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NCLEX- RN Practice Exam 9 (PM)
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Question 1
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
A
Administer atropine intravenously
B
Increase the infusion of Dextrose in normal saline
C
Place the client in Trendelenburg position
D
Move the emergency cart to the bedside
Question 1 Explanation:
In clients who have not had surgery to the face or neck, the answer would be placing the client in Trendelenburg position ; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Administering atropine intravenously is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Moving the emergency cart to the bedside is not necessary at this time.
Question 2
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
A
The infant is at high risk for intrauterine growth retardation.
B
The infant is at high risk for birth trauma.
C
The infant is at low risk for congenital anomalies.
D
The infant is at high risk for respiratory distress syndrome.
Question 2 Explanation:
When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma. The L/S ratio does not indicate congenital anomalies, and the infant is not at risk for intrauterine growth retardation, .
Question 3
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
A
Notify the registered nurse.
B
Place the infant in a prone position.
C
Call a code blue.
D
Prepare to administer morphine sulfate.
E
Prepare to administer 100% oxygen by face mask.
F
Prepare to administer intravenous fluids.
Question 3 Explanation:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
Question 4
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
A
Elevated hepatic enzymes
B
Elevated creatinine clearance
C
Elevated platelet count
D
Elevated blood glucose
Question 4 Explanation:
The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. Elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in other choices. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome .
Question 5
Which selection would provide the most calcium for the client who is 4 months pregnant?
A
A granola bar
B
A bran muffin
C
A cup of yogurt
D
A glass of fruit juice
Question 5 Explanation:
The food with the most calcium is the yogurt. Other answer choices are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.
Question 6
A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?
A
Postural blood pressure changes
B
Slow bounding pulse
C
Intense thirst
D
Dry mucous membranes
Question 6 Explanation:
Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.
Question 7
Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.
A
Assist with activities of daily living.
B
Monitor for hemorrhage.
C
Administer eye medications.
D
Encourage coughing and deep breathing.
E
Educate regarding symptoms of retinal detachment.
F
Maintain the eye patch or shield.
Question 7 Explanation:
An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
Question 8
A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?
A
Inquiring about the client’s perception of the cause of the neighbor’s death
B
Identifying the client’s ability to function
C
Identifying the client’s potential for self-harm
D
Inquiring about the client’s feelings that may affect coping
Question 8 Explanation:
The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis.Inquiring about the client’s feelings that may affect coping pertains directly to the client’s feelings. Other answer choices do not directly address the client’s feelings.
Question 9
A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
A
Prevent cardiac irritability.
B
Treat hypocalcemic tetany.
C
Treat thyroid storm.
D
Stimulate the release of parathyroid hormone.
Question 10
A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.
A
Wearing a lead apron when providing direct care to the client
B
Placing the client in a semiprivate room at the end of the hallway
C
Keeping all linens in the room until the implant is removed
D
Wearing a film (dosimeter) badge when in the client’s room
E
Wearing gloves when emptying the client’s bedpan
Question 10 Explanation:
A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.
Question 11
A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
A
Early onset cough
B
Marked weight loss
C
Mild episodes of dyspnea
D
Purulent mucus production
E
Scant mucus
Question 11 Explanation:
Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.
Question 12
A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown?
A
Disconnecting the IV tubing from the catheter in the vein
B
Using a hospital gown with snaps at the sleeves
C
Putting the bag and tubing through the sleeve, followed by the client’s arm
D
Checking the IV flow rate immediately after changing the hospital gown
Question 12 Explanation:
The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection.Using a hospital gown with snaps at the sleeves and putting the bag and tubing through the sleeve, followed by the client’s arm are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.
Question 13
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
A
Continue primary care as prescribed
B
Report the finding to the doctor
C
Prepare the client for a C-section
D
Document the finding
Question 13 Explanation:
Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so documenting the finding is incorrect. The physician must make the decision to perform a C-section, making preparing the client for a C-section incorrect. It is not enough to continue primary care, so continuing primary care as prescribed is incorrect.
Question 14
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
A
Drinks several carbonated drinks per day
B
Likes to play football
C
Has two sisters with sickle cell tract
D
Is taking acetaminophen to control pain
Question 14 Explanation:
The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Other choices are not factors for concern.
Question 15
A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?
A
A 60-year-old male client with rhinitis
B
A 24-year-old male client with a lower back injury
C
A 10-year-old female client with a urinary tract infection
D
A 45-year-old female client with a history of migraine headaches
Question 15 Explanation:
Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in the remaining options.
Question 16
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
A
Warm toes
B
Paresthesia of the toes
C
Pain beneath the cast
D
Pedal pulses weak and rapid
Question 16 Explanation:
At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, pain beneath the cast, warm toes , and pedal pulses weak and rapid are incorrect.
Question 17
The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
A
Cover the insertion site with a Vaseline gauze
B
Order a chest x-ray
C
Call the doctor
D
Reinsert the tube
Question 17 Explanation:
If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Other answer choices are not the first action to be taken.
Question 18
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
A
Florescent treponemal antibody (FTA)
B
Thayer-Martin culture (TMC)
C
Venereal Disease Research Lab (VDRL)
D
Rapid plasma reagin (RPR)
Question 18 Explanation:
Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis. The Thayer-Martin culture is done for gonorrhea.
Question 19
A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?
A
Respiratory
B
Neurological
C
Cardiovascular
D
Psychosocial
Question 19 Explanation:
The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.
Question 20
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
A
Decrease the rate of IV infusion
B
Increase the rate of the IV infusion
C
Place her in Trendelenburg position
D
Administer oxygen per nasal cannula
Question 20 Explanation:
If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client.The IV rate should be increased, not decreased. In administering oxygen, the oxygen should be applied by mask, not cannula.
Question 21
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
A
The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
B
The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
C
The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
D
The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
Question 21 Explanation:
The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow elicits the triceps reflex, so it is incorrect. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer elicits the patella reflex, making it incorrect.The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist elicits the radial nerve, so it is incorrect.
Question 22
The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?
A
The client’s tissue turgor improves.
B
The client’s hemoglobin and hematocrit improve.
C
The client gains weight.
D
The client selects a balanced diet from the menu.
Question 22 Explanation:
The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat, making it incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, it is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so it is incorrect.
Question 23
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
A
Gonorrhea
B
Syphilis
C
Condylomata
D
Herpes
Question 23 Explanation:
A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so Syphilis is incorrect. Condylomata lesions are painless warts, so Condylomata is incorrect. Gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.
Question 24
A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?
A
A client admitted on the previous shift who has a diagnosis of gastroenteritis
B
A postoperative client preparing for discharge
C
A client on a ventilator
D
A client in skeletal traction
Question 24 Explanation:
The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in remaining options have needs that would be identified as intermediate priorities.
Question 25
A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
A
Explain the consequences without treatment
B
Ask the mother to leave while the blood transfusion is in progress
C
Encourage the mother to reconsider
D
Notify the physician of the mother’s refusal
Question 25 Explanation:
If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Asking the mother to leave while the blood transfusion is in progress is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, these choices are incorrect.
Question 26
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
A
Inspection of the abdomen for enlargement
B
Bimanual palpation for hepatomegaly
C
Daily measurement of abdominal girth
D
Assessment for a fluid wave
Question 26 Explanation:
Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers inspection of the abdomen for enlargement and bimanual palpation for hepatomegaly are incorrect. Palpation of the liver will not tell the amount of ascites; thus, assessment for a fluid wave is incorrect.
Question 27
A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
A
Increase the frequency of neurological assessments
B
Instruct the client regarding the drug therapy
C
Assess for signs of abnormal bleeding
D
Anticipate an increase in the Coumadin dosage
Question 27 Explanation:
The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Other answer choices may be needed at a later time but are not the most important actions to take first.
Question 28
A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
A
Hypovolemia
B
Hyperkalemia
C
Hypernatremia
D
Laryngeal edema
Question 28 Explanation:
The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be hypovolemia , as well as hyponatremia and hypokalemia, but these answers are not of primary concern so are incorrect.
Question 29
A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?
A
Gloves, a gown, and shoe protectors
B
Gloves and goggles
C
Gloves, a gown, and goggles
D
Gloves and a gown
Question 29 Explanation:
Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
Question 30
The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.
A
With the head in a midline position
B
With extreme hip flexion
C
With the neck flexed
D
Supine on the left side
E
In a semi-Fowler’s position
F
On the left side
Question 30 Explanation:
Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.
Question 31
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
A
Decreased urinary output
B
Hypersomnolence
C
Absence of knee jerk reflex
D
Decreased respiratory rate
Question 31 Explanation:
The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so these answers are incorrect.
Question 32
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
A
Alteration in bowel elimination
B
Ineffective individual coping
C
Alteration in skin integrity
D
Alteration in nutrition
Question 32 Explanation:
Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern.
Question 33
A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
A
Respiratory acidosis
B
Respiratory alkalosis
C
Metabolic acidosis
D
Metabolic alkalosis
Question 33 Explanation:
The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition.Respiratory acidosis and respiratory alkalosis deal with respiratory problems. Metabolic acidosis relates to acidosis.
Question 34
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
A
Wakefulness
B
Yawning
C
Crying
D
Jitteriness
Question 34 Explanation:
Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so Crying , Wakefulness, and Yawning are incorrect.
Question 35
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
A
The nurse places a padded tongue blade at the bedside.
B
The nurse darkens the room.
C
The nurse inserts a Foley catheter.
D
The nurse places a sign over the bed not to check blood pressure in the right arm.
Question 35 Explanation:
The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary, so other answer choices are incorrect.
Question 36
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
A
Ineffective airway clearance
B
Alteration in cerebral tissue perfusion
C
Fluid volume deficit
D
Alteration in sensory perception
Question 36 Explanation:
The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations.
Question 37
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
A
Ancef 2gm IVPB every 6 hours
B
Magnesium sulfate 4gm (25%) IV
C
Stadol 1mg IV push every 4 hours as needed prn for pain
D
Brethine 10mcg IV
Question 37 Explanation:
Brethine is used cautiously because it raises the blood glucose levels. Magnesium sulfate 4gm (25%) IV , Stadol 1mg IV, and Ancef 2gm IVPB are all medications that are commonly used in the diabetic client, so they are incorrect.
Question 38
A client with a diagnosis of HPV is at risk for which of the following?
A
Hodgkin’s lymphoma
B
Cervical cancer
C
Ovarian cancer
D
Multiple myeloma
Question 38 Explanation:
The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned like hodgkin’s lymphoma , multiple myeloma , and ovarian cancer, so those are incorrect.
Question 39
A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe?
A
Respirations that are regular but abnormally slow
B
Respirations that are abnormally deep, regular, and increased in rate
C
Respirations that cease for several seconds
D
Respirations that are labored and increased in depth and rate
Question 39 Explanation:
Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
Question 40
The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
A
Allow the client to keep the fruit
B
Offer to wash the fruit for the client
C
Place the fruit next to the bed for easy access by the client
D
Tell the family members to take the fruit home
Question 40 Explanation:
The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible.Other answer choices will not help prevent bacterial invasions.
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NCLEX- RN Practice Exam 9 (EM)
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Question 1
The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
A
Cover the insertion site with a Vaseline gauze
B
Call the doctor
C
Order a chest x-ray
D
Reinsert the tube
Question 1 Explanation:
If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Other answer choices are not the first action to be taken.
Question 2
A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
A
Metabolic alkalosis
B
Metabolic acidosis
C
Respiratory acidosis
D
Respiratory alkalosis
Question 2 Explanation:
The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition.Respiratory acidosis and respiratory alkalosis deal with respiratory problems. Metabolic acidosis relates to acidosis.
Question 3
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
A
Ancef 2gm IVPB every 6 hours
B
Brethine 10mcg IV
C
Stadol 1mg IV push every 4 hours as needed prn for pain
D
Magnesium sulfate 4gm (25%) IV
Question 3 Explanation:
Brethine is used cautiously because it raises the blood glucose levels. Magnesium sulfate 4gm (25%) IV , Stadol 1mg IV, and Ancef 2gm IVPB are all medications that are commonly used in the diabetic client, so they are incorrect.
Question 4
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
A
Administer oxygen per nasal cannula
B
Increase the rate of the IV infusion
C
Decrease the rate of IV infusion
D
Place her in Trendelenburg position
Question 4 Explanation:
If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client.The IV rate should be increased, not decreased. In administering oxygen, the oxygen should be applied by mask, not cannula.
Question 5
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
A
Ineffective airway clearance
B
Alteration in sensory perception
C
Fluid volume deficit
D
Alteration in cerebral tissue perfusion
Question 5 Explanation:
The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations.
Question 6
A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?
A
Postural blood pressure changes
B
Intense thirst
C
Dry mucous membranes
D
Slow bounding pulse
Question 6 Explanation:
Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.
Question 7
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
A
Is taking acetaminophen to control pain
B
Has two sisters with sickle cell tract
C
Likes to play football
D
Drinks several carbonated drinks per day
Question 7 Explanation:
The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Other choices are not factors for concern.
Question 8
A client with a diagnosis of HPV is at risk for which of the following?
A
Ovarian cancer
B
Hodgkin’s lymphoma
C
Multiple myeloma
D
Cervical cancer
Question 8 Explanation:
The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned like hodgkin’s lymphoma , multiple myeloma , and ovarian cancer, so those are incorrect.
Question 9
The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?
A
The client gains weight.
B
The client selects a balanced diet from the menu.
C
The client’s tissue turgor improves.
D
The client’s hemoglobin and hematocrit improve.
Question 9 Explanation:
The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat, making it incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, it is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so it is incorrect.
Question 10
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
A
Condylomata
B
Syphilis
C
Herpes
D
Gonorrhea
Question 10 Explanation:
A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so Syphilis is incorrect. Condylomata lesions are painless warts, so Condylomata is incorrect. Gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.
Question 11
Which selection would provide the most calcium for the client who is 4 months pregnant?
A
A glass of fruit juice
B
A bran muffin
C
A granola bar
D
A cup of yogurt
Question 11 Explanation:
The food with the most calcium is the yogurt. Other answer choices are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.
Question 12
A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?
A
Cardiovascular
B
Neurological
C
Respiratory
D
Psychosocial
Question 12 Explanation:
The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.
Question 13
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
A
Decreased urinary output
B
Absence of knee jerk reflex
C
Hypersomnolence
D
Decreased respiratory rate
Question 13 Explanation:
The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so these answers are incorrect.
Question 14
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
A
The nurse places a sign over the bed not to check blood pressure in the right arm.
B
The nurse inserts a Foley catheter.
C
The nurse places a padded tongue blade at the bedside.
D
The nurse darkens the room.
Question 14 Explanation:
The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary, so other answer choices are incorrect.
Question 15
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
A
Document the finding
B
Prepare the client for a C-section
C
Continue primary care as prescribed
D
Report the finding to the doctor
Question 15 Explanation:
Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so documenting the finding is incorrect. The physician must make the decision to perform a C-section, making preparing the client for a C-section incorrect. It is not enough to continue primary care, so continuing primary care as prescribed is incorrect.
Question 16
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
A
Warm toes
B
Pain beneath the cast
C
Pedal pulses weak and rapid
D
Paresthesia of the toes
Question 16 Explanation:
At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, pain beneath the cast, warm toes , and pedal pulses weak and rapid are incorrect.
Question 17
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
A
Alteration in nutrition
B
Alteration in bowel elimination
C
Ineffective individual coping
D
Alteration in skin integrity
Question 17 Explanation:
Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern.
Question 18
A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe?
A
Respirations that are regular but abnormally slow
B
Respirations that are labored and increased in depth and rate
C
Respirations that cease for several seconds
D
Respirations that are abnormally deep, regular, and increased in rate
Question 18 Explanation:
Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
Question 19
A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
A
Explain the consequences without treatment
B
Ask the mother to leave while the blood transfusion is in progress
C
Notify the physician of the mother’s refusal
D
Encourage the mother to reconsider
Question 19 Explanation:
If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Asking the mother to leave while the blood transfusion is in progress is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, these choices are incorrect.
Question 20
A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
A
Hypernatremia
B
Laryngeal edema
C
Hyperkalemia
D
Hypovolemia
Question 20 Explanation:
The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be hypovolemia , as well as hyponatremia and hypokalemia, but these answers are not of primary concern so are incorrect.
Question 21
A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?
A
A 10-year-old female client with a urinary tract infection
B
A 45-year-old female client with a history of migraine headaches
C
A 60-year-old male client with rhinitis
D
A 24-year-old male client with a lower back injury
Question 21 Explanation:
Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in the remaining options.
Question 22
A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
A
Instruct the client regarding the drug therapy
B
Increase the frequency of neurological assessments
C
Anticipate an increase in the Coumadin dosage
D
Assess for signs of abnormal bleeding
Question 22 Explanation:
The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Other answer choices may be needed at a later time but are not the most important actions to take first.
Question 23
The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
A
Tell the family members to take the fruit home
B
Allow the client to keep the fruit
C
Offer to wash the fruit for the client
D
Place the fruit next to the bed for easy access by the client
Question 23 Explanation:
The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible.Other answer choices will not help prevent bacterial invasions.
Question 24
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
A
Jitteriness
B
Wakefulness
C
Yawning
D
Crying
Question 24 Explanation:
Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so Crying , Wakefulness, and Yawning are incorrect.
Question 25
A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown?
A
Checking the IV flow rate immediately after changing the hospital gown
B
Putting the bag and tubing through the sleeve, followed by the client’s arm
C
Disconnecting the IV tubing from the catheter in the vein
D
Using a hospital gown with snaps at the sleeves
Question 25 Explanation:
The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection.Using a hospital gown with snaps at the sleeves and putting the bag and tubing through the sleeve, followed by the client’s arm are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.
Question 26
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
A
Elevated platelet count
B
Elevated hepatic enzymes
C
Elevated blood glucose
D
Elevated creatinine clearance
Question 26 Explanation:
The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. Elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in other choices. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome .
Question 27
A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
A
Treat thyroid storm.
B
Stimulate the release of parathyroid hormone.
C
Prevent cardiac irritability.
D
Treat hypocalcemic tetany.
Question 28
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
A
Inspection of the abdomen for enlargement
B
Daily measurement of abdominal girth
C
Assessment for a fluid wave
D
Bimanual palpation for hepatomegaly
Question 28 Explanation:
Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers inspection of the abdomen for enlargement and bimanual palpation for hepatomegaly are incorrect. Palpation of the liver will not tell the amount of ascites; thus, assessment for a fluid wave is incorrect.
Question 29
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
A
The infant is at high risk for birth trauma.
B
The infant is at high risk for intrauterine growth retardation.
C
The infant is at high risk for respiratory distress syndrome.
D
The infant is at low risk for congenital anomalies.
Question 29 Explanation:
When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma. The L/S ratio does not indicate congenital anomalies, and the infant is not at risk for intrauterine growth retardation, .
Question 30
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
A
Increase the infusion of Dextrose in normal saline
B
Administer atropine intravenously
C
Move the emergency cart to the bedside
D
Place the client in Trendelenburg position
Question 30 Explanation:
In clients who have not had surgery to the face or neck, the answer would be placing the client in Trendelenburg position ; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Administering atropine intravenously is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Moving the emergency cart to the bedside is not necessary at this time.
Question 31
A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?
A
Gloves and goggles
B
Gloves, a gown, and goggles
C
Gloves, a gown, and shoe protectors
D
Gloves and a gown
Question 31 Explanation:
Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
Question 32
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
A
The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
B
The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
C
The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
D
The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
Question 32 Explanation:
The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow elicits the triceps reflex, so it is incorrect. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer elicits the patella reflex, making it incorrect.The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist elicits the radial nerve, so it is incorrect.
Question 33
A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?
A
Inquiring about the client’s feelings that may affect coping
B
Inquiring about the client’s perception of the cause of the neighbor’s death
C
Identifying the client’s ability to function
D
Identifying the client’s potential for self-harm
Question 33 Explanation:
The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis.Inquiring about the client’s feelings that may affect coping pertains directly to the client’s feelings. Other answer choices do not directly address the client’s feelings.
Question 34
A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?
A
A client admitted on the previous shift who has a diagnosis of gastroenteritis
B
A postoperative client preparing for discharge
C
A client on a ventilator
D
A client in skeletal traction
Question 34 Explanation:
The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in remaining options have needs that would be identified as intermediate priorities.
Question 35
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
A
Call a code blue.
B
Notify the registered nurse.
C
Prepare to administer 100% oxygen by face mask.
D
Place the infant in a prone position.
E
Prepare to administer intravenous fluids.
F
Prepare to administer morphine sulfate.
Question 35 Explanation:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
Question 36
A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
A
Early onset cough
B
Marked weight loss
C
Mild episodes of dyspnea
D
Scant mucus
E
Purulent mucus production
Question 36 Explanation:
Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.
Question 37
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
A
Thayer-Martin culture (TMC)
B
Venereal Disease Research Lab (VDRL)
C
Florescent treponemal antibody (FTA)
D
Rapid plasma reagin (RPR)
Question 37 Explanation:
Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis. The Thayer-Martin culture is done for gonorrhea.
Question 38
The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.
A
With the neck flexed
B
On the left side
C
In a semi-Fowler’s position
D
With the head in a midline position
E
With extreme hip flexion
F
Supine on the left side
Question 38 Explanation:
Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.
Question 39
A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.
A
Keeping all linens in the room until the implant is removed
B
Wearing a film (dosimeter) badge when in the client’s room
C
Placing the client in a semiprivate room at the end of the hallway
D
Wearing gloves when emptying the client’s bedpan
E
Wearing a lead apron when providing direct care to the client
Question 39 Explanation:
A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.
Question 40
Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.
A
Monitor for hemorrhage.
B
Administer eye medications.
C
Encourage coughing and deep breathing.
D
Assist with activities of daily living.
E
Educate regarding symptoms of retinal detachment.
F
Maintain the eye patch or shield.
Question 40 Explanation:
An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
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1. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
Document the finding
Report the finding to the doctor
Prepare the client for a C-section
Continue primary care as prescribed
2. A client with a diagnosis of HPV is at risk for which of the following?
Hodgkin’s lymphoma
Cervical cancer
Multiple myeloma
Ovarian cancer
3. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
Syphilis
Herpes
Gonorrhea
Condylomata
4. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
Venereal Disease Research Lab (VDRL)
Rapid plasma reagin (RPR)
Florescent treponemal antibody (FTA)
Thayer-Martin culture (TMC)
5. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
Elevated blood glucose
Elevated platelet count
Elevated creatinine clearance
Elevated hepatic enzymes
6. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
7. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
Magnesium sulfate 4gm (25%) IV
Brethine 10mcg IV
Stadol 1mg IV push every 4 hours as needed prn for pain
Ancef 2gm IVPB every 6 hours
8. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
The infant is at low risk for congenital anomalies.
The infant is at high risk for intrauterine growth retardation.
The infant is at high risk for respiratory distress syndrome.
The infant is at high risk for birth trauma.
9. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
Crying
Wakefulness
Jitteriness
Yawning
10. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
Decreased urinary output
Hypersomnolence
Absence of knee jerk reflex
Decreased respiratory rate
11. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
Place her in Trendelenburg position
Decrease the rate of IV infusion
Administer oxygen per nasal cannula
Increase the rate of the IV infusion
12. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
Alteration in nutrition
Alteration in bowel elimination
Alteration in skin integrity
Ineffective individual coping
13. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
Inspection of the abdomen for enlargement
Bimanual palpation for hepatomegaly
Daily measurement of abdominal girth
Assessment for a fluid wave
14. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
Alteration in cerebral tissue perfusion
Fluid volume deficit
Ineffective airway clearance
Alteration in sensory perception
15. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
Likes to play football
Drinks several carbonated drinks per day
Has two sisters with sickle cell tract
Is taking acetaminophen to control pain
16. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
Allow the client to keep the fruit
Place the fruit next to the bed for easy access by the client
Offer to wash the fruit for the client
Tell the family members to take the fruit home
17. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
Place the client in Trendelenburg position
Increase the infusion of Dextrose in normal saline
Administer atropine intravenously
Move the emergency cart to the bedside
18. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
Order a chest x-ray
Reinsert the tube
Cover the insertion site with a Vaseline gauze
Call the doctor
19. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
ssess for signs of abnormal bleeding
Anticipate an increase in the Coumadin dosage
Instruct the client regarding the drug therapy
Increase the frequency of neurological assessments
20. Which selection would provide the most calcium for the client who is 4 months pregnant?
A granola bar
A bran muffin
A cup of yogurt
A glass of fruit juice
21. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
The nurse places a sign over the bed not to check blood pressure in the right arm.
The nurse places a padded tongue blade at the bedside.
The nurse inserts a Foley catheter.
The nurse darkens the room.
22. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
Ask the mother to leave while the blood transfusion is in progress
Encourage the mother to reconsider
Explain the consequences without treatment
Notify the physician of the mother’s refusal
23. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
Hypovolemia
Laryngeal edema
Hypernatremia
Hyperkalemia
24. The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?
The client selects a balanced diet from the menu.
The client’s hemoglobin and hematocrit improve.
The client’s tissue turgor improves.
The client gains weight.
25. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
Pain beneath the cast
Warm toes
Pedal pulses weak and rapid
Paresthesia of the toes
26. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
Scant mucus
Early onset cough
Marked weight loss
Purulent mucus production
Mild episodes of dyspnea
27. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?
Identifying the client’s ability to function
Identifying the client’s potential for self-harm
Inquiring about the client’s feelings that may affect coping
Inquiring about the client’s perception of the cause of the neighbor’s death
28. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown?
Using a hospital gown with snaps at the sleeves
Disconnecting the IV tubing from the catheter in the vein
Checking the IV flow rate immediately after changing the hospital gown
Putting the bag and tubing through the sleeve, followed by the client’s arm
29. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?
A client on a ventilator
A client in skeletal traction
A postoperative client preparing for discharge
A client admitted on the previous shift who has a diagnosis of gastroenteritis
30. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?
Respiratory
Psychosocial
Neurological
Cardiovascular
31. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.
Wearing gloves when emptying the client’s bedpan
Keeping all linens in the room until the implant is removed
Wearing a film (dosimeter) badge when in the client’s room
Wearing a lead apron when providing direct care to the client
Placing the client in a semiprivate room at the end of the hallway
32. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.
On the left side
With the neck flexed
Supine on the left side
With extreme hip flexion
In a semi-Fowler’s position
With the head in a midline position
33. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
Treat thyroid storm.
Prevent cardiac irritability.
Treat hypocalcemic tetany.
Stimulate the release of parathyroid hormone.
34. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?
Gloves and a gown
Gloves and goggles
Gloves, a gown, and goggles
Gloves, a gown, and shoe protectors
35. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
36. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe?
Respirations that cease for several seconds
Respirations that are regular but abnormally slow
Respirations that are labored and increased in depth and rate
Respirations that are abnormally deep, regular, and increased in rate
37. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.
Monitor for hemorrhage.
Administer eye medications.
Maintain the eye patch or shield.
Assist with activities of daily living.
Encourage coughing and deep breathing.
Educate regarding symptoms of retinal detachment.
38. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?
Intense thirst
Slow bounding pulse
Dry mucous membranes
Postural blood pressure changes
39. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?
A 60-year-old male client with rhinitis
A 24-year-old male client with a lower back injury
A 10-year-old female client with a urinary tract infection
A 45-year-old female client with a history of migraine headaches
40. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
Call a code blue.
Notify the registered nurse.
Place the infant in a prone position.
Prepare to administer morphine sulfate.
Prepare to administer intravenous fluids.
Prepare to administer 100% oxygen by face mask.
Answers and Rationales
Answer B. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.
Answer B . The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.
Answer B . A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Condylomata lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.
Answer C . Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis, so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea, so answer D is incorrect.
Answer D . The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer C is incorrect.
Answer A . Answer B elicits the triceps reflex, so it is incorrect. Answer C elicits the patella reflex, making it incorrect. Answer D elicits the radial nerve, so it is incorrect.
Answer B . Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so they are incorrect.
Answer C. When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer D is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, making answer B incorrect.
Answer C . Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers A, B, and D are incorrect.
Answer B. The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers A, C, and D are incorrect.
Answer D. If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B, the IV rate should be increased, not decreased. In answer C, the oxygen should be applied by mask, not cannula.
Answer A . Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus, answers B, C, and D are incorrect.
Answer C. Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus, answer D is incorrect.
Answer B. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect.
Answer A. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Answers B, C, and D are not factors for concern.
Answer D. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions.
Answer B. In clients who have not had surgery to the face or neck, the answer would be answer A; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time.
Answer C. If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers A, B, and D are not the first action to be taken.
Answer A. The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B, C, and D may be needed at a later time but are not the most important actions to take first.
Answer C. The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.
Answer C. The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary, so answers A, B, and D are incorrect.
Answer D. If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, so answers B and C are incorrect.
Answer B. The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, as well as hyponatremia and hypokalemia in C and D, but these answers are not of primary concern so are incorrect.
Answer D. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat, so answer A is incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, answer B is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so answer C is incorrect.
Answer D. At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, Answers A, B, and C are incorrect.
Answers: B, D, and E. Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.
Answer: C. The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis.Inquiring about the client’s feelings that may affect coping pertains directly to the client’s feelings. Other answer choices do not directly address the client’s feelings.
Answer: B. The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection.Using a hospital gown with snaps at the sleeves and putting the bag and tubing through the sleeve, followed by the client’s arm are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.
Answer: A. The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in remaining options have needs that would be identified as intermediate priorities.
Answer: B. The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.
Answer: A, B, C, and D. A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.
Answers: E and F. Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.
Answer: C.
Answer: C. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
Answer: B. The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition.Respiratory acidosis and respiratory alkalosis deal with respiratory problems. Metabolic acidosis relates to acidosis.
Answer: D. Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
Answers: A, B, C, D, and F. An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
Answer: D. Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.
Answer: C. Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in the remaining options.
Answers: B, D, E, and F. The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.