cord will shrivel and fall off within 7 to ment: Safety and Infection Control 10 days, the clamp should not be removed Subcategory: Adult: Cardiovascular for the first 24 hours after birth. Choice c is Disorders incorrect. The nurse should not be encour- 73. a. The nurse should instruct the client to first aged to continue, as the cord should not be exhale fully (step 1). The client should then unclamped for the first 24 hours after birth. place the mouthpiece of the spirometer in Category: Safe and Effective Care Manage- the mouth, inhale, and hold the breath for ment: Safety and Infection Control three seconds (step 2). The client should Subcategory: Maternal Infant: Neonate then exhale passively (step 3). Finally, the Care client should take a deep breath and cough (step 4). Choices b, c, and d are incorrect. Category: Safe and Effective Care Environ- ment: Management of Care Subcategory: Adult: Respiratory Disorders

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74. b. A child with aortic stenosis typically will not 76. b. Lanugo develops during the fifth month of present with cyanosis. Choices a, c, and d gestation. It is common for neonates to have are incorrect. Each of these conditions is a lanugo, and it will generally disappear on its symptom of aortic stenosis. own. Choice a is incorrect. The nurse Category: Physiological Integrity: Physio- should recognize the fine downy hair as logical Adaptation lanugo, a common occurrence in newborns. Subcategory: Pediatrics: Cardiovascular Choice c is incorrect. Milia appear as small Disorders white bumps over the infant’s nose, chin, 75. c. Finger foods should be offered frequently to and/or cheeks. Choice d is incorrect. Lanugo the client with severe depression who exhib- will generally disappear on its own. its a loss of appetite and lack of interest in Category: Psychosocial Integrity food, because smaller portions will likely be Subcategory: Maternal Infant: Neonate less disagreeable. Choice a is incorrect. Assessment Experiencing a decreased appetite and a loss 77. d. Oliguria, or a low urine output, occurs dur- of interest in food is a symptom of the ing cardiogenic shock due to reduced blood depression; therefore the client will not flow to the kidneys. Other typical signs of want to select his or her own food. Choice b cardiogenic shock include low blood pres- is incorrect. Although an attractive presen- sure, rapid and weak pulse, and signs of tation of food is important for the client, diminished blood flow to the brain (confu- the client with severe depression who exhib- sion and restlessness). Cardiogenic shock is its a loss of appetite and lack of interest in a serious complication of a myocardial food will not want to eat large meals. Choice infarction, often with mortality rates d is incorrect. To ensure the intake of ade- approaching 90%. Choice a is incorrect. The quate nutrients, nutrient-dense versus client would experience a rapid and weak calorie-dense foods should be offered to the pulse, not bradycardia, which is a slow client with severe depression who exhibits a pulse. Choice b is incorrect. The client loss of appetite and lack of interest in food. would experience a decreased blood pres- Category: Physiological Integrity: Basic sure, not an elevated blood pressure. Choice Care and Comfort c is incorrect. Fever is not a sign or symp- Subcategory: Mental Health: Mood tom associated with cardiogenic shock. Disorders Category: Physiological Integrity: Reduc- tion of Risk Potential Subcategory: Adult: Cardiovascular Disorders

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78. a. The use of Pitocin to induce labor places the 81. b. The client should maintain the head of the client at risk for postpartum hemorrhage bed between 15 and 30 degrees (1). Moni- from the uterus’s becoming soft or boggy toring neurological status using the GCS is when the Pitocin wears off. Choices b, c, correct (3). An ICP greater than 20 mm Hg and d are incorrect. The use of Pitocin to indicates increased ICP, and the nurse induce labor does not increase the risk for should notify the healthcare provider any of these conditions in the postpartum immediately if this occurs (4). Choices a, c, period. and d are incorrect. The nurse should not Category: Physiological Integrity: Pharma- encourage the client to cough (2) nor cological and Parenteral Therapies engage in range-of-motion exercises (5), as Subcategory: Maternal Infant: Maternal these will increase ICP and should be Medications avoided in the early postoperative stages. 79. d. First, the nurse will need to calculate the Category: Physiological Integrity: Physio- number of milligrams per milliliter: logical Adaptation ______50 mg ____1 mg ______0.2 mg 250 mL = 5 mL = 1 mL Subcategory: Adult: Neurological Disorders Next, the nurse will need to calculate the 82. d. The first sign of Parkinson’s disease is usu- number of micrograms in each milligram: ally tremors. The client is often the first to 0.2 mg × 1,000 mcg = 200 mcg. notice the tremors. Tremors may initially be Choices a, b, and c are incorrect. minimal. Choice a is incorrect. Akinesia, the Category: Physiological Integrity: Pharma- inability to initiate movement, is a later sign cological and Parenteral Therapies of Parkinson’s disease. It follows bradykine- Subcategory: Adult: Cardiovascular sia. Choice b is incorrect. Bradykinesia, the Disorders slowness of movement, is the third sign gen- 80. a. Eating dry crackers before getting out of erally associated with Parkinson’s disease. bed in the morning can decrease feelings of Choice c is incorrect. Rigidity is the second morning sickness. Choice b is incorrect. The sign generally associated with Parkinson’s client should eat small, frequent meals disease. throughout the day. Choice c is incorrect. Category: Physiological Integrity: Physio- Foods high in fat can increase feelings of logical Adaptation morning sickness. Choice d is incorrect. The Subcategory: Adult: Neurological Disorders client should increase fluids between meals, not during meals. Category: Physiological Integrity: Basic Care and Comfort Subcategory: Maternal Infant: Antepartum

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83. c. One of the symptoms of rheumatic fever is 85. b. As the depressed client begins to have painful joints. Choice a is incorrect. The increased energy levels, the risk for suicide sedimentation rate would be increased with increases. Choice a is incorrect. While allow- rheumatic fever. Choice b is incorrect. ing the depressed client to verbalize feelings Rheumatic fever occurs after a partially or is important, as the depressed client begins untreated streptococcal throat infection. to have increased energy levels, the risk for Choice d is incorrect. While one of the suicide increases and assumes a higher pri- symptoms of rheumatic fever is shortness of ority than verbalization of feelings. Choice c breath, this is not typically accompanied by is incorrect. Although ensuring adequate inspiratory pain. nutritional intake is important, assessing for Category: Physiological Integrity: Physio- suicide risk is a higher priority, especially as logical Adaptation the depressed client begins to have increased Subcategory: Pediatrics: Cardiovascular energy levels. Choice d is incorrect. Clients Disorders taking monoamine oxidase inhibitors as 84. b. Chest physiotherapy is best performed treatment for depression are at risk for a before meals to avoid tiring the client or hypertensive crisis. However, Celexa is not a inducing vomiting. Choice a is incorrect. monoamine oxidase inhibitor; therefore, Chest physiotherapy performed after meals while monitoring this client’s blood pres- risks tiring the client or inducing vomiting. sure is important, it is a lower priority than Choice c is incorrect. Scheduling chest phys- assessing for thoughts of suicide. iotherapy around the client’s convenience is Category: Safe and Effective Care Manage- inappropriate. Choice d is incorrect. Sched- ment: Safety and Infection Control uling chest physiotherapy around the Subcategory: Mental Health: Mood nurse’s convenience is inappropriate. Disorders Category: Safe and Effective Care Environ- 86. b. Cracked nipples are often caused by having ment: Safety and Infection Control only the nipple versus the nipple and areola Subcategory: Adult: Respiratory Disorders inserted into the infant’s mouth, causing incorrect latching. Choice a is incorrect. Cracked nipples can be prevented by having the infant latch on correctly. Choice c is incorrect. The nipple and the areola should be guided into the infant’s mouth. Choice d is incorrect. The nipples should not be washed with soap, because soap can cause the skin to dry and crack. Category: Physiological Integrity: Basic Care and Comfort Subcategory: Maternal Infant: Maternal Complications: Postpartum

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87. b. Decorticate posturing is also called decorti- 88. b. Clients with gout should avoid foods that cate response, decorticate rigidity, flexor are high in purines, such as cod (2), liver posturing, or, colloquially, mummy baby. (5), and sardines (6), as well as anchovies, Clients with decorticate posturing present kidneys, sweetbreads, lentils, and alcoholic with the arms flexed, or bent inward on the beverages—especially beer and wine. chest, the hands clenched into fists, and the Choices a, c, and d are incorrect. Chocolate legs extended and feet turned inward. A per- (1), eggs (3), and green, leafy vegetables (4) son displaying decorticate posturing in aren’t high in purines and are acceptable response to pain gets a score of 3 in the foods for the client to eat. motor section of the Glasgow Coma Category: Physiological Integrity: Basic Scale. Choice a is incorrect. Decerebrate Care and Comfort posturing—also called decerebrate response, Subcategory: Adult: Musculoskeletal decerebrate rigidity, or extensor posturing— Disorders is the involuntary extension of the upper 89. a. The infant with an Apgar score of 4 to 7, extremities in response to external stimuli. while not needing resuscitation measures, In decerebrate posturing, the head is arched may benefit from gentle stimulation and the back, the arms are extended by the sides, administration of oxygen. Choice b is incor- and the legs are extended. Choice c is incorrect. Apgar scores of 0 to 3 require resuscita- rect. Opisthotonus is a state of a severe tion measures. Choice c is incorrect. Infants hyperextension and spasticity in which an with an Apgar score of 4 to 7 may benefit individual’s head, neck, and spinal column from gentle stimulation and the administra- enter into a complete “bridging” or arching tion of oxygen. It would be inappropriate to position. This abnormal posturing—an complete the first bath at this time. Choice d extrapyramidal effect—is caused by spasms is incorrect. While bonding is important, of the axial muscles along the spinal col- this infant is in need of gentle stimulation umn. Choice d is incorrect. In anatomy, the and administration of oxygen. prone position is a position of the body Category: Safe and Effective Care Environ- lying face down. In anatomical terminology, ment: Management of Care the ventral side is down, and the dorsal side Subcategory: Maternal Infant: Neonate is up. The prone position is the opposite of Assessment the supine position, which is face up. Category: Physiological Integrity: Physio- logical Adaptation Subcategory: Adult: Neurological Disorders

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90. b. The axillary (1) and tympanic (3) routes are 92. a. The cardinal physiologic abnormalities of the preferred methods for taking the tem- acute respiratory failure are hypoventilation, perature of a three-year-old. Choice a is hypoxemia, and hypercapnia. The nurse incorrect. It is difficult to obtain an accurate should focus on resolving these problems. oral temperature (2) on a three-year-old. Choices b, c, and d are incorrect. The nurse Choice c is incorrect. It is not appropriate to should not focus on hyperoxemia, hypocap- take a rectal temperature (4) on a three- nia, hyperventilation, hypertension, or year-old due to the risk of perforating the hypotension. Signs of respiratory failure anus. Choice d is incorrect. It is difficult to include hypoventilation, hypoxemia, and obtain an accurate oral temperature (2) on a hypercapnia. three-year-old. It is not appropriate to take a Category: Physiological Integrity: Physio- rectal temperature (4) on a three-year-old logical Adaptation due to the risk of perforating the anus. Subcategory: Adult: Respiratory Disorders Category: Safe and Effective Care Environ- 93. a. Graves’ disease, or hyperthyroidism, is a ment: Safety and Infection Control hypermetabolic state that is associated with Subcategory: Pediatrics: weight loss as well as rapid, bounding pulses 91. d. Mafenide acetate (Sulfamylon) is bacterio- (1), heat intolerance (4), tremors (5), and static for gram-negative and gram-positive nervousness (6). Choices b and c are incor- organisms and is used to treat burns to rect. Bradycardia (2) and constipation (3) reduce bacteria present in the avascular tis- are signs and symptoms of hypothyroidism, sues. The nurse should explain to the client not hyperthyroidism. Choice d is incorrect. that the medication will cause local discom- Rapid, bounding pulses (1) and nervousness fort and a burning sensation and that this is (6) are other symptoms of Graves’ disease. a normal reaction. Choice a is incorrect. Category: Health Promotion and Altering the prescribed amount of medica- Maintenance tion is not within the scope of practice of Subcategory: Adult: Endocrine Disorders the nurse. Choice b is incorrect. Discontinu- 94. c. The nurse should gently massage the fundus ing the medication is not within the scope to increase its tone. Choice a is incorrect. of practice of the nurse. Choice c is incor- While it is appropriate for the nurse to doc- rect. It is unnecessary to notify the health- ument the finding of a boggy fundus, the care provider, as this is a normal occurrence nurse should first massage the fundus to when this medication is used. prevent postpartum hemorrhage. Choice b Category: Physiological Integrity: Pharma- is incorrect. Voiding will not change the cological and Parenteral Therapies tone of the fundus. Choice d is incorrect. Subcategory: Adult: Integumentary The nurse should first gently massage the Disorders fundus to increase its tone. If the fundus remains boggy, the physician should then be notified. Category: Physiological Integrity: Reduc- tion of Risk Potential Subcategory: Maternal Infant: Maternal Complications: Postpartum

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95. b. Clients with antisocial personality disorder 98. a. When a client has eyedrops and eye oint- are at risk for harming themselves (2) and ment scheduled at the same time, the nurse others (3) and are at risk for developing should administer the eyedrops first and substance abuse problems (4). Choices a, then the eye ointment. The instillation of c, and d are incorrect. Clients with anti- two medications is separated by a time social personality disorder do not exhibit period of three to five minutes. Choice b is anxiety (1). incorrect. This is not the proper technique; Category: Safe and Effective Care Environ- it isn’t necessary to wait 10 minutes before ment: Safety and Infection Control administering the eye ointment. Choices c Subcategory: Mental Health: Personality and d are incorrect. These are not the Disorders proper techniques; the eyedrops should be 96. a. To test for the Babinski reflex, the nurse uses administered first. a tongue blade to slowly stroke the lateral Category: Physiological Integrity: Pharma- side of the underside of the foot. The nurse cological and Parenteral Therapies will start at the heel and move toward the Subcategory: Adult: Eye Disorders great toe. The normal response in an adult 99. b. A prenatal fetal heart rate of 130 beats per is plantar flexion of the toes. Upward move- minute is within the normal limits of 120 to ment of the great toe and fanning of the 160 beats per minute and should be docu- little toe, called the Babinski reflex, is abnor- mented as such. Choice a is incorrect. A pre- mal. Choices b, c, and d are incorrect. These natal fetal heart rate of 130 beats per minute locations are incorrect starting points to test is within the normal limits of 120 to 160 the Babinski reflex. beats per minute. This information alone Category: Health Promotion and does not precipitate an ultrasound. Choice c Maintenance is incorrect. A prenatal fetal heart rate of Subcategory: Adult: Neurological Disorders 130 beats per minute is within the normal 97. b. The nurse should elevate the head of the limits of 120 to 160 beats per minute; there- bed, as this will allow for increased lung fore, the nurse does not need to reassess the expansion by decreasing ascites pressing on rate at this time. Choice d is incorrect. A the diaphragm. Following this intervention, prenatal fetal heart rate of 130 beats per the client requires reassessment. Choice a is minute is within the normal limits of 120 incorrect. Heart sounds are assessed with a to 160 beats per minute; therefore, the routine physical assessment. Choice c is mother does not need to be positioned on incorrect. There is no indication that blood her left side. cultures are needed. Choice d is incorrect. A Category: Physiological Integrity: Physio- paracentesis is reserved for clients symp- logical Adaptation tomatic of ascites with impaired respiration Subcategory: Maternal Infant: Fetal or abdominal pain not responding to other Assessment measures such as sodium restriction and the administration of diuretic medications. Category: Physiological Integrity: Physio- logical Adaptation Subcategory: Adult: Gastrointestinal Disorders

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100. c. The Guthrie test screens for phenylketon- 103. d. Echopraxia is imitation of another’s move- uria. Choice a is incorrect. The screening ments. Choice a is incorrect. Aphasia is the test for cystic fibrosis is the immunoreactive inability to use and/or understand language. trypsinogen (IRT). Choice b is incorrect. Choice b is incorrect. Ataxia is a lack of The screening test for Down syndrome is coordination when performing voluntary the maternal alpha fetoprotein test. Choice muscle movements. Choice c is incorrect. d is incorrect. The screening test for spina Echolalia is repetition of a word or phrase. bifida is the maternal alpha fetoprotein test. Category: Psychosocial Integrity Category: Physiological Integrity: Reduc- Subcategory: Mental Health: Schizophrenic tion of Risk Potential Disorders Subcategory: Pediatrics: Endocrine 104. a. When the fetal head is palpated at the top of Disorders the fundus (position 4), the fetus is in a 101. c. This medication will not stain the client’s breech presentation. Choices b and c are skin. Choice a is incorrect. This medication incorrect. When the fetus is lying horizon- is an antibacterial, which has a broad spec- tally across the fundus, it is referred to as trum of activity against gram-negative bac- being in a transverse presentation and the teria, gram-positive bacteria, and yeast. fetal head would be palpated at the side of Choice b is incorrect. This medication is the abdomen, such as in position 2 or posi- directly applied to the wounds. Choice d is tion 3. Choice d is incorrect. The vertex pre- incorrect. This medication will help heal the sentation occurs when the fetus is in a client’s burned areas. head-down position. If the fetus were in the Category: Physiological Integrity: Pharma- vertex presentation, the fetal head would be cological and Parenteral Therapies palpated at position 1. Subcategory: Adult: Integumentary Category: Physiological Integrity: Physio- Disorders logical Adaptation 102. a. Following glaucoma surgery, clients will use Subcategory: Maternal Infant: Fetal miotic eyedrops. These agents cause the Assessment pupil to constrict, which can compromise a 105. c. Essential hypertension (also called primary client’s ability to adjust safely to night hypertension) is defined as a consistent vision. For safety, extra lighting should be systolic blood pressure level greater than added to the home. Choice b is incorrect. It 140 mm Hg and a consistent diastolic blood is unnecessary for the client to decrease pressure level greater than 90 mm Hg. fluid intake. This intervention is not associ- Choices a, b, and d are incorrect. These ated with glaucoma surgery. Choice c is blood pressure readings are not the defined incorrect. The client is not restricted from values for essential hypertension. exercise; however, excessive exertion should Category: Physiological Integrity: Reduc- be avoided. Choice d is incorrect. There is tion of Risk Potential no need to avoid sunlight by wearing dark Subcategory: Adult: Cardiovascular sunglasses. Sunlight will not disturb the cli- Disorders ent’s eyesight. Category: Physiological Integrity: Basic Care and Comfort Subcategory: Adult: Eye Disorders

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106. c. Arterial steal syndrome may be experienced 108. d. By reflecting back the father’s thoughts, this by clients with renal failure after the cre- statement encourages the father to continue ation of a fistula. Such clients often exhibit to verbalize his feelings and concerns. pallor and diminished pulse resulting from Choice a is incorrect. While home care will the fistula. Additionally, the client may also usually be ordered for children with new complain of pain distal to the fistula. The ostomies, the nurse should encourage the pain is caused by tissue ischemia. Choice a is father to verbalize his feelings and concerns. incorrect. Edema is not a sign or symptom Choice b is incorrect. This statement disre- of arterial steal syndrome. Choice b is incor- gards the father’s fears and concerns, and rect. Edema and reddish discoloration are discourages the father from further verbal- not signs or symptoms of arterial steal syn- ization of his feelings and concerns. Choice drome. Choice d is incorrect. Warmth and c is incorrect. While the procedure may not redness may be indicative of an infection, be difficult, this statement disregards the not arterial steal syndrome. father’s feelings and concerns, and discour- Category: Physiological Integrity: Physio- ages the father from further verbalization of logical Adaptation his feelings and concerns. Subcategory: Adult: Renal Disorders Category: Psychosocial Integrity 107. d. This action shows acceptance of the change Subcategory: Pediatrics: Gastrointestinal in body image. By touching the altered body Disorders part, the client recognizes the body change and establishes that the change is real. Choice a is incorrect. When the client avoids openly and readily speaking about the surgery, this reflects some level of denial, instead of full acceptance of the change. Choice b is incorrect. Requesting the spouse to leave the room reflects denial, not acceptance, of the change. It also signifies that the client is ashamed of the change and is not coping with it. Choice c is incorrect. In closing his eyes when the colostomy is exposed, the client reflects denial, not acceptance, of the change. Category: Psychosocial Integrity Subcategory: Adult: Gastrointestinal Disorders

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109. c. The nurse correctly identifies this rhythm as 110. d. Symptoms of ectopic pregnancy include sinus rhythm with premature ventricular amenorrhea, slight vaginal bleeding, and contractions. PVCs are extra, abnormal unilateral pelvic pain. Choice a is incorrect. heartbeats that begin in one of the heart’s Cervical dilation at five weeks gestation two lower pumping chambers (ventricles). places the client at risk for spontaneous These extra beats disrupt the regular heart abortion. Choice b is incorrect. The nurse rhythm. Unifocal PVCs look alike; if they would expect to find a small amount of vag- differed in appearance, they would be called inal bleeding, not a hemorrhage, in the cli- multifocal PVCs, as seen in this tracing. ent with an ectopic pregnancy. Choice c is Choice a is incorrect. This tracing does not incorrect. Nausea and vomiting during early indicate sinus rhythm with premature atrial pregnancy might be indicative of morning contractions. PACs can momentarily inter- sickness or hyperemesis gravidarum. rupt normal sinus rhythm by inserting an Category: Physiological Integrity: Physio- extra heartbeat. PACs are caused by occa- logical Adaptation sional, early (or premature) electrical Subcategory: Maternal Infant: Maternal impulses that can arise from almost any- Complications: Antepartum where within the cardiac atria. In other 111. d. Stadol is an opioid administered for pain words, PACs are early atrial heartbeats that relief during labor. Adverse reactions are not produced by the sinus node. Choice include respiratory depression; therefore, it b is incorrect. This tracing does not indicate should not be given if the maternal respira- sinus rhythm with second-degree AV tory rate is less than 12 breaths per minute. block—Mobitz I. Mobitz type-I AV block Choice a is incorrect. Stadol is an opioid shows a progressive PR interval prolonga- administered for pain relief during labor. tion preceding a nonconducted P-wave. The fundal height does not influence the Choice d is incorrect. This tracing does not nurse’s decision to administer or to hold indicate ventricular pacing. Ventricular pac- Stadol. Choice b is incorrect. Stadol does ing with 100% capture is diagnosed when not adversely impact the maternal heart the electrocardiogram shows only com- rate. Choice c is incorrect. Lochia refers to plexes that result from the ventricular pace- the vaginal discharge after labor. maker; each QRS complex is preceded by a Category: Physiological Integrity: Pharma- pacemaker stimulus/pacer spike. cological and Parenteral Therapies Category: Physiological Integrity: Physio- Subcategory: Maternal Infant: Maternal logical Adaptation Medications Subcategory: Adult: Cardiovascular Disorders

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112. d. The nurse should implement interventions 114. b. Skin testing is based on the antigen/anti- to decrease the discomfort of pruritus. This body response and will show a positive reac- will include those that prevent vasodilation, tion after a client has been exposed to decrease anxiety, and maintain skin integ- tuberculosis and has formed antibodies to rity and hydration. Medicated baths with the tuberculosis bacteria. Thus, a positive salicylic acid or colloidal oatmeal can be Mantoux test indicates the production of an soothing as a temporary relief measure. immune response. Choices a, c, and d are Choice a is incorrect. Administration of incorrect. A positive test doesn’t confirm antihistamines should be used cautiously, that a person is actively immune to tubercu- depending on the cause of the pruritus. losis or that a person has or will develop Choice b is incorrect. Administration of tuberculosis. It only confirms exposure to topical steroids should be used cautiously, tuberculosis, and exposure doesn’t confer depending on the cause of the pruritus. immunity. Choice c is incorrect. The use of silk sheets Category: Safe and Effective Care Environ- is not a common practice for patients who ment: Safety and Infection Control are hospitalized and experiencing pruritus. Subcategory: Adult: Respiratory Disorders Category: Physiological Integrity: Basic 115. a. The nurse should provide the mother with Care and Comfort an opportunity to hold the infant. This will Subcategory: Adult: Oncology Disorders allow the mother to bond with and grieve 113. c. La belle indifference is a lack of appropriate for the loss of the child. Choice b is incor- concern for symptoms and a lack of anxiety rect. While labor and delivery units will that can occur with conversion disorders. often utilize a sign or symbol to alert health- Choice a is incorrect. Catatonic excitement care personnel of the fetal demise, the first is excessive motor activity that can occur in action of the nurse should be to provide the catatonic schizophrenia. Choice b is incor- mother with an opportunity to hold the rect. Catatonic stupor is when a client is in a infant. Choice c is incorrect. It is inappro- vegetative-like condition. It occurs with priate to remove the infant from the room catatonic schizophrenia. Choice d is incor- without providing the mother with an rect. Pseudoneurologic manifestation is the opportunity to hold the infant. Choice d is term used for conversion disorders where incorrect. While referring the mother to a symptoms present and resolve themselves support group is an appropriate measure, it based on the presence of life-stress triggers. is inappropriate to do so immediately after Category: Psychosocial Integrity the delivery. Subcategory: Mental Health: Somatoform Category: Psychosocial Integrity Disorders Subcategory: Maternal Infant: Maternal Complications: Intrapartum

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116. b. Pain disorder is a type of somatoform disor- 118. b. The nurse can best palpate the liver by der where the pain is due to a medical con- standing on the client’s right side and plac- dition that is significant enough to warrant ing his right hand on the client’s abdomen, clinical attention; however, psychological to the right of the midline (area 2). He factors impact the onset, severity, exacerba- should point the fingers of his right hand tion, and/or continuation of the pain. toward the client’s head, just under the right Choice a is incorrect. Hypochondria is a rib margin. Choice a is incorrect. Area 1 is somatoform disorder where physical com- incorrect placement to palpate the liver, as it plaints are exaggerated to the point that the is too low. Choice c is incorrect. Area 3 is client experiences impairment in social or incorrect placement to palpate the liver, as it occupational functioning. Choice c is incor- is on the client’s left side. Choice d is incorrect. In a conversion disorder, the client rect. Area 4 is incorrect placement to palpate experiences motor/sensory symptoms that the liver, as it is too low and on the client’s are suggestive of a neurological condition, left side. as the anxiety is unconsciously converted Category: Health Promotion and into functional defects. Choice d is incor- Maintenance rect. In body dysmorphic disorder, there is a Subcategory: Adult: Gastrointestinal pervasive feeling of ugliness due to an imag- Disorders ined or exaggerated physical defect. 119. d. The nurse should include instructions for Category: Psychosocial Integrity proper hand washing technique, as pin- Subcategory: Mental Health: Somatoform worms are spread when someone with pin- Disorders worms scratches around the anus, gets the 117. b. In a female client, the nurse should advance eggs on his or her hands, and then touches a an indwelling urinary catheter two to three surface or handles food that is later touched inches (5 to 7.5 cm) into the urethra. In a or eaten by another person. Choice a is male client, the nurse should advance the incorrect. Tinidazole (Tindamax) is utilized catheter six to eight inches. Choices a, c, and to treat giardiasis. Choice b is incorrect. d are incorrect. The urinary catheter should Abdominal cramping is not a symptom of be advanced two to three inches (5 to 7.5 pinworms; it is a symptom of giardiasis. cm) into the urethra. Choice c is incorrect. Dehydration is not a Category: Safe and Effective Care Environ- symptom of pinworms; it is a symptom of ment: Safety and Infection Control giardiasis. Subcategory: Adult: Fluid and Electrolyte Category: Physiological Integrity: Reduc- Disorders tion of Risk Potential Subcategory: Pediatrics: Gastrointestinal Disorders

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120. d Hypocalcemia—low calcium level in the 121. d. The nurse should instruct the client to be blood—is defined as a value below 8.6 mg/ seen by the physician that same day so the dL. An elevated phosphorus level is defined client can be evaluated and treated, if as a value above 4.5 mg/dL. Hypocalcemia is needed, for mastitis. Choice a is incorrect. a calcium deficit that causes nerve fiber irri- The mother may be able to continue to tability and repetitive muscle spasms. Signs breast-feed the infant, depending on the and symptoms of hypocalcemia include car- safety of any medications prescribed during diac arrhythmias (1). Clients may begin to lactation. Choice b is incorrect. While the experience confusion, depression, and for- client should be evaluated by a physician, getfulness. Additional neurological symp- this is not a medical emergency necessitat- toms include memory loss, hallucinations, ing a visit to the emergency room. Choice c disorientation, and drowsiness and lethargy is incorrect. Having the client wait until the (4), Trousseau sign (6), diarrhea, increased following week to be seen by a physician is clotting times, anxiety, and irritability. The too long a time period. The nurse should calcium-phosphorus imbalance leads to instruct the client to be seen by the physi- brittle bones and pathologic fractures (5). cian that same day so the client can be eval- Choice a is incorrect because signs and uated and treated, if needed, for mastitis. symptoms of hypocalcemia include Category: Physiological Integrity: Reduc- increased, not decreased, clotting times (3). tion of Risk Potential Choice b is incorrect because signs and Subcategory: Maternal Infant: Maternal symptoms of hypocalcemia include diar- Complications: Postpartum rhea, not constipation (2), and increased 122. c. Vaginisimus (4), vaginal spasms that inter- clotting times, not decreased clotting times fere with sexual intercourse, may occur in (3). Choice c is incorrect because signs and sexual pain disorders. Dyspareunia (2), symptoms of hypocalcemia also include car- recurrent genital pain during or after inter- diac arrhythmias (1). course, may also occur in sexual pain disor- Category: Physiological Integrity: Reduc- der. The nurse should assess for both. tion of Risk Potential Choice a is incorrect. Aversion (1) occurs in Subcategory: Adult: Renal Disorders sexual desire disorders when the client experiences fear, disgust, and/or anxiety when confronted with a sexual opportunity. Choices b and d are incorrect. Hypoactive desire (3) occurs in sexual desire disorders. Category: Physiological Integrity: Physio- logical Adaptation Subcategory: Mental Health: Sexual Disorders

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123. b. The fetal heart rate is able to be heard by 124. b. The Glasgow Coma Scale assesses the cli- Doppler during the third month. Choice a is ent’s level of consciousness by testing and incorrect. The fetal heart rate is not able to scoring three observations: eye opening, be heard by Doppler until the third month. motor response, and verbal stimuli Choices c and d are incorrect. The fetal response. Clients are scored on their best heart rate is not able to be heard by stetho- responses, and these scores are totaled. The scope until the fifth month. highest score is 15. The highest responses in Category: Health Promotion and these three categories are spontaneous eye Maintenance opening (response 5) for four points; obey- Subcategory: Maternal Infant: Fetal ing motor commands for six points; and Development orientation to person, place, and time (response 4) for five points. Choice a is incorrect. Incomprehensible verbal response (response 2) is a low score of 2 on the Glasgow Coma Scale, and therefore couldn’t contribute to a score of 15. Bradycardia and hypotension (response 1) are not taken into consideration when assessing a patient’s Glasgow Coma Scale score. Choice c is incorrect. Bradycardia and hypotension (response 1) are not taken into consideration when assessing a patient’s Glasgow coma score. Responding to localized pain (response 3) is worth five points out of six on the motor scale, so could not contribute to a maximum score of 15. Choice d is incorrect. Incomprehensible verbal response (response 2) is a low score of 2 on the Glasgow Coma Scale, and therefore couldn’t contribute to a score of 15. Changes in vital signs and unequal pupil size (response 6) occur with increased intracranial pressure and do indicate neurological compromise; however, these findings are not taken into consideration when assessing a patient’s Glasgow coma score. Responding to localized pain (response 3) is worth five points out of six on the motor scale, so could not contribute to a maximum score of 15. Category: Physiological Integrity: Physio- logical Adaptation Subcategory: Adult: Neurological Disorders

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125. c. The priority nursing intervention is to 126. b. This tracing is asystole. Asystole (flat line) is dilute the corrosive agent. This can be a state of no cardiac electrical activity; accomplished with either milk or water. hence, there are no contractions of the myo- Choice a is incorrect. Activated charcoal is cardium and no cardiac output or blood administered to decrease the amount of flow. Choice a is incorrect. This tracing does toxic substance absorbed through the gas- not show artifact. As a result of artifact, nor- trointestinal system. However, with corro- mal components of the ECG are distorted. sive agents such as turpentine, the priority is Choices c and d are incorrect. This tracing is to dilute the corrosive. Choice b is incorrect. not coarse or fine ventricular fibrillation Cathartics are utilized to hasten expulsion (VF). VF is a rhythm in which multiple of the substance. However, with corrosive areas within the ventricles display marked agents such as turpentine, the priority is to variation in depolarization and repolariza- dilute the corrosive. Choice d is incorrect. tion. Since there is no organized ventricular Inducing vomiting is contraindicated with depolarization, the ventricles do not con- corrosive agents. tract as a unit. When observed directly, the Category: Safe and Effective Care Environ- ventricular myocardium appears to be quiv- ment: Safety and Infection Control ering. There is no cardiac output. The terms Subcategory: Pediatrics: Gastrointestinal coarse and fine have been used to describe Disorders the amplitude of the waveforms in VF. Coarse VF usually indicates the recent onset of VF, which can be readily corrected by prompt defibrillation. The presence of fine VF that approaches asystole often means there has been a considerable delay since collapse, and successful resuscitation is more difficult. Category: Physiological Integrity: Physio- logical Adaptation Subcategory: Adult: Cardiovascular Disorders

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127. c. Complications and/or side effects of the 129. c. The client should receive recumbent t-PA lidocaine infusion include tinnitus, as well treatment within three hours after the onset as dizziness, blurred vision, tremors, numb- of the stroke to have better outcomes. The ness and tingling of extremities, excessive time from the onset of a stroke to t-PA perspiration, hypotension, seizures, and treatment is critical. Choice a is incorrect. coma. Cardiac effects include slowed con- While the nurse should identify which med- duction and cardiac arrest. Choices a, b, and ications the client is taking, it is more d are incorrect. These conditions are not important to know the onset time of the considered side effects related to the admin- stroke to determine the course of action for istration of IV lidocaine. administering t-PA. Choice b is incorrect. A Category: Physiological Integrity: Pharma- complete health assessment and history is cological and Parenteral Therapies not possible when a client is receiving emer- Subcategory: Adult: Cardiovascular gency care. Choice d is incorrect. Upcoming Disorders surgical procedures may need to be delayed, 128. c. The client is most likely experiencing because the administration of t-PA is the HELLP syndrome (hemolysis, elevated liver priority. enzymes, lower platelet count), which can Category: Physiological Integrity: Reduc- be a complication of preeclampsia or tion of Risk Potential eclampsia. In patients experiencing HELLP Subcategory: Adult: Neurological Disorders syndrome, a coagulation cascade is acti- 130. d. Nuts are a good source of thiamine. Choices vated. This in turn creates fibrin formation a and c are incorrect. Apples and green in small blood vessels, leading to microangi- beans are good sources of vitamins A and C opathic hemolytic anemia and destruction but not thiamine. Choice b is incorrect. of red blood cells with consumption of Fish is a good source of protein but not platelets. Palpation of the abdomen is con- thiamine. traindicated at this time due to the potential Category: Health Promotion and Mainte- for liver rupture. Choice a is incorrect. nance Administration of magnesium sulfate per Subcategory: Mental Health: Substance order should be continued to assist in the Abuse management of the client’s eclampsia. Choice b is incorrect. Fetal monitoring should occur to assess fetal well-being. Choice d is incorrect. The client is most likely experiencing HELLP syndrome and should be prepared for delivery. Category: Safe and Effective Care Environ- ment: Management of Care Subcategory: Maternal Infant: Maternal Complications: Antepartum

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131. b. A client with a laryngectomy cannot speak, 133. b. This client is exhibiting symptoms of dis- but still needs to communicate. The nurse seminated intravascular coagulation (DIC) should plan to develop an alternative com- that need to be brought to the immediate munication method. Choice a is incorrect. attention of the physician. Choice a is incor- To prevent injury to the tracheal mucosa, rect. There is no need to monitor the client’s the nurse should deflate the tracheostomy intake and output. This client is exhibiting cuff or use the minimal leak technique. symptoms of disseminated intravascular Choice c is incorrect. Post-laryngectomy, coagulation (DIC), and the physician edema interferes with the ability to swallow should be notified. Choice c is incorrect. and necessitates tube (enteral) feedings. The ecchymosis was not caused by the tight- Choice d is incorrect. To decrease edema, ness of the cuff. Rather, it is a symptom of the nurse should place the client in the disseminated intravascular coagulation semi-Fowler’s position. (DIC). Choice d is incorrect. There is no Category: Psychosocial Integrity need to retake the blood pressure at this Subcategory: Adult: Respiratory Disorders time. The client is exhibiting symptoms of 132. c. This response acknowledges the father’s disseminated intravascular coagulation concerns and encourages the father to elab- (DIC), and the physician should be notified orate on his feelings. Choice a is incorrect. immediately. This statement is most likely not true and it Category: Safe and Effective Care Environ- does not allow the father to discuss his con- ment: Management of Care cerns and feelings. Choice b is incorrect. Subcategory: Maternal Infant: Maternal This statement evades the question and does Complications: Postpartum not address the father’s concerns and feel- 134. a. Frequent linen changes are appropriate for ings. Choice d is incorrect. This statement this client because of the diaphoresis. Dia- shuts down communication between the phoresis produces general discomfort. The father and the nurse and does not allow the client should be kept dry to maintain an father to verbalize his concerns and feelings. acceptable level of comfort. Choice b is Category: Psychosocial Integrity incorrect. There is no indication that the cli- Subcategory: Pediatrics: Hematologic and ent needs a bedpan. Choice c is incorrect. Immune Disorders Nasotracheal suctioning is not indicated, because the client has a productive cough. Choice d is incorrect. The client should be repositioned every two hours. Category: Physiological Integrity: Basic Care and Comfort Subcategory: Adult: Respiratory Disorders

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135. a. Symptoms of cocaine overdose include car- 137. c. This value is abnormal. Bleeding precau- diac arrhythmias (1), increased blood pres- tions must be initiated when the platelet sure (2), and diarrhea (3). Choices b, c, and count decreases. The normal platelet count d are incorrect. Symptoms of cocaine over- is 150,000 to 450,000/mm3. When the plate- dose do not include pupil constriction (4). let count falls below 50,000/mm3, any small Category: Physiological Integrity: Physio- trauma can lead to episodes of prolonged logical Adaptation bleeding. Choice a is incorrect. This value is Subcategory: Mental Health: Substance within the normal range for ammonia, Abuse which is 10 to 80 mcg/dL. Choice b is incor- 136. b. The nurse is helping the client manage pain rect. This value is within the normal range and comfort level. The nurse has completed for clotting time, which is 8 to 15 minutes. assessment of the client and should now Choice d is incorrect. This value is within dim the room lights to create a quiet envi- the normal range for white blood cell count, ronment. Nonpharmacologic measures such which is 4,500 to 11,000/mm3. as adjusting the lighting level in the room Category: Safe and Effective Care Environ- can facilitate pain management. Decreasing ment: Management of Care stimulation from the environment, such as Subcategory: Adult: Oncology Disorders brightness to the optic nerve, aids in the cli- 138. b. Each dose of sulfisoxazole should be admin- ent’s ability to relax skeletal muscles and fall istered with a full glass of water, and the cli- asleep. Choice a is incorrect. There is no ent should maintain a high fluid intake. The indication that oxygen should be adminis- medication is more soluble in alkaline tered. Choice c is incorrect. Checking on urine. Choice a is incorrect. The client whether the client’s family is comfortable is should not be instructed to taper off or dis- important, but is not higher in priority than continue the dosage of medication. Choice c the client’s comfort. Choice d is incorrect. is incorrect. Some forms of sulfisoxazole The nurse has already completed the client may cause urine to turn dark brown or red. assessment. It is too soon to reassess the cli- This is an expected side effect and the physi- ent’s vital signs. cian does not need to be notified. Choice d Category: Safe and Effective Care Environ- is incorrect. The client should be instructed ment: Management of Care to maintain a high fluid intake, not to Subcategory: Adult: Gastrointestinal restrict fluid intake. Disorders Category: Physiological Integrity: Pharma- cological and Parenteral Therapies Subcategory: Adult: Renal Disorders

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139. c. The nurse should include the avoidance of 141. c. Increased exercise (3) and monitoring and popping an acne pimple (1), the application control of the client’s glucose (4) can pro- of topical creams (2), and the use of birth mote increased blood flow to the brain and control with Accutane (4). Choices a, b, and assist in the prevention of further cognitive d are incorrect. Sebum production (3) changes. Choice a is incorrect. Aricept (1) is increases during the teen years. used to treat Alzheimer’s dementia. A diet Category: Health Promotion and high in thiamine (2) is used to prevent Wer- Maintenance nicke’s encephalopathy in clients with alco- Subcategory: Pediatrics: Integumentary holism. Choice b is incorrect. While Disorders increased exercise (3) can increase blood 140. d. An injection of Tensilon makes the client in flow to the brain and assist in the preven- cholinergic crisis temporarily worse. Cho- tion of further cognitive changes, a diet high linergic crisis indicates an overdose of medi- in thiamine (2) is used to prevent Wer- cation; thus, it is reasonable that a nicke’s encephalopathy in clients with alco- worsening of the condition will occur when holism. Choice d is incorrect. While additional medication is administered. monitoring and controlling the client’s glu- Choice a is incorrect. The client experienc- cose (4) can promote increased blood flow ing cholinergic crisis would have worsening to the brain and assist in the prevention of symptoms, but they would not include further cognitive changes, Aricept (1) is muscle spasms. Choice b is incorrect. used to treat Alzheimer’s dementia. Improvements in the client’s weakness indi- Category: Physiological Integrity: Reduc- cate myasthenic crisis. Choice c is incorrect. tion of Risk Potential The client experiencing cholinergic crisis Subcategory: Mental Health: Cognitive would have worsening of symptoms. Disorders

Category: Physiological Integrity: Pharma- 142. c. Medications 1, 2, 4, and 5 are H2-receptor cological and Parenteral Therapies antagonists, which suppress secretions of Subcategory: Adult: Neurological Disorders gastric acid, alleviate symptoms of heart- burn, and assist in preventing complications of peptic ulcer disease. These medications suppress gastric secretions and are prescribed for clients experiencing active ulcer disease, erosive esophagitis, and pathologi- cal hypersecretory conditions. Choice d is incorrect. Prevacid (3) is a protein pump inhibitor. Choices a and b are incorrect. Each does not list all the medication choices that apply. Category: Physiological Integrity: Pharma- cological and Parenteral Therapies Subcategory: Adult: Gastrointestinal Disorders

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143. c. When a client’s station is +3, the fetal pre- 145. c. The headache and irritability may be indica- senting part is 3 cm below the ischial spines. tive of shunt malfunction, and the nurse This client’s fetus is furthest into the birth should notify the physician of the findings. canal and, based only on this information, is Choice a is incorrect. Although the nurse most likely to be the first to deliver. Choice a should document the findings, the nurse is incorrect. When a client’s station is 0, the should first notify the physician, as these fetal presenting part is at the level of the findings are indicative of shunt malfunc- ischial spines. Choice b is incorrect. When a tion. Choice b is incorrect. Tylenol can be client’s station is –1, the fetal presenting part ordered for treatment of headaches. How- is 1 cm above the ischial spines. Choice d is ever, in this case, the headache may be incorrect. When a client’s station is –3, the indicative of shunt malfunction and there- fetal presenting part is 3 cm above the fore needs to be brought to the attention of ischial spines. the physician. Choice d is incorrect. Category: Safe and Effective Care Environ- Restraints are utilized when there is a risk of ment: Management of Care self-harm or harm to others. In this case, the Subcategory: Maternal Infant: Intrapartum irritability and combativeness and the head- 144. d. During an MRI, the client should wear no ache may be indicative of shunt malfunc- metal objects, such as jewelry, because the tion, so the physician needs to be notified. strong magnetic field can pull on them, Category: Safe and Effective Care Environ- causing injury to the client and, if the ment: Management of Care objects fly off, causing injury to others. Subcategory: Pediatrics: Neurological/ Choice a is incorrect. The client is permitted Cognitive Disorders to ask questions during the scan. The MRI 146. c. The client who has a fever and is diaphoretic scanner is equipped with a microphone. is the priority because this client requires Choice b is incorrect. The client must lie still comfort measures and interventions to during the scan. Choice c is incorrect. The relieve the fever. Choice a is incorrect. The client will hear thumping sounds during the client requiring colostomy irrigation would scan, which are caused by changes in the not take precedence over the client who has magnetic field created by the MRI machine. a fever and is diaphoretic. Choice b is incor- Category: Safe and Effective Care Environ- rect. The client requiring a chest X-ray ment: Safety and Infection Control would not take precedence over the client Subcategory: Adult: Miscellaneous who has a fever and is diaphoretic. Choice d is incorrect. The nurse should allow the pain medication to take effect before providing care for this client. Category: Safe and Effective Care Environ- ment: Management of Care Subcategory: Adult: Miscellaneous

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147. b. The client who is recovering from a rela- 150. d. A surfactant is used to facilitate develop- tively minor surgery, such as an appendec- ment of the lungs and would not be an tomy (2) and the client who is experiencing appropriate intervention for a toddler. an exacerbation of ulcerative colitis (4) are Choice a is incorrect. Antibiotics would be appropriate clients to assign to an LPN, as ordered to treat the respiratory infection. the care they require falls within the scope Choice b is incorrect. Steroids would most of practice for an LPN. Choices a, c, and d likely be ordered to decrease inflammation are incorrect. It is not within the scope of in the lungs. Choice c is incorrect. Broncho- practice for the LPN to administer TPN (1), dilators would most likely be ordered to provide client teaching related to medica- facilitate oxygenation. tions (3), or insert NG tubes (5). Category: Safe and Effective Care Environ- Category: Safe and Effective Care Environ- ment: Management of Care ment: Management of Care Subcategory: Pediatrics: Respiratory Subcategory: Adult: Miscellaneous Disorders 148. b. To help the client control episodes of hypo- 151. b. To convert pounds into kilograms, the nurse glycemia, the nurse should instruct the cli- should divide the weight in pounds by 2.2; ent to eat a high-protein, low-carbohydrate 62 divided by 2.2 is 28.18. The nurse should diet, and avoid fasting. Choice a is incorrect. document the child’s weight as 28.18 kg. Consuming a candy bar when feeling light- Choice a is incorrect. To convert pounds headed will not control hypoglycemia. into kilograms, the nurse should divide the Choice c is incorrect. Increasing foods high weight in pounds by 2.2, not 2.3. Choice c is in saturated fats and fasting in the afternoon incorrect. To convert pounds into kilo- will not control hypoglycemia. The client grams, the nurse should divide, not multi- should also be instructed to avoid simple ply, the child’s weight by 2.2; 62 divided by sugars. Choice d is incorrect. Taking iron 2.2 is 28.18. Choice d is incorrect. To con- and increasing foods high in vitamins B and vert pounds into kilograms, the nurse D will not control hypoglycemia. should divide the child’s weight by 2.2, not Category: Physiological Integrity: Basic multiply by 2.22. The nurse should not Care and Comfort round. Subcategory: Adult: Endocrine Disorders Category: Health Promotion and 149. a. The nurse should pull the pinna down and Maintenance back. Choice b is incorrect. Pulling the Subcategory: Pediatrics: Assessment pinna down and outward would not fully open the ear canal. Choices c and d are incorrect. Pulling the pinna up and either back or outward would obstruct entry into the ear canal. Category: Physiological Integrity: Pharma- cological and Parenteral Therapies Subcategory: Pediatrics: Medication Administration

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152. b. The nurse should always respect the client’s 154. b. It is important for the nurse to assess this cultural beliefs (4) and ask if the client has client for dysphasia. Radiation-induced cultural or religious requirements (1); this esophagitis with dysphasia is rather com- may include food choices or restrictions, mon in clients who received radiation to the body coverings, or time for prayer. Nonver- chest. The anatomic location of the esopha- bal cues may have different meanings in dif- gus is posterior to the mediastinum and is ferent cultures (5). In one culture, eye within the field of primary treatment. contact is a sign of disrespect; in another, Choice a is incorrect. Diarrhea is uncom- eye contact shows respect and attentiveness. mon in the treatment of lung cancer. Choice Choices a, c, and d are incorrect. The nurse c is incorrect. Decreased energy level is a should attempt to understand the client’s potential complication of radiation therapy. culture; the client does not need to under- Choice d is incorrect. Decreased white blood stand the nurse’s culture (2), and nurses cell count is a potential complication of should never impose their own beliefs on radiation therapy. clients. Culture influences a client’s experi- Category: Physiological Integrity: Reduc- ence with pain (3); not all cultures experi- tion of Risk Potential ence or describe pain in the same way. Subcategory: Adult: Oncology Disorders Category: Psychosocial Integrity 155. c. Clients with Addison’s disease will experi- Subcategory: Adult: Miscellaneous ence decreased hepatic gluconeogenesis and 153. b. Clients with depersonalization disorder may increased tissue glucose uptake, which experience feeling detached from the body. causes hypoglycemia. Choice a is incorrect. Choice a is incorrect. Hallucinations occur Clients with Addison’s disease will experi- with dissociative identity disorder. Choice c ence an elevated BUN level. There is a is incorrect. Memory loss is associated with decrease in excretion of waste products. dissociative amnesia. Choice d is incorrect. Choice b is incorrect. Clients with Addison’s While anxiety can be a symptom of many disease will experience hyponatremia, not types of mental illness, it is not a symptom hypernatremia. Choice d is incorrect. Cli- of depersonalization disorder. ents with Addison’s disease will experience Category: Physiological Integrity: Physio- hyperkalemia, not hypocalcemia. logical Adaptation Category: Physiological Integrity: Reduc- Subcategory: Mental Health: Personality tion of Risk Potential Disorders Subcategory: Adult: Endocrine Disorders

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156. a. Mongolian spots appear as blue to slate gray 157. a. Sudden, severe abdominal pain can be marks on an infant’s buttocks, back, and indicative of placental abruption, which is legs. While they may resemble bruising, they the premature separation of the placenta are a benign color variation that will usually from the uterus. Choice b is incorrect. A cli- disappear by two years of age. Mongolian ent with eclampsia would experience ele- spots are common among darker-skinned vated blood pressure, protein in the urine, persons, such as those who are of Asian, and seizures, but not abdominal pain and East Indian, and African descent. Choice b is dark red vaginal bleeding. Choice c is incor- incorrect. Montgomery spots appear as rect. A client with HELLP syndrome would white spots on the areola of a pregnant/ experience upper abdominal pain, changes nursing woman. Choice c is incorrect. The in vision, and nausea and vomiting, but not nurse is observing Mongolian spots, which dark red vaginal bleeding. Choice d is incor- are a benign color variation; therefore, noti- rect. The client with placenta previa would fying the physician is inappropriate at this experience painless vaginal bleeding, usually time. Choice d is incorrect. The nurse is bright red in color. observing Mongolian spots, which appear as Category: Safe and Effective Care Environ- blue to slate-grey marks on an infant’s but- ment: Management of Care tocks, back, and legs. While they may resem- Subcategory: Maternal Infant: Maternal ble bruising, they are a benign color Complications: Intrapartum variation that will usually disappear by two 158. d. The nurse should assess the client’s cogni- years of age. tion (2) and utilize relaxation techniques Category: Health Promotion and (4). Choice a is incorrect. The use of chemi- Maintenance cal restraints (1) is not appropriate at this Subcategory: Maternal Infant: Neonate time, as there is no indication that the client Assessment is at risk for harming self or others. Choices b and c are incorrect. The nurse should ensure a nonstimulating environment for the client, rather than one that provides stimulation (3). Category: Psychosocial Integrity Subcategory: Mental Health: Cognitive Disorders

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159. b. Diplegia is the term used when the dysfunc- 162. d. The client should be instructed to wear tion is greater in the lower extremities. loose clothing to protect extremities from Choice a is incorrect. Quadriplegia is the the cold. Wearing gloves when handling term utilized when the dysfunction is equal cold objects will help prevent vasospasms. in all four extremities. Choice c is incorrect. Choice a is incorrect. Elevating the hands In diplegic cerebral palsy, the dysfunction is and feet as much as possible is contraindi- greater in the lower extremities. Choice d is cated, as this will decrease arterial perfusion incorrect. Hemiplegia is the term utilized during periods of vasospasms. Choice b is when the dysfunction involves only one side incorrect. The client should be taught to of the body. avoid caffeine as well as tobacco. Choice c is Category: Physiological Integrity: Basic incorrect. The client should be instructed Care and Comfort not to use vibrating equipment, as this con- Subcategory: Pediatrics: Neurological/ tributes to the production of vasospasms. Cognitive Disorders Category: Safe and Effective Care Environ- 160. d. During the taking-hold phase, the mother ment: Management of Care feels more in control and is ready to focus Subcategory: Adult: Cardiovascular on learning how to care for her infant. Disorders Choice a is incorrect. Symptoms of depres- 163. c. When dehiscence occurs, the nurse should sion usually surface during Rubin’s letting- immediately cover the wound with a sterile go phase. Choice b is incorrect. The dressing moistened with normal saline. If taking-hold phase is an appropriate time to the dehiscence is extensive, the client may be conduct client education. Contacting the returned to surgery to be resutured. Choice physician to perform a circumcision on the a is incorrect. Applying an abdominal infant is inappropriate at this time. Choice c binder may be appropriate, but it is not is incorrect. The client should be encour- what the nurse should do immediately. aged to verbalize her birthing experience Choice b is incorrect. After the sutures are during the taking-in phase, not the taking- removed, not before, additional support hold phase. may be provided to the incision by applying Category: Psychosocial Integrity strips of tape as ordered by the surgeon. Subcategory: Maternal Infant: Postpartum Choice d is incorrect. Irrigating the wound 161. d. Clients with acute pancreatitis are at risk for with sterile water is not an appropriate developing complications associated with nursing intervention. the respiratory system. Atelectasis, pneumo- Category: Physiological Integrity: Reduc- nia, and pleural effusions are some examples tion of Risk Potential of complications that can develop as a result Subcategory: Adult: Gastrointestinal of pancreatic enzyme exudate. Choices a, b, Disorders and c are incorrect. Acute pancreatitis does not cause any of these conditions. Category: Physiological Integrity: Reduc- tion of Risk Potential Subcategory: Adult: Gastrointestinal Disorders

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164. a. Proximodistal refers to growth from the 165. c. The period of preoperational thought center of the body outward. The arms are occurs in children two to seven years old located closer to the center of the body than and is characterized by attributing life to the fingers, so the child will gain control of inanimate objects, use of pretend play, and arm movement before finger movement. seeing the self as the center of the world. Choice b is incorrect. Control of arm then Choice a is incorrect. The period of concrete leg movement is an example of cephalocau- operational thought occurs in children ages dal, or head-to-feet, growth. Choice c is seven to 12 years old and is characterized by incorrect. Proximodistal refers to growth focusing on the present and a realistic from the center of the body outward. The understanding of the world. Choice b is arms are located closer to the center of the incorrect. The period of formal operational body than the fingers, so the child will gain thought occurs in children over the age of control of arm movement before finger 12 and is characterized by the ability to movement. Choice d is incorrect. According think abstractly. Choice d is incorrect. The to the growth and development principle of sensorimotor period occurs in children zero cephalocaudal growth (head to-feet growth) to two years old and is characterized by an the child will gain control of arm then leg understanding of night and day, object per- movement. manence, and cause and effect. Category: Physiological Integrity: Basic Category: Physiological Integrity: Basic Care and Comfort Care and Comfort Subcategory: Pediatrics: Growth and Devel- Subcategory: Pediatrics: Growth and Devel- opment Theories opment Theories

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