Answer and Rationale :Pre-board Exam for November 2009 NLE

1. A. The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the drug.

2. B. It is of paramount importance to prevent the client from hurting himself or herself or others.

3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.

4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.

5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.

6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.

7. B. This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.

8. D. Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.

9. B. It is important to externalize the anger away from self.

10. D. Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.

11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to followhospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.

12. C. The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.

13. A. Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.

14. B. Assignments should be based on scope of practice and expertise.

15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.

16. A. The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.

17. D. Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.

18. B. Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.

19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.

20. B. This option is least threatening.

21. D. In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.

22. A. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.

23. B. This is the proper use of anger.

24. C. There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.

25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.

26. C. Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.

27. D. Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.

28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.

29. D. The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.

30. C. It describes a democratic process in which all members have input in the client’s care.

31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.

32. B. In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.

33. A. Smoke inhalation affects gas exchange.

34. C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.

35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).

36. D. Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.

37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.

38. A. This suggests that the level of consciousness is decreasing.

39. D. An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.

40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.

41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.

42. D. The priority for this client is being able to establish an airway.

43. A. Signs of placental separation include a change in the shape of the uterus from ovoid to globular.

44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.

45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.

46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.

47. D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.

48. C. Directing and evaluation of staff is a major responsibility of a nursing manager.

49. A. The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.

50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.

51. C. Erythema toxicum is the normal, nonpathological macular newborn rash.

52. D. The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.

53. A. Bending from the waist in pregnancy tends to make backache worse.

54. B. Support and limit setting decrease anxiety and provide external control.

55. C. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.

56. B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.

57. C. An advocate role encourage freedom of choice, includes speaking out for the client, and supports the client’s best interests.

58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.

59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy.

60. D. Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.

61. B. The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior.

62. C. The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.

63. B. Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours.

64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.

65. A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.

66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.

67. A. It is best to establish baseline information first.

68. B. Listening is probably the most effective response of the four choices.

69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).

70. C. A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.

71. A. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane.

72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange.

73. A. Somatoform disorders provide a way of coping with conflicts.

74. C. Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.

75. A. Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.

76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance “burned” the esophagus going down, it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac.

77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage.

78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority.

79. C. The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision.

80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.

81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.

82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.

83. A. Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings.

84. C. The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated.

85. C. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.

86. D. Legos are small plastic building blocks that could easily slip under the child’s cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the child’s cast and lead to a break in skin integrity and infection.

87. D. Oxytocin (Pitocin) is used to maintain uterine tone.

88. B. The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues.

89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)

90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors.

91. A. Personality disorders stem from a weak superego, implying a lack of adequate controls.

92. C. The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

93. A. This choice implies concern for client care and self-improvement.

94. C. The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.

95. C. This response does not contradict the client’s perception, is honest, and shows empathy.

96. D. Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.

97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit.

98. C. Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges.

99. B.  A normal respiratory rate for a newborn is 30-40 breaths per minute.

100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)