MOCK BOARD 3

NP1
101

A The focus of Nurse Managed Clinic is on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first
assess the clients and their needs to effectively plan the seminar. Options B, C and D do not address to the needs of the clients.

102

A In this situation, the nurse has noted an unusual occurrence, but before deciding what action to next take, the nurse needs more data than just
suspicion. This can be obtained by reviewing the client’s record. State and federal labor and narcotic regulations as well as institutional policies and
procedures must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. The
client doesn’t need to increase narcotics. To avoid assigning the LPN to the clients receiving narcotics only ignores the issue. A confrontation is not the most
advisable action, because the appropriate administrative authorities need to be consulted first.

103

C Myasthenia gravis can affect the client’s ability to swallow. The primary assessment is determining the clients ability to handle PO medications or
any oral substance. Options A and D are not appropriate. In this situation there is no reason for client to lie down to swallow medication or to look up to the
ceiling. There is no specific reason for the client to void before taking this medication.

104

A A tort is a wrongful act intentionally or unintentionally committed against a person or his or her property. The nurses’ inaction in the situation
described is consistent with the definition of a tort offense. Option B is an offense under criminal law. Option C describes case law that has evolved over time
via precedents. Option D describe laws that are enacted by state, federal, or local governments.

105

B Defamation takes place when something untrue is said (slander) or written (libel) about a person. Resulting injury to that person’s good name and
reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals
that fall below the standard of care for specific professional group.
106

C The incident report is confidential and privileged information and should not be copied, placed in the chart or have any reference made to it in the
client’s record. The incident report is not a substitute for complete entry in the client’s record concerning the incident

107

A For negligence to be proven, there must be a duty, then a breach of duty; the breach of duty must cause the injury, and damages or injury must be
experienced. Options B, C and D do not fall under the criteria for negligence. Option A is the only option that fits the criteria of negligence.

108

C Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goal directed, individualized
client care. Option A identifies functional nursing. Option B identifies a component of case management. Option D identifies team nursing.

109

C The client has the right to donate her or his own organs for transplantation. Any person 18 years of age or older may become an organ donor by
written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent’s organs.

110

D When a corneal donor dies, the eyes are closed and gauze pads wet with saline solution are placed over them with a small ice pack. Within 2 to 4
hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated.

111

A Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources
to maximize hospital revenues while providing optimal outcome care. It manages the client care by managing the client care environment.
112

A Work that is delegated to others must be done consistent with the individual’s level of expertise and licensure or lack of licensure. In this case, the
least appropriate activity for a nursing assistant would be assisting with feeding profoundly developmentally disabled child. The child is likely to have
difficulty in eating, and therefore has a high potential for complications such as choking and aspiration. The remaining three options do not include situations
to indicate that these activities carry any risk.

113

C Variances are actual deviation or detours from the critical path. Variances can be either positive or negative, avoidable, or unavoidable and can be
caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance
occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early so
that appropriate action can be taken. Option C is the only option that identifies the need for further action.

114

D Participative leadership suggests a compromise between authoritarian and democratic style. In participative leadership, the leader represents his and
her own analysis of the problems and proposal for action to members of the team, inviting critics and comments. The participative leader then analyzes the
comments and makes final decision. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, and
supervision. The autocratic style of leadership is task oriented and directive. In the situational leadership style, the style employed depends on the situation and
events.
115

D To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of bed leaning over the bedside table with the feet
supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45
degrees. The prone and Sims’ positions are inappropriate positions for this procedure.

116

B Use the following formula for calculating medication dosages: Desired divided by Available multiplied by 1 Capsule = Capsule(s) per dose; 100 mg
divided by 50 mg multiplied by 1 Capsule = 2 Capsules

117

C Restraints should never be applied tightly, because it could impair the circulation. The restraint should be applied securely to prevent the client from
slipping through the restraint and endangering himself/herself. A hitch knot may be used on the client because it can easily be released in an emergency over 2
hours (or per agency policy) to inspect the skin for abnormalities. The call light must always be within the client’s reach in case the client needs assistance.

118

A Warm water should be used for hand washing, because it increases the sudsing action of the soap. Hands should be kept downward to enable the
unsanitary material to fall off the skin. The faucet should be turns off by using towels to prevent the hands from getting recontaminated.

119

B Standard precautions involves body substance and universal precautions. The nurse would wear a mask and goggles when suctioning the client.
Sterile gloves are worn. A mask would offer full protection of the nose and the mouth. Goggles would protect the eyes from getting injured. A gown would
protect the nurse’s uniform and a cap would protect the nurse hair, but these items are not required for suctioning a client.

120

B To reduce the risk of falls, all obstacles must be removed from the home. Not all pets are trip hazards (fish, birds, guinea pigs). Grab bars in the
bath tub or shower will not necessarily assist the client while walking with crutches. Shoes with nonslip soles should be worn.

121

C Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly
may cause the client to have a violent episode. Walking up behind the client may cause the client to become startled and react violently. Remaining at the
entrance of the room may make the client feel alienated. If the client’s agitation is not addressed, it will only increase. Therefore waiting for the agitation to
subside is not an appropriate option.

122
B Syringes should never be recapped in any circumstances because of the risk of getting pricked with a contaminated needle. Used syringe should
always be placed in a sharps container immediately after use to avoid individuals getting injured. A syringe should not be swept up, because this action poses
an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe

123

A When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four point of the walker two feet
forward flat on the floor before putting weight on the hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then
instructed to move the walker forward and walk into it.

124

B With the client’s elbows flexed 20 to 30 degrees, the shoulders in a relaxed position, and crutches placed approximately 15 cm (6 inches)
anterolateral from the toes, the nurse should be able to place two fingers comfortably between the axillae and axillary bars. Crutches are adjusted if there is too
much or too little space for the axillary area. The client is advised never to rest the axillae and the axillary bars because this could injure the brachial plexus (the
nerve in axillae that supply the arm and shoulder area). The nurse should terminate ambulation and recheck the crutch height if the client complains of
numbness or tingling in the hands or arms.

125

A A sterile solution such as normal saline should be used for perineal care using an aseptic syringe or a water pick. This should be done regularly at
least twice a day and after each voiding and BM. The wound is intermittently exposed to air to permit drying and prevent maceration. Once sutures are
removed, sitz baths may be prescribed to stimulate healing and for the soothing effect.

126

B Early ambulation should not exceed the client’s tolerance. The client should be assisted before sitting. The client is assessed to rise from the lying
position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed
slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client’s side to provide physical support and encouragement.

127

D The catheter’s balloon is behind the opening at the insertion tip. The catheter is inserted to 2.5 to 5 cm after urine begins to flow in order to provide
sufficient space to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra.
Inflating the balloon in the urethra could produce trauma.

128

C Sputum specimens for culture should be labeled and transported at the laboratory immediately. Identification of the organism is critical in
determining the appropriate treatment for the client. If the sputum sample is not transported immediately for culture, organisms will collect and the potential
for contamination of the sample exists, which will then alter results. Options A, B, and D are important but option C identifies the priority action.

129

C Chlamydia is a sexually transmitted disease, and is frequently called non-gonococcal urethritis in the male client. It requires no special precautions
other than universal precautions. Caregivers cannot acquire the disease during administration of care, and using universal precautions is the only measure that
needs to be used.

130
A A client must be alert, able to communicate and competent to sign an informed consent. If the client is unable to, the family can sign the consent. A
living will lists the medical treatment a person chooses to omit or refuse if the person becomes unable to make decisions and is terminally ill. Advance
directives are forms of communication in which persons can give direction on how they would like to be treated when they cannot speak for themselves.

131

A Clients known or suspected of having TB should wear a mask when out of the room to prevent the spread of the infection to others. A gown or
gloves are not necessary.

132

C The nurse removes the goggles first. The nurse unties the gown at the waist and then removes the goggles and discards them. The nurse then
removes and discards the mask, unties the neck strings of the gown and allows the gown to fall from the shoulders. The gown is removed without touching the
outside of the gown and discarded. The hands are then washed.

133

D Following administration of an IM injection, the nurse would massage the site to assist in medication absorption. Then the nurse assists the client to
a comfortable position. The uncapped needle is discarded in a puncture-resistant container, gloves are removed and hands are washed. A needle is never
recapped. Of the options provided, the nurse would perform the option D first.
134

D Since the telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call.
This, however, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach.
Additionally, the client’s door should be closed or the room curtains pulled around the bathing area.

135

A Restraints do not necessarily prevent falls. Restraints are devices used to restrict client’s movement in situations when it is necessary to immobilize
a limb or other body part. They are applied to prevent self-inflicted injury or from injuring others; from pulling out intravenous lines, catheters, or tubes; or
from removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures.
Restraints should not be used as a form of punishment.

136

A A urine specimen in not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily
reflect the current client status. In addition, it may become contaminated with bacteria from opening system.

137

A Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The
perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level
of the bladder to prevent urine from being trapped in the bladder, and for the same reason, the drainage tubing is not placed or looped under the client’s leg.
The tubing must drain freely at all times.

138
.
D Safe nursing actions intended to prevent injury to the client include keeping the side rails up, the bed in low position, use of a night-light, and
providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get
up alone, which could result in a fall. Communicating with the client via an intercom does not meet the client's need to prevent potential injury.

139

B The use of restraints needs to be avoided if possible. If the nurse determines that a restraint is necessary, this should be discussed with the family and
an order needs to be obtained from the physician. The physician’s order protects the nurse from liability. The nurse should explain carefully to the client and
family about the reasons that the restraint is necessary, the type of restraint selected, and the anticipated duration of restraint. If the nurse applied a restraint on a
client who was refusing it, the nurse could be charged with battery. Compromising with the client is unethical.

140

B Oxygen is a highly combustible gas, although it will not spontaneously burn or cause explosion. It can easily cause a fire to ignite in a client’s room
if it contacts a spark from a cigarette, burning candle, or electrical equipment. Options A, C and D are appropriate oxygen safety measures.

141

D Electrical equipment should be grounded. The third longer prong in an electrical plug is the ground. Theoretically, the ground prong carries any
stray electrical current back to the ground, hence its name. The other two prongs carry power to the piece of electrical equipment. In this situation the nurse
obtains three-prong grounded plug adapter, attaches it to the cord, and plugs it into the wall. Option A, B, and C are unsafe actions.

142

C Area rugs and runners should not be based on stairs. Any carpeting on the stairs should be secured with carpet tacks. Injuries from the home
frequently result from objects, including small rugs on the stairs and on the floor, wet spots on the floor, clutter on the bedside tables, on closet shelves, on the
top of refrigerator, and on bookshelves. Care should always be taken to ensure that the tables are secure and have stable straight legs. Nonessential items
should be placed in drawers to eliminate clutter.

143

D A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Most health care
facilities have documents for the client to sign that relate the client’s responsibilities when he or she leaves against medical advice (AMA). The client should be
asked to sign this document before leaving. The nurse should request the client to wait and speak to the physician before leaving, but if the client refuses to do
so, the nurse cannot hold the client against his will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a
right to health care and cannot be told otherwise.

144
B Defamation occurs when information is communicated to a third party that causes damage to someone else's reputation either in writing (libel) or
verbal (slander). Common examples are discussing information about a client in public areas, or speaking negatively about co-workers. The situation
identified in the question can cause emotional harm to the client and the nurses could be charged with slander. This situation also violates the client’s right to
confidentiality.

145

D Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can only work in specified areas, or the nurse can prove the lack
of knowledge for the performance of an assigned task. When encountered with this situation, the nurse should set priorities and identify potential areas of
harm to the client. All pertinent facts related to client care problems and safety issues should be documented. The nurse should perform only those tasks in
which training has been received. It is the nurse’s responsibility to clearly describe these tasks.

146

D The RN must remember that even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall
nursing care of the client. Only the task, not the ultimate accountability may be delegated to another. The RN is responsible for ensuring that competent and
accurate care is delivered to the client. Requesting that another LPN observe the procedure does not ensure that the procedure will be done correctly. Since this
is a new procedure for this LPN, the RN should accompany the LPN, provide guidance and answer questions following the procedure.

147

D In accordance with the agency's policies, nurses are required to file incident reports when a situation arises that could or did cause client harm. The
nurse also contacts the physician. If a dose of 0.125 mg was prescribed, and a dose of 0.25 was administered, then the client received too much medication.
Additional medication is not required and in fact could be detrimental. The client should be informed when an error has occurred, but in a professional manner
so as not to cause great fear and concern. In many situations, the physician will discuss this with the client.

148

D Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower
extremity, movement should always occur toward the client's unaffected (strong) side. For example, if the client's right leg is involved, and the client is sitting
on the edge of the bed, position the wheelchair next to the client's left side. This wheelchair position allows the client to use the unaffected leg effectively and
safely.
149

C A potential organ donor must meet age eligibilty requirements, which vary by organ. For example, age must not exceed 65 years for kidney
donation, 55 years for pancreas or liver donation, and 40 years for heart donation. The client should be free of communicable disease, such as human
immunodeficiency virus, hepatitis, or syphilis and the involved organ must not be diseased. Another contraindication is malignancy, with the exception of
noninvolved skin and cornea.

150

A Adequate perfusion must be maintained to all vital organs in order for the client to remain viable as an organ donor. A urine output of 45 mL / hr
indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH
of 7.32 is acidotic, which adversely affects all body tissues.

151

B Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore, the client who was
previously dehydrated to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. Thus, the nurse prepares to infuse IV
fluids as prescribed, and continues to monitor urine output. Options A, C and D will not maintain viability of the kidneys.

152

D Basic rules for handling evidence include limiting the number of people with access to the evidence; initiating a chain of custody log to track
handling and movement of evidence; and careful removal of clothing to avoid destroying evidence. This usually includes cutting clothes along seams, while
avoiding areas where there are obvious holes or tears. Potential evidence is never released to the family to take home.

153

A The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and
would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as delayed,
requiring intervention within 30 to 60 minutes. A green or minimal designation would be given to the client with a fractured tibia, who requires intervention but
who can provide self-care if needed. A designation of expectant would be applied to the client with massive injuries and minimal chance of survival. This client
would be color coded black in the triage process. The client who is color-coded black is given supportive care and pain management, but is given definitive
treatment last.

154
B The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of
the problem. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services, and support from the family
at home.

155

D Proper handwashing procedure involves wetting hands and wrists, keeping hands lower than forearms so water flows toward the fingertips. The
nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds using rubbing and circular motions. The hands are rinsed and then dried, moving from the fingers
to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination.

156

B When using a hydraulic lift, the client is positioned in the center of the sling, which is then attached to chains or straps that attach the sling to the lift.
The client's hands and arms are crossed over the chest, and the client is raised from the bed into a sitting position. The client is also raised off the mattress with
the lift, and is lowered slowly once the sling is positioned over the chair.

157

D If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm activating bracelet, or "wandering
bracelet." This allows the client to move about the residence freely while preventing the client from leaving the premises. Options A,B,and C are restrictive
devices and should not be used.

158

D When completing an incident report, the nurse should state the fact clearly. The nurse should not record assumptions, opinions, judgments, or
conclusions about what occurred. The nurse should not point blame or suggest how to prevent an occurrence of a similar incident.

159

A Nurses are advised not to document the filing of an incident report in the nurses notes for legal reasons. Incident reports inform the facility's
administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences in the future. Incident reports also
alert the facility's insurance company to a potential claim and the need for further investigation. Option B,C and D are accurate interventions.

160

C Nurses are encouraged not to accept verbal orders from the physician because of the risks of error. The only exception to this may be in an
emergency situation and then the agency policy and procedure must be adhered to. Although the client will be informed of the change of the treatment plan, this
is not the most appropriate action at this time. The physician needs to write the new order. It is inappropriate to ask another individual other than the physician
to write the order.

161

C Mercury is a hazardous material. Accidental breakage of a mercury-in-glass thermometer is a health hazard to the client, nurse, and other health care
workers. Mercury droplets are not to be touched. If a breakage or spill occurs, the Environmental Services Department is called and a mercury spill kit is used
to clean up the spill.

162

D Remember the acronym RACE to set priorities if a fire occurs. “R” stands for rescue. “A” stands for alarm. “C” stands for confine. “E” stands for
extinguish. In this situation, the client has been rescued from the immediate vicinity of the fire. The next action is to activate the fire alarm.

163
A Proper documentation of unusual occurrences, incidents and accidents, and the nursing actions taken a result of the occurrence, are internal to the
institution or agency and allow the nurse and administration to review the quality of care and determine any potential risks present. Incident reports are not
routinely filled out for interventions nor are they used to report occurrences to other agencies.

164

B Nurse practice acts require reporting the suspicion of impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may
develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing.

165
A Invasion of privacy takes place when an individual’s private affairs are unreasonably intruded into. Telling the client that he or she cannot leave the
hospital constitute false imprisonment.
166

C A Good Samaritan Law is passed by state legislator to encourage nurses and other health care providers to provide care to a person when an
accident, emergency, or injury occurs, without fear of being sued for the care provided. Called immunity from suit, this protection usually applies only if all of
the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and
wantonly negligent.
167

B Generally, the informed consent of an adult client is not needed in two instances. One instance is when the emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to
give informed consent.

168

C Living wills are required to be in writings and signed by the client. The client’s signature either must be witnessed by specified individuals or
notarized. Many states prohibit any employee, including a nurse of a facility where the declaring is receiving care, from being a witness. The nurse should
decline to sign the will.

169

B Confidential issues are not to be discussed with non-medical personnel or the person’s family or friend without the person’s permission. Clients
should be assured that information is kept confidential, unless it places the nurse under a legal obligation. The nurse must report situations related to child or
elderly abuse, gunshot wounds, and certain infectious diseases.

170

C When a corneal donor dies, the eyes are closed and gauze pads wet with saline solution are placed over them with a small ice pack. Within 2 to 4
hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated.

171

A External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a
written “Do Not Resuscitate” (DNR) order from the physician must be present. The DNR order must be reviewed or renewed on a regular basis per agency
policy. Although options B, C, and D may be appropriate, remember that first a written physician’s order is necessary.

172

B External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a
written “Do Not Resuscitate” (DNR) order from the physician must be present on the client’s record. The DNR order must be reviewed or renewed on a regular
basis per agency policy.

173

A Nurses need their own liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an
agency’s professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse’s actions or inaction’s. Even though this is the
norm, nurses are encouraged to have their own malpractice insurance.

174

C Floating is an acceptable, legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless union
contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When
encountered with this situation, nurses should set priorities and identify potential areas of harm to the client. The nursing supervisor or the nurse educator may
need to become involved in the situation at some point if the nurse requires assistance or education regarding a new skill, but the action that the nurse must take
is identified in option C.

175

D The nurse should document task completion continuously throughout the day. Options A, B, and C identify accurate components of time
management.

176

D Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical
paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward event preclude a
timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options A, B and C are incorrect.
177

A The autocratic style of leadership is task oriented and directive. The leader used his or her power and position in an authoritarian manner to set and
implement organizational goals. Decisions are made without input from the staff. Democratic styles best empower staff toward excellence because this style of
leadership allows nurses an opportunity to grow professionally. Situational leadership style utilizes a style depending on the situation and events. Laissez-faire
allows staff to work without assistance, direction or supervision.

178

A The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual
staff members. Team nursing is characterized by a high degree of communication and collaboration between members. The team is generally led by a registered
nurse who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client’s plan of care. In an exemplary model of nursing,
each staff member works fully within the realm of his or her educational and clinical experience in an effort to provide comprehensive individualized client
care. Each staff member is accountable for client care and outcomes of care. In primary nursing, the concern is with keeping the nurse at the bedside actively
involved in care, providing goal-directed and individualized client care.

179

D Edema of the stump is controlled by elevating the foot of the bed for the first 24 hours after surgery. Following the first 24 hours, the stump is placed
flat on the bed to prevent hip contracture. Edema is also controlled by stump wrapping techniques.

180

D When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first
step can prevent many future problems, because if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is
followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.

181

C Following spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This individual is able to provide
information about resources available to the client. The physical therapist has the best knowledge of techniques form increasing mobility and endurance. The
clinical nurse specialist and surgeon would not have the necessary information to financial resources.

182

C The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward oneself, the dying person, God
or other spiritual being, or the caregivers. Option A and B indicate possibly rash and unilateral decisions made by the husband, without taking into consideration
anyone else’s feelings. There is evidence of denial in option D, as he refuses to visit his wife or discuss her illness. The only response that indicates effective
individual coping by the husband is option C

183

B The sun’s rays are as damaging to the skin on cloudy hazy days as they are on sunny days. Sunscreens with an SPF of 15 or more are recommended
and should be applied before exposure to the sun and reapplied frequently and liberally at least every 2 hours. A hat, long sleeved shirt, and long pants should
be worn when out in the sun. Tightly woven materials provide greater protection from the sun’s rays.

184

C An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious
circumstances. It is not a requirement of federal law. It is not mandatory that every client who is DOA have an autopsy. If a family requests not to have an
autopsy performed on a family member, then the nurse should contact the medical examiner about the request.

185

D While discontinuing an IV is a painless experience, it is not therapeutic to tell a client not to worry. Option B does not acknowledge the client’s
feelings and does not tell the client that an infiltrated IV may need to be restarted. Option C does not address the client’s feelings. Option D addresses the
client’s anxiety and honestly informs the client that the IV will need to be restarted. This option uses the therapeutic technique of giving information as well as
acknowledging the client’s feelings.

186

D Before radial puncture for obtaining an arterial specimen for ABGs, an Allen test should be performed to determine adequate ulnar circulation.
Failure to assess collateral circulation could result is severe ischemic injury to the hand, if damage to the radial artery occurs with arterial puncture. The other
options are incorrect.

187
D The family member is exhibiting the first stage of grief, denial. Option A may be an appropriate intervention for the bargaining stage. Option B
may be an appropriate intervention for the depression stage. Option C is an appropriate intervention for the acceptance or reorganization and restitution stage.

188

C The principles of maintaining IV therapy at home are the same as in the hospital. It is extremely important to assure that the IV site is anchored
properly in order to reduce the risk of phlebitis and infiltration. Massaging the site may actually contribute to catheter movement and tissue damage. Dressing
surrounding peripheral IV sites are changed and cleansed at various times (usually every 2 to 5 days) depending on facility protocols. Immobilizing the
extremity is not routinely necessary for peripheral IV sites.

189

D Food items and liquids that are naturally high in phosphate should be avoided by the client with hyperphosphatemia. These include fish, egg, milk
products, vegetables, whole grains, and carbonated beverages.

190

B Elevation of the affected leg facilitates blood flow by the force of gravity and also decrease venous pressure, which in turn relieves edema and pain.
Bed rest is indicated to prevent emboli and to prevent pressure fluctuation in the venous system that occur with walking. Thus, the nurse documents to elevate
the left leg. Options A, B and D are inappropriate positions and will not facilitate blood flow.

191

B Acquisition of psychomotor skills is best evaluated by observing how a client can carry out a procedure. The client may be able to verbalize how to
do the procedure, but may not be able to actually perform the psychomotor function. Reviewing the entire plan again, and demonstrating it again will not
evaluate the client’s ability. Actively demonstrating is always the best method of evaluating a psychomotor skill.

192

D This procedure requires a signed informed consent, because it involves injection of a radiopaque dye into the blood vessel. Although options A, B
and C are components of the preprocedure assessment, the risk of allergic reaction and possible anaphylaxis is most critical.

193

B Intravenous fat emulsions (Intralipids) can cause overloading syndrome (focal seizures, fever, shock) and adverse effects including chest pain, chills,
and shock. The priority action is to stop the infusion and limit the adverse response before obtaining additional assistance.

194
B An implanted port is placed under the skin and is not visible. There is no tubing external to the body. Tubing is used only when the port is assessed
intermittently and the IV line is connected. Showing the client various other tubes will not be beneficial because the client will not be using them. It is
premature to notify the physician. Option D does not correct the client’s confusion regarding the implanted port.

195

A Foods containing high amount of purines should be avoided in the client with uric acid stones. This include limiting or avoiding organ meats, such
as liver, brain, heart, and kidney. Other foods to avoid include sweetbreads and gravies. Food that are low in purines include all fruits, many vegetables, milk,
cheese, eggs, refined cereals, coffee, tea, chocolate, and carbonated beverages.

196

C A client dehydration has a low CVP. The normal CVP is between 4 and 11 mm H2O. Other assessment finding with fluid volume deficit are
increased pulse and respiration, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific
gravity, increased hematocrit and altered level of consciousness. The assessment signs in options A, B and D occur with fluid volume excess.

197

C The pain associated with drainage of pleural effusion is minimized by positioning the client for comfort and administering analgesics for relief of
pain. The nurse also offers verbal support reassurance. All of these measures help the client to cope with the pain and discomfort associated with this problem.
It is least helpful to leave the client alone for extended periods, because the client may experience continued pain, which may be augmented by isolation.

198

B Oral antacids commonly contain bicarbonate or other alkaline components. These bind into the hydrochloric acid in the stomach to neutralize the
acid. Excessive used of oral antacid containing bicarbonate can cause a metabolic alkalosis over time. Options A, C and D are incorrect.
199

A An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness and swelling are the result of IV
fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The
corrective action will be to remove the catheter and have a new IV line started. The other three options are likely to be accompanied by warmth at the site, not
coolness. The nurse would document that the client’s IV has infiltrated.

200

D Antibiotics are not taken prophylactically to prevent Chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners,
and by the use of condoms. In some instances, follow-up culture is requested in 4 to 7 days to confirm a cure.

NP 2
201

A The expression is known to be a normal response to impending loss, and the anger may be directed toward oneself, God or other spiritual being, or
the caregivers. The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. Notifying the
hospital lawyer is inappropriate. Guilt may or may not be a component of the client’s feelings, and the data in the question do not provide an indication that
guilt is present.

202

C. Treatment for a recurrent infection should be continued through the menstrual period, because the vagina is more alkaline during this time, and a
flare-up is likely to occur. The client should refrain from sexual intercourse while the infection remains active. If this is not possible a condom is
recommended. Options A B and D are correct.

203

D Keeping the testes cool by avoiding hot baths and tight clothing appears to improve the sperm count. Avoiding factors that depress spermatogenesis
such as the use of drugs, alcohol, marijuana, and exposure to occupational or environmental hazards, and maintaining good nutrition are key components to
prevent infertility.
204

C Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring therefore options C is correct.
Options A, B and D are secondary prevention measures that seek to detect existing health problems or trends.

205

C The nurse assists the client to express feelings and deal with the aspects of illness and treatment. In option C, the nurse use clarifying and focusing to
encourage the client to explore concerns. Blocks to communication such as giving opinions and changing the subject will stop the client from verbalizing
feelings.

206

D In the European-American culture, eye contact is viewed as indicating trustworthiness. Eye contact is considered rude in the Asian-American
culture. Arrogance and uneasiness are incorrect interpretation of this nonverbal communication in the European-American client.

207

D Primary prevention for PID includes avoiding unprotected intercourse, avoiding multiple sexual partners, avoiding the use of an IUD, and avoiding
douching.

208

D Having the bathroom on the second floor and the bedroom on the first floor may pose a problem for the elderly client with incontinence. The need
to negotiate the stairs and the distance may interfere with reaching the bathroom in a timely fashion. It is more helpful to the incontinent client to have a
bathroom on the same floor as the bedroom, or to have a commode rented for use. The presence of night-lights and hand railings is helpful to the client in
reaching the bathroom quickly and safely.

209

B Caregiver strain can occur when a client is significantly dependent on someone for their personal and health care needs. Options A is not
appropriate. The nurse should not expect the client to assess the coping abilities of the caregiver. Although a social worker may be helpful, the nurse needs to
perform the assessment of the situation before making the referral. Waiting for the caregiver to express concern is not appropriate. The caregiver may be
exhausted or incapable of caring for the client by this time.

210

A Food preferences of European-American include carbohydrates, such a potatoes and red meat. Native American preferences include blue cornmeal,
fish, game, fruits, and berries. Asian-Americans prefer rice and raw fish. Dietary laws are adhered to by members of the Jewish community.

211

B Asian-American food preferences include raw fish, rice, and soy sauce. African-American food preference includes pork, greens, rice, and fried
foods. Hispanic Americans prefer beans, fried foods, spicy foods, chili, and carbonated beverages. European-Americans prefer carbohydrates and red meat.

212

A A fracture pan is designed for used in clients with body or leg acts. A client with a spica cast (body cast) that covers a lower extremity cannot bend
at the hips to sit up. Therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care.

213

D In the European-American culture, the man is the dominant figure. Community social organizations are important in this culture. Health is often
viewed as the absence of disease or illness. European-Americans tend to be aloof, to avoid physical contact, and to appear stoic when expressing physical
concerns.

214

C Clients receiving total parental nutrition are at risk for development of essential fatty acid deficiency. However, the client's comment requires more
than an informational response initially. Option C assists the client to express feelings and deal with aspects of illness and treatment. Option A provides an
option. Option B places the client's feelings on hold. Option D devalues the client's feelings.

215

A Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The nurse needs to
maintain and enhance communication as well as preserve the family’s sense of self-direction and control. Option B is likely to enhance communication. Option
C is also an effective intervention, because spiritual practices give meaning to life and have impact on how people react to crisis. Option D is also an effective
technique, and the family needs to know that someone will be there who is supportive and nonjudgmental. Option A removes autonomy and decision making
from the family members at a time when they are already experiencing feelings of loss of control This is an ineffective intervention that can impair
communication.

216

A The family’s response is an external perception and is extremely important. Families derive a great deal of comfort from knowing that their loved
ones received the best care possible. Option A provides external validation that the client received comprehensive, high-quality care. Option B focuses on
physician’s orders rather than client care. Option C focuses on the feelings of a new nurse, who may be expressing his or her own anxiety. Option D reflects
only one aspects of caring for a dying client.

217

D If a nurse makes an error in documenting in the client's record, The nurse should follow agency policy to correct the error. This includes drawing
one line through the error, initialing and dating the correction, and then providing the correct information. Erasing data from the client's record and the use of
whiteout are prohibited. A late entry is used to document additional information not remembered at the initial time of documentation.

218

A The incident report should contain the client’s name, age, and diagnosis. It should contain a factual description of the incident, any injuries
experienced by those involved, and the outcome of the situation. Option A is the only option that describes the facts as observed by the nurse. Option B, C and
D are interpretations of the situation and are not factual data as observed by the nurse.

219

C Major sources of fats include meats, salad dressings, eggs, butter, cheese, and bacon. Options A, B and D contain high-fat foods.

220

B Confusion in the elderly client with a hip fracture could result from the unfamiliar hospital setting, stress due to the fracture, concurrent systemic
diseases, cerebral ischemia, or side effects of medications. Use of eyeglasses and hearing aides enhance the client’s interaction with the environment, and can
reduce disorientation.

221

C When a client has central line place in the subclavian area, the client is able to move as tolerate with no restrictions of movement. The client may
have pain when the catheter is placed, but the pain will not last continuously. The client may, however, be self-conscious about the IV altering body image

222

A Strict aseptic technique is vital during dressing changes because the IV catheter can serve as a direct entry for microorganisms. Options B, C and D
are not measures that will prevent infection.

223

C In option A, the nurse is seeking clarification and empathy. The client’s question reflects the fact that the client has been thinking about the will and
how best to obtain an executor. What is unknown is why the client is asking the nurse to be executor of the will and other specific and important information. In
addition, the nurse would want to investigate the legal ramifications, which could arise if such a position was accepted. In option A, the nurse responds with a
social communication with no assessment of the consequences, which is lacking critical thinking and exploration of motivation or client needs. In option B, the
nurse uses histrionic language and crass ideation. In option D, nurse provides false reassurance, which is nontherapeutic.

224

C Clients admitted from home into a long-term-care facility are dealing with losses in independence, privacy, and control over their environment.
Providing total care does not facilitate independence. Medicating for pain will keep the client comfortable, but this does not address psychological needs.
Sitting with the client to allow the client to express feelings is the best way to address psychosocial needs. Participation in daily social activities will not meet
the special psychosocial needs of this client.

225

C In the correct option, the more uses reflection to redirect the client’s feelings back for validation and focuses on the client’s desire to talk with the
physician. Options B and D are nontherapeutic responses. Option A is a response that reinforces the client to continue this behavior.

226

A Procainamide (Pronestyl) is an antidysrrhythmic that is available in a sustained-release (SR) form. The sustained-release preparations should not be
broken, chewed, or crushed. The SR form has a wax matrix that may be noted in the stool and is not significant. If a dose is missed, a sustained-release tablet
may be taken if remembered within 4 hours (2 hours for regular acting form); otherwise the dose should be omitted. The client or family member should be
taught to monitor the client’s pulse, and report any change in rate or rhythm.

227

C Products that are naturally high in calcium are dairy products, including milk, cheese, ice cream, and yogurt. High-calcium foods generally have
greater than 100 mg of calcium per serving. The other options are foods that are low in calcium, which means that they have less than 25 mg of calcium per
serving.

228

D Avoiding physical closeness, limiting eye contact, avoiding hand gestures, and clarifying responses to questions are all components of the plan of
care for an Asian-American client. The head is considered to be sacred; therefore touching the client’s head only when necessary, and inform the client before
doing so.

229

B For effective communication, the nurse uses active listening and creates an environment in which the client feels comfortable expressing feelings.
An authorization approach is directive and demeaning and will not create an environment for verbal exchange from the client. Reacting only to the facts is an
example of inactive listening. Reacting enthusiastically is not the most effective strategy.

230

C The nurse determines that the client has maintained adequate nutritional state if the client does not lose more than 10% of body weight.
Mathematically, this is the same as maintaining 90% of body weight.

231

C The most accurate way of measuring the effectiveness of nutritional management of the client is monitoring of daily weight. This should be done at
the same time (preferably early morning), in the same clothes, and with the same scale. Options A, B and D assist in monitoring nutrition and hydration status.
However, the effectiveness of the diet is evidenced by maintenance of body weight.

232

C Option C allows the family member to verbalize and begin to cope with and adapt to what is happening. By restating what was said, the nurse is
able to clarify the family member’s feelings and begin to offer information that will help to ease some of the fears that he or she may face at the moment.
Options A and B offer disapproval and put the family member’s feeling on hold. Option D provides false hope at this point.

233

B The client’s statement reflects a psychosocial concern regarding his or her appearance after surgery. Therefore, Body Image Disturbance is the
correct option. Options A and C identify physiological nursing diagnoses and option D is inappropriate, because the client is addressing a concern, rather than
avoiding one.

234

D Initiating a tube feeding prior to determining tube placement can lead to serious complications, such as aspiration. Options A and B are part of the
total plan of care for a client on enteral feedings. Options C is instituted for a client who has been identified as being at high risk for aspiration. Option D is the
priority nursing action.

235

C Body weight is an accurate indicator of fluid status. As a client is hydrated with IV fluids, the nurse monitors for increasing body weight. Accurate
body weight is a better measurement of gains and losses than intake and output records. An IV should not greatly alter sleep patterns, and clients will still be
able to ambulate with a peripheral IV site.

236

C In the Cuban-American culture, loud crying and other physical manifestations of grief are considered socially acceptable. Of the options provided,
option C is the only option that represents culturally sensitive and caring approach on the part of the nurse. Options A, B and D are inappropriate nursing
interventions.
237

B All questions relate to aspects of post-hospital care, but only option B explores the client’s feelings about the disease. Exploring feelings as the
initial assessment will assist in determining the individualized plan of care for the client.

238

D Following vasectomy, the client must continue to practice a method of birth control until the follow-up semen analysis shows azoospermia. Live
sperm may be present in the ampula of vas following this procedure. Options A,B and D are appropriate client statements.

239

C An implanted port does not need to be pumped in order to maintain patency. The site will need to be kept clean and dry and the physician would
need to be notified of signs and symptoms of infection. Saline is used to flush the site to maintain patency.

240

A Secondary prevention focuses on the early diagnosis and prompt treatment of disease. Tertiary prevention is represented by rehabilitation services.
Options C and D identify screening procedures and option B identifies a treatment of a disease. Option A identifies a rehabilitative service.

241

C A high intake of dietary fat is a risk factor for prostate cancer. Options A, B and D are accurate statements regarding the risks and prevention
measures related to this type of cancer.

242

A TPN solutions contain amino acid and dextrose solutions, with electrolytes and trace elements added. The physician uses the electrolytes values to
determine whether changes are needed in the composition of the TPN solutions that will be administered over the next 24 hours. This prevents the client from
developing electrolyte imbalance. Options, B, C and D are not directly related to evaluating client status related to TPN.

243

C The cause of the confusion in this situation is bed rest and decreased sensory stimulation from prolonged confinement. Therefore it is best to
ambulate the client in the hall. This will increase sensory stimulation and may decrease confusion. Options A and B will not address the client’s need for
sensory stimulation. Option D is an action that should have been performed in preparation for ambulation while the client was on bed rest

244

C Intervention for prostatitis include anti-inflammatory agents or short-term antimicrobial medication. Sitz baths and normal sexual activity are
recommended. Dietary restrictions are not necessary unless the person finds that certain foods are associated with manifestations.

245

C Use the formula for a calculating a medication dose. Formula: Desired/ Available x Volume = mL per dose; 7.5 mg/10 mg x 1.0 mL = 0.75 mL

246

C Salt tablets should not be taken, because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early
detection of decreased body weight alerts an individual to drink fluids before becoming dehydrated. Sixteen ounces of fluid should be consumed for every
pound lost to prevent dehydration.

247

B All forms of tobacco use are health hazards. Option A, C and D are accurate regarding the health hazards of tobacco use.

248

B 5% dextrose in water is an isotonic solution. Another example of an isotonic solution is 0.9% saline. 0.45% saline is a hypotonic solution. 10%
dextrose in water and 5% dextrose in 0.9% saline are hypertonic solutions.

249

A How a client feels is an important part of the psychological assessment. Option B deals with physical issue.Options B, C and D are closed – ended
responses and are barriers to effective communication.

250

A Early ambulation in the postoperative period is important because if a client does not increase activity, the bones will lose calcium. Increasing
calcium intake in an immobile client would cause elevated amounts of calcium in the blood, which could lead to kidney stones. Iron, not iodine, is
recommended for hemoglobin synthesis. Clients who are not turned in bed will develop pressure ulcers. A client who is immobile and is 85 years old needs to
be turned every 2 hours by the nursing staff. The client should not be expected to turn himself or herself.

251

D The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option D is the only option reflecting a value that has dropped down into the
normal range. Option A, B and C are elevated potassium levels.

252

D With earlier hospital discharge, clients are returning home with greater acuity of problems than was previously true, and may require support from a
home health agency until they are independent in functioning. Option C does nothing to actively assist the client, and option B is not realistic in the current
health care environment. Although option A is a viable option, it does not assure the client continued care until the client is able to be independent in managing
his or her own care.

253

D With earlier hospital discharge, clients may require support from a home health agency until they are independent in functioning. Option 1 does not
ensure that the client will receive continued care until able to be independent in managing his or her own care. Option C does nothing to actively assist the
client, and option B is not realistic in the current health care environment. Option D is the method of ensuring the client necessary assistance for as long as
required.

254

D Allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution

255

D Most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication due to skin popping or using
an infected drug apparatus
256
B Reduced GI motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate,
side effect of medications, emotional problems, insufficient fluid intake and excessive dietary fat

257

C Gives an objective description of the client's behavior and affect

258

C Good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients

259

C It is important for the nurse to understand what the client expects from the rehabilitation program for future success

260

C Allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema

261

C X-rays of entire urinary tract taken, evaluates kidney function

262

D Apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not
be able to put clothes on properly

263

B Loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement

264

C Requires the assessment and teaching skills of RN

265

A Acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children

266

C 900 x 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-1,800 kcal/day); 3 mg x 3 = 9 mg/day of iron and women need
15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required

267

C Suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies

268

A Signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pain, tachycardia, and hypotension

269

B To improve the quality of ventilation would refer to levels of carbon dioxide and oxygen

270

B Assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is
essential; nurse documents the client's response and clinical status after being restrained

271

B Specimens should be obtained in the early morning because secretions develop during the night
272

A 445 - 235 = 210 - 60 = 150

273

C Important that accurate documentation be maintained on the internal radium implant

274

C Physician should provide explanation and obtain patient's signature

275

C Inappropriate; movement in area could cause displacement

276

C Procedure takes approximately 90 minutes, not painful

277

D Requires assessment skills of the RN

278

C Arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line

279

D Symptoms of pulmonary edema; requires immediate attention

280

A Contaminated gloves should be removed before answering the phone

281

C Epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting

282
B Skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this

283
D Before a new IV is started on this client, physician should be called and PO medications recommended

284

B To go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down

285

C Hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate

286

D Insulin should be administered at room temperature, temperature extremes should be avoided

287

A Standard, unchanging procedure

288

B Foods contained in whole grains, legumes, vegetables, fruits, seeds, nuts and bulk promotes peristalsis

289

D Requires contact precautions

290
C Indicates hypersensitivity reaction, should stop medication and notify the physician

291

A There is an increased growth of organisms after four hours

292

B Unexpected, should be reported to physician immediately, also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech,
worsening headache

293

B Indicates arterial bleeding; apply direct pressure; high risk for shock

294

B Indicates chest pain, needs to seek medical attention immediately

295

D Parent or legal guardian required to give informed consent prior to surgical procedure

296

C If wet dressing touches skin it could cause skin breakdown

297

D Abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern
with these clients

298

A Standard, unchanging procedure

299

B Should hold cane on strong side, widens base of support, reduces stress on affected side

300

B Disoriented, requires immediate assessment to determine underlying cause

NP 3
301

A Sterile articles should be dropped at a reasonable distance from the edge of the sterile area
302

A Duration of coumadin 2-5 days, client at risk for a repeat CVA

303

B Hemolytic reaction, most dangerous type of transfusion reaction, symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to
stop blood, obtain urine specimen, maintain blood volume and renal perfusion

304

D Provides relief from tension, ensures client naps less during the day, helps client to relax

305

D Most appropriate option due to decreased risk

306

A Being free from any drain bags during the day would appeal to a 13-year-o
307

A To avoid dislodging drain, remove the dressing layers one at a time

308

D Is characteristic of midlife crisis

309

A Decreases intracranial pressure

310

B Correctly stated, appropriate nursing diagnosis

311

A Transplant clients require protective isolation following surgery

312

A Ewald tube is a large orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be
immediately available to reduce the risk of aspiration

313

B Face, neck, chest, or abdominal burns result in severe edema, causing airway restriction

314

D Is nurse's initial priority to encourage client to begin dealing with what happened by verbalizing her feelings and gaining some acceptance and
perspective
315

D Battery is harmful or offensive touching of another's person; unless court ordered, clients have the right to refuse medication, even if client is
psychotic
316

A Not considered acceptable procedure

317

B Blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers

318

C The patient who needs the nurse's immediate attention is the patient who has vomited six (6) times in the previous 24 hours. This patient is in danger
of fluid and electrolyte imbalance and has a great chance of becoming dehydrated if the vomiting continues. The patient with cold symptoms and a fever, the
patient with a dressing that has come off, or the patient who is complaining of leg pain after exercise can be dealt with after the patient who possibly is
dehydrated is assessed by the nurse.
319

D Minimizes intestinal cramping

320

C Day nurse can make a "late entry" to add any additional information

321

B Requires strict aseptic technique

322

C Due to low platelet count, normal platelets 150,000-400,000/mm3, decrease causes problems with blood clotting

323

B With this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report

A Lack of attending behaviors are always a barrier to learning

325 The nurse is performing screening at the local senior citizens facility. The nurse would be MOST concerned if which of the following was
observed?

a. A 69-year-old man has a slightly elevated systolic blood pressure.

b. The nurse has difficulty palpating an apical pulse on a 74-year-old woman.
c. The nurse auscultates an S3 ventricular gallop on a 78-year-old woman.
d. An 81-year-old man has a temperature of 98.2°F (36.7°C).

C Ventricular gallop is the earliest sign of CHF

326

D Infection in a neutropenic individual may cause morbidity and fatality; place the neutropenic client in a private room; limit and screen visitors and
hospital staff with potentially communicable illnesses

327
D Glasgow coma scale of 5 indicates coma, client requires frequent assessment
328

C Nurse should not reinforce client's hallucinatory experiences; direct challenge to client's belief about sensory-perceptual intake will only increase
mistrust and conflict between nurse and client
329

A Indicates Candida, standard precautions required

330

A Possibility of internal bleeding, life-threatening situation

331

B Hemorrhage and shock, most life-threatening conditions that occur after surgery

332

A Stable patient with expected outcome

333

D Physical, these skills are requisite for discharge

334

C Open-ended question, allows client to verbalize

335

A Protein needed to slow down degeneration process of aging

336

C Will hydrate the mucous membranes and keep mouth clean

337

A Client confidentiality is being violated, nurse should intervene to protect client

338

B Side effects of medication include decreased BP, orthostatic hypotension, bradycardia

339

A stand slightly behind patient on strong side

340

B Daily weight is the best way to evaluate for fluid volume deficit

341

A IV fluids are critical to reduce clotting and pain

342

B May indicate neurovascular compromise; requires immediate assessment

343

C Should be removed before the test

344

B Indicates understanding of asepsis, whose hallmark is handwashing

345

A Breakfast with some substance, won't leave her feeling hungry most of the morning

346

D Highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites

347

B The nurse obligated to share client information with the physician.

348

D Indicate cardiovascular fluid overload

349

C Assessment, dressing should be checked on admission to the room.

350
C Physician needs to be informed

351
A Should be removed dry so wound debris and necrotic tissue are removed with old dressing

352

C Scissors always secured at the bedside, remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of
esophageal balloon

353
B Handwashing should be done prior to beginning any procedure, especially irrigating a wound

354

C principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent in close proximity to the client

355

C Chief complaint should be recorded using the client's own words

356

D Assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia

357 Which of the following actions, if performed by the nurse, would be considered negligence?

B manipulation of mass may cause dissemination of cancer cells

358

D Side rails should always be elevated for any disoriented client

359

C Indicates acceptance and a readiness to participate in postoperative care

360

D Gives objective information

361

C Describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact physician

362

C Delay in medication may cause difficulty in swallowing, might have difficulty taking medication

363

B Air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation

364

A Is a priority to prevent accidental countershock

365

B life-threatening condition which can last longer than 24 hours, constantly monitor client

366

A All invasive procedures should be done last, so as not to alter cardiopulmonary assessment of the child

367

B Drain should be attached to patient's gown or pajamas, never to the sheet or mattress

368

A Evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician

369

C Encourages drying and helps to prevent infection

370
C Potential anaphylactic reaction, administer epinephrine, corticosteroids; treat for shock

371

D To prevent spread of infection, clients should have private rooms with different nurses

372

B Masks not needed and doors do not need to be closed

373

B Basic care needs can be met by the LPN/LVN, don't make patient assignments based on equipment

374

C is part of basic hygiene and grooming that must be done daily to maintain overall health

375

C Required elements of malpractice are duty, breach of duty, causation, and injury

376

C Role of nurse is to be a family and client advocate; this provides individualized care

377

B Site should be observed every five minutes for signs of tissue intolerance, including blanching, mottling, or graying

378

C Prevents complications such as skin breakdown

379

B Able to care for non-high risk clients; cover lesions

380

D Even confused client should have his/her medications rechecked when there is any possibility of an error; always observe the five rights of
medication administration

381

B Excellent means of obtaining information and support for the client

382

C Role of the nurse is to function as client advocate; is important to individualize care with all clients

383

B breathing slowly will enhance relaxation of the abdominal muscles

384

A Stable client with standard, unchanging procedures

385

A Iron supplements can cause color of stool to resemble melena

386

B implementation; major priority of the nurse is to provide and maintain safety for the client who is unable to provide for herself; safe environment
will generate trust and rapport; will decrease resistance to doing preliminary physical exam, which includes orienting client and doing a mental status exam

387
A stable patient with an expected outcome

388
C Will only increase the client's anxiety and need for the rituals, limits must be gradually instituted

389
C Care not within the scope of a nursing assistant

390

B Withdrawing from pain is a sign of deterioration in client's condition; doctor should be notified

391

C Produces dilation of neck and shoulder vessels, making entry easier and preventing air embolus

392

A Concrete measure of the client's eating patterns indicates adequate intake of a well-balanced diet

393

D Associated with cocaine use by inhalation, nose is most common route for administration

394

C Requires the assessment and teaching skills of RN

395

C Should avoid strenuous exercise and do not immerse T-tube in water

396

D Should avoid heat (sauna, hot tubs, sunbathing)

397

A being able to state one's name demonstrates orientation to person, positive sign with head trauma

398

A Documentation is subjective

399

A Should be 12-18 inches; too high causes rapid distention and pressure in intestine causing rapid expulsion of solution, poor defecation, damage to
mucous membranes

NP 4
401

A Disoriented client with irregular vital signs represents a grave safety risk

402

C Client commitment to completing or learning techniques for self-care is supported by participation in goal-setting

403

D red, swollen gums can indicate pyorrhea, which is caused by improper cleaning and poor mouth hygiene

404
B is important that multidisciplinary team discuss and collaborate with the client all discharge placements; client will need support and assistance in
making decisions about discharge and residential living arrangements

405
A contains foods highest in fiber (green vegetables and grains) to assist in counteracting constipation

406

C clearing the air vent with air will reestablish proper suction in the Salem Sump tube

407

C client's confidentiality is being violated; it is nurse's responsibility to intervene to protect the client

408

B represents the best technique for a sterile field

409

C may be accompanied by nausea caused by dye injection

410

A As long as behavior is not unsafe, nurse should try other methods to engage patient in activities to reduce wandering

411

B implementation; bowel movements can dislodge radium implant; this diet will decrease amount of stool and number of bowel movements

412

A to minimize the risk for aspirations, the client should be maintained in semi-Fowler's position

413

C Haldol is particularly effective in reducing assaultive behavior associated with severe anxiety

414

C straining at stool increases intraocular pressure and should be avoided

415

B The Foley catheter is always positioned so that the level of the bladder with the catheter inserted is higher than the level of the drainage container;
gravity causes urine flow.
416

D If the nasogastric tube is accidentally passed into the trachea rather than the esophagus, it will occlude the airway, causing cyanosis.

417

B This hypertonic solution should be administered in a continuous and uniform infusion to prevent hyperosmolar diuresis.

418

A A strange environment, as well as the anxiety associated with private body functions like elimination, interferes with the client's ability to relax the
urinary sphincter to void.
419

C Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance; the nurse's technique should be
assessed.

420

C The body is supported partially on the affected limb and partially on the cane as the unaffected limb moves forward.

421

A Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube.

422
B This attempts to explore why the client is refusing the procedure and promotes communication.

423

A The stomach produces about 3 L of secretions per day; fluid lost through vomiting can produce a fluid volume deficit. The priority is fluid volume
deficit, which can lead to dysrhythmias and death. Ë´

424

B Cellular swelling and cerebral edema are associated with hyponatremia; as the extracellular sodium level decreases, the cellular fluid becomes
relatively more concentrated and pulls water into cerebral cells.

425

C A decreased urinary output will result in the retention of potassium, causing hyperkalemia.

426

B The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to
respiratory alkalosis.

427

C This provides the opportunity for the client to verbalize the feelings underlying behavior.

428

C Policies relative to DNR orders vary among hospitals and the nurse must adhere to the policies of the institution

429

D The medical history could be obtained during assessment, and a relationship could be established if they were uninterrupted.

430

D The release of information to an unauthorized person, gossiping about a client's activities, and the nurse's unwanted intrusion into private family
matters constitute invasion of privacy.

431

A Placing an aide in the home will allow the mother to rest and provide the child with attention.

432

A The decreased hemoglobin and hematocrit levels and RBC count may be a result of malnutrition; also, cancer of the esophagus can cause dysphagia
and anorexia.

433

C Complementary mixtures of essential amino acids in plant proteins provide complete dietary protein equivalents.

434

B This serum albumin value indicates severe depletion of visceral protein stores; the normal range for serum albumin is 3.5 to 5.5 g/dl; white meat
turkey (two slices 4 x 2 x 1/4 inch) contains approximately 28 g of protein.

435

A Tofu products increase protein without increasing vitamin D because, unlike milk products, tofu does not contain vitamin D.

436

A The nurse asks the client to void at the beginning of the collection period and discards this urine sample. All subsequent voided urine is saved in a
container, which is placed on ice or refrigerated. The client is asked to void at the finish time, and this sample is added to the collection. The container is
labeled, placed on fresh ice, and sent to the laboratory immediately.

437

B The nurse first attempts to unclog a feeding tube by aspirating the tube. If this is not successful, the nurse then tries to flush the tube with warm
water. Carbonated liquids, such as cola, are sometimes used to prevent clogging, but the tube must be rinsed thoroughly to avoid stickiness. Replacement of
the tube is the last step if other actions are unsuccessful.
438

A The TPN line is used only for the administration of the TPN solution. Any other intravenous medication must be administered though a separate IV
access site.

439

B If the balloon is positioned in the urethra, inflating the balloon could produce trauma and cause pain. If pain occurs, the fluid should be aspirated
and the catheter inserted a little farther to provide sufficient space to inflate the balloon. The catheter's balloon is behind the opening at the insertion tip.
Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter
and reinsert a new one. Pain when the balloon is inflated is not normal.

440

B The normal magnesium is 1.6 to 2.6 mg/dL. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition.
The client should be monitored for dysrhythmias, since the client is at risk for ventricular dysrhythmias. Magnesium sulfate is not administration in saline
solutions. Ground beef, eggs, and chicken breast are examples of foods that are low in magnesium.

441

B The nurse monitors for postoperative complications such as deep wein thrombosis, pulmonary emboli, and wound infection. Pain in the calf could
indicate a deep vein thrombosis. Change in color, temperature, or size of the client’s calf could also indicate this complication. Options C and D could result in
an embolus if in fact this client had a deep vein thrombosis. Pain medication for this client complaint is not the appropriate nursing action. Further assessment is
needed.

442

A In the assessment of an IV for signs and symptoms of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the
IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluids into the vein or surrounding tissues, which could
cause more tissue damage. Increasing the flow rate may be damaging to the tissues if the IV has infiltrated. The IV site will feel cool if the IV fluid has
infiltrated into the surrounding tissues.

443

C In suspected neck injuries the most appropriate way to open the airways is the jaw-thrust maneuver. If a neck injury is present, this maneuver will
prevent further injury. Options A,B and D are incorrect.

444

B If there is leakage at the IV site, the nurse should first locate source. The nurse should assess the site further to be certain that all connections are
secure. The nurse should not increase the flow rate. While it is true that it may leak more, it may also cause more tissue damage if the IV was infiltrating. While
the infusion most likely will need to be stopped, the physician would not need to be notified. Slowing and discontinuing the IV is also premature. The IV must
first be assessed as to the cause of the leaking.

445

B Aspiration is a possible complication associated with nasogastric tube feeding. The head of the bed is elevated 35 to 40 degrees for at least 30
minutes following bolus tube feeding to prevent vomiting and aspiration. The right-lateral position uses gravity to facilitate gastric retention to prevent
vomiting. The flat supine position is avoided for the first 30 minutes after a tube feeding.

446

A Incentive devices have many desired and positive effects. Incentive devices provide the stimulus for a spontaneous deep breath. Spontaneous deep
breathing, using the sustained maximal inspiration concept, reduces atelectasis, opens airways, stimulates coughing, and actively encourages individual
participation in recovery. Shallow breaths, wheezing, and unilateral chest expansion would indicate that the incentive spirometry was not effective. Wheezing
indicates narrowing or obstruction of the airway, and unilateral chest expansion could indicate atelectasis.

447

A Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock. Clamping the tubing for 30
minutes allows equilibrium to prevent complications. Option B would increase the flow of urine, which would lead to hypovolemic shock. Option C is an
assessment and would not affect the flow of urine or prevent the possible hypovolemic shock. Option D could cause backflow of urine. Infection is likely to
develop if urine is allowed to flow back into the bladder.

448

B Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Although options A,
C, and D may be a concern, these are not the priority.
449
B The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a
slower rate. Slow enema administration and stopping the flow temporarily, if necessary will decrease the likelihood of intestinal spasm and premature ejection
of the solution. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to
discontinue the enema and notify the physician at this time.

450. A The sigmoid and descending colon are located on the left side. Therefore, the left-lateral position uses gravity to facilitate the flow solution into the
sigmoid and descending colon. Acute flexion of the right leg allows for adequate exposure of the anus. Options B, C, and D are incorrect positions.

451

D All stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual. The gastric
residual is determined in order to evaluate whether undigested formula from a previous feeding remains. It is important to assess gastric residual because
administration of the tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.
Assessing residual does not confirm placement, determine patency, or assess fluid and electrolyte status.

452

A Long, firm strokes in the direction of venous flow promote venous return when bathing the extremities. Circular strokes are used on the face. Short,
patting strokes and light strokes are not as comfortable for the client, and they do not promote venous return.

453

B The Z-tract variation of the standard intramuscular technique is used to administer intramuscular medications that are highly irritating to
subcutaneous and skin tissues. Attaching a new sterile needle is done because the new needle will not have any medication adhering to the outside that could be
irritating to the tissues. Preparing an air lock keeps the needle clean of medication on insertion, and as the air is injected behind the medication, it will provide a
seal at the point of insertion to prevent tracking of the medication. Retracting the skin provides a seal over the injected medication to prevent tracking trough
the subcutaneous tissues. The site should not be massaged because this can lead to tissue irritation.

454

D If not contraindicated, before a tracheostomy is suctioned, the client is placed in semi-Fowler’s position to promote deep breathing, maximum lung
expansion, and productive coughing. In this position, gravity pulls downward on the diaphragm, which allows greater chest expansion and lung volume. High-
Fowler’s position, the supine position, or the lateral position would not allow easy visualization of the tracheostomy or easy access of the suction catheter.

455

C A sample of the client’s blood is collected, and the leukocytes are tagged with indium. The leukocytes are then reinjected into the client. They
accumulate in infected areas of bone and can be detected with scanning. No special preparation or aftercare is necessary. Options A, B, and D are incorrect
descriptions.

456

B The patient has a right to confidentiality. The duty of confidentiality prohibits a professional from disclosing information obtained as a result of the
treatment relationship, except to fellow professionals involved in the patient’s care.

457

D The nurse should be assertive and state that he/she would like to continue the report. This is the task at hand and needs to be completed so that the
nurse can complete the work shift.

458

B By staying with the patient, the nurse provides support and is able to intercede for the patient when she is unable to speak on her own behalf.

459

A Intramuscular pain medication should be administered as ordered in the immediate postoperative period so that the pain does not become severe and
interfere with recovery.

460

C Initial treatment of epistaxis includes applying direct pressure by pinching the soft, outer portion of the nose against the midline septum.

461

A The nurse should assess the patient with multiple myeloma for pathologic fractures of the ribs and weight bearing bones and compression fractures
of the spine due to osteoporosis. These may be evidenced by sudden, severe pain usually related to bending or lifting.
462

C Instruct the patient and family to observe the skin daily for changes and to maintain good foot care.

463

A Septic shock can be caused by any microorganism. Obtaining specimens for culture should be done prior to the administration of antibiotic therapy.

464

A Manifestations such as periorbital edema, dark-colored urine and decreased urinary output indicates glomerulonephritis, which occurs after a
streptococcal infection.

465

C Community education should indicate that when walking at night or in an isolated area, the best rape prevention strategy is not to walk alone.

466

D The irradiated area should be cleansed daily with water alone, or with a mild soap and water.

467

A The nurse should provide an opportunity for the patient to ventilate and to discuss her concerns. This response lets the patient know that there are
care options and allows for discussion of treatment.

468

D Antibiotics are used to prevent toxic shock syndrome and sinusitis in patients with nasal packing.

469

C The nurse should not insert gauze packing into the nose of a patient. The nurse should further discuss this action with a colleague.

470

D The decrease in white blood cells (leukopenia) places the patient at risk for infection. The white blood cells are the first line of defense against
invading organisms.

471

C Bringing both parties together is the most effective strategy for discussing the issues and developing a plan to resolve them. Both parties have an
opportunity to express themselves, have the same information from the charge nurse, and can be involved in, and have responsibility for, the resolution.

472

D Current guidelines include monthly breast self-examination (BSE) starting at age 20; physical examination of the breasts by a trained professional
every three years during ages 20 to 40, and every year thereafter; and screening mammography ages 40 to 49 every one to two years, and annually thereafter.

473

C The patient should be observed when medication is administered to ensure that the drug is swallowed and not held in the patient’s cheek and
discarded later. Giving a liquid form of the drug makes it much more difficult for the patient to “cheek” the medication.

474

B Developing infection is the greatest hazard following a shunting procedure. The nurse should be on the alert for potential sources of infection. The
patient with a shunt should not be placed with a patient who has viral pneumonia.

475

C Relief measures includes pharmacological and/or environmental intervention, the most effective of which is the use of antipyretics to lower the set
point.

476
A Medications that affect wound healing, such as corticosteroids, impair phagocytosis, inhibit fibroblast proliferation, depress formation of granulation
tissue and inhibit wound closure. They should not be used by patients with varicella.

477
B The telephone number of the local safe house (a place where battered spouses and children may go) would be most useful to the person in a situation
of domestic violence.

478

B Immediately after an endotracheal tube is inserted, its placement must be verified. This is done by assessing for bilateral, equal breath sounds.

479

C Patients receiving mechanical ventilation can experience barotraumas, or damage to the lungs by positive pressure. Barotrauma includes
pneumothorax, subcutaneous emphysema and pneumomediastinum.

480

D Tracheostomy care is initiated with suctioning of the tracheostomy tube, as needed.

481

A Inquiring as to the types of food eaten at home shows the nurse’s awareness of the patient’s cultural and dietary norms.

482

C Cardiogenic shock occurs when the contractility of the cardiac muscle is directly impaired. Vasodilatation results in a declining blood pressure and
altered tissue perfusion. The priority nursing diagnosis is altered tissue perfusion: peripheral.

483

A Decreased RBC production can indicate anemia or hemorrhage. In either case the patient experiences fatigue due to decreased oxygen-carrying
capacity. Priority should focus on risk for activity intolerance.

484

A Once cells sickle, the red blood cells become rigid and may obstruct capillary blood flow causing further hypoxia, and consequently more sickling.
Due to the increased viscosity and the irregular shape of the cells, the sickle cells tend to clump together or “log jam” within the smaller blood vessels.
Occlusion of the microcirculation increases hypoxia, which causes more erythrocytes to sickle. Therefore, altered tissue perfusion is the most appropriate
nursing diagnosis.

485

C A transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction commonly manifested by a sudden loss of motor, sensory or
visual function. The cause of this clinical entity is a temporary impairment of blood flow to a specific region of the brain.

486

A The laryngeal tube should be suctioned for 10 seconds. Suctioning for longer periods can result in hypoxia.

487

C Sensory neuropathy leads to loss of pain and pressure sensation. Autonomic neuropathy leads to increased dryness and fissuring of the skin. The
typical sequence of events in the development of a diabetic foot ulcer begins with a soft-tissue injury of the foot and formation of a fissure between the toes or
in an area of dry skin.

488 Which of the following approaches would a nurse take first when preparing to insert an intravenous catheter into an eight-year-old boy?

C Preparing children for procedures decreases their anxiety, promotes their cooperation, supports their existing coping skills and may teach them new
ones and facilitates a feeling of mastery in experiencing a potentially stressful event.

489

D The purpose of a nasogastric tube following a subtotal gastrectomy is to drain the stomach or intestinal tract to prevent postoperative vomiting,
obstruction of the intestinal tract and distention of the stomach or intestinal tract caused by fluid or gas. The first action when a patient complains of nausea
would be to determine the patency of the patient’s nasogastric tube.
490

C The mental status examination, done as part of the admission interview, should be conducted by the registered nurse rather than the licensed
practical nurse. Part of the mental status examination is determining if the patient is in touch with reality or is delusional and/or hallucinating.

491

C Propulsid is indicated for the treatment of heartburn from reflux esophagitis.

492

C Because of the prolonged onset of celiac disease, the parent’s ability to cope with the situation may be severely altered.

493

C After anesthesia and surgery, patients experience a reduction in pulmonary function including a reduction in lung volume secondary to pain,
anesthesia and immobility. There is also a decrease in the clearance of mucus secondary to anesthesia and narcotics.

494

B Confidential information may be shared with the treatment team directly involved in the care of the patient.

495

C Careful monitoring of the neurovascular status of the extremities is crucial in the detection and prevention of compartment syndrome. This
syndrome is a complication of fractures and is caused by the progressive development of arterial vessel compression and reduced blood supply to an extremity.
Fracture of the forearm or tibia usually precedes the onset of muscle edema in the fasciar, which form compartments for the muscles of the forearm and lower
leg. When there is severe trauma, such as in fractures or compression from a tight cast, muscle ischemia can occur. Irreversible ischemia can occur within six
hours due to compression of the arteries, nerves and tendons entering the compartment.

496

D The patient with facial and neck burns is at high risk for ineffective airway clearance related to possible upper airway edema, secondary to inhalation
of superheated air, smoke or noxious chemicals.

497

C Most state laws specify that electroconvulsive therapy can be administered only if informed consent is obtained from the patient. In the case of an
incompetent patient, consent must be obtained from the guardian. The patient’s right to refuse electroconvulsive therapy is specifically addressed in many state
laws.

498

D With myasthenia gravis, weakness of the bulbar muscle causes problems with chewing and swallowing, and presents a danger of choking and
aspiration. Nursing diagnoses identified for the patient with myasthenia gravis are ineffective breathing pattern, impaired physical mobility and risk for
aspiration related to weakness in the muscles.

499

D Minors become emancipated by pregnancy, marriage, high school graduation, living independently or military service.

500
A Alteration in skin integrity is the priority nursing diagnosis. Skin excoriation can occur if the leather and plastic pads of the brace touch the child’s
skin. The brace can be worn over a t-shirt.

NP 5
501 D The parent should be advised that anyone can get lice. Since it is transmitted from one person to another, all family members
should receive treatment.

502 C During all procedures with the newborn, care must be taken to avoid heat loss. Cold stress is detrimental to the newborn. It increases the
need for oxygen and can upset the acid base balance. The infant may react by increasing its respiratory rate and may become cyanotic. An axillary temperature
should be taken every hour until the newborn’s temperature stabilizes. Initial temperatures as low as 96.8ºF are not uncommon. By the twelfth hour, the
newborn’s temperature should stabilize within the normal range. Good hand-washing between infants is the single most important factor in preventing
infection. Cover gowns are not necessary.
503 C Portal-systemic encephalopathy, also called hepatic encephalopathy, is one o the major complications of cirrhosis. It results
from several metabolic derangements including increased blood ammonia levels. Portal-systemic encephalopathy results in alterations in the state of
consciousness, intellectual function, behavior, personality and in neuromuscular dysfunction. Alteration in thought processes is the most appropriate diagnosis.

504 C Relationships developed with staff on the psychiatric unit during hospitalization should be terminated when the patient is discharged.
The patient, when told about an upcoming discharge, often feels a need to hold onto what has become familiar. The patient’s strengths, his/her ability to cope
and the fact that the patient will have an out-patient therapist should be emphasized.

505 D Nursing diagnoses identified for the patient with inflammatory bowel disease include pain, altered nutrition: less than body requirements,
diarrhea, ineffective individual coping and altered health maintenance.

506 C Increasing fluid volume prior to the administration of epidural anesthesia can help to decrease the possibility of Hypotension,
a frequent complication of the anesthesia due to peripheral vasodilation.

507 A Immediately after surgery intake and output must be accurately monitored. The patient should be observed for signs and symptoms of
fluid and electrolyte imbalances, particularly potassium, sodium and fluid deficits.

508 C Hodgkin’s disease is a malignancy that originates in the lymphoid system. It is characterized by the painless enlargement of
lymph nodes and occurs in children 15-19 years of age.

509 B Fluctuations of five to 10 centimeters during normal breathing is common. The absence of fluctuations could mean that the tubing is
obstructed, that expanded lung tissue has blocked the chest tube or that there is no more air leaking into the pleural space.

510 B Initial manifestations of a nephritic reaction in acute glomerulonephritis include periorbital edema, anorexia and dark-colored urine.

511 B The registered nurse should know the level of skill required to care for a patient so that the nurse can assign appropriate staff who can
best meet the patient’s needs.

512 B Restlessness is one of the earliest symptoms of hypoxia. Poor concentration and Tachycardia also are early clinical manifestations of
hypoxia.

513 A Following a lumbar laminectomy the patient should wear antiembolism stockings or another antiembolism device to prevent deep vein
thrombosis.

514 B Nausea is a symptom of impending myocardial infarction and should be assessed immediately, so that treatment can be
instituted and further damage to the heart avoided.

515 A For best results, the thermometer should be kept by the bedside and the temperature taken upon awakening and before any activity.

516 C The preschool child is striving for initiative. The nurse should involve the child in care, whenever possible, by having the child hold
equipment, remove dressings, select the extremity, etc.

517 C Talcum powder may enter the laryngectomy site and act as a respiratory irritant. It should not be used by a patient with a laryngectomy,
or any patient with respiratory disease.

518 B Humidification helps to remove crusts and prevent obstruction of the laryngectomy tube.

519 C Activity intolerance should be addressed as a priority. The pain of intermittent claudication is alleviated by cessation of activity.

520 B The nurse should reinforce that an HIV positive test result means that the patient is infected with the virus, but a positive test does not
necessarily mean that the patient has AIDS. AIDS is the last state of continuum of HIV infection. The median time between HIV infection and a diagnosis of
AIDS is 10 or more years.

521 D The nurse should reposition an immobile patient every two hours while in bed and every hour while sitting in a chair in order to prevent
pressure ulcers.

522 A Dressing changes for the burn patient can be very painful. Daily debridement removes the eschar (black, leathery crust that forms over
burned tissue) that can harbor microorganisms and cause infection. Narcotics should be administered before dressing changes, debridement and other painful
procedures. The nurse should allow enough time for the medication to take effect before beginning the procedure.

523 C Mineral oil should be administered before breakfast or in the evening for better absorption. Patients should be encouraged not to use
laxatives for long-term therapy. Bowel tone will be lost from long-term use.

524 C Establishing a “no-harm” contract allows for regular checks with the patient regarding safety and level of suicidal feelings.

525. A Hypothyroidism is associated with altered thought processes related to diminished cerebral blood flow secondary to decreased cardiac output. It is
manifested by forgetfulness, impaired ability to conceptualize and personality changes.
526 C The individual’s strengths are those effective coping mechanisms on which the individual can draw when encountering difficulty. The
patient needs a repertoire of effective coping mechanisms in order to function more independently in the residential treatment center.

527 B All burn patients are considered at risk for an often-fatal infection with Clostridium tetani. A routine prophylactic procedure when a
patient is admitted to the hospital is the administration of tetanus toxoid intramuscularly. Burn wound infection occurs through either auto-contamination or
cross-contamination. The high risk for infection is related to loss of the skin barrier, an impaired immune response, the presence of invasive catheters and
invasive procedures. Medical management of the patient during the acute burn phase focuses on infection control, wound care, wound closure, nutritional
support, pain management and physical therapy.

528 C The supervisor is the person next in the chain of command. It is the supervisor’s responsibility to call together the interdisciplinary team
to decide on the appropriate intervention.

529 B The patient should be assessed for nausea, abdominal discomfort and the presence of bowel sounds.

530 B Hematocrit is an effective indicator of body fluid volume. Increased hematocrit levels can indicate shock due to a large fluid loss and
hemoconcentration. Activity intolerance would be the priority nursing diagnosis for this patient.

531 D The charge nurse should discuss patient comments with the nurse and work with the nurse to develop a plan that promotes change in the
behavior.

532 D Bargaining is a phase of coping during which the dying person attempts to negotiate a trade. Usually it involves a deal with God or fate:
"If I can live long enough to attend, I'll be ready to die"

533 C Primary prevention of abuse includes strengthening individuals and families so they can cope more effectively with stress. Assessment of
family growth and development would identify potential situations that could lead to abuse and, thereby, decrease the incidence of abuse.

534 A To verify nasogastric tube placement the nurse should either instill air into the tube with a syringe and listen with a stethoscope for the air
passing into the stomach or aspirate gastric contents.

535 D Bending at the knees results in the use of the large muscles of the legs. Keeping the back straight avoids using the small, easily injured
back muscles. When the client’s hands rest on the nurse’s shoulders, this provides security for the client. Placing the hands under the axillae of the client avoids
placing pressure on the chest, which can be uncomfortable for the client.

536 A The question is asking you to select an action to AVOID. The key word in this option is “quickly.” Jerky movements produce increased
strain on muscles and are usually uncomfortable for the client. This question has a false response stem.

537 B This option addresses the client’s concern, which is the painful perineum. This is the issue in the question. This option is also
the best because it is an assessment action. The nurse should always assess first.

538 B The nurse should always wear a gown and gloves when changing the client’s bed linen. This is to prevent the spread of pathogens, which
may attach to the nurse’s clothing during the bed change; then, when the nurse goes to another client’s room, there is no threat of contaminating that client with
this client’s pathogens.

539 B Faucets have many bacteria on the handles. To prevent transmission of the bacteria, paper towels are used to turn faucets on
and off.

540 C You spotted the action that is unsafe! The neck of the ampule should be broken away from the body, to prevent shattering of glass toward
the hand or face.

541 B Vital signs should be taken before administering morphine to provide a baseline for measuring respiratory depression, which can occur
afterwards.

542 B The tip of the container can injure the client’s eye and should not come in contact with the eye.

543 C Safe nursing care takes precedence over any other nursing interventions.

544 B Explaining the use of the call light provides for the client’s safety.

545 A Teaching the client how to cough and deep breathe prior to surgery is the most important nursing action to prevent pneumonia from
developing after surgery. Having the client practice before she has incisional pain increases compliance, since she will know how to perform.

546 D The client is at risk of falling because of the injection. This action ensures the client’s safety.
547 B When the client is an adolescent, the nurse needs to include him in the teaching, or compliance will probably not be achieved.

548 B When the pulse is regular, it may be counted for 15 seconds and multiplied by four, or counted for 30 seconds and multiplied by two.
However,, if the pulse is irregular, it must be counted for a full minute to obtain an accurate rate. The irregularity should be described in the chart.

549 B The nurse ensures the client’s safety by accompanying him to his room. Assessment is also essential because the client’s bumping into
walls suggests that oxygenation problems may be interfering with the client’s balance and level of consciousness.

550 B A child lying quietly, medicated six hours ago, who is one day postoperative, is probably in pain. Children at this age are apt to lie
motionless to prevent pain. They may not request pain medication for fear of needles. Before any other nursing care is provided, the nurse should complete an
assessment of pain and medicate the child. Ambulating and deep breathing will be better tolerated with pain relief.

551 C This action would be inappropriate. The client’s body temperature will continue to cool after the blanket is removed. The client will
become too cold if the blanket is not taken off until the temperature is below the desired level.

552 B A graduate nurse should be able to carry out the care, maintaining appropriate technique based on the principles of communicable disease
transmission.

553 C The client has expressed her concern for privacy. The nurses uses both verbal and nonverbal communication to respond
therapeutically, addressing the client’s concern.

554 C The nurse should provide privacy by exposing only the portion of the body that is being bathed. A bath blanket should be used because it
provides a covering for the client that absorbs water and avoids chilling of the client.

555 C Changing employment is a private concern of the client. The client has the right to withhold this information, and it is NOT to be
reported.

556 C Marital quarrels are not subject to reporting requirements. This client data is protected by the clients right to privacy

557 A Gunshot wounds must be reported. The nurse should follow the institution’s procedures.

558 A This is the necessary first action to take in providing for the child’s safety. As “mandated reporter,” the nurse is legally
obligated to report any cases of suspected abuse. The reporter does not need to prove the case, just report the facts known. This is the law.

559 A Pulling the curtain provides the most privacy for the client. With the curtain pulled, neither the roommate nor anyone entering the room
will have visual access to the client or the treatment being performed
560 C Talking about the client is the most common cause of invasion of privacy in the health care setting. No information about the client,
including personal concerns, diagnosis, and treatment, should be discussed with anyone who is not involved in the care of the client. The nurse should take
special care not to compromise the client’s privacy by discussing client care in such places as elevators, restaurants, or other areas that are accessible to the
public and where the discussion might be overheard.

561 An elderly client is confused. The charge nurse says that the client is constipated and is to have a soap suds enema. As the nurse is explaining the
procedure, the client states that she doesn’t think that she is supposed to have an enema. At this time, the nurse should: Tell the client that her doctor must
have ordered the procedure Assure the client that although the procedure sounds unpleasant, she will feel better afterwards Check the client's chart
for the doctor’s order to help clarify the situation Record on the chart that the client refused the enema C Looking at the doctor’s orders will
help to clarify the situation and will reassure the client that the procedure was ordered for her. Even with a confused client, the nurse must address the client’s
concern and take action to provide for the client’s safety.

562 B It is most important that the nurse understand the client’s routines at home so that these routines may be integrated in his present care.
The goal of the nurse is to create a safe environment for the client and provide for his well-being. Following pre-existing routines will help the client feel more
secure and less threatened. This question requires the ability to plan nursing care for an elderly client.

563 D The nurse should document the findings on assessment in order to provide information concerning the status of the client on admission.

564 D The nurse is prohibited from witnessing the living will because of his/her professional relationship with the client. Such a witness would
be invalid. This response also promotes communication by encouraging the client to think of others who could witness the will.

565 B This is the best action for providing maximum privacy for the client. In each of the other options, the client’s privacy will not be
protected if someone enters the room
566 D A written summary of the nursing care plan for the client is the best way of conveying the client’s nursing care needs to the nurses who
will actually work with her in the long-term care facility

567 C The client’s motivation and goals are essential for success, and they are a primary concern in any teaching program. Teaching/Learning
theory tells us that if the client is not motivated or goal directed, the discharge teaching program is unlikely to be effective.
568 C This is an assessment activity and should be done first. Before initiating 15 minutes checks, calling the doctor, or giving a back rub, an
assessment should be made. Following the assessment, one or more of the actions in the other options may be done, as appropriate.

569 C This option provides for the client’s safety by reducing the risk of falling

570 C The client needs an identification bracelet to provide for his safety in all aspects of hospitalization

571 D This is client is confused, which means there is a high safety risk due to decreased ability to perceive danger. Providing opportunities for
regular toileting helps ensure that the clients basic needs for elimination will be met, and will greatly reduce the risk of the client’s falling while trying to get up
and go to the bathroom, without the assistance of the nurse. This nursing action provides for the comfort and safety of the client, and it should be recorded in
the plan of care.

572 B This client is confused, and thus may not be able to perceive danger. A confused client is also unlikely
to remember instructions concerning the use if the call light. This action will not effectively provide for client’s safety.

573 B Locking the wheels stabilizes the cart and bed, preventing the client from falling between them during the transfer. This is the priority
action for transferring a client

574 B The bed and wheelchair must both be stabilized to prevent the client from falling and being injured.

575 C This is something that the nurse should NOT do! Restraints should be tied with knots that can be undone easily, in case the client’s well
being necessitates removal of the restraints to protect the client from releasing the restraints, the knot should be placed where the client cannot reach it.

576 C Easing the client gently to the floor is the best action, since it protects both the client and the nurse from injury

577 C The client in the room with the fire is at highest risk for injury. The smoke from a fire can deprive a client of adequate oxygenation, and
the fire poses a direct threat to the safety of the client. Moving this client to safety receives first priority.

578 B The issue in this question is the puddle of water on the floor. The water on the floor threatens the immediate safety of the
client and others on the unit. The nurse’s first action should be to alleviate the safety hazard by wiping up the water.

579 B The nurse is in control of his or her own body and the client’s movement during the transfer. Providing for the safety of the client, and
utilizing the principles of the body mechanics to provide safety for the nurse and the client, is the best nursing approach

580 . D Straps and belts are provided for the client’s safety and should be used to prevent falls. This is the best option because it is the
only correct option that provides for the client’s safety.

581 C The introductory statement tells you that the client got out of a bed that had the side rails up. This is an unsafe situation, since the client
is at risk of falling. Such an injury can be life-threatening. Placing a restraining vest on the client will provide for her safety.

582 C The admitting office must be informed of the error, and the client’s identification bracelet should show his name correctly.

583 C This question has a false response stem, and this correct answer is something the nurse should NOT do. A client with poor circulation in
the lower extremities will not be able to accurately detect feelings of hot and cold when stepping into a tub. For the safety and comfort of the client, the nurse
should regulate the water temperature to between 105-110° F.

584 B This nursing action will help prevent nerve and musculoskeletal injuries to the client as a result of poor circulation caused by the
restraints.

585 B You identified the inappropriate option. This option implies that ALL elderly clients should be restrained in order to reduce the risk of
falls. Many elderly clients can care for themselves without falling. Each individual should be assessed for risk to fall

586 B This question has a false response stem. The call system should be used whenever a client needs help, not only in emergencies. For the
safety and well-being of the client, the client should be instructed how to use the system, and should be able to reach it easily and safely
587 B Post-operative clients who have received anesthesia are usually very sleepy and not aware of their surroundings. The client may fall out
of bed if the side rails are not raised. This is the best option because it provides for the safety of the client

588 C Making sure that slippers or shoes are worn by the client is the priority action, since it addresses immediately the problem of slipping on
the tile floor

589 A Addressing the client’s feelings is the first action by the nurse. This response lets the client know that his feelings are important and need
to be addressed. This response also addresses the client’s physiological need for sleep. Finally, this is also a safety issue: Sleep-deprived clients are at risk for
injury related to decreased judgment, slower response time, and slower reflexes.

590 D Applying restraints to both upper extremities provides protection for the intravenous site. The client does not have the opportunity to
disturb the site

591 A This is the priority action, because the client with restraints is at risk of circulatory problems and possible permanent injury. Releasing
the extremity for range of motion exercises addresses this risk, and allows the nurse to assess for possible injury from the restraints

592 D This option is the priority action concerned with the client’s safety. Observing the extremities for pulses and color allows the nurse to
assess the potential for injury to the client that can be caused by the restraints.

593 A The client should never be touched at the same time that a piece of electrical equipment is being handled. If there were any electrical
current leakage from the pump, it would transfer from the nurse to the client

594 B Water may be used on fires, which involve paper, wood or cloth. A soda and acid extinguisher may also be used for this type of fire.

595 B Even though the client is confused, the call light must be available to allow the client to communicate his or her needs. This option is the
best choice because it is the only action that provides for the client’s immediate safety.

596 B Providing earphones provides both clients with an immediate (and low-cost) solution to the problem. This action promotes
rest for the client in the question and does not interfere with the roommate’s right to watch television.

597 D You have identified the inappropriate action! If the water is too hot, the child may sustain burned feet. Instead, the nurse should use a
thermometer to ensure that the temperature is in the correct range of between 100° and 105° F.

598 B This action is unsafe! The bag should be filled only two-thirds full, to keep the bag easy to mold and lessen the chances of
leakage.

599 C The phone number for the Poison Control Center can place the parents in contact with an immediate source of information for initial
emergency measures that can be implemented to help decrease the severity of the poisoning prior to transportation to the emergency room.

600 B The nurse should check that the device is set to the temperature recommended by the manufacturer. The nurse should also assess
whether the pad feels warm
 601 A nurse is caring for a client with Buck's traction. Which assessment finding indicates a complication associated with this type of
traction? Weak pedal pulses Drainage at the pin sites Warm toes with brisk capillary refill Complaints of discomfort A
Weak pedal pulses are a sign of vascular compromise,which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure
this type of traction. This type of traction does not use pins;rather, it is secured by elastic bandages or a prefabricated boot. Warm toes with brisk capillary refill
is a normal assessment finding. Discomfort is an expected finding.

602 A client had a seizure an hour ago. The family was present during the episode and reported that the client’s jaw was moving as though grinding
food. In helping to determine the origin of this seizure, the nurse assesses for the evidence of: History of prior trauma Diaphoresis
Rotating eye movements Loss of consciousness A Seizures that originate with specific motor phenomena are considered
focal/jacksonian and are indicative of a focal structural lesion in the brain, often caused by trauma, infection or drug consumption. Options B, C and D address
signs and symptoms rather than an origin of the seizure.
603 A nurse is caring for a client who is diagnosed with cystitis. Which assessment finding, if obtained by the nurse, would not be consistent with the
typical clinical picture seen in this disorder? Urinary retention Burning on urination Low back pain Hematuria A Clinical manifestations
of cystitis usually include urinary frequency, urgency, dysuria, inability to void, or voiding only small amounts. The urine may be cloudy with Hematuria and
bacteriuria. The client may complain of pain that is suprapubic or in the lower back. Nonspecific signs include fever, chills, malaise, and nausea and
vomiting. Some clients, particularly the elderly, may be asymptomatic.

604 A client has fallen and sustained a leg injury. Which question would a nurse ask the client to help determine whether the pain is the result of a
fracture? "Does the pain feel like a series of cramps?" "Does the pain feel like pins and needles?" "Is the pain dull ache?" "Is the pain sharp and
piercing?" D Fracture pain is generally described as sharp and piercing. Bone pain is often described as a boring, dull, deep ache. Pain of muscle
origin is often described as an aching or cramping pain, or soreness. Altered sensations, such as paresthesias (pins and needles), indicate that there is pressure
on nerves or impairment of circulation.

605 A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. The nurse assesses to ensure that which of the following items are
in place or maintained before sending the client for the procedure? Signed consent, clear liquid restriction, Foley catheter Signed consent, NPO status, IV line
IV line, clear liquid restriction, Foley catheter IV line, NPO status, Foley catheter B Extracorporeal shock wave
lithotripsy is done under epidural or general anesthesia. The client must sign an informed consent form for the procedure and must be NPO for the procedure.
The client needs an IV line for the procedure as well. A Foley catheter is not needed.

606 A client has developed atrial fibrillation with a ventricular rate of 150 beats/min. The nurse assess the client for: Hypotension and dizziness
Nausea and vomiting Hypertension and headache Flat neck veins A The client with uncontrolled atrial fibrillation with a
ventricular rate over 100 beats/min is at risk for low cardiac output as a result of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or
discomfort, Hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
607 A nurse is performing a respiratory assessment on a client with asthma. The nurse is alert to a worsening on the client's respiratory status when
which of the following occurs? Loud wheezing heard throughout the lung fields The absence of wheezing during inhalation Wheezing heard only
during exhalation Noticeably diminished breath sounds D Wheezing is not a reliable manifestation to determine the severity of an asthma
attack. Clients with minor attacks may experience loud wheezes, while others with severe attacks may not wheeze. The client with severe asthma attacks may
have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds.
Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may wheeze during both inspiration and expiration. Noticeably
diminished breath sounds are an indication of severe obstruction and respiratory failure.

608 A nurse is assessing the casted extremity of a client. The nurse would assess for which of the following signs and symptoms indicative of infection?
Coolness and pallor of the extremity Presence of a hot spot on the cast Diminished distal pulse Dependent edema B
Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast, or the presence of “hot spots”, which areas on
the cast are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal extremity include coolness
and pallor of the skin, diminished arterial pulse and edema.

609 A home care client with chronic obstructive pulmonary disease (COPD) is complaining of increased dyspnea. The client is on home oxygen via
concentrator at 2 L/min. The respiratory rate is 22 breaths/min. The most appropriate nursing action is to: Determine the need to increase the oxygen
Conduct further assessment of the client’s respiratory status Call emergency services to come to the home Reassure the client that
there is no need to worry B Obtaining further assessment data is the most appropriate nursing action. Reassuring the client that there is no
need to worry is inappropriate. Calling emergency services is a premature action. Oxygen is not increased without the approval of the physician, especially
since the client with COPD can retain carbon dioxide.

610 A home health nurse is making follow-up visits to a client following renal transplant. The nurse assesses for signs of acute graft rejection, which
include: Hypotension, graft tenderness and anemia Hypertension, oliguria, thirst and hypothermia Fever, vomiting, Hypotension, and copious
amounts of dilute urine Fever, hypertension, graft tenderness, and malaise D Acute rejection usually occurs within the first 3 months
after transplant, although it can occur for up to 2 years after transplant. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment is
immediately begun with coticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents.
611 A client arrives in the emergency department and carbon monoxide poisoning is suspected. Nursing assessment of the client primarily is directed
toward assessment of the: Level of consciousness Cardiac status Respiratory rate Skin color A The neurological system
is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. Although
cardiac status, respiratory rate, and skin color are components of assessment, neurological status is primarily affected.

612 A nursing instructor has taught a student about increased intracranial pressure (ICP). The instructor asks the student about the three types of
noncompressible cranial contents. The student responds correctly by stating that these include the: Ventricles, blood volume, and the subarachnoid space
Cerebrospinal fluid, brain, and the foramen ovale Semisolid brain, cerebrospinal fluid and the intravascular blood Gray matter, white
matter, and the extrapyramidal tract C When the volume of any of these three components increases, one or both of the other components
must decrease, proportionally, or an increase in ICP will occur.

613 A nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse determines
that the most appropriate choice for this client to meet nutritional needs is: Hot herbal tea with graham crackers Iced coffee with peanut butter and
crackers Vanilla wafers and milk Cocoa with honey and toast C Because mild tactile stimulation of the face of clients with trigeminal
neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause
trigeminal pain.

614 A nurse is preparing to perform an assessment on a client with peptic ulcer disease. The nurse understands that which of data are unrelated to the
client’s disorder? Use of acetaminophen (Tylenol) A history of tarry black tools Complaints of gastric pain 2 to 4 hours after meals History of
alcohol abuse A Unlike aspirin, acetaminophen has little effect on platelet function, does not affect bleeding time, and generally produces no
gastric bleeding. Therefore, acetaminophen is not a risk factor for bleeding from peptic ulcers. Options B and C are signs and symptoms of peptic ulcers and
bleeding peptic ulcers. Because alcohol may aggravate the stomach mucosa, a history of alcohol abuse is often seen in clients with peptic ulcer disease.
615 A nurse is admitting a client with suspected tuberculosis (TB) to the hospital. The nurse understands that the most accurate method of diagnosing
TB is: The client long history of hemoptysis A positive result to a purified protein derivative (PPD) test A sputum culture positive for
Mycobacterium tuberculosis A chest x-ray examination that is positive for lung lesions C The most accurate means of diagnosing TB is
by sputum culture. Establishing the presence of tubercle bacilli is essential for a definitive diagnosis. Hemoptysis is not a common finding and is usually
associated with more advanced cases of TB. A positive PPD indicates exposure to TB. Other diseases may mimic TB on the chest x-ray film.

616 A nurse is assessing a client with a brainstem injury. In addition to performing the Glasgow Coma Scale, the nurse plans to: Check cranial
nerve functioning and respiratory rate and rhythm Perform arterial blood gas measurement Assist with a lumbar puncture Perform a pulmonary
wedge pressure measurement A Assessment should be specific to the area of the brain involved. Assessing the respiratory status and cranial nerve
function is a critical component of the assessment process in a client with a brainstem injury. Options B, C and D are incorrect.

617 A client has had a Miller-Abbott tube in place for 24 hours. Which assessment finding indicates that the tube is located in the intestine?
Aspirate from the tube that has a pH of 7 The abdominal x-ray film indicates that the end of the tube is above the pylorus Bowel sounds
are absent The client continues to be nauseated A The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and to
correct a bowel obstruction. The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic and the pH of the intestinal fluid is
alkaline (7 or higher). Location of the tube can also be determined by x-ray evaluation.

618 While a nurse is admitting a client with myxedema to the hospital, the client reports having lack of energy, cold intolerance and puffiness around the
eyes and face. The nurse knows that these symptoms are caused by a lack of production of which hormone or hormones? Luteinizing hormone (LH)
Adrenocorticotropic hormone (ACTH) Triiodothyronine (T3) and thyroxine (T4) Prolactin (PRL) and growth hormone (GH) C
While all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client’s symptoms. Myxedema results
from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually
every body system and leading to weakness and fatigue. Many metabolic processes are affected and the client experiences a decrease in heat production.
There is also an accumulation of hydrophilic proteoglycans in the interstitial space, which causes increased interstitial fluid and subsequent edema. A decrease
in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease along with a decrease in glucocorticoids and
mineralocorticoid hormones, resulting in hypoglycemia and orthostatic hypotension. PRL affects mammary glands to stimulate breast milk production, and
GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.
619 A 33-year-old woman is admitted to the hospital with a tentative diagnosis of Graves’ disease. Which symptom related to the client’s menstrual
cycle would the client most likely report during the initial assessment? Dysmenorrhea Metrorrhagia Amenorrhea Menorrhagia
C Amenorrhea or a decreased menstrual flow is not uncommon in a client with Graves’ disease. Dysmenorrhea, metrorrhagia, and
menorrhagia are also disorders related to the female reproductive system; however, they do not manifest themselves in the presence of Graves’ disease.

620 A nurse has just administered a purified protein derivative (PPD) skin test to a client. The nurse determines that the test is positive if which of the
following occurs? An induration of 10 mm or greater A large area of erythema The presence of a wheal Client complaints of
constant itching A An induration of 10 mm or greater is usually considered a positive result. Erythema is not a positive reaction. The presence
of a wheal would indicate that the skin test was administered appropriately. Itching is not an indication of a positive PPD.

621 A nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. The nurse would expect to note which of the
following if this disorder was present? An immobile tympanic membrane A pearly colored tympanic membrane A mobile tympanic
membrane A transparent tympanic membrane A Otoscopic examination in a client with mastoiditis reveals red, dull, thick, and immobile
tympanic membrane with or without perforation. Options B, C and D indicate normal findings in an otoscopic examination.

622 A nurse is reviewing the record of a client with a disorder involving the inner ear. Which of the following would the nurse expect to see
documented as an assessment finding in this client? Severe hearing loss Complaints of severe pain in the affected ear Complaints of burning in the ear
Complaints of tinnitusD Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the
inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere
with the client’s thinking process and attention span. The assessment findings noted in options A, B and C are not specifically noted in a client with an inner
ear disorder.
623 A client who has fallen from a ladder and fractured three ribs has arterial blood gas results of pH 7.38, Pco2 38 mm Hg, PO2 86 mm Hg, HCO3 23
mEq/L. The nurse interprets that the client's arterial blood gases (ABGs) indicate which of the following? Normal results Metabolic alkalosis
metabolic acidosis Respiratory acidosis A Normal ABG results include a pH of 7.35 to 7.45, a Pco2 of 35 to 45 mm Hg, a PO2 of 80 to
100, and an HCO3 of 22 to 27 mm Hg. The client's results fall in the normal range.

624 A nurse caring for a client with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's
swallowing ability. Which of the following food items would the nurse plan to avoid in this client's diet? Cheese casserole Scrambled eggs
Mashed potatoes Spinach D In general, flavorful, warm or well - chilled foods with texture stimulate the swallow reflex. Moist
pastas, casseroles, egg dishes, and potatoes are usually effective. Raw vegetables, chunky vegetables such as dried bects, and string vegetables such as spinach,
corn, and peas are foods commonly excluded from the diet of a client with a poor swallow reflex.

625 A client is resuming a diet after hemigastrectomy. To minimize complications from eating, the nurse would tell the client to avoid doing which of the
following? Eating six small meals per day Avoiding concentrated sweets Lying down after eating Drinking liquids with meals D
The client who has had a hemigastrectomy is at risk for dumping syndrome. The client should avoid drinking liquids with meals to prevent this
syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. Frequent small meals are encouraged and the client
should avoid concentrated sweets.

626 Based on assessment and diagnostic evaluation, it has been determined that a client has Lyme disease , stage II. The nurse assesses the client for
which of the following that is most indicative of this stage? Erythematous rash Neurological deficits Headache Lethargy B Stage II of
Lyme disease develops within1 to 6 months in the majority of untreated individuals. The most serious problems in this stage include cardiac conduction defects
and neurological disorders such as Bell's palsy and paralysis. These problems are not usually permanent. Flulike symptoms and a rash appear in stage I.
627 A nurse is caring for a client with a diagnosis of pemphigus. On assessment of the client, the nurse looks for which hallmark sign characteristic of
this condition? Homans' sign Chvostek's sign Trousseau's sign Nikolsky's sign D A hallmark sign of pemphigus is
Nikolsky's sign. Nikolsky's sign is when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture
easily and emit a foul - smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, and umbilicus. Even slight pressure
on an intact blister may cause spread to adjacent skin. Trousseau's sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm
and causing ischemia to the nerves distally. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of
the parotid gland. Homans' sign, a sign of thrombosis in the leg, is discomfort in the calf on forced dorsiflexion of the foot.

628 A nurse is performing pin site care on a client in skeletal traction. Which finding would the nurse expect to note when assessing the pin sites?
Redness and swelling around the pin sites Loose pin sites Purulent drainage from the pin sites Serosanguineous draining from the
pin sites D A small amount of serosanguineous drainage may be expected after cleaning and removing crusting around the pin sites. Redness and
swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose and if this is noted, the physician should be
notified.

629 A nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of fractured femur. The nurse prepares
to perform a complete neurovascular assessment of the affected extremity and plans to assess: Color, sensation, movement, capillary refill, and pulse of
the affected extremity Warmth of the skin and the pedal pulse in the affected extremity Vital signs and bilateral lung sounds Nail thickness and for
the presence of edema in the affected extremity A A complete neurological assessment of an extremity includes
color,sensation,movement,capillary refill, and pulse of the affected extremity. Option B identifies only some of the components of a neurological assessment.
Option C and D do not identify the components of a neurovascular assessment.

630 A client in the emergency department has a plaster of Paris spica cast applied. The client arrives to the nursing unit and the nurse prepares to transfer
the client into the bed by: Supporting the cast with the finger tips only Using the crossbar on the cast Placing ice on top of the cast to decrease
swelling Using the palms of the hands and using soft pillows to support the cast D The palms or the flat surface of the extended fingers
should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast
from the weight of the body. Half - full bags of ice may be placed next to the cast to prevent swelling but this action would be performed after the client is
placed in bed. Lifting a cast by the crossbars is never done and could cause breakage of the cast.
631 A physician orders the deflation of the esophageal balloon of a Sengstaken Blakemore tube in a client. The nurse prepares for the procedure knowing
that the deflation of the esophageal balloon places the client at risk for: Increased ascites Esophageal necrosis Recurrent hemorrhage from the
esophageal varices Gastritis C A Sengstaken - Blakemore tube is inserted in clients with cirrhosis who have ruptured esophageal varices. It has
esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the
esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues including esophageal rupture or necrosis. When the balloon is
deflated, the client may begin to bleed again from the esophageal varices.

632 A 45- year -old client is admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia noted on Holter monitoring. The client
is scheduled for electrophysiology studies(EPS) the following morning. Which statement would the nurse include in a teaching plan for this client?
During the procedure, a special wire is used to increase the heart rate and produce the irregular beats that caused your signs and symptoms. You will be
sedated during the procedure and will not remember what has happened. This test is a noninvasive method of determining the effectiveness of your
medication regimen. You will continue to take your medications until the morning of the test. A The purpose of EPS is to study heart's
electrical system . During this invasive procedure , a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the
client should be NPO for 6 to 8 hours before and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmias
without the influence of medications. Since the client's verbal response to rhythm changes are extremely important, heavy sedation is avoided if possible.

633 A nurse is providing diet teaching to a client with congestive heart failure (CHF). The nurse tells the client to avoid: Leafy green vegetables
Catsup Cooked cereal Sherbet B Catsup is high in sodium. Leafy green vegetables, cooked cereal, and sherbet are all low
in sodium. Clients with CHF should monitor sodium intake.

634 A home care nurse is developing a plan of care for an elderly client with diabetes mellitus who has gastroenteritis. In order to maintain food and
fluid intake to prevent dehydration, the nurse plans to: Offer water, only, until the client is able to tolerate solid foods Withhold all fluids until vomiting
has ceased for at least 4 hours Encourage the client to take 8 to 12 ounces of fluid for every hour while awake Maintain a clear liquid diet for at
least 5 days before advancing to solids to allow inflammation of the bowel to dissipate C The client should be offered liquids containing both
glucose and electrolytes. Small amounts of fluid may be tolerated even when vomiting is present. The diet should be advanced as tolerated and should
include a minimum of 100 to 150 g of carbohydrates daily. Offering water only and maintaining liquids for 5 days will not prevent dehydration but may
promote it in this client.
635 A nurse is preparing to initiate an intravenous nitroglycerin drip for a client with acute myocardial infarction. In the absence of an invasive
(arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside? Defibrillator Pulse oximeter
Central venous pressure (CVP) tray Noninvasive blood pressure monitor D Nitroglycerin dilates both arteries and veins,
causing peripheral blood pooling and thus reducing preload,afterload,and myocardial work. This action accounts for the primary side effect of
nitroglycerin,which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the
bedside.

636 A client is scheduled for several dignostic test to rule out renal disease. As an essential component of the nursing assessment, the nurse plans to
asks the client about a history of:Frequent antibiotic use Long-term diuretic therapy Allergy to shellfish or iodine Famillial renal disease.
C The client undergoing any type of diagnostic testing should be questioned about allergy to shellfish,seafood, or iodine. This essential
to identify the risk for potential allergic reaction to contrast dye, which may be used in some diagnostic tests. The other items are also useful as part of the
assessment but are not as critical as the allergy determination.

637 A client in ventricular tachycardia, and the physician orders a STAT dose of lidocaine (Xylocaine) by intravenous (IV) bolus. An IV of 5% dextrose
in water (D5W) is infusing . To administer the lidocaine, the nurse: Stops the IV, flushes the IV line, and then gives the Lidocaine. Stops the IV and gives
the Lidocaine directly into the IV line Starts another IV site Checks for incompatability of Lidocaine with other IV medications B A bolus of
lidocaine can be given directly into an IV line if 5% dextrose in water (D5W) is infusing, because it is compatible with D5W is the primary solution, the IV
line does not need to be flushed. A new IV line is not required for the administration of this medication in this situation. There are no data in this question that
other IV medications are being administered; therefore option D is necessary

638 A client with aquired immunodeficiency syndrome(AIDS) who has cytomegalovirus (CMV) retinitis is receiving ganciclovir sodium(Cytovene).
The nurse implements which of the following in the care of this client? Monitors blood glucose levels for elevation Administers the medication on an
empty stomach only Tells the client to use a soft toothbrush and an electric razor Applies pressure to venipuncture sites for at least 2 minutes C
Gaciclovir causes neutropenia and thombocytopenia as the most frequent side effects.For this reason the nurse monitors the client for signs and
symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. Thus, venipuncture sites should be held
for approximately 10 minutes. The medication does not have to be taken on an empty stomach. The medication may cause hypoglycemia,but not
hyperglycemia.
639 A client without history of respiratory disease has experienced sudden onset of chest pain and dyspnea,and pulmonary embolus is diagnosed. The
nurse immediately implements which of the following therapeutic orders prescribed for this client? Semi-Fowler's position, oxygen at 4 L/min, and morphine
sulfate (MS) 2 mg intravenously (IV) Semi-Fowler's position, oxygen at 1 L/min,and meperidine hydrchloride (Demerol) 100mg intramuscular (IM)
High-Fowler's position, oxygen at 4 L/min, and 2 tablets acetaminophen with codeine (Tylenol#3) High-Fowler's position, oxygen at 1 L/min, and
MS 10mg IV A Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and
intravenous analgesics. The head of the bed is placed in semi-Fowler's position. High-Fowler's is avoided because extreme hip flexure slows venous return
from the legs and increases the risk of new thrombi. The client without preexisting respiratory disorders can tolerate oxygen at levels exceeding 2 to 3
L/min. The usual analgesic of choice is MS administered IV. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the
pulmonary vessels because it causes peripheral venous dilatation.

640 A client who recently experienced myocardial infarction is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) . The
nurse plans to teach the client that during this procedure a balloon-tipped catheter will: Cut away the plaque from the coronary vessel wall using a cutting
blade Be used to compress the plaque against the coronary blood vessel wall Inflate a meshlike device that will spring open and keep the plaque
against the coronary vessel wall Be positioned in a coronary artery to take pressure measurements in the vessel B Option A describes coronary
atherectomy. Option B describes PTCA. Option C describes placement of a coronary stent and option D describes part of the process used in cardiac
catheterization.

641 A nurse is caring for a client who has ben placed in Buck's extension traction. The nurse provides countertraction to reduce shear and friction by:
Slightly elevating the head of the bed Slightly elevating the foot of the bed Providing an overhead trapeze Using a footboard B
The part of the bed under an area in traction is usually elevated to aid in countetraction. For the client in Buck's extension traction (which is applied
to a leg), the foot of the bed is elevated. An overhead trapeze or footboard is not used for the purpose of providing countertraction. Option B provides a force
that opposes the traction force effectively without harming the client, and is the answer to the question.

642 A nurse insreted a nasogastric(NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The
client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke.
Which of the following nursing actions would least likely result in proper tube insertion and promote client relaxation? Continuing to advance the tube to
the desired distance Pulling the tube back slightly Checking the back of the pharynx using a tongue blade and flashlight Instructing the client to
breathe slowly A As the NG tube is passed through the oropharynx, the gag refex is stimulated, which may cause coughing, gagging,and
choking. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx,or it may enter the larynx and obstruct the airway.
Since the tube may enter the larynx, advancing the tube may position it in the trachea. Slow breathing helps the client relax to reduce the gag response. The
tube may be advanced after the client relaxes.

643 A nurse is planning care for a client with heart failure. The nurse asks the dietary department to remove which item from all meal trays before
delivering them to the client? Salt packets 1% milk Margarine Decaffeinated tea A Sodium restriction reduces water retention and
improves cardiac efficiency. A standard dietary modification for the client with heart failure is sodium restriction.

644 A client with pulmonary edema has oxygen via nasal cannula at 6 liters per minute. Arterial blood gas (ABG) results indicate the following: pH
7.29, Pco2 49 mm Hg, Po2 58 mm Hg, HCO3 18 mEq/L.The nurse anticipates that the physician will order which of the following for respiratory support?
Lowering the oxygen to 4 liters per minute via nasal cannula Keeping the oxygen at 6 liters per minute via nasal cannula Adding a
partial rebreather mask to the current order Intubation and mechanical ventillation D If respiratory failure occurs, endotracheal intubation and
mechanical ventillation are necessary. The cleint is exhibiting respiratory acidosis, metabolic acidosis, and persistent hypoxemia. Lowering or keeping the
oxygen at the same liter flow will not improve the client's condition. A partial rebreather mask will raise CO2 levels even further.

645 A client with an arteriovenous (AV) shunt in place,for hemodialysis, is at risk for bleeding. The nurse does which of the following as a priority
action to prevent this complication. Checks the results of partial thromboplastin time (PTT) tests as they are ordered Checks the shunt once
per shift Checks the shunt for the presence of a bruit and thrill Ensures that small clamps are attached to the AV shunt dressing D An AV shunt
is a less common form of access site, but carries a risk for bleeding when it is used. This is because two ends of a cannula are tunneled subcutaneously into an
artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps
are attached to the dressing that covers the insertion site for use if needed. The shunt should be checked at least every 4 hours. Checking the results of the PTT
does not prevent bleeding. Checking the results of the PTT does not prevent bleeding. Checking for the presence of a bruit and thrill assesses the patency.

646 A client is due in hydrotherapy for a burn dressing change. To ensure that the procedure is most tolerable for the client, the nurse takes which of the
following actions? Sends dressing supplies with the client to hydrotherapy Ensures that the client has a robe and slippers Administers an analgesic
20 minutes before therapy Administers the intravenous antibiotic 30 minutes before therapy C The client should receive pain medication
approximately 20 minutes before a burn dressing change. This will help the client to tolerate an otherwise painful procedure. Antibiotics are timed evenly
around the clock, and not necessary in relation to timing of burn dressing changes. Dressing supplies are generally available in the hydrotherapy area and do
not need to be sent with the client. A robe and slippers are beneficial for the client's comfort if travelling by wheelchair, but pain medication is more essential.
647 A nurse is preparing to care for a client who has undergone a parathyroidectomy. The nurse plans care anticipating which postoperative order?
Place in a flat position with the head and neck immobilized Take a rectal temperature only until discharge Maintain endotracheal
tube for 24 hours Administer a continuous mist of room air or oxygen D Humidification of air or oxygen helps to liquefy mucous secretions
and promotes easier breathing following parathyroidectomy. Pooling of thick mucous secretions in the trachea, bronchi, and lungs will cause respiratory
obstruction. Semi-Fowler’s position is the position of choice to assist in lung expansion and prevent edema. Rectal temperatures are not required. Tympanic
temperatures can be taken. The client will not necessarily have an endotracheal tube.

648 A client with carbon monoxide poisoning is to receive hyperbaric oxygen therapy. During the therapy, the nurse implements which priority
intervention? Assessing that oxygen is being delivered Maintaining an intravenous access Administering sedation to prevent
claustrophobia Providing emotional support to the client’s family A Hyperbaric oxygen therapy is a process by which 100% oxygen is
administered at greater than normal pressure. In carbon monoxide poisoning this therapy causes an increase in alveolar oxygen pressure and allows the carbon
monoxide that is attached to the hemoglobin to be replaced by oxygen. Since the client is placed in a closed chamber, the administration of oxygen is of primary
importance. Although options B, C, and D may be appropriate interventions, option 1 is the priority.

649 A nurse is caring for a client with a herniated lumbar intervertebral disc. The nurse plans to place the client in which position to minimize the pain?
High-Fowler’s position with the foot of the bed flat Semi-Fowler’s position with the knee gatch slightly raised Semi-Fowler’s position
with the foot of the bed flat Flat with the knee gatch raised B Clients with low back pain are often more comfortable when placed in semi-
Fowler’s position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve
root. Keeping the foot of the bed flat will enhance extension of the spine. Keeping the bed flat with the knee gatch raised would excessively stretch the lower
back and would also put the client at risk for thrombophlebitis.

650 A client with a fractured right ankle has a short leg plaster cast applied in the emergency department. During discharge teaching, the nurse provides
which information to the client to prevent complications? Keep the right ankle elevated with pillows above the heart for 24 to 48 hours Weight-bear
on the right leg only after the cast is dry Expect burning and tingling sensations under the cast for 3 to 4 days Trim the rough edges of the cast
after it is dry A Leg elevation is important to increase venous return and decrease edema, which can cause compartment syndrome, a major
complication of fractures and casting. Weight-bearing on a fractured extremity is prescribed by the physician during follow-up examination, after an x-ray film
is taken. Although the client may feel heat after the cast is applied, burning or tingling sensations indicate nerve damage or ischemia and are not expected.
These complaints should be reported immediately. Option D is incorrect, because any cast modifications should be done by trained personnel under medical
supervision. The client and family may be taught how to petal the cast to prevent skin irritation and breakdown, but rough edges, if trimmed , can fall into the
cast and cause a break in skin integrity.

651 An older adult woman client with a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse
assesses for which of the following signs and symptoms that indicate a complication associated with crutch walking? Forearm muscle weakness
Left leg discomfort Triceps muscle spasms Weak biceps brachii A Forearm muscle weakness is a sign of radial nerve injury
caused by crutch pressure on the axillae. When clients lack upper body strength, especially in the flexor and extensor muscles of the arms, they frequently allow
their weight to rest on their axillae instead of their arms while ambulating with crutches. Leg discomfort is expected as a result of the injury. Triceps muscle
spasms may occur as a result of increased muscle use but it is not a complication of crutch walking. Weak biceps brachii is a common physical assessment
finding in older adults and is not a complication of crutch walking.

652 A client with myasthenia gravis is experiencing prolonged periods of weakness. The physician orders an edrophonium (Tensilon) test. A test dose is
administered and the client becomes weaker. The nurse interprets this test result as: Normal Positive Myasthenia crisis Cholinergic crisis D
A Tensilon test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenia is caused by a
cholinergic crisis (overmedication with anticholinesterase drugs) or myasthenic crisis (under medication with cholinesterase inhibitors). Worsening of the
symptoms after the test dose of medication is administered indicates a cholinergic crisis.

653 A nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. The most appropriate nursing action is to: Continue to
monitor the rhythm Notify the physician immediatelyPrepare for defibrillation Administer the ordered lidocaine hydrochloride (LidoPen) A
As an isolated occurrence, the PVC is not life threatening. In this situation the nurse should continue to monitor the client. Frequent PVCs, however,
may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurred, the physician needs to be
notified.

654 A nurse is caring for a client admitted with the diagnosis of active tuberculosis (TB). This nurse determines that this diagnosis was confirmed by a:
Mantoux test Sputum culture Tine test Chest x-ray evaluation B A sputum culture showing mycobacterium
tuberculosis confirms the diagnosis of TB. Usually three sputum samples are obtained for the acid-fast smear. After the initiation of medication therapy, sputum
samples are obtained again to determine the effectiveness of therapy. A positive result to a tine or Mantoux test indicates exposure to TB but does not confirm
the presence of M. tuberculosis. A positive chest x-ray evaluation may indicate the presence of tuberculosis lesions but again does not confirm active disease.
655 A client with acquired immunodeficiency syndrome (AIDS) is admitted to the hospital for chills, fever, nonproductive cough, pleuritic chest pain. A
diagnosis of Pneumocystis carinii pneumonia is made, and the client is started on IV pentamidine (Nebupent). The nurse plans to infuse the medication over: 1
hour with the client in a supine position 30 minutes with the client in a reclining position 1 hour and the client may be ambulatory 15 minutes
with the client in a supine position A IV pentamidine is infused over 1 hour with the client supine to minimize severe hypotension and
dysrhythmias. Options B,C, and D are inaccurate in either the length of time pentamidine is administered or the client’s position.

656 A nurse is caring for the client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen.
The nurse’s response is based on the understanding that: An injured artery causes impaired arterial perfusion through the compartment The fascia
expands with injury, causing pressure on underlying nerves and muscles A bone fragment has injured the nerve supply in the area Bleeding and
swelling cause increased pressure in an area that cannot expand D Compartment syndrome is caused by bleeding and swelling within a
compartment, which is lined by fascia that does not expand. The bleeding and swelling places pressure on the nerves, muscles, and blood vessels in the
compartment, triggering the symptoms.

657 A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse prepares to provide which type of wound care of the
fasciotomy site? Dry sterile dressings Moist sterile saline dressings Hydrocolloid dressings One-half strength Betadine dressings B
The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5
days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open
incisions. The incision is clean, not dirty, so there should be no reason to require Betadine. In addition, Betadine can be irritating to normal tissues.

658 A nurse assists the physician with the removal of a chest tube. During removal of the chest tube, the nurse instructs the client to: Breathe out
forcefully Breathe in deeply Hold the breath Breathe normally C The client is instructed in the Valsalva maneuver so that the client can
hold the breath and bear down as the physician removes the chest tube. This maneuver will increase intrathoracic pressure, thereby lessening the potential for
air to enter the pleural space. Options A,B, and D are incorrect.
659 A nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse determines that this
finding indicates that: An air leak is present The tubing has a kink.The lung has reexpanded The system is functioning as expected D
Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer
requires chest drainage. If fluctuations are absent, it could indicate an air leak, kinking, or that the lung has reexpanded.

660 An elderly client admitted to the hospital with a hip fractures is placed in Buck’s traction. The nurse plans to frequently monitor the client’s:
Vital signs Mental state Range of motion Neurovascular status D The neurovascular status of the extremity of the client in
Buck’s traction must be assessed every 2 hours for the first 24 hours. Elderly clients are especially at risk for neurovascular compromise because many elderly
clients already have disorders that affect the peripheral vascular system. The client’s physiological status determines the frequency of vital signs, not the
presence or absence of Buck’s traction. Although clients in some types of traction do become depressed after a few days or weeks, Buck’s traction is usually
used preoperatively, which typically involves a few hours or 1 to 2 days at the most. Range of motion of the involved leg is contraindicated in hip fractures.

661 A client who has a renal mass.The client asks the nurse why ultrasonography has been scheduled, as opposed to other diagnostic tests that may be
ordered. The nurse formulates a response based on the understanding that: Ultrasonography can differentiate a solid mass from a fluid-filled cyst
Ultrasonography is much more cost effective than other diagnostic tests All other tests are more invasive than ultrasonography All other tests
require more elaborate postprocedure care A A significant advantage of ultrasonography is that it can differentiate a solid mass from a fluid-filled
cyst. It is noninvasive and does not require any special aftercare. There are other diagnostic tests, such as magnetic resonance imaging and computed
tomography scanning, that are also noninvasive (unless a contrast agent is used) and that require no special aftercare either. However, it is ultrasonography that
can discriminate between solid and fluid masses most optimally.

662 A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. On assessment, the nurse first asks the client about a recent
history of: Bleeding ulcer Hypertension Fungal infection Streptococcal infection D The predominant cause of acute
glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, infectious agents that could
trigger the disorder include viruses or parasites. Hypertension and bleeding ulcer are not precipitating causes.
663 A male client has just been admitted to the emergency cepartment with chest pain. Serum enzyme levels are drawn. Results indicate an elevated
creatinine phosphokinase (CPK), elevated CPK-MB, and elevated lactic dehydrogenase (LDH), with the LDH2 exeeding LDH1. The nurse concludes that these
results are compatible with: New onset myocardial infarction (MI) Myocardial infarction of at lest 3 days’ duration Unstable angina
Prinzmetal’s angina A CPK and its cardiac isoenzyme, CPK-MB, are sensitive indicators of myocardial damage. Levels begin to rise 3 to
6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Normal values for males are 12 to 70 U/mL or 38 to
174 U/L. LDH begins to rise in 24 hours, peaks at 48 to 72 hours, and returns to normal in 7 to 14 days. LDH1 rises above the level of LDH2 with MI. The
elevations identified in the question are consistent with new onset MI.

664 A client with heart failure has cardiomegaly noted on a chest x-ray film. As part of cardiac assessment, the nurse auscultates the apical rate and
places the stethoscope: At the normal point of maximal impulse (PMI) Slightly upward and medial to the normal PMI Slightly
downward and medial to the normal PMI Lateral to the normal PMI D The point of maximal impulse (PMI), where the apical rate is
auscultated, is normally located in the fifth intercostals space, midclavicular line. With heart failure, the heart enlarges, shifting the PMI laterally.

665 A nurse is caring for a client with acute pancreatitis who has a history of alcohoism. The nurse closely monitors the client for paralytic ileus knowing
that which assessment data indicate this complication of pancreatitis? Firm, nontender mass palpable at the lower right costal margin Severe,
constant pain with rapid onset Inability to pass flatus Loss of anal sphincter control C An inflammatory reaction such as acute pancreatitis can
cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Option A is the
description of the physical finding of liver enlargement. The liver is usually enlarged in the client with cirrhosis or hepatitis. Although this client may have an
enlarged liver, an enlarged liver is not a sign of paralytic ileus, or intestinal obstruction. Pain is associated with paralytic ilues, but the pain usually presents as a
more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Loss of sphincter
control is not a sign of paralytic ileus.

666 After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are
normal. Which of the following descriptions best describes this assessment finding? Waves of loud gurgles auscultated in all four quadrants Very high-
pitched loud rushes auscultated especially in one or two quadrants Relatively high-pitched clicks or gurgles auscultated in all four quadrants Low-pitched
swishing auscultated in one or two quadrants C Although frequency and intensity of bowel sounds will vary depending on the phase of
digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be more
high pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents
turbulent blood flow associated with a bruit. No aortic bruits should be heard.
667 A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses which of the following most important parameters on a daily
basis? Albumin levels Weight Blood urea nitrogen (BUN) level Activity tolerance B The client with nephrotic syndrome typically
presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight,
intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client's
activity level is adjusted according to the amount of edema and water retention. As edema increases, the client’s activity level should be restricted.

668 A client is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the client for pain that is Dull and
aching in the costovertebral area Sharp and radiating posteriorly to the spinal column Excruciating wavelike, and radiating toward the genitalia
Aching and cramplike throughout the abdomen C The pain of ureteral colic is caused by movement of a stone through the ureter
and is sharp, excruciating and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because
of the stone's abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a deep ache in the costovertebral area. Renal colic is
characterized by pain that is acute, with tenderness over the costovertebral area.

669 A nurse is assessing a client with left-sided heart failure. The client states that it is necessary to use three pillows under the head and chest at night to
be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing Dyspnea on exertion Dyspnea at rest Orthopnea
Paroxysmal nocturnal dyspnea C Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress
and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring
the client to asssume a "three point" position while upright and to use pillows to support the head and thorax at night. Paroxysmal nocturnal dyspnea is a severe
form of dyspnea occuring suddenly at night as a result of rapid fluid reentry into the vasculature from the interstitium during sleep.

670 A nurse witness a client going into pulmonary edema. The client exhibits respiratory distress, but the blood pressure is stable at this time. As an
immediate action before help arrives, the nurse plans to first Suction the client's airway vigorously Place the client in high-Fowler's position
Begin assembling medications that the nurse anticipates will be given Call the respiratory therapy department for a ventilator B
The client in pulmonary edema is placed in high Fowler's position, if the blood pressure is stable. Vigorous suctioning may deplete the client of vital
oxygen at a time when the respiratory system is compromised. Assembling medications is useful, but not critical to the immediate well-being of the client. The
client may or may not need mechanical ventilation
671 A nurse suspects that cardiogenic shock is developing in a client who had a myocardial infarction. The nurse assesses for which of the following
peripheral vascular manifestations of this complication?Flushed, dry skin with bounding pedal pulses Warm, moist skin with irregular pedal pulses
Cool, dry skin with alternating weak and strong pedal pulses Cool, clammy skin with weak or thready pedal pulses D Classic sign
of cardiogenic shock include increased pulse (weak and thready) decreased blood pressure, decreasing urinary output, signs of cerebral ischemia (confusion,
agitation) and cool, clammy skin.

672 A nurse is caring for a client who returns from cardiac surgery with chest tubes in place. The nurse measures the drainage on an hourly basis and
assesses that the client is stable as long as drainage does not exceed how many milliliters over the first 24 hours? 100 200 500
1000 C Approximately 500 mL of drainage is expected in the first 24 hours after cardiac surgery. Up to 100 mL may be lost in the
first hour postoperatively. The nurse measures and records the drainage on an hourly basis. The drainage is initially dark red and becomes more serous over
time.

673 A client with renal cancer is being treated preoperatively with radiation therapy. The nurse evaluates that the client has an understanding of proper
care of the skin over the treatment field if the client states the need to: Avoid skin exposure to direct sunlight and chlorinated water Use lanolin-
based cream on the affected skin on a daily basis Remove the lines or ink marks using a gentle soap after each treatment Use the hottest water
possible to wash the treatment site twice daily A The client undergoing radiation therapy should avoid washing the site until instructed to do
so. The client should then wash using mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on
the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be
protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools)

674 A client with renal failure is receiving epoetin alfa (Epogen) to support erythropoiesis. The nurse questions the client about compliance with taking
which of the following medications that supports red blood cell (RBC) production Calcium supplement Iron supplement Magnesium supplement
Zinc supplement B Iron is needed for RBC production. Otherwise, the body cannot produce sufficient erythrocytes or produce cells
that are deficient in iron. In either case, the client is not receiving the full benefit of epoetin alfa therapy if iron is not taken.
675 A home health nurse is performing an initial assessment on a client who has arrived home with a permanent pacemaker following cardiac surgery.
The nurse determines the client's ability regarding self-care related to the pacemaker when the nurse Asks the client to take the pulse in the wrist or neck and
checks the accuracy of the client's reading Determines whether the client knows not to operate a microwave oven Determines whether the client
knows that he or she can resume sexual activity immediately Asks the client to move the arms and the shoulders vigorously to check pacemaker
functioning A Clients with permanent pacemakers must be able to take their pulse in the wrist or neck accurately in order to note any
variation in the pulse rate or rhythm that may need to be reported to the physician. Clients can safely operate microwave ovens, VCRs, AM-FM radios, electric
blankets, lawn mowers, leaf blowers, and cars. Proper grounding must be ensured if the client is to operate electric typewriters, copying machines, and personal
computers. Sexual activity is not resumed until 6 weeks after surgery. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.

676 A nurse is assessing a client with a Miller-Abbot tube. Which finding indicates correct placement of tube? A pH of aspirate of 7.0 or greater A
pH of aspirate less than 7.0 The presence of gastric contents when checking residuals The auscultation of the air when the tube is inserted into
the abdomen A The Miller-Abbot tube is an intestinal tube. The nurse ensures intestinal placement by checking the pH of aspirate. A pH
reading greater than 7 indicates intestinal contents; one less than 7 indicates gastric contents.

677 A nurse performs a neurovascular assessment on a client with a newly applied cast. Close observation and further evaluation would be required if
the nurse notes: Capillary refill less than 6 seconds Palpable pulses distal to the cast Sensation when the area distal to the cast is pinched
Blanching of the nail bed when depressed A To assess for adequate circulation, the nail bed of each finger or toe is depressed until it
blanches, and the pressure is released. Optimally, the color will change from white to pink rapidly ( less than 3 seconds). If this does not occur, the toes or
fingers will require close observation and further evaluation. Palpable pulse and sensations distal to the cast are expected. However, if the pulses could not be
palpated or if the client complained of numbness or tingling, the physician should be notified.

678 A nurse is preparing to care for a client arriving from the operating room following a wedge resection of the right lower lobe. In planning for the
client safety the nurse: Removes obstructions to the transport stretcher Notifies the pharmacy of the clients location Places
rubber-shod clamps at the bedside Ensures that the wall suction unit is operational C Following wedge resection, the client will have
a chest tube. Clamps should always be available at the bedside of a client with a closed drainage system so that they can be applied in the event of an accidental
disconnection of the drainage tubing. It is also important to remember that chest tubes are never clamped without specific orders of the physician, except in
emergencies. While operational wall suction is desirable, it does not directly affect the safety of the client. Option A relates to safety but is less directly related
to the client. Option B is unrelated to the issue of the question.
679 A nurse is caring for a client admitted to the surgical nursing unit following right modified radical mastectomy. The nurse includes which of the
following in the nursing plan of care for this client? Position the client supine with the right arm elevated on a pillow Take blood pressures in the right
arm only Draw serum laboratory samples from the right arm only Check the right posterior axilla area when assessing the surgical dressing D If
there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the
dressing first. The nurse checks this area to detect early bleeding. The client should be positioned with the head in semi-Fowler’s position and the arm elevated
on pillows to decrease edema. Edema is likely to occur because lymph drainage channels have been resected during the surgical procedure. Blood pressure,
venipunctures, and IV sites should not involve use of operative arm.

680 A nurse is assisting a client with a hepatic encephalopathy to fill out the dietary menu. The nurse advice the client to avoid which of the following
entrée items that could aggravate the clients condition? Fresh fruit plate Tomato soup Vegetable lasagna Ground beef patty D
Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit dietary intake of protein- and ammonia-
containing foods. The client should avoid foods such as chicken, beef, ham, cheese, buttermilk, Idaho potato, onions, peanut butter, and gelatin.

681 A client with a colostomy is complaining of gas building up on the colostomy bag. The nurse instruct the client that which of the following food
items will not aggravate the problem? Beans Cauliflower Potatoes Corn C Gas-forming foods include corn, cauliflower,
onions, beans and cabbage. These should be avoided by the client with a colostomy until tolerance to them is determined.

682 A client receiving total parenteral nutrition (TPN) complains of nausea, excessive thirst, and increase frequency of voiding. A nurse initially assess
which of the following data? Serum blood urea nitrogen and creatinine Capillary blood glucose Last serum potassium Rectal temperature B
The symptoms exhibited by the client are consistent with hyperglycemia. The nurse would need to assess the clients blood glucose level to verify
these data. Clients receiving TPN are at risk for hyperglycemia related to the increased glucose load of the solution. The other options would not provide any
information that would correlate with the clients symptoms.
683 A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and has difficulty breathing. A nurse performs which interventions
as a priority measure to assist the client with breathing? Auscultates the lung fields every 4 hours Repositions side to side every 2 hours
Encourage deep breathing exercise every 2 hours Elevates the head of the bed 60 degrees D The client is having difficulty
breathing because of upward pressure of the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the
diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves
diaphragmatic pressure.

684 A client with diverticulitis has just been advanced from a liquid to solid diet. The nurse encourages the client to eat foods that are: Low residue
High residue Moderate in fat High roughage A The purpose of low-residue diet for a client with diverticulitis is to
allow the bowel to rest while the inflammation subsides. The client should avoid foods such as nuts, corn, popcorn and low celery, which are high roughage

685 A client with Cushing's syndrome is being admitted to the hospital after a stab wound to the abdomen. The nurse places highest priority on which
of the following nursing diagnoses developed for this client? Risk for Fluid Volume Deficit Risk for Infection Body Image Disturbance
Altered Health Maintenance B The client with a stab wound has a break in the body's first line of defense against infection. The
client with Cushing's syndrome is at great risk for infection as a result of excess cortisol secretion, subsequent impaired antibody function, and decreased
proliferation of lymphocytes. The client may also have an Altered Health Maintenance and Body Image Disturbance, but these are not the highest priority at
this time. The client would be at risk for Fluid Volume Excess, not Fliud Volume Deficit, with Cushing's syndrome.

686 A nurse evaluates a client following treatment for carbon monoxide poisoning. The nurse would document that the treatment was effective when
the: Client is awake and talking Carboxyhemoglobin levels are less than 5% Heart monitor shows sinus tachycardia client is sleeping soundly
B Normal carboxyhemoglobin levels are less than 5%. Clients can be awake and talking with abnormally high levels. The symptoms of
carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.
687 A nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. The nurse would use which of the following
dressing method to cover the leg? Apply a large , soft pad, and tape it to the skin Apply a Kerlix roll, and tape it to the skin Apply small
Montogomery straps, and tie the edges together Apply a Kling roll, and tape the edge of the roll onto the bandage D With an arterial ulcer,
the nurse applies tape only to bandage itself. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason,
Montogomery straps could not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway). Standard dressing
technique incudes the use of Kling rols on circumferential dressings.

688 A a client who undergoes a gastric resection is at risk for developing dumping syndrome. The nurse monitors the client for: Extreme
thirst Bradycardia Dizziness Constipation C Early manifestations of dumping syndrome occur 5 to 30 minutesm after
eating. Symptoms include vasomotor disturbances such as dizzines, tachycardia, syncope, sweating pallor,palpitations, and the desire to lie down.

689 A nurse is caring for a client who had a craniotomy. When assessing the client for the major postoperative complication, the nurse monitors for:
Restlessness Bleeding Hypotension Bradycardia A The major postoperative complication is increased
intracranial pressure (ICP) from cerebral edema, hemorrhage, or obstruction of the normal flow of cerebrospinal fluid (CSF). Symptoms of increased ICP
include severe headache, deteriorating level of consciousness, restlessness, irritability, and dilated or pinpoint pupils that are slow to react or nonreactive to
light. Without prompt recognition and treatment, herniation syndromes develop and death can occur.

690 Buck's traction is applied to an elderly client following a hip fracture. The client asks the nurse about the traction. The nurse tells the client that
this type of traction is: Skin traction involving the use of elastic bandages applied to the skin and soft tissues Skeletal traction involving the use
of surgically insrted pins Circumferential traction involving the use of belt around the body Plaster traction involving the use of a cast A
Buck's traction is a form of skin traction and involves the use of elastic bandages applied to the skin and soft tissues. The purpose of this type of
traction is to decrease painful muscle spasms that accompany fractures. The weight that is used as a pulling force is limited (5 to 10 lb), to prevent injury to
the skin. Options B, C, and D are incorect descriptions.
691 An adult client arrives in the emergency unit with burns to both legs and perineal areas. Using the Rule of Nines, the nurse would determine
that approximately what percentage of the client's body surface has been burned? 19% 46% 37% 0.65 C The most
rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the Rule of Nines. This
method divides the body into areas that are in multiples of 9%. Each leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36% and the perineal area
is 1%. Both legs and the perineal are equal 37%.

692 Skin closure with heterograft is performed on the burn client. The client asks the nurse about the meaning of a heterograft. The nurse tells the
client that heterograft is skin from: Another species A cadaver The burned client A skin bank A Biological dressings are
usually heterograft or homograft material. Heterograft is skin from another species. The most commonly used type of heterograft is pigskin because of its
availability and its relative compatibility with human skin. Homograft is skin from another human, Which is usually obtained from a cadaver and is provided
through a skin bank. Autograft is skin from the client.

693 A nurse is determining the need for suctioning in a client with endotracheal (ET) tube attached to a mechanical ventilator. Which observation by the
nurse is not consistent with the need for suctioning? Low peak inspiratory pressure on the ventilator Gurgling sound with respiration Restlessness
Presence of rhonchi A Indications for suctioning include moist, wet respirations, restlessness, rhonchi on auscultation of the lungs, visible
mucus bubbling in the ET tube, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator. A low peak inspiratory
pressure would indicate a leak in the mechanical ventilation system.

694 A client is intubated and receiving mechanical ventilation. The physician has added 5 cm of positive end expiratory pressure (PEEP) to the
ventilator settings of the client. The nurse assesses for which of the following expected but adverse effects of PEEP? Systolic blood pressure decrease
from 122 to 98 mm Hg Decreased heart rate from 78 to 64 beats/min Decreased peak pressure on the ventilator Increased temperature
from 98° to 100° F rectally A PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested
in the client by decreased blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at
the end of expiration remains positive at the level set for the PEEP. Fever would indicate respiratory infection, or infection from another source.
695 A nurse is assessing the respiratory status of the client following thoracentesis. The nurse would become most concerned with which of the
following assessment findings? Respiratory rate of 22 breaths/min Equal bilateral chest expansion Few scattered wheezes, unchanged from
baseline Diminished breath sounds on the affected side D Following thoracentesis, the nurse assesses the vital signs and breath sounds.
The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of
these signs should be reported to the physician.

696 A nurse is preparing to administer a Mantoux skin test to a client. The nurse determines that which area is most appropriate for injection of the
medication? Inner aspect of the forearm that is not heavily pigmented Inner aspect of the forearm that is close to a burn scar Dorsal aspect
of the upper arm near a mole Dorsal aspect of the upper arm that has a small amount of hair A Intradermal injections are most commonly
given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area
that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.

697 A home care nurse is planning therapeutic measures for the client who experienced a rib fracture 2 days earlier. The nurse avoids including which of
the following items in the nursing care plan? Rest Local heat Ice Analgesics C Common therapies for fractured ribs include rest,
analgesics and local application of heat. Heat has an analgesic effect and speeds resolution of inflammation.

698 A hospitalized client is dyspneic, and left pneumothorax has been diagnosed on the basis of chest x-ray evaluation. Which of the following signs or
symptoms observed by the nurse most clearly indicates that the pneumothorax is rapidly worsening? Pain with respiration Hypertension Tracheal
deviation to the right Tracheal deviation to the left C A pneumothorax is characterized as distended neck veins, displaced point of minimal
impulse (PMI), subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis. The client could have pain
with respiration even with milder pneumothorax. The increased intrathoracic pressure would cause the blood pressure to fall, not to rise.
699 A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note
which of the following types of breath sounds? Bronchial Bronchovesiclar Vesicular Absent A A client with pneumonia will have
bronchial breath sounds over area(s) of consolidation, because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also
have crackles in the affected area as a result of fluid in the interstitium and alveoli. Absence of breath sounds is not likely to occur unless a serious
complication of the pneumonia occurs. Option B and C are not noted in pneumonia.

700 A nurse assesses the client with acquired

immunodeficiency syndrome (AIDS) for early signs of Kaposi’s sarcoma. The nurse observes the client for lesion(s) that are: Unilateral, raised, and
bluish purple Bilateral, flat, and pink, turning to dark violet or black. Unilateral, red, raised and resembling a blister Bilateral, flat, and
brownish and scaly in appearanceB Kaposi’s sarcoma generally starts with an area that is flat and pink and then changes to a dark violet or black color.
The lesions are usually present bilaterally. They may appear in many areas of the body and are treated with radiation, chemotherapy and cryotheraphy.

701 A client has a suspected pleural effusion. The nurse assesses the client for which typical manifestations of this respiratory problem? Dyspnea at
rest and moist, productive cough Dyspnea on exertion and moist, productive cough Dyspnea at rest and dry, nonproductive cough Dyspnea on
exertion and dry, nonproductive cough D Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs
with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.

702 A client with pleural effusion had a thoracentesis and a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell
count. The nurse interprets that this result is most consistent with: Trauma Infection Congestive heart failure (CHF) Liver failure A
Pleural effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other
causes of pleural effusion include infection, CFH, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by increased
white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.

703 A nurse is scheduling a client for diagnostic studies of the gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse
schedule last? Abdominal scan Ultrasonography Colonoscopy Barium enema D Barium is instilled into the lower GI
tract during a barium enema and may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear
visualization and accurate results of the other tests listed, if they are performed before client has fully excreted the barium. For this reason, diagnostic studies
that involve barium contrast are scheduled at the conclusion of other diagnostic studies.
704 A nurse is caring for a client who is scheduled to have a liver biopsy. Before this procedure, it is most important for the nurse to assess the client’s:
History of nausea and vomiting Tolerance for pain Allergy to iodine or shellfish Ability to lie still and hold the breath D It
is most important for the nurse to assess the client’s ability to lie still and hold the breath for procedure. This helps the physician to avoid complications such as
puncturing the lung or other organs. Assessment of allergy to iodine or shellfish is unnecessary for this procedure, because no contrast dye is used. Knowledge
of the history related to nausea and vomiting is generally a part of assessment of the gastrointestinal system but has no relationship to the procedure. The
client’s tolerance for pain is a useful item to know. However, the area will receive local anesthetic.

705 A nurse is caring for a client who has a diagnosis of pneumonia. The nurse plans which of the following as the best time to take the client for a short
walk? After the client uses the metered dose inhaler After oxygen saturation is recorded on the bedside flow sheet After the client eats
lunch After the client has a brief nap A The nurse should schedule activities for the client with pneumonia after the client has received
respiratory treatments or medications. After the administration of bronchodilators (often administered my metered-dose inhaler), the client has the best oxygen
exchange possible and would tolerate the activity best. Still, the nurse implements activity cautiously so as not to increase the client’s dyspnea.

706 A nurse has an order to administer amphotericin B (Fungizone) intravenously to a client with histplasmosis. The nurse plans to do which of the
following during administration of the medication? Monitor for hypothermia Administer a concurrent fluid challenge Assess the intravenous
infusion site Monitor for an excessive urine output C Amphotericin B is a toxic medication that can produce symptoms during
administration such as chills, fever, headache, vomiting, and impaired renal function. The medication is also very irritating to the IV site, commonly causing
thrombophlebitis. The nurse administering this medication monitors for these complications.

707 A client with repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. The nurse plans to do which of the following after
the physician injects the sclerosing agent through the chest tube? Clamp the chest tube Ambulate the client Ask the client to cough and deep breathe
Ask the client to remain in one position only A After injection of the sclerosing agent, the nurse clamps the chest tube to prevent the agent
from draining back out of the pleural space. A repositioning is used by some physicians, but its usefulness in dispersing the agent is controversial. Ambulation,
coughing, and deep breathing have no specific purpose in immediate period after injection.
708 A client with a bladder injury had surgical repair of the injured area and placement of a suprapubic catheter. The nurse plans to do which of the
following to prevent complications of this procedure? Monitor urine output every shift Encourage a high intake of oral fluids Prevent kinking of the
catheter tubing Measure specific gravity once a shift C A complication after surgical repair of the bladder is disruption of sutures caused
tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter
care, including keeping the tubing free from kinks, keeping the tubing below the level of the bladder, and monitoring the flow of urine frequently. A high oral
fluid intake and measurement of urine specific gravity do not prevent complications of a suprapubic catheter. Monitoring of urine output every shift is
insufficient to detect decreased flow from catheter kinking.

709 A client with benign prostatic hyperplasia undergoes transurethral resection of the prostate (TURP). The nurse orders which of the following
solutions from the pharmacy so that it is available postoperatively for continuous bladder irrigation (CBI)? Sterile water Sterile normal saline
solution Sterile Dakin’s solution Sterile water 5% dextrose B Continuous bladder irrigation is done following TURP using sterile
normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly renal
failure. Dakin’s solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not
introduced into bladder.

710 A client with acquired immunodeficiency syndrome (AIDS) is being admitted for treatment of Pneumocystis carinii infection. Which of the
following activities that assists in maintaining comfort does the nurse plan to include in the care of this client? Assess respiratory rate, rhythm, depth, and
breath sounds every 8 hours. Evaluate arterial blood gas results Keep the head of the bed elevated Monitor vital signs every hour C
Clients with respiratory difficulties are often more comfortable with the head of the bed elevated. Options A, B, & D are appropriate measures to
evaluate respiratory function and to avoid complications. Option C is the only option that addresses th planning for client comfort.

711 A client with significant flail chest has arterial blood gas (ABG) results that reveal a PaO2 of 68 and PaCO2 of 51. Two hours ago Pa02 was 82 and
the PaCO2 was 44. Based on these changes, the nurse obtains which of the following items? Injectable lidocaine (Xylocaine) Portable chest x-ray
machine Intubation tray Chest tube insertion set C The client with flail chest has painful, rapid, shallow respirations while
experiencing severe dyspnea. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia.
Respiratory failure develops, and the client requires intubation and mechanical ventilation, usually with positive and expiratory pressure (PEEP). Therefore, an
intubation tray is necessary.
712 A client with empyema is to have a thoracentesis performed at the bedside. The nurse plans to have which of the following equipments available in
the event that the procedure is not effective. Code cart Chest tube and drainage system Extra large drainage bottle A small-bore needle B If
the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion. A small-bore
needle would not effectively allow exudate to drain. Options A and C are also unnecessary

713 A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse avoids which of the following activities
to prevent a tension pneumothorax? Adding water to the suction chamber as it evaporates Taping the connection between the chest tube and the
drainage system Maintaining the collection chamber below the client’s waist. Clamping the chest tube D To prevent a tension
pneumothorax, the nurse avoids clamping the chest tube, unless specifically ordered. In many facilities, clamping of the chest tube is contraindicated by agency
policy. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level ordered. Taping
the connection between the chest tube and system is also indicated tot prevent accidental disconnection. Maintaining the system below waist level is indicated
to prevent fluid from reentering the pleural space.

714 A nurse is assisting client with a chest tube to get out of bed. The tubing accidentally gets caught in the bed rail and disconnects. During the attempt
to re-establish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse should first: Call the physician Immerse the chest tube
in a bottle of sterile normal salineApply petrolatum gauze over the end of the chest tube Clamp the chest tube B If a chest tube accidentally
disconnects the tubing of the drainage apparatus, the nurse should first reestablish underwater seal to prevent tension pneumothorax and mediastinal shift. This
can be accomplished by reconnecting the chest tube, or in case, immersing the chest tube in a bottle of sterile normal saline or water. The physician should be
notified after corrective action is taken. If the physician is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause
tension pneumothorax. Petrolatum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from
the chest.

715 A nurse is caring for a client with a diagnosis of Cushing’s syndrome. The nurse plans which of these measures to prevent complications from this
medical condition? Monitoring glucose levels Monitoring epinephrine levels Encouraging daily jogging Encouraging visits from friends A
In the client with Cushing’s syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus.
Epinephrine levels are not affected. Clients experience activity intolerance related to muscle weakness and fatigue, so option C is incorrect. Visitors should be
limited because of the client’s impaired immune response.
716 A client receiving hemodialysis suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The
nurse, suspecting an air emolism, should: Continue dialysis at a slower rate after checking the lines for air Discontinue dialysis and notify the physician
Monitor vital signs every 15 minutes for the next hour Administer a 500-mL bolus of normal saline to break up the air embolus. B If
the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed.
The other options are incorrect.

717 A nurse notes on the cardiac monitor that a client with aldosteronism is experiencing a dysrhythmia. The nurse immediately assess the client’s:
Plasma potassium level Intake and output Peripheral pulses Superficial reflexes A Aldosteronism can lead to
hypokalemia, which in turn can cause life-threatening dysrhythmias. Options B, C, and D are not immediate priorities for this client.

718 A nurse is monitoring the results of series arterial blood gases for a client in which carbon monoxide poisoning has been diagnosed. The client does
not want to keep the oxygen in place. The nurse evaluates that the oxygen may be safely removed once the carboxyhemoglabin level decreases to less than:
5% 10% 15% 0.25 A Oxygen may be removed safely from the client with carbon monoxide poisoning once
carboxyhemoglabin levels are less than 5%. Options B, C, and D are elevated levels.

719 A client is admitted to the hospital with a diagnosis of Cushing’s syndrome. The nurse monitors the client for which of the following that is most
likely to occur in this client. Fluid volume deficit Hypoglycemia Hypovolemia Mental status changes D When Cushing’s
syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated
physiological action can cause mental status changes, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause
persistent hyperglycemia along with sodium and water retention, producing edema and hypertension.

720 A physician is performing direct visualization of the larynx on a client to rule out laryngeal cancer. The nurse tells the client to do which of the
following to decrease the sensation of gagging during the procedure? Try to swallow Hold the breath Breathe in and out normally
Roll the tongue to the back of the mouth C The client is instructed to breathe in and out normally, to decrease the sensation of gagging
during the procedure. The tongue cannot be moved back because it would occlude the airway. Swallowing cannot be done with the instrument in place. The
procedure takes longer than the time the client would be able to hold breath, and this action is ineffective anyway.

721 A nurse is caring for a client scheduled for bilateral adrenalectomy for treatment of an adrenal tumor that is producing excessive aldosterone. The
nurse most appropriately tells the client which of the following? You will most likely need to undergo chemotherapy after surgery You will need to take
hormone replacements for the rest of your life You will need to wear an abdominal binder after surgery You will not require any special
long-term treatment after surgery.B The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma.
Surgery is the treatment of choice. Clients undergoing bilateral adrenalectomy will need a permanent of adrenal hormones. Options A, C, and D are inaccurate.

722 A nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication is preoperative period to
prevent Addison’s crisis. Spironolactone (Aldactone) intramuscularly Methylprednisolone sodium succinate (Solu-Medrol) intravenously
Prednisone (Deltasone) orally Fludrocortisone (Florinef) subcutaneously B A glucocorticoid preparation will be administered
intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methyl-prednisolone sodium succinate
protects the client from acute adrenal insufficiency (Addison’s crisis), which occurs as a result of the adrenalectomy. Aldactone is a potassium-sparing diuretic.
Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid

723 A nurse prepares a nursing care plan for a client with Grave’s disease who is to receive radioactive iodine therapy. Which of the following
statements would be most appropriate for the nurse to include in the teaching plan for this client? The radioactive iodine is designed to destroy the entire
thyroid gland with just one dose. It takes 6 to 8 weeks after treatment to experience relief from symptoms of the disease The high levels of radioactivity
prohibit contact with family for 4 weeks after initial treatment Following the initial dose, subsequent treatments must continue lifelong B
Following treatment with radioactive iodine therapy, a decrease in thyroid hormone should be noted, which would help to alleviate symptoms.
Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. This form of therapy is not design to destroy the entire gland; rather, some of the
cells that synthesize thyroid hormone will be destroyed the local radiation. The nurse needs to reassure the client and family that unless the dosage is extremely
high, clients are not required to observe radiation precautions. The rationale for this is that radioactivity dissipates quickly. Occasionally, a client may require
a second or third dose, but treatments are never lifelong.

724 A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to:
Ask the client about the precipitating events Insert a nasogastric (NG) tube and perform a Hematest on the emesis. Complete an abdominal
physical examination Obtain vital signs D The priority action is to obtain vital signs to determine whether the client is in shock from blood loss
and to obtain a baseline by which to monitor the progress treatment. The client may not be able to provide subjective data until the immediate physical needs
are met. Insertion of an NG tube may be prescribed but it is not the priority action. A complete abdominal physical examination needs to be performed but it is
not the priority.
725 A fluid restriction of 1500 mL per day is ordered for a client with acute renal failure. The nurse best plans to assist the client maintaining the
restriction by: Prohibiting beverages with sugar to minimize thirst Using mouthwash with alcohol for mouth care Asking the client to
calculate the IV fluids into the total daily allotment Removing the water pitcher from the edside D The nurse can help the client to maintain fluid
restriction through a variety of means. One way is to provide frequent mouth care; however, alcohol-based products should be avoided because they are drying
to mucous membranes. The use of ice chips and lip ointments are other interventions that may be helpful to the client on a fluid restriction. Beverages that the
client enjoys are provided and are not restricted based on sugar content. The client is not asked to keep track of IV fluid intake; this is the responsibility of the
nurse. The water pitcher should be removed from the bedside to aid in compliance.

726 A nurse is preparing to care for a client returning from the operating room following a subtotal thyroidectomy. The nurse anticipates the need for
which of the following items to be placed at the bedside? Emergency tracheostomy kit Ampule of saturated solution of potassium iodine (SSKI)
Hypothermia blanket Magnesium sulfate in a ready-to-inject vial A Respiratory distress can occur following thyroidectomy as a result
from swelling in the tracheal area. The nurse would ensure that that an emergency tracheostomy kit is available. SSKI is typically administered preoperatively
to block thyroid hormone synthesis and release, as well as place the client in an euthyroid state. Iodine makes the thyroid gland less vascular before surgery.
Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated, since the incidence of
hypomagnesemia is not a common problem after thyroidectomy.

727 A nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which of the following is available to
maximize the effectiveness of this procedure? Ambu bag Incisional splinting device Suction equipment Nebulizer B The use of
Incisional splint such as a “cough pillow” can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep
breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options A, C, and D will not encourage the client to cough and deep
breathe.

728 A nurse is caring for a client scheduled to undergo a renal biopsy. To minimize the risk of postprocedure complications, the nurse reports which of
the following laboratory results before procedure? Blood urea nitrogen (BUN) 20 mg/dL Serum creatinine 1.2 mg/dL Bleeding time 13
minutes Potassium 3.8 mEq/L C Postprocedure hemorrhage is a significant complication after renal biopsy. Because of this, bleeding times are
assessed before the procedure. The normal bleeding is 1 to 6 minutes depending on the type of test performed by the laboratory. The nurse assures that these
results are available, and report abnormalities promptly. Options A, B, and D identify normal values. The normal BUN is 8 to 25 mg/dL. The normal serum
creatinine is 0.6 to 1.3 mg/dL and the normal potassium is 3.5 to 5.1 mEq/L.
729 A client involve in a house fire is experiencing respiratory distress and an inhalation injury is suspected. The nurse monitors which of the following
for the presence of carbon monoxide poisoning. Pulse oximetry Urine myoglobin Sputum carbon levels Serum carboxyhemoglobin levelsD
Serum carboxyhemoglobin are the most direct measures of carbon monoxide poisoning, provide the level pf poisoning, and thus determine the
appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule,
causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen. Options A, B, and C would not identify carbon monoxide
poisoning.

730 A client with acute pyelonephritis has nausea and is vomiting. The client is scheduled for an intravenous pyelogram. The nurse places highest
priority on which action? Place the client on hourly intake and output measurements Request an order for an IV infusion from the physician
Ask the client to sign the informed consent Explain the procedure thoroughly to the client B The highest priority of the nurse
would be to obtain an order to intravenous therapy. This is needed to replace fluid lost with vomiting, will be necessary for dye injection for the procedure and
will assist with the elimination of the dye following the procedure. The intake and output should be measured, but this will not assist in preventing dehydration.
The procedure is explained and the signed consent is obtained once the client’s physiological needs are met.

731 A nurse is planning for a client with a T3 spinal cord injury. The nurse includes which intervention in the plan to prevent automatic dysreflexia
(hyperreflexia)? Assess vital signs, and observe for hypertension, tachycardia, and tachypnea Teach the client that this condition is relatively minor with
few symptoms Assist the client to develop a daily bowel routine to prevent constipation. Administer dexamethasone (Decadron) as per physician's
order. C Automatic dysreflexia (hyperreflexia) may be triggered bowel distention. A daily bowel program eliminates this trigger. A client with
autonomic dysreflexia would be hypertensive and bradycardic. Autonomic dysreflexia is potentially life threatening if intervention does not occur. Removal of
the stimuli results in prompt resolution of the signs and symptoms. Option D is unrelated to this specific condition.

732 A client has a left a pleural effusion that has not yet been treated. The nurse plans to have which of following items available for immediate use?
Thoracentesis tray Parecentesis tray Intubation tray Central line insertion tray A The client with a significant
effusion is usually treated by thoracentesis. This procedure allows drainage of the fluid, which may then be analyzed to determine the precise cause of the
effusion. The nurse ensures that a thoracentesis tray is readily available, in case the client’s symptoms should rapidly become more severe. A Parecentesis tray
is needed for the removal of abdominal effusion. Options C and D are not specifically indicated for this procedure.
733 A client with urolithiasis is being evaluated to determine the type of stone that is being formed. The nurse plans to keep which of the following
items available in the client’s room to assist in this process? A calorie count sheet A strainer An intake and output record A vital signs graphic
sheet B The urine is stained until the stone is passed and obtained for analysis. Straining the urine will catch small stones that may be sent to the
laboratory for analysis. Once the type of stone is determined, an individualized plan of care prevention and treatment is developed. Options A, B. and D are
unrelated to the question.

734 A client develops bilateral wheezes, orthopnea, and tachypnea. The nurse notes the presence of 2+ pitting edema and suspects pulmonary edema and
notifies the physician. While awaiting the physician’s arrival, the nurse avoids which action? Preparing to administer IV morphine sulfate Placing the
client in the high-Fowler’s position Elevating the client's legs Preparing to administer IV furosemide (Lasix) C Elevating the
client’s leg would rapidly increase venous return to the right side of the heart and worsen the client’s condition. The feet should be in the horizontal position, or
the client could dangle at the bedside if the client’s condition permits. Morphine sulfate reduces anxiety and is likely to be prescribed. Anxiety causes an
increase in the oxygen demands on the heart. A high-Fowler’s position increases the thoracic capacity, which improves ventilation. Furosemide will be
prescribed because of its diuretic action.

735 A nurse is caring for a client following a ureterolithotomy. The client has a ureteral tube. On review of the physician's orders, the nurse notes that
the client has a PRN order to irrigate the tube. The nurse plans to avoid which of the following in the management of this tube? Irrigating using gentle
force Irrigating using gravity Clamping the tube Using a separate drainage bag for the ureteral catheter C A ureteral tube is never
clamped, because the renal pelvis can hold only about 5 mL at a time. The nurse who has an order to irrigate the tube may do so using gravity or gentle force
only. A drainage bag attached to the ureteral catheter is used so that accurate measurement of urine flow can be done.

736 A nurse is caring for a client with suspected carbon monoxide poisoning. Of the following interventions that the nurse assists in implementing,
which is of highest priority? Requesting a building inspection at the site of the incident from local health department Drawing blood for
carboxyhemoglobin levels Frequently observing the client Administering 100% oxygen D 100% oxygen is administered at atmospheric
pressure or hyperbaric pressure to speed up the elimination of carbon monoxide from the hemoglobin and to reverse hypoxia. The next important action is
constant observation of the client. The client may exhibit a variety of symptoms caused by central nervous system damage, which include ataxia, spastic
paralysis, visual disturbances, personality changes, and psychoses. Blood is drawn serially to monitor carboxyhemoglabin levels; once they drop under 5%
oxygen may be removed. If the episode was unintentional and precipitated by conditions in a dwelling, the health department is notified.
737 A client with adult respiratory distress syndrome has an order to be placed on a continuous positive airway pressure (CPAP) face mask. The nurse
ensures that which of the following is implemented, for this procedure to be most effective? Apply the mask to the face with a snug fit Obtain
baseline arterial blood gases Obtain baseline arterial oxygen saturation levels Allow the client to remove the mask frequently for coughing A
The face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client’s airways. The
nurse obtains baseline respiratory assessments and arterial blood gasses to evaluate the effectiveness of therapy, but these are not done to increase the
effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating or drinking. This removes benefit
of positive pressure in the airway each time the mask is removed.

738 A nurse is caring for a client scheduled to undergo a cardiac catheterization for the first time. The nurse tells the client that:The procedure is
performed in the operating room (OR), with the personnel wearing scrub gowns and masks The client may feel fatigue and have various aches,
because it is necessary to lie quietly on a hard x-ray table for about 4 hours The client may feel certain sensations at various points during the procedure,
such as fluttery feeling, a flushed warm feeling, a desire to cough, or palpitations Initial catheter insertion is quite painful; after that, there is little or no
pain C Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are
attached to the client. A local anesthetic is used, so there is little to no pain with catheter insertion. The x-ray table is hard and may be tilted periodically. The
procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.

739 A client with acquired immunodeficiency syndrome (AIDS), will be receiving aerosolized pentamidine isethionate (NebuPent) pro-phylactically
once every 4 weeks. The home health nurse visits and instructs the client about the medication. Which statement by the client indicates a need for further
teaching? If you develop a cough or shortness of breathe after receiving the inhalation therapy, I need to let a doctor or nurse know. If I have any visual
disturbances, I need to let the doctor know. There are no known side effects of this therapy. I may experience some nausea with the inhalation therapy.
C Side effects associated with this therapy include nausea, visual disturbances, or shortness of breath. The client needs to inform the health
care provider if cough, shortness of breath, or visual disturbances occurs.

740 A nurse admits a client with myocardial infarction (MI) to the coronary care unit (CCU). The nurse plans to do which of the following in delivering
care to this client? Administer oxygen at a rate of 6 liters/minute by nasal cannula Infuse intravenous (IV) fluid at a rate of 150 mL/hr Begin a
continuous heparin infusion at a rate of 2000U/hr Place the client on a continuous cardiac monitoring D Standard interventions upon
admittance to the CCU as they relate to this question include continuous cardiac monitoring, oxygen at a rate of 2 L/min unless otherwise ordered, an IV line
insertion or intermittent lock. If an IV infusion is administered, it is maintained at a keep vein open rate to prevent fluid overload and heart failure. A heparin
drip may be instituted according to protocol, but a rate of 2000 units per hour is excessive
741 A nurse is trying to analyze an ECG rhythm strip on an assigned client and asks another nurse how much time each small box on the ECG paper
represents. The second nurse responds that each small box measures: 0.02 second 0.04 second 0.20 second 0.40 second
B Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm
(measuring voltage) for each small box on the vertical axis

742 A nurse is applying ECG electrodes to a diaphoretic client. The nurse does which of the following to keep the electrodes from coming loose?
Secures the electrodes with adhesive tape Places clear, transparent dressings over the electrodes Applies lanolin to the skin before applying the
electrodes Applies a little benzoin to the skin before applying the electrodes D Tincture of benzoin is commonly used on a diaphoretic client to help
the electrodes adhere to the skin. Placing adhesive tape or a clear dressing over the electrodes will not help the adhesive gel of the actual electrode to make
better contact with diaphoretic skin. Lanolin or any other lotion makes the skin slippery and prevents good initial adherence.

743 A nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention would the nurse include in the plan
of the care? Assess the client for pain before physical therapy Remind the client to change positions slowly Assess the sensation of
touch and vibration above the level of injury Teach the client about loss of motor function and temperature sensation D Clinical findings related
to anterior cord syndrome include loss of motor function and temperature sensation below the level of injury. The syndrome is not painful and does not affect
the sensations of touch, motion, position, and vibration.

744 A nurse is caring for a client with thoracic spinal cord injury. As part of the nursing care plan, the nurse monitors for spinal shock. In the event that
spinal shock occurs, the nurse anticipates that the most likely intravenous (IV) fluid to prescribed would be: 5% dextrose in water (D5W) Dextran
5% dextrose in normal saline solution (D5NS) Normal saline solution (NS) D NS in an isotonic solution that primary remains
in the intravascular space, increasing intravascular volume. This IV fluid would increase the client’s blood pressure. Dextran is rarely used in spinal shock
because isotonic fluid administration is usually sufficient. Additionally, Dextran has potentially serious side effects. (D5W) is a hypotonic solution that pulls
fluid out at the intravascular space and is not indicated for shock. (D5NS) is hypertonic and indicated for shock resulting from hemorrhage or burns.
745 A client has Buck’s extension traction applied to the right leg. The nurse plans which of the following interventions to prevent complications of the
device? Massage the skin of the right leg with lotion every 8 hours Provide pin care once a shift Inspect the skin on the right leg at least once
every 8 hours Release the weights on the right leg for range of motion exercises daily C Buck’s extension traction is a type of skin
traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not
indicated. The nurse never releases the weights of the traction unless specifically ordered by the physician. There are no pins to care for with skin traction.

746 A nurse is in the room of a client on a cardiac monitor whose cardiac rhythm changes to ventricular fibrillation (VF). The nurse calls for help,
knowing that which of the following items will be needed immediately? Pacemaker insertion tray Ventilator Defibrillator Lidocaine
hydrochloride (Xylocaine) C A defibrillator is needed to correct VF. Options A and C will do nothing to correct this rhythm. Lidocaine is given
for ventricular tachycardia (an organized, although potentially deadly rhythm)

747 A nurse is caring for a client with a newly applied plaster leg cast. The nurse prevents the development of compartment syndrome by:Elevating the
limb and applying ice to the affected leg Elevating the limb and covering the limb with bath blankets Placing the leg in a slightly dependent position
and applying ice Keeping the leg horizontal and applying ice to the affected leg A Compartment syndrome is prevented by controlling
edema. This is achieved most optimally with the use of elevation and the application of ice. The use of bath blankets or a dependent or horizontal leg position
will not prevent this syndrome.

748 A client undergoing hemodialysis becomes hypotensive. The nurse avoids taking which of the following contraindicated actions?
Administering albumin Administering a bolus of 250 mL normal saline (NS) solution Increasing the blood flow into the dialyzer
Raising the client's legs and feet C To treat hypotension during hemodialysis, the nurse raises the client's feet and legs to enhance cardiac
return. An NS bolus of up to 500 mL may be given to increase circulating volume. Albumin may be given as per protocol to increase colloid oncotic pressure.
Finally, the transmembrane hydrostatic pressure or the blood flow rate into the dialyzer may be decreased. All of these measures should improve the
circulating volume and blood pressure (BP).

749 A nurse is preparing a client for cardioversion using anterolateral paddle placement. The nurse places the conductive gel pads at which areas on the
client's chest in preparation for this procedure? Right second intercostal space and left fifth intercostal space at anterior axillary line Left second
intercostal space,and left fifth intercostal space at midaxillary line Right fourth intercostal space, and left fifth intercostal space at anterior axillary line.
Left fourth intercostal space, and left fifth intercostal space at midaxillary line A Anterolateral paddle placement for external countershock
involves placing one paddle at the right second intercostal space and the other at the fifth intercostal space at the anterior axillary line.
750 A nurse is planning care for a client scheduled for venography. The nurse plans care knowing that which action does not have to be implemented
before this procedure?Asking the client about allergies to iodine or shellfish Obtaining a signed informed consent Determining the location and
strength of peripheral pulses Places the client on an NPO after midnight status D Venography is similar to anteriography, except it evaluates
the venous system. A radiopaque dye is injected into selected veins to evaluate patency and blood flow characteristics. The client signs an informed consent
because venography is an invasive procedure. Allergies to shellfish or iodine must be noted. Peripheral pulses are assessed so that comparisons can be made
after the procedure. The client is usually given clear liquids for 3 to 4 hours before the procedure to help with dye excretion afterward.

751 A physician writes an order to obtain a 12-lead ECG on a client. The nurse informs the client of the procedure. Which client statements indicates
that the client understands the procedure? " I cannot breathe while the ECG is running." "When the ECG begins, I must take a deep breathe." "I
need to lie still while the ECG is being done." "If I move when the ECG begins, I will be shocked." C Good contact between the skin and
electrodes are necessary to obtain a clear 12-lead ECG printout. Therefore, the electrodes are placed on the flat surfaces of the skin just above the ankles and
wrists. Movement may cause a disruption in that contact. The client does not need to hold the breath or take a deep breath during the procedure. The client
needs to be reassured that shock will not be received. Option A, B, and D are inappropriate statements.

752 A client receiving chemotherapy has an infiltered intravenous line and extravasation at the site. The nurse avoids doing which of the following in
the management of this situation? Stopping the administration of the medication Leaving the needle in place and aspirating any residual
medicationAdministering an available antidote as prescribed Applying direct manual pressure to the site D General recommendations for
managing extravasation of a chemotherapy agent include stopping the infusion, leaving the needle in place and attempting to aspirate any residual medication
from the site, administering an antidote if available, and assessing the site for complications. Direct pressure is not applied to the site because it could further
injure tissues exposed to the chemotherapeutic agent.

753 A nurse is suctioning the airway of a client with a tracheostomy. To perform the procedure, the nurse: Turns on the wall suction to 180
mm Hg Inserts the catheter until coughing and resistance is felt Withdraws the catheter while suctioning continuously Reenters the tracheostomy after
suctioning the mouth B The wall suction unit is usually set to 80 to 120 mm Hg pressure. This allows adequate removal of secretions while protecting
the airway from trauma. The nurse inserts the catheter until resistance is felt, and then withdraws it 1 cm to move away from mucosa. The nurse suctions
intermittently and does not reenter the tracheostomy after suctioning the client’s mouth.
754 A nurse has prepared a client for an intravenous pyelogram. The nurse evaluates that the client is knowledgeable about the procedure if the client
states the need to report which of the following sensations immediately? Nausea Difficulty of breathing Warm flushed feeling in the body
Salty taste in the mouth B Intravenous pyelography is a contrast study of the kidneys to determine a variety of disorders of the
kidneys, ureters, and bladder. Normal sensation during injection of the iodine-based radiopaque dye include a warm flushed feeling, salty taste in the mouth,
and transient nausea. Difficulty breathing, wheezing, hives, or itching signals an allergic response and should be reported immediately. Inquiring about
allergies to iodine or shellfish before the procedure prevents this complication.

755 A client with repeated episodes of pulmonary emboli from thromboembolism is scheduled for insertion of an inferior vena cava filter. A nurse
determines that the client has an adequate understanding of the procedure if the client makes which of the following statements: "The filter will keep new
blood clots from forming in my legs." "I don’t mind having a filter in my artery if it means I don’t have any trouble." "The filter will be like a catcher’s
mitt and keep the clots from going to my lungs." "It’s too bad I have to continue anti-coagulant therapy after the surgery." C Insertion of
an inferior vena cava filter is indicated for clients with recurrent deep vein thrombosis or pulmonary emboli, who do not respond to medical therapy and cannot
tolerate anticoagulant therapy. The filter device or umbrella is inserted percutaneously in the inferior vena cava, where it springs open and attaches itself to the
vena cava wall. The device has holes to allow the blood flow but traps larger clots, thus preventing pulmonary emboli. The filter does not prevent blood clots
from forming and is not placed in an artery.

756 A client is admitted to the hospital with a diagnosis of infective endocarditis from Streptococcus viridans. The client asks the nurse about the
antibiotic therapy that will be given. Knowing that the client has no medication allergies, the nurse prepares the client to receive: Penicillin G benzathine
(Bicillin) intravenously (IV) for 10 days, followed by oral doses for 2 weeks Penicillin G benzathine (Bicillin) IV for 4 to 6 weeks, continuing at home after
hospital discharge Amphotericin B (Fungizone) IV for 10 days, followed by oral doses for 3 weeks Amphotericin B (Fungizone) IV for 4 to 6
weeks, continuing at home after hospital discharge B Penicillin is frequently the medication of choice for treating endocarditis of bacterial origin.
The standard duration of therapy is 4 to 6 weeks, with home care support after hospital discharge. Which is usually 7 to 10 days. Amphotericin B is an ant
fungal agent and would not be effective with this type of infection.

757 During the admission assessment, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse
notices the rhythmic tremors of the leg being tested and concludes that the client has an alteration in the area of: Muscle strength and flexibility Balance and
coordination Sensation and reflexes Bowel and bladder function B In this situation, the nurse is performing one test of
cerebellar function and is testing for ataxia. Alterations in the cerebellar function are noted by alterations in balance and coordination.
758 A nurse in monitoring the intracranial pressure (ICP) of a client with a head injury. The cerebrospinal fluid pressure (CSP) is averaging 25 mm Hg.
The nurse analyze these results as: Normal Compensation, indicating adequate brain adaptation Borderline in elevation, indicating the initial
stage of compensationIncreased, indicating a serious compromise in cerebral perfusion D The normal CSF pressure is 5 to 15 mm Hg. A pressure of
25 Hg is increased

759 A client with a Sengstaken-Blakemore tube in place is admitted to the nursing unit from the emergency department. The nurse plans care knowing
that the purpose of this tube is to: Control bleeding from gastritis Apply pressure to the esophageal varices Control ascites Remove ammonia-
forming bacteria from the gastrointestinal tract B A Sengstaken-Blakemore tube is inserted in clients with cirrhosis who have ruptured
esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding.
The gastric balloons holds the tube in correct position and prevents migration of the esophageal balloon. Options A, C and D are not the purpose of this tube.

760 A home health care nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to perform breathing techniques that will
assist in exhaling carbon dioxide and open he airways. The nurse teaches the client which technique? Pursed-lip breathing Intercostals chest
expansion Abdominal breathing Chest physical therapy A Pursed-lip breathing allows the client to slowly exhale carbon dioxide while
keeping the airways open. Intercostal chest expansion is not a technique. Abdominal breathing is recommended for clients with dyspnea. Chest physical
therapy is not a breathing technique.

761 A physician has ordered a partial re-breather facemask for a client who has terminal lung cancer. The nurse prepares to implement knowing that the
mask: Delivers accurate fraction of inspired oxygen (F102) to the client. Conserves oxygen by having the client re-breathe his or her owned exhaled air.
Requires that the reservoir bag deflate during inspiration to work effectively Requires a low liter to prevent rebreathing of carbon dioxide B
Rebreathing masks have reservoir bag that conserves oxygen and requires a high liter flow to achieve that conserves oxygen and requires a high liter
flow to archieve concentrations of 40% to 60%. It does not deliver accurate F102 to the client. The bag should not deflate during inspiration. Rebreathing
bags conserve oxygen by having the client rebreathe their own exhaled air
762 A client has a slow regular pulse. On the monitor, the nurse notes the regular QRS complexes with no associated P waves and with a ventricular rate
of 50 beats/min. The nurse suspects that there is a problem at which part of the cardiac conduction system? The sinoatrial (SA) node The
atrioventricular (AV) node The bundle of His The left ventricle A A normal wave indicates that the impulse that depolarized the atrium
was initiated in the SA node. A change in the form or the absence of a Pwave can indicate a problem at this part of the conduction system, with the resulting
impulse originating from an alternate site lower in the conduction pathway. Options B, C and D are incorrect.

763 A client who has abdominal aortic aneurysm repair is on postperative day 1. The nurse performs an abdominal assessment and notes the absence of
bowel sounds. The nurse best action is to: Call the physician immediately Remove the nasogastric (NG) tube. Feed the client Continue to
assess for bowel sounds. D Bowel sounds may be absent for 3 to 4 days after surgery because of bowel manipulation during the procedure.
The nurse should continue to monitor the client, the nasogastric tube should stay in a place in a place if present, and the client is kept NPO until after the onset
of bowel sounds. There is no need to call the physician immediately at this time.

764 A nurse is evaluating the outcomes of care for a client who experienced an acute myocardial infarction. Which of the following findings indicate
that an expected outcome for the nursing diagnosis of decreased cardiac output has been met? Cardiac output of 3L/min when measured with a
pulmonary artery catheter Cardiac monitor shows a heart rate of 50 beats/min after the client has eaten dinner. The client complains of symptoms
that require immediate action following client teaching The client reports absence of dyspnea and anginal pain with activity. D Dyspnea and
angina are signs of altered cardiac output. The absence of these activity idicates that cardiac output is adequate. Normal adult cardiac output is 4 to 8 L/min.
Option A identified a low reading. A low heart rate affects cardiac output. The client’s heart rate should be between 60 to 100 beats/min. complaints of
symptoms that require immediate action is not an expected outcome.

765 A nurse analyzed a 6 second ECG strip for a client with left-sided heart failure, as follows; atrial rate: no identifiable P waves; baseline irregular
ventricular rate; 160 betas/ min; rhythm; irregular PR interval and indiscernible, QRS at 0.08. The nurse interprets the rhythm strip as: Sinus dysrhytmia
Atrial fibrillation Ventricular fibrillationThird-degree heart block B Atrial fibrillation is characterized by rapid, chaotic artrial
depolarization, with ventricular rates ranging from 160 to 180 beats/min. The ECG reveals no identifiable P waves and a baseline that is irregular. The PR
interval is irregular. A sinus dysrhythmia has a normal P wave, PR interval, and QRS complex. In ventricular fibrillation, there are no identifiable P waves,
QRS complexes, or T waves. In third degree heart block, the atria and ventricles beat independently.
766 A nurse is caring for a client with multiple myeloma. The client is receiving intravenous hydration at 100 mL/hr. Which of the following
assessment findings would indicate a positive response to the treatment plan? Weight increase of 1kg White blood cell count of 6000/mm3
Respirations of 18 breathes/min Creatinine level of 1mg/dL D Renal failure in the client with multiple myeloma. In multiple
myeloma, hydration is essential to prevent renal damage resulting from precipitation of protein in the renal tubules and from excessive calcium and uric acid in
the blood. Creatinine is the most accurate measure of renal status. Options B and C are unrelated to the tissue of hydration. Weight gain is not a positive sign
when concerned with renal status.

767 A nurse provides discharge instructions to a client with testicular cancer who had testicular surgery. The nurse tells the client: To report any
elevation in temperature to the physician Not to drive for 6 weeks Not to be fitted for a prothesis for 6 months To refrain from sitting for long
periods A For the client who has had a testicular surgery, the nurse should emphasize the importance of notifying the physician if chills, fever,
drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive.
Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostate surgery because of hemorrhage, but the risk is not as high with testicular
surgery.

768 A nurse is admitting a client with a diagnosis of myxedema. The nurse performs which physical assessment technique that will provide data related
to this diagnosis? Inspection of facial features Palpation of the adrenal glands Percussion of the thyroid gland Auscultation of lung sounds A
Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and blank expression that are
characteristic of myxedema. The assessment techniques in options B, C, and D will not reveal the information related to the diagnosis of myxedema.

769 A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) how to purse lip breathe. The nurse tells the client: That
inhalation should be twice as long as exhalation To loosen the abdominal muscles while breathing out That exhalation should be twice as long as
inhalation To inhale with pursed lips and exhale with mouth open wide. C Prolonging exhalation time reduces the air trapping caused by airway
narrowing that occurs in COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lip (not with the mouth wide
open) increases the intraluminal pressure and prevents the airways from collapsing.
770 A nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which nursing diagnosis, if formulated by the nurse,
has the highest priority for this client? Self Care deficit Risk for Infection Nutrition Deficit Activity Intolerance B Clients with
HIV often show some evidence of immune dysfunction and may have increased vulnerability to common infections. HIV infection impairs cellular and
humoral immune function. Individuals with HIV are vulnerable to common bacterial infections. Not every client with HIV will have problems with activity,
self-care, or nutrition. Although nutrition deficit is a concern, infection is specifically related to HIV and is a priority.

771 A nurse is caring for a client with a spinal cord injury who has spinal shock. The nurse performs an assessment on the client knowing that which
assessment will provide the best information about recovery from spinal shock? Blood pressure Pulse rate Reflexes Temperature C
Areflexia characterizes spinal shock. Therefore, reflexes would provide the best information about recovery. Vital signs changes (options A, B, and
D) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about the spinal shock
recovery. Blood pressure would provide good information about recovery from other types of shock, but not spinal shock

772 A client is admitted to the hospital for repair of an unruptured cerebral aneurysm. Before surgery, the nurse performs frequent assessments on the
client. Which assessment finding would be noted first if the aneurysm ruptures? Widened pulse pressure Unilateral slowing of pupil response
Unilateral motor weakness A decline in the level of consciousness D Rupture of a cerebral aneurysm usually results in
increased intracranial pressure (ICP). The first sign of pressure in the brain of the brainstem is a change in the level of consciousness. This change in
consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brainstem than those that
control consciousness, pulse pressure alteration is a later sign. Slowing of pupil response and motor weaknesses are also late signs.

773 A client has not eaten or had anything to drink for 4 hours following two episodes of nausea and vomiting. Which of the following items would be
best to offer the client who is ready to resume oral intake? Ginger ale Gelatin Toast Dry cereal A Clear liquids are best tolerated first
after episodes of nausea vomiting. If the client tolerates sips (20 to 30 mL at a time) of clear liquids, such as water or ginger ale, the amounts may be increased
and gelatin, tea, broth may be added. Once these are tolerated, easily digested solid foods such as toast, cereal, and chicken may be tried.
774 A client has just undergone an upper gastrointestinal (GI) series. The nurse provides which of the following upon the client’s return to the unit as an
important part of routine postprocedure care? Increased fluids Bland diet NPO status Laxative D Barium sulfate, which is
used as a contrast material during an upper GI series, is constipating. If it is not eliminated from the GI tract, it can cause obstruction. Therefore, laxatives or
cathartics are administered as part of routine postprocedure care. Fluids are also helpful but do not act in the same way as a laxative to eliminate the barium.
Options B and C are not routine postprocedure measures.

775 A physician is inserting a chest tube. The nurse selects which of the following materials to be used as the first layer of the dressing at the chest tube
insertion site? Sterile 4 x 4 gauze pad Absorbent Kerlix dressing Gauze impregnated with providone iodine Petrolatum jelly gauze
D The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site.
Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape.

776 A client being seen in the physician’s office for follow-up 2 weeks after pneumonectomy complains of numbness and tenderness at the surgical site.
The nurse tells the client that this is: A severe problem, and the client will probably be rehospitalized Often the first sign of wound infection, and
checks the client’s temperature. Probably caused by permanent nerve damage as a result of surgery Not likely to be permanent, but may last for some months
D Clients who undergo pneumonectomy may experience numbness, altered sensation, or tenderness in the area that surrounds the incision.
These sensations may last for months. It is not considered to be a severe problem and is not indicative of wound infection.

777 A client scheduled for pneumonectomy asks the nurse how long the chest tubes will be in place. The nurse responds that: They will be in place for
24 to 48 hours They will be removed after 3 to 4 days They usually function for a full week after surgery Most likely, there will be no chest
tubes in place after surgery D Pneumonectomy involves removal of the entire lung, usually because of extensive disease such as bronchogenic,
carcinoma, unilateral tuberculosis, or lung abscess. Chest tubes are not inserted because the cavity is left to fill with serosanguineous fluid, which later
solidifies. The phrenic nerve is severed or crushed to elevate the diaphragm, further decreasing the size of the chest cavity on the operative side.

778 A nurse is caring for a client with a dissecting abdominal aortic aneurysm. The nurse avoids which of the following while caring for the client?
Turning the client to the side to look for ecchymoses on the lower back Auscultating the arteries for bruits Performing deep
palpation of the abdomen Telling the client to report back, shoulder, or neck pain C The nurse avoids deep palpation in the client in which a
dissecting aneurysm is known or suspected. Doing so could place the client at risk for rupture. The nurse looks for ecchymoses on the lower back to determine
whether the aneurysm is leaking, and tells the client to report back, neck, shoulder, and extremity pain. The nurse may auscultate the arteries for bruits.
779 A client has undergone angioplasty of the iliac artery. The nurse best detects bleeding from the angiosplasty in the region of the iliac artery by:
Measuring abdominal girth Auscultating over the area with a doppler Periodically asking the client about mild pain in the area
Palpating the pedal pulses A Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can
most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency. Assessment of pain is routinely done, and
mild regional discomfort is expected.

780 A client is scheduled for a right femoralpopliteal bypass graft. The client has a nursing diagnosis of Altered Peripheral Tissue Perfusion. The nurse
takes which of the following actions before surgery to address this nursing diagnosis? Completes a preoperative checklist Marks the location of
pedal pulses on the right leg Has the client void before surgery Checks the results of any baseline coagulation studies B A nursing
diagnosis of Altered Peripheral Tissue Perfussion in the client scheduled for femoral-popliteal bypass grafting indicates that the client is likely to have
diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the
postoperative period. The other options are part of routine preoperative care.

781 Thrombophlebitis has been diagnosed in a hospitalized client. A nurse would avoid doing which of the following during the care of this client?
Maintaining the client on bed restApplying moist heat to the leg Elevating the feet above heart level Placing a pillow under the client’s
knees D The nurse avoids placing pillow under the client’s knees with thrombophlebitis because it obstructs venous return to the heart and
exacerbates impairment of blood flow. The client is maintained on bed rest for 3 to 7 days after a diagnosis of thrombophlebitis is made to prevent the
occurrence of pulmonary embolus. The feet are elevated above heart level to aid in venous return, and warm moist heat may be used to aid in comfort and
reduce venospasm.

782 A client who underwent peripheral arterial bypass surgery 16 hours ago complains of increasing pain in the leg at rest, which worsens with
movement and is accompanied by paresthesias. The nurse should take which of the following actions? Administer a narcotic analgesic Apply warm
moist heat for comfortApply ice to minimize any developing swelling Call the physician D The classic signs of compartment syndrome are
pain at rest that intensifies with movement, and the development of paresthesias. Compartment syndrome is characterized by increase pressure within a muscle
compartment that results from bleeding or excessive edema. It compresses the nerves that can cause vascular compromise. The physician is notified
immediately because the client could require an emergency fasciotomy. Options A, B, and C are incorrect actions.
783 A nurse is an amulatory care clinic takes a client’s blood pressure (BP). The nurse measures the client’s BP in the left arm 200/118 mm Hg. The
first action of the nurse is to: Notify the physician Inquire about the presence of kidney disorder Check the blood pressure in the right arm
Recheck the pressure in the same arm within 30 seconds C When a high BP reading is noted, the nurse takes the pressure at the
opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm but would wait at
least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The
nurse would notify the physician because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.

784 A nurse in the emergency department admits a client who is bleeding freely from a scalp laceration obtained during a fall from a stepladder when the
client was doing outdoor home repair. The nurse takes which of the following actions first in the care of this wound? Ask the client about the timing of
the last tetanus vaccination Cleanses the wound with sterile normal saline Prepares for suturing the area Administers a prophylactic
antibiotic B The initial nursing action is to clean the wound thoroughly with sterile normal saline. This removes dirt or foreign matter from the
wound and allows visualization of the size of the wound. Direct pressure is applied as needed to control bleeding. If suturing is necessary, the surrounding hair
may be shaved. Prophylactic antibiotics are often ordered. The date of the client’s last tetanus shot is determined, and prophylaxis is given if needed.

785 A client was admitted to the nursing unit with a closed head injury 6 hours ago. After report, the nurse finds that the client has vomited, is confused,
and complains of dizziness and headache. Which of the following is the most important nursing action? Administer an antiemetic Change the
client’s gown and bed linens Reorient the client to surroundings Notify the physician D The client with a closed head injury is at risk
for increased intracranial pressure (ICP). This is evidenced by such symptoms as headache, dizziness, confusion, weakness, and vomiting. Because of the
implications of the symptoms, the most important nursing action is to notify the physician. Other nursing actions that are appropriate include physical care of
the client and reorientation to surroundings.

786 A client is being brought into the emergency after suffering a head injury. The first action by the nurse is to determine the client’s: Respiratory
rate and depth Pulse and blood pressure Level of consciousness Ability to move extremities A The first action of the
nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client’s circulatory status is evaluated (option B),
followed by evaluation of the neurological status (options C and D).
787 A client with a spinal cord injury is at risk for foot drop. The nurse uses which of the following as the most effective preventing measure?
Heel protectors Posterior splints Pneumatic boots Foot board B The most effective means of preventing foot drop is the
use of posterior splints or high-top sneakers. A foot board prevents plantar flexion but also places the client at greater risk for pressure ulcers of the feet.
Pneumatic boots prevent deep vein thrombosis but not foot drop. Heel protectors protect the skin but do not prevent foot drop.

788 A client is ambulatory and wearing a halo vest after a cervical spine fracture. The nurse tells the client to avoid which of the following, since the
client has a risk for injury? Bending at the waist Using a walker Wearing a rubber-soled shoes Scanning the environment A
The client with a halo vest should avoid bending at the waist, since the halo vest is heavy and client’s trunk is limited in flexibility. It is helpful for
the client to scan the environment visually because the client’s peripheral vision is diminished from keeping the neck in a stationary position. Use of a walker
and rubber-soled shoes may help prevent falls and injury and is therefore also helpful.

789 A nurse preparing postoperative discharge instructions for a client who had one adrenal gland removed. The nurse includes which of the following
in the instructions? The need for lifelong replacement for all adrenal hormones Instructions about early signs of a wound infection The reason
for maintaining a diabetic diet Teaching proper application of an ostomy pouch B A client who had a unilateral adrenalectomy will be placed
corticosteroids temporarily to avoid a cortisol deficiency. The client will be gradually weaned from these medications in the postoperative period until they are
discontinued. Also, because of the antiinflammatory properties of corticosteroids produced by the adrenal glands, clients who undergo an adrenalectomy are at
increased risk for wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs
of infection, and what to do if an infection seems to be present.

790 A nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, the nurse teaches the
client to: Remove the nasal packing after 48 hours Cough and deep breathe hourly Take acetaminophen (Tylenol) for severe headache Report
frequent swallowing or postnasal drip D The client should report frequent swallowing or postnasal drip after transsphenoidal surgery because it
could indicate a cerebrospinal fluid (CFS) leakage. The surgeon removes the nasal packing, usually after 24 hours. The client should deep breathe, but
coughing is contraindicated because it could cause increased intracranial pressure. The client should also report severe headache because it could indicate
increased intracranial pressure.
791 Acetylsalicylic acid (aspirin) is prescribed for a client with coronary artery disease before a percutaneous transluminal coronary angioplasty
(PTCA). The nurse administers the medication knowing that it is prescribed to: Prevent postprocedure hyperthermia Relieve postprocedure
pain Prevent thrombus formation Prevent inflammation of the puncture site C Before PTCA, the client is usually given an anticoagulant,
commonly aspirin, to help reduce the risk of occlusion of the artery during procedure. Options A, B and D are unrelated to the purpose of administering aspirin
to this client.

792 A nurse develops a plan care for a client admitted to the hospital with a diagnosis of an acute myocardial infarction (MI). The priority nursing
diagnosis in the acute phase would be: Anxiety Altered family process Altered comfort Impaired tissue integrity C
Pain is the prevailing symptom of acute MI. Relief of pain is a priority. Pain stimulates the autonomic nervous system, increasing myocardial
oxygen demand. Although options A, B, and D are also appropriate nursing diagnoses, the presence of pain has an impact on these additional nursing
diagnoses.

793 A nurse is caring for a male client with a diagnosis of urolithiasis. The nurse instructs the client that it is most important to:Turn, cough and deep
breathe every 2 hours Restrict physical activities Strain all urine from each voiding Record weight every day C Obstruction
of the urinary tract is the primary problem associated with urolithiasis. Stones recovered from straining urine can be analyzed and can provide direction for
prevention of further stone formation. Activities should not be restricted. Option A, and D are not specifically related to the client’s diagnosis.

794 A nurse is caring for a client scheduled for an arthroscopy. The nurse develops a postoperative plan of care and includes which priority nursing
action in the plan? Monitor intake and output Monitor the area for numbness and tingling Assess the complete blood cell count results Assess the
tissue at the surgical site B The priority nursing is to monitor the affected area for numbness or tingling. Options A, B, and D are also a
component of postoperative care but, from the options presented, are not the priority.

795 A nurse is caring for a client with active tuberculosis who has started medication therapy that includes rifampin (Rifadin). The nurse instructs the
client to expect which side effect of this medication? Orange secretions Bilious urine Yellow sclera Clay-colored stools A
 Secretions will become orange as a result of the rifampin. The client should be instructed that this side effect will be likely to occur and should be
told that soft contact lenses, if used by the client, will become permanently discolored. Options B, C, and D are not expected effects.

796 A nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that
Mycobacterium tuberculosis is cultured. The nurse analyzes these results as: Positive for active tuberculosis Inconclusive until a repeat sputum is sent
Not reliable unless the client has also had a positive Mantoux test result Positive for a less virulent strain of tuberculosis A
Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue is the only method of confirming the diagnosis. Options B
and D are incorrect statements. The Mantoux test is performed to assist in diagnosing TB but does not confirm active disease.

797 A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI).The nurse monitors for which most common
complication of MI? Cardiogenic shock Cardiac dysrhythmias Congestive heart failure (CHF) Recurrent myocardial infarction B Dysrhythmias
are the most common complication and cause of death after an MI. Cardiogenic shock, CHF, and recurrent MI are also complications but occur less frequently.

798 A client has a nursing diagnosis of Fluid Volume Excess. After assessing the client, the nurse records which assessment data in the medical record
that support continued use of this nursing diagnosis? Bibasilar crackles Weak pulse Decreased blood pressure Flat neck veins with the
head of the bed at 45 degrees A Signs of fluid volume excess bounding pulse, elevated blood pressure, crackles or other adventitious breath
sounds, edema of the sacrum or lower extremities, and neck vein distention with the head of the bed positioned at a 45 degree angle. Other signs may include
peripheral veins that do not flatten when raised above the head for 3 to 5 seconds and changes in level of consciousness if fluid shifts are occurring.

799 A client is experiencing acute cardiac and cerebral symptoms related to fluid volume excess. The nurse implements which of the following
measures to increase the client’s comfort until specific therapy is ordered by the physician? Administers oxygen at 4 liters per minute by nasal cannula
Elevates the client’s head to at least 45 degrees Measures urine output on an hourly basis Measures intravenous and oral fluid intake B
Elevating the head of the bed for 45 degrees decreases venous return to the heart from the lower body, thus reducing the volume of blood that has to
be pumped. It is also promotes venous drainage from the brain, reducing cerebral symptoms. Oxygen is a medication and is not administered without an order.
Intake and output should be monitored and recorded to provide current information about the client’s volume status. Options A, C, and D are important
measures, although they do not improve the client’s comfort.
800 A nurse notes that a client’s urinalysis report contains a notation of positive red blood cells (RCBs). The nurse interprets that this finding is
unrelated to which of the following items that is part of the client’s clinical picture? Diabetes mellitus Concurrent anticoagulant therapy History of
kidney stones History of recent blow to the right flank A Hematuria can be caused by trauma to the kidney, such as with blunt trauma to
the lower posterior trunk of flank. Kidney stones can cause hematuria as they scrape the endothelial lining of the urinary system. Anticoagulant therapy can
cause hematuria as a side effect. Diabetes mellitus does not cause hemutaria, although it can lead to renal failure from prerenal causes.

801 A nurse has an order to ambulate a client with a nephrostomy tube in the half four times a day. The nurse determines that the safest way to
accomplish this while maintaining the integrity of the nephrostomy tube is to: Tie the drainage bag to the client’s waist while ambulating Hang the
drainage bag from a walker while the client is ambulating Tell the client to hold the drainage bag higher than the level of the bladder Change the
drainage bag to a leg collection bag D The safest approach to protect integrity and safety of the nephrostomy tube with a mobile client is to
attach the tube to leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgement. The drainage
bag is kept below the level of the bladder. Option B presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.

802 A client with newly diagnosed polycystic kidney disease has just finished speaking with the physician about the disorder. The client asks the nurse
to explain again what the most serious complication of the disorder might be. In formulating a response, the nurse incorporates the understanding that the most
serious complication is: Diabetes insipidus Syndrome of inappropriate antidi-uretic hormone (ADH) secretion End stage renal disease (ESRD)
Chronic urinary tract infection (UTI) C The most serious complication of polycystic kidney disease is ESRD, which would be
managed with dialysis or transplant. There is no reliable way to predict who will ultimately progressed to ESRD. Chronic UTIs are the most common
complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and syndrome of
inappropriate ADH secretion are unrelated disorders.

803 A nurse is assigned to care for a client who has returned to the nursing unit following left nephrectomy. The nurse places the highest priority on
obtaining which of the following assessments? Tolerance for sips of clear liquids Temperature Hourly urine output Ability to turn side to
side C Following nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the
remaining kidney and to detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the
client’s ability to reposition, cough, and deep breathe. Therefore the next most important measurements are vital signs (including temperature), pain level, and
bed mobility. Clean liquids are not given until the client has bowel sounds.
804 A client with a history or respiratory disease is ambulating with the nurse to the doorway of the hospital room. The client becomes pale and
dyspneic. The nurse made the client sit down and takes the client’s vital signs. The respiratory rate is 32 breaths/min, oxygen saturation is 90%, and the heart
rate has increased from 76 to 98 beats/min. The nurse interprets that this client is experiencing: Impaired Physical Mobility Activity Intolerance
Ineffective Breathing Pattern Ineffective Airway Clearance B Activity Intolerance is characterized by exertional dyspnea, adverse
changes in blood pressure or heart rate with activity, and fatigue. Ineffective Breathing Pattern occurs when the rate, timing, depth, or rhythm of breathing is
insufficient to maintain optimal ventilation. Ineffective Airway Clearance occurs when the client is unable to clear own secretions from the airway. Impaired
Physical Mobility occurs when the client is limited in physical movement and has limited muscle strength, rage of motion, or coordination.

805 A client with gastric tumor is scheduled for subtotal gastrectomy (Billroth II procedure). The nurse explains the procedure to the client and tells the
client that the: Proximal end of the distal stomach is anastomosed to the duodenum Antrum of the stomach is removed with the remaining
portion anastomosed to the duodenum Entire stomach is removed and the esophagus is anastomosed to the duodenum Lower portion of the
stomach is removed and the remainder is anastomosed to the jejunum. D In the Billroth II procedure, the lower portion of the stomach is
removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options A, B, and C are
incorrect descriptions.

806 A nurse prepares a postoperative plan of care for a client scheduled for hypophysectomy. The nurse avoids including which of the following in the
plan? Mouth care Coughing and deep breathing Monitoring intake and output Daily weights B Toothbrushing, sneezing,
coughing, nose blowing and bending are activities that should be avoided postoperatively in the client that underwent a hypophysectomy. These activities
interfere with the healing of the incision and can disrupt the graft. Options A, C, and D are appropriate postoperative interventions.

807 A client undergoes a thyroidectomy. The nurse monitors the client for signs of damage to the parathyroid glands postoperatively. Which of the
following findings would indicate damage to the parathyroid glands? Hoarseness Tingling around the mouth Respiratory distress
Neck pain B The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany
result when parathyroid (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers, and muscular
twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek’s and Trousseau’s signs
808 A nurse is caring for a client who is comatose. The nurse notes in the chart that the client is exhibiting decerebrate posturing. Based on this
documented finding, the nurse expects to note which of the following? Extension of the extremities after a stimulus Flexion of the extremities after a
stimulus Upper extremity flexion with lower extremity extension Upper extremity extension with lower extremity flexion A Decerebrate posturing,
which can occur with the upper brainstem injury, is the extension of the extremities after a stimulus. Options B, C, and D are incorrect descriptions of this type
of posturing.

809 A nurse is caring for a client who had a total knee replacement. Postoperatively, which of the following nursing assessments is the highest priority?
Bladder distention Homans’ sign Extremity shortening Heel breakdown B Deep vein thrombosis is a potentially serious
complication of lower extremity surgery. Checking for a positive Homans’ sign assesses for this complication. Although bladder distention, extremity
lengthening or shortening, or heel breakdown can occur, these complications are not potentially serious complications.

810 A nurse is assessing a client’s smoking habit. The client admits smoking ¾ pack per day for the last 10 years. The nurse calculates that the client has
a smoking history of how many pack-years? 0.75 pack-years 7.5 pack-years 15 pack-years 30 pack-years B The standard
method for quantifying smoking history is to multiply the number of packs smoked per day by the number pack-years of smoking. The number is recorded as
the number of pack-years. The calculation for the number of pack-years for the client who has smoked ¾ pack a day for 10 day for 10 years is: 0.75 (3/4) packs
x 10 years = 7.5 pack-years.

811 A nurse is conducting a health history of a client with hyperparathyroidsm. Which of the following questions made to the client would elicit
information about this condition? "Have you had problems with diarrhea lately?" " Do you have tremors in your hands?" "Are you experiencing
pain in your joints?" "Do you notice swelling in your legs at night?" C Hyperparathyroidism causes and oversecretion of parathyroid
hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the
bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological
fractures. Options A and B relate to assessment of hypoparathyroidism. Option D is unrelated to hyperparathyroidism.
812 An 18 year-old client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb, followed by
redness and swelling and throbbing, achy pain. Raynaud’s disease is suspected. The nurse further assesses the client to see if these episodes occur with:
Exposure to heat Being in a relaxed environment Prolonged episodes of inactivity Ingestion of coffee or chocolate D Raynaud’s
disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold,
numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine,
trauma to the fingertips, and stress. Prolonged episodes of inactivity is unrelated to these episodes.

813 A client is admitted to the hospital with a diagnosis of pericarditis. A nurse assesses the client for which manifestation that differentiates pericarditis
from other cardiopulmonary problems? Chest pain that worsens on inspiration Pericardial friction rub Anterior chest pain Weakness
and irritability B A pericardial friction rub is heard when there is inflammations of the pericardial sac, during the inflammatory phase of
pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina
pectoris and myocardial infrction. Weakness and irritability are nonspecific complaints and could accompany a wide variety of disorders.

814 An ambulatory care nurse is assessing client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated
to this problem? Purulent nasal discharge Chronic cough Headache more pronounced in the evening Anosmia C Chronic
sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and
headache that is worse upon arising after sleep.

815 A client has Impaired Verbal Communication as a result of a temporary tracheostomy following a laryngectomy. In planning for communication
with this client, a nurse would avoid which of the following methods because it would be the least helpful for this particular client? Use of hand or finger
signals Nodding and shaking the head for yes and no Use of a picture board Use of a pencil and paper B Following laryngectomy,
the client should not be asked to nod or shake the head because it is painful for the client. The use of eye blink or hand or finger signals is acceptable. Other
helpful methods include the use of a pencil and paper, word or picture board, flash cards or a magic slate.

816 A client seeks treatment in an ambulatory clinic for a complaint of hoarseness that has lasted for 6 weeks. Based on the symptom, the nurse
interprets that the client is at risk of having: Laryngeal cancer Acute Laryngitis Bronchogenic cancer Thyroid cancer A Hoarseness is
a common early sign of laryngeal cancer but not of bronchogenic or thyroid cancer. Hoarseness that lasts for 6 weeks is not associated with an acute problem,
such as laryngitis.
817 A client is admitted to the nursing unit following lobectomy. The nurse notes that in the first hour after admission the chest tube drainage was 75
mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets that: The lung has fully reexpanded This is normal The client
needs to cough and deep breathe The tube may be occluded D Chest tube drainage in the first 24 hours after thoracic surgery may total 500 to
1000 mL. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the
nurse. Option A, B and C are incorrect interpretations

818 A nurse is auscultating the chest of a client with new onset of pleurisy. The client does not have a pleural friction rub when auscultated the previous
day. The nurse interprets that this is most likely due to: Decreased inflammatory reaction at the site The deep breaths that the client is taking
Accumulation of pleural fluid in the inflamed area Effectiveness of medication therapy C Pleural friction rub is auscultated
early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and
parietal lung surfaces, and the pleural friction rub disappears. Options A, B and D are incorrect interpretations

819 A client is admitted to the nursing unit with a diagnosis of pleurisy. The nurse assesses the client for which of the following characteristic symptoms
of this disorder? Early morning fatigue Dyspnea that is relieved by lying flat Pain that worsens when the breath is held Knifelike pain that
worsens on inspiration D A typical symptom of pleurisy is a knifelike pain that worsens on inspiration. This is due to the friction caused by
the rubbing together of the inflamed pleural surfaces. The pain usually disappears when the breath is held, because these surfaces stop moving. The client does
not experience early morning fatigue or dyspnea relieved by lying flat.

820 A nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. Which of the following assessment findings should
the nurse expect to note? Ipsilateral paralysis and loss of touch and vibration Bilateral loss of pain and temperature sensation Contralateral
paralysis and loss of touch sensation and vibration Complete paraplegia or quadriplegia, depending on the level of injury A Brown-
Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration and proprioception.
Contralaterally, pain and temperature sensation is lost because these fibers decussate after entering the cord. Options B, C, and D are not assessment findings in
this syndrome.
821 A nurse is performing an assessment on a client who has a suspected spinal cord injury. Which of the following is the priority nursing assessment?
Pupillary response Respiratory status Mobility level Pain level B All of the above assessments would be performed on a
client with a suspected spinal cord injury. Respiratory status is the priority.

822 A nurse is caring for a client who is newly diagnosed with a spinal cord injury. The nurse would anticipate that the most likely medication to be
prescribed would be: Propranolol (Inderal) Dexamethasone (Decadron) Furosemide (Lasix) Morphine (Astramorph) B The most
likely medication to be prescribed for a newly diagnosed spinal cord injury is dexamethasone (Decadron). This medication is a short-acting glucocorticoid and
would be administered to reduce traumatic edema. The use of propranolol, a beta blocker, furosemide, a diuretic, or morphine (Astramorph), an opioid
analgesic, would not be indicated based on the information in this question.

823 A nurse is admitting a client with a diagnosis of acquired immunodeficiency syndrome (AIDS) to the medical-surgical unit. The nurse most
importantly assesses for which of the following findings? Jaundice skin White patches in the oral cavity Bradypnea Urine specific gravity of
1.010 B Clients with AIDS frequently have opportunistic infections. Candida albicans, the causative organism of thrush, is a common
opportunistic infection. Thrush presents as white patches in the oral cavity. Hairy leukoplakia also presents as white patches in the oral cavity. Jaundice is a
symptom of hepatic disease. Clients with AIDS frequently acquire pneumonia and may present with tachypnea, not bradypnea. Clients with aids frequently
have inadequate nutrition and hydration and may present with dehydration, resulting in a high specific gravity rather than a low specific gravity.

824 A nurse assesses a client who was involved in a motor vehicle accident. The nurse determines the need to prepare for chest tube insertion if the client
exhibits: Shortness of breath and tracheal deviation Chest pain and shortness of breath Decreasing oxygen saturation and bradypneaPeripheral
cyanosis and hypotension A Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. The trachea deviates
to the unaffected side in the presence of a tension pneumothorax. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The
increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from a decreased area available for diffusion of
gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Clients requiring chest tubes exhibit
decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia. Peripheral cyanosis is caused by circulatory disorders.
Hypotension may be a result of tracheal shift and impedance of venous return to the heart. However, it may also be the result of other problems such as a failing
heart.
825 A nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which of the following nursing actions would be
most important to include in the plan in order to ensure accurate monitoring of the client’s oxygenation status? Notify the physician immediately of an oxygen
saturation less than 90% Instruct the client not to move the sensor Tape the sensor tightly to the client’s finger Place the sensor on a finger below
the blood pressure cuff B The pulse oximeter passes a beam of light through the tissue, and a sensor is attached to the fingertip, toe, or ear
lobe measures the amount of light absorbed by the oxygen-saturated hemoglobin. The oximeter then gives a reading of the percentage of hemoglobin that is
saturated with oxygen (Sao2). Motion at the sensor site changes light absorption. The motion mimics the pulsatile motion of blood, and because the detector
cannot distinguish between movement of blood and movement of the finger, results can be inaccurate. The sensor should not be placed distal to blood pressure
cuffs, pressure dressings, arterial lines, or any invasive catheters. The sensor should not be taped to the client’s finger. If values fall below preset norms (usually
90%), the client should be instructed to deep breathe if this is appropriate.

826 A nurse is teaching a client with thromboangiitis obliterans (Buerger’s disease) about interventions to control the disease process. The nurse avoids
telling the client to: Stop smoking immediately Take nifedipine (Procardia) As directed Keep the extremities cool Assess for signs and
symptoms of ulceration C Interventions are directed at preventing the progression of Buerger’s disease and include conveying the need for
immediate smoking cessation and providing medications prescribed for vasodilation, such as the calcium channel blocker nifedipine (Procardia) or the alpha-
adrenergic blocker prazosin. (Minipress). The client should maintain warmth to the extremities especially by avoiding exposure to cold. The client should
inspect the extremities and report signs of infections or ulceration.

827 A home health nurse is assessing a client who has begun using peritoneal dialysis. The nurse would determine that which of the following
manifestations noted in the client would most likely indicate the onset of peritonitis? Temperature of 990 F oral History of gastrointestinal (GI)
upset 1 week ago Cloudy dailysate output Presence of crystals in dialysate output C Typical symptoms of peritonitis include fever,
nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. The very slight temperature elevation in option A is not the clearest indicator of
infection. The complaint of GI upset is too vague to indicate peritonitis. Peritonitis would cause cloudy dialysate, but would not cause crystals to appear in the
dialysate.

828 A nurse is working on a medical surgical nursing unit and is caring for several clients with renal failure. The nurse interprets that which of the
following clients is best suited for peritoneal dialysis as a treatment option? A client with severe congestive heart failure A client with a history of ruptured
diverticula A client with a history of herniated lumbar disk A client with a history of three previous abdominal surgeries A Peritoneal
dialysis may be the treatment option of choice for clients with severe cardiovascular disease. Severe cardiac disease can be worsened by the rapid shifts in
fluids, electrolytes, urea, and glucose that occurs with hemodialysis. For the same reason peritoneal dialysis may be indicated for the client with diabetes
mellitus. Contraindications to peritoneal dialysis include diseases of the abdomen such as ruptured diverticula or malignancies; extensive abdominal surgeries;
history of peritonitis; obesity and those with a history of back problems, which could be aggravated by the fluid weight of the dialysate. Severe disease of the
vascular system may also be a relative contraindication.
829 A client undergoing long-term peritoneal dialysis is currently experiencing a problem with reduced outflow from the dialysis catheter. The home
health nurse inqures whether the client had a recent problem with: Vomiting Diarrhea Constipation Flatulence C Reduced outflow may be
due to catheter position and adherence to the omentum, infection, or constipation. Constipation may contribute to reduced outflow in part because peristalsis
seems to aid in drainage. For this reason, bisacodyl suppositories are sometimes used prophylactically, even without a history of constipation. The other
options are unrelated to impaired catheter drainage.

830 A client with a history of heart failure who is undergoing peritoneal dialysis has developed crackles in the lower lung fields. The nurse interprets
that this finding is most likely related to: Compliance with dietary sodium restriction Adherence to digoxin (Lanoxin) therapy schedule Natural
progression of the renal failure Intake greater than output as indicated on the dialysis record D Crackles in the lung fields of the peritoneal
dialysis client result form overhydration or from insufficient fluid removal during dialysis. An intake that is greater than the output of peritoneal dialysis fluid
would overhydrate the client, resulting in lung crackles. Adherence to medication and diet therapy should control this sign, not exacerbate it. If dialysis is
effective, there is no connection between the progression of renal failure and the development of signs of overhydration.

831 A nurse is teaching the client with asthma how to use a peak flow meter. The nurse tells the client to: Inhale an average size breath
Form a loose seal with the mouth around the mouthpiece Blow out as slowly as possible Record the final position of the indicator D
A peak flow meter is to provide an objective measure of the client's peak expiratory flow. The client is instructed to take the deepest possible
breath, form a tight seal around the mouthpiece with the lips, and exhale forcefully and rapidly. The final position of the indicator on the meter is recorded.

832 A nurse is teaching the client taking medications by inhalation about the advantages of a newly prescribed spacer. The nurse determines the need
for further education, if the client states that the spacer: Reduces the frequency of medication to only once per day Reduces the chance of yeast
infection because large drops aren't deposited on the oral tissues Disperses medication more deeply and uniformly Reduces the need to coordinate
timing between pressing the inhaler and inspiration A There are key advantages to the use of a spacer for medications administered by inhalation.
One is that it reduces the incidence of yeast infections, since large medication droplets are not deposited on oral tissues. The medication is also dispersed more
deeply and uniformly than without a spacer. There is less need to coordinate the effort of inhalation with pressing on the canister of the inhaler. Finally, the
use of a spacer may decrease either the number or the volume of the puffs taken. Option A is too absolute and limiting by description.
833 A nurse is assessing a client with a tentative diagnosis of pulmonary emphysema. The nurse assesses the client for which of the following signs that
distinguishes emphysema from chronic bronchitis? Copious sputum production Marked Dyspnea Minimal weight loss Cough that began before
the onset of dyspnea B Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after the onset of dyspnea) scant
mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by early onset of cough (before dyspnea), copious purulent sputum
production, minimal weight loss, and milder severity of dyspnea.

834 A client with late stage emphysema complains of an occipital headache, drowsiness, and difficulty concentrating. The nurse interprets that these
symptoms are indicative of which complication of emphysema? Encephalopathy Carbon dioxide narcosis Carbon monoxide poisoning
Cerebral embolism B With late stage emphysema, the retention of carbon dioxide can lead to carbon dioxide narcosis. This is
manifested by occipital headache, drowsiness, and inability to concentrate. Other signs are bounding pulse, arterial carbon dioxide level greater than 75 mm
Hg, confusion, coma, and asterixis (flap tremor).

835 A nurse witness an accident in which a pedestrian is hit by an automobile. The nurse stops at the scene and assures the victim. The nurse notes that
the client is responsive and has suffered a flail chest involving at least three ribs. The nurse does which of the following to assist the client's respiratory status
until help arrives? Assist the victim to sit up Turns the client onto the side with the flail chest Removes the victim's shirt Applies firm
but gentle pressure with the hands to the flail segment D If significant flail chest is present, the nurse applies firm yet gentle pressure to the flail
segments of the ribs to stabillize the chest wall, which will ultimately help the client's respiratory status. The nurse does not move an injured person for fear of
worsening an undetected spinal injury. Removing the victim's shirt is of no value in this situation, and could in fact chill the victim, which is
counterproductive. Injured persons should be kept warm until help arrives at the scene.

836 A nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days
ago. The nurse plans to do which of the following next after noting this finding? Review the intake and output records for the last 2 days Change the
time of diuretic administration from morning to eveningRequest a sodium restriction of 1 g/day from the physician Order daily weights starting on the
following morning A Edema is the accumulation of the excess fluid in the interstitial spaces, which can be measured by intake greater than output,
and by a sudden increase in weight (2.2 lb = 1 kg). Diuretics should be administered in the morning whenever possible to avoid nocturia. Strict sodium
restriction are reserved for client with severe symptoms.
837 A nurse in the emergency room is assessing a client with a chest pain. Which of the following observation by the nurse helps to determine that this
pain is due to myocardial infarction (MI)? The pain, unrelieved by nitroglycerin, was relieved with morphine sulfate The pain was described as
substernal and radiating to the left arm The client experienced no nausea or vomiting The clients report that the pain began while the client was
pushing a lawnmower A The pain of angina may radiate to the left arm, is often precipitated by exertion or stress, has few associated symptoms, and is
relieved by rest and nitroglycerin. The pain of MI may radiate to the left arm, shoulder, jaw or neck. It typically begins spontaneously, lasts longer than 30
minutes, is frequently accompanied by associated symptoms (nausea, vomiting, dyspnea, diaphoresis, anxiety), and requires opioid analgesics for relief

838 A nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade knowing that which of the
following is not associated with this complication of pericarditis? Pulsus paradoxus Distant heart sounds Distended jugular veins Bradycardia
D Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distension, and a falling
blood pressure (BP), accompanied by pulsus paradoxus ( a drop in inspiratory BP by greater than 10 mm Hg).

839 A nurse is assisting to position the client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client: Lying on left side with a
pillow under the chest wall Lying on right side with a pillow under the head Supine with the head of bed elevated at a 45-to-60 degree angle
Supine with slight Trendelenburg position C The client undergoing pericardiocentesis is positioned supine with the head of the bed raised
to a 45 to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. Options A, B and
D are incorrect positions.

840 A nurse is monitoring drainage from a nasogastric (NG) tube in a client who had a gastric resection. No drainage has been noted during the past 4
hours, and a client complains a severe nausea. The most appropriate nursing action would be to: Reposition the tube Irrigate the tube Notify the
physician Medicate for nausea C Nausea and vomiting should not occur if the NG tube is patent. The NG tube should not be repositioned or
irrigated after gastric surgery because it is placed directly over the suture line. The NG tube is irrigated gently with normal saline only with a physician’s order.
The client may need medication for the nausea, but in this situation the physician should be notified.
841 A client recovering from a craniotomy complains of a “runny-nose.” The most important nursing action in this situation is to: Provide the
client with tissues Tell the client to use tissues for the drainage Monitor the client for signs of a cold Notify the physician D If the client
has sustained a craniocerebral injury or is recovering from a craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic area is
critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its presence is indicative of a serious breach of cranial integrity. Any suspicious
drainage should be reported immediately.

842 A nurse is caring for a client who has returned from the postanesthesia care unit following prostatectomy. The client has a three-way Foley catheter
with infusion of continuous bladder irrigation. The nurse assess that the flow rate is adequate if the color of the urinary drainage is: Dark cherry colored
Concentrated yellow with small clots Clear as water Pale yellow or slightly pink D The infusion of bladder irrigant is
not at a preset rate, but rather it is increased or decreased to maintain urine that is a clear, pale yellow color or that has just a slightly pink tinge. The infusion
rate should be increased if the drainage is cherry colored or if clots are seen. Correspondingly, the rate can be slowed down slightly if the returns are as clear as
water.

843 A nurse is assessing a client who is at risk of developing acute renal failure (ARF). The nurse would become most concern if which of the following
assessments was made? Urine output 30 mL/hr for the last 3 hours, blood urea nitrogen (BUN) 10 mg/dL creatinine 1.2 mg/dL Urine output
40 mL/hr for the last 3 hours, BUN 15 mg/dL, creatinine 0.8 mg/dL Urine output 20 mL/hr for the last 3 hours, BUN 35 mg/dL, creatinine 2.1 mg/dL
Urine output 60 mL/hr for the last 3 hours, BUN 40 mg/dL, creatinine 1.1 mg/dL C With acute renal failure, the client is often
oliguric or anuric, although the client may have nonoliguric renal failure. The BUN and serum creatinine levels also rise, indicating defective kidney function.
Normal serum BUN levels are usually 5 to 20 mg/dL. Normal creatinine, levels range from 0.6 to 1.3 mg/dL. The client who has the greatest abnormality in
urine output and laboratory values is the client in option C. This is the client who is the most at risk for the development of the renal failure.

844 A client with acute renal failure has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse would evaluate this therapy
as effective if which of the following values was noted on follow-up laboratory testing? Potassium 4.9 mEq/L Sodium 142 mEq/L Phosphorus 3.9 mg/dL
Calcium 9.8 mg/dL A Of all the electrolyte imbalances that accompany renal failure, hyperkalemia is the most dangerous because it can
lead to cardiac dysrhythmias and death. If the potassium level rises too high, Keyexalate may be administered to cause excretion of potassium through the
gastrointestinal tract. Each of the electrolyte levels noted in the options falls within the normal reference range for that electrolyte. The potassium level,
however, is measured following administration of this medication to note the extent of its effectiveness.

845 A nurse is admitting a client with chronic renal failure (CRF) to the nursing unit. The nurse assesses for which of the following most frequent
cardiovascular sign that occurs in the client with CRF? Hypertension Hypotension Tachycardia Bradycardia A
Hypertension is the most common cardiovascular finding in the client with CRF. It is due to a number of mechanisms, including volume overload,
renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and the absence of prostaglandins. Hypertension may also be the cause of
renal failure. It is an important item to assess because hypertension can lead to heart failure in the CRF client because of increased cardiac workload in
conjunction with fluid overload.
846 A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has
elevated the limb, applied an ice bag, and administered an analgesic, which has provided very little relief. The nurse interprets that this pain may be due to:
Impaired tissue perfusion The newness of the fracture The anxiety of the client Infection under the cast A
Most pain with fractures can be minimized with rest, elevation, application of cold, and the administration of analgesics. Pain that is not relieved
from these measures should be reported to the physician, because it may be due to impaired tissue perfusion, tissue breakdown, or necrosis. Since this is a new
closed fracture and cast, infection would not have had time to set in.

847 The client with a fractured femur experiences sudden dyspnea. A set of arterial blood gases reveal the following: pH 7.32, PaCO2 43, PaO2 58,
HCO3 20. The nurse interprets that the client probably has experienced fat embolus because of the: PaCO2 PaO2 HCO3 pH B A
key feature of fat embolism is a significant degree of hypoxemia, with a PaO2 often less than 60 mm Hg. Other features that distinguish fat embolism from
pulmonary embolism are an elevated temperature and the presence of fat in the blood with fat embolus

848 A nurse assesses a client with chronic arterial insufficiency. After walking three blocks the client complains of leg pain and cramping, which was
relieved when the client stop and rests. The nurse documents that the client is experiencing: Arterial-venous shunting Deep vein thrombosis
Intermittent claudication Venous insufficiency C Intermittent claudication is a classic symptom of peripheral vascular disease, also
known by other names, including peripheral arterial and chronic arterial insufficiency. It is described as a cramplike pain that occurs with exercise and is
relieved by rest. Intermittent claudication is due to ischemia and is very reproducible; that is, a predictable amount of exercise causes the pain each time.
Options A, B and D are incorrect.

849 A nurse has an order to administer two ophthalmic medications to the client who has undergone eye surgery. The nurse waits how many minutes
after the first medication before giving the second? It is not necessary to wait; the second medication can be administered immediately 1 to 2 3
to 5 8 to 10 C The nurse waits 3 to 5 minutes between administration of the two separate ophthalmic medications. This allows for adequate
ocular absorption of the medication and prevents the second medication from flushing out the first.

850 A client calls the ambulatory care clinic and tells a nurse that she found an area that looks like the peel of an orange when performing breast self-
examination (BSE) but found no other changes. The nurse should: Tell the client there is nothing to worry about Arrange for the client to be seen at
the clinic as soon as possible Tell the client to take her temperature and call back if she has a fever Tell the client to point out the area to the
physician at her next regularly scheduled appointment B Peau d’orange, and orange-peel appearance of the skin over the breast, is associated with
late breast cancer. Therefore the nurse would arrange for the client to come to the clinic at the earliest time possible. Peau d’orange is not indicative of an
infection.
851 A client with Cushing’s syndrome is being instructed by the nurse on the follow-up care. Which of this statements, if made by the client , would
indicate a need for further instructions? I should avoid contact sports. I need to avoid foods high in potassium. I should check my ankles for
swelling. I need to check my blood glucose regularly. B Hypokalemia is a common characteristic of Cushing’s syndrome and the client is instructed
to consume foods high in potassium. Clients experience activity intolerance, osteoporosis, and frequent bruising. Fluid volume excess results from water and
sodium retention. Hyperglycemia is caused by an increased cortisol secretion.

852 A client with aldosteronism is being treated with spironolactone (Aldactone). Which of the following indicates to the nurse that the medication is
effective? A decrease in blood pressure A decrease in sodium excretion A decrease in plasma potassium A decrease in body metabolism A
Aldactone antagonizes the effect of aldosterone and decreases circulating volume by inhibiting tubular reabsorption of sodium and water. Thus it
produces a decrease in blood pressure. It increases potassium retention and promotes sodium and water excretion. It has no effect on the body metabolism.

853 A nurse is caring for a postoperative adrenalectomy client. The nurse monitors the clients for which of the following? Signs and symptoms of
hypocalcemia Peripheral edema Signs and symptoms of hypovolemia Bilateral exopthalmos C Aldosterone, secreted by the adrenal
cortex, plays a major role in fluid volume balance by retaining sodium and water. Thus a deficiency can cause hypovolemia. A deficiency of adrenocortical
hormones (adrenalectomy) does not cause the clinical manifestation noted in options A, B and D

854 A client with cancer who is receiving chemotherapy tells the nurse that the food on metal tray tastes “funny.” Which intervention by the nurse is
appropriate? Keep the client NPO Administer an antiemetic as ordered Provide oral hygiene care Obtain an order for total prenatal
nutrition (TPN) C Cancer treatments may cause distortion of taste. Frequent oral hygiene aids in preserving taste function. Keeping a client NPO
increases nutritional risks. Antiemetics are used when nausea and vomiting are a problem. TPN is used when oral intake is not possible.

855 A nurse is performing a health history on a client with chronic pancreatitis. The nurse expects to most likely note which of the following when
obtaining information regarding the client’s health history? Abdominal pain relieved with food or antacids Exposure to occupational chemicals
Weight gain Use of alcohol D Chronic pancreatitis occurs more often in alcoholics. Abstinence from alcohol is important
to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Pain would not be relieved with foods or
antacids. Chemical exposure is associated with cancer of the pancreas.
856 A client with a diagnosis of Cushing syndrome is undergoing a dexamethasone suppression test. The nurse plans to implement which steps during
this test? Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning and evening Administer an injection
of dexamethasone, and then collect a 24-hour urine specimen to measure serum cortisol levels Draw blood samples before and after exercise to evaluate
the effect of exercise on serum cortisol levels Administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing blood to
measure serum cortisol levels A The dexamethasone suppression test is performed to evaluate the function of the adrenal cortex. The procedure for
this test is to administer 1 mg of dexamethasone at 11 pm to suppress ACTH formation and then obtain 8 am and 8 pm serum cortisol level on the following
day.

857 A nurse is performing an abdominal assessment on the client. The nurse determines that which of the following findings should be reported to the
physician? Concave, midline umbilicus Pulsation between the umbilicus and pubis Bowel sound frequency of 15 sounds per minute Absence of a
bruit B The umbilicus should be in the midline, with a concave appearance. The presence of pulsation between the umbilicus and the pubis could
indicate an abdominal aortic aneurysm and should be reported to the physician. Bowel sounds vary according to the timing of the last meal and usually range in
frequency from 5 to 35 per minute. Bruits are not normally present.

858 A nurse is performing a cardiovascular assessment on a client. Which of the following items would the nurse assess to gain the best information
about the client’s left-sided heart function? Breath sounds Peripheral edema Jugular vein distention Hepatojugular reflux A
The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral
edema, jugular vein distention, and hepatojugular reflux are all indicators of right-sided heart function. Breath sounds are an accurate indicator of left-sided
heart function.

859 A nurse is caring for the following group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the
development of pulmonary embolism? A 65-year-old man out of bed 1 day after prostate resection A 73-year-old woman who had just has a
pinning of a hip fracture A 25-year-old woman with diabetic ketoacidosis A 38-year-old woman with a pulmonary contusion after an
automobile accident B Clients frequently at risk for pulmonary embolism include clients who are immobilized. This is especially true in immobilized
postoperative clients. Other clients at risk include those of advanced age, with endothelial disease, or with conditions characterized by hypercoagulability.

860 A physician has inserted a nasoenteric tube into a client for the treatment of intestinal obstruction. Following insertion, the nurse tells the client to lie
in which position to help the tube advance into the duodenum, past the pyloric sphincter? Supine with the head of the bed flat Supine with the head
elevated 30 degrees On the right side On the left side C Following insertion of a nasoenteric tube, the client is instructed to lie on the
right side to aid the passage of the tube from the stomach into the duodenum, past the pyloric sphincter. Options A, B, and D are incorrect positions.
861 A client with coronary artery disease suddenly complains of palpitations and an irregular heartbeat. The nurse would assess for which of the
following to determine an inadequacy of stroke volume? Pulse pressure Pulse deficit Pulsus alternans Water-hammer pulse B
Palpitations are often a subjective complaint that accompanies dysrhythmias. Irregular rhythms produce varying strengths of stroke volume because
of irregular ventricular filling times, and therefore arterial pulsations may become weakened or intermittently absent. The nurse determines this by assessing an
apical-radial pulse. An apical rate that is greater than the radial rate is called a pulse deficit. The pulse pressure is an indirect indicator of overall cardiac output.
A water-hammer accompany events that produce an increased cardiac output. Pulsus alternans has regular. Rhythm accompanied by a pulse volume that
alternates strong with weak.

862 A nurse is listening to the client’s breath sounds and hears a creaking, grating sound on inspiration and expiration over the posterior right lower lobe.
The nurse documents that this client has: Crackles Wheezes Rhonchi Pleural friction rub D The nurse is hearing a pleural friction rub,
which is characterized by sounds that are described as creaking, groaning or grating in quality. The sounds are localized over an area of inflammation of the
pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle. Crackles have the sound that is heard when a few strands of hair
are rubbed together near the ear; they indicate fluid in the alveoli. Wheezes are musical noises heard on inspiration, expiration, or both. They are the result of
narrowed air passages. Rhonchi are usually heard on expiration when there is excessive production of mucus, which accumulates in the air passages.

863 A nurse is assessing the renal function of a client. After directly noting urine volume and characteristics, the nurse assesses which of the following
items as the best indirect indicator of renal function? Bladder distention Level of consciousness Pulse rate Blood pressure D
The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal
perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The pulse rate
affects the cardiac output but can be altered by factors unrelated to kidney functions. Bladder distention reflects a problem or obstruction that is most often
distal to the kidneys. Level of consciousness is an unrelated item.

864 A nurse notes that the infusion bag of a client receiving total parenteral nutrition (TPN) has become empty. The nurse calls the pharmacy, but the
next bag will not be delivered for another 30 minutes. The nurse hangs which of the following solutions until the TPN arrives? 5% dextrose in water
(D5W) 10% dextrose in water (D10W) 50% dextrose in saline solution (D50NS) 5% dextrose in 0.45% saline solution (D51/2NS) B If
a TPN solution bag stops running or becomes empty, the nurse should hang an infusion of 10% dextrose in water until another TPN solution arrives or the
problem is fixed. This minimizes the chance that hypoglycemia will develop, since the body produces more insulin in the presence of the high TPN glucose
load.

865 A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse assesses the client for a history of chronic use of which of the
following medications? Acetaminophen (Tylenol) Acetylsalicylic acid (Aspirin) Ibuprofen (Advil) Ranitidine (Zantac) A
Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a
client presents with symptoms compatible with liver disease (such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified
in options B,C and D.

866 A nurse is assigned to care for a client who has just undergone eye surgery. The nurse plans to instruct the client that which of the following
activities is permitted in the postoperative period? Reading Watching television Bending over Lifting objects B The client is
taught to avoid activities that raise intraocular pressure and could cause complications in the postoperative period. The client is also taught to avoid activities
that cause rapid eye movements, which are irritating in the presence of postoperative inflammation. For these reasons the client is taught to avoid bending over,
lifting heavy objects, straining, sneezing, making sudden movements, or reading. Watching television is permissible, since the eye does not need to move
rapidly with this activity and it does not increase the intraocular pressure.

867 A nurse is listening to the lungs of a client who has left lower lobe pneumonia. The nurse interprets that the pneumonia is resolving if which of the
following is heard over the affected lung area? Bronchophony Egophony Vesicular breath sounds Whispered pectoriloquy C
Vesicular breath sounds are normal sounds that are heard over peripheral lung fields where the air enters the alveoli. A return of breath sounds to
normal is consistent with a resolving pneumonia. Bronchophony is an abnormal finding indicative of lung consolidation and is identified if the nurse can clearly
hear the client say “ninety-nine” through the stethoscope. (Normally the client’s words are unintelligible if heard through a stethoscope). Egophony, which
occurs when the sound of the letter “e” is heard as an “a” with auscultation, also indicates lung consolidation. Finally, whispered pectoriloquy is present if the
nurse hears the client when one-two-three is whispered. This is an abnormal finding, aging heard over an area of consolidation. Consolidation typically occurs
with pneumonia.

868 A female client with a history of chronic infection of the urinary system complains of burning and urinary frequency. To determine whether the
current problem is of renal origin, the nurse would assess whether the client has pain or discomfort in the: Suprapubic area Right or left
costovertebral angle Urinary meatus Labium B Pain or discomfort from a problem that originates in the kidney is felt at the costovertebral
angle on the affected side. Ureteral pain is felt in the ipsilateral labium in the female client, or the ipsilateral scrotum in the male client. Bladder infection is
often accompanied by suprapubic pain and by pain or burning at the urinary meatus when voiding.

869 During a routine visit to the physician’s office for monitoring of diabetic control, an elderly client complains to the nurse of vision changes. The
client describes blurring of the vision, with difficulty in reading and driving at night. Given the client’s history, the nurse interprets that which of the following
conditions is probably developing? Detached retina Papilledema Glaucoma Cataracts D Although the incidence of cataracts
increases with age, the elderly client with diabetes mellitus is at greater risk for cataracts. The most frequent complaint is of blurred vision that is not
accompanied by pain. The client may also experience difficulty with reading, night driving, and glare. Options A,B, and C are not directly associated with this
client’s history or complaints.
870 A nurse inquires about smoking history while conducting a hospital admission assessment with a client with coronary artery disease (CAD). The
most important item for the nurse to assess is the: Number of pack-yearsBrand of cigarettes used Desire to quit smoking Number of
past attempts to quit smoking A The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-
years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the
information has no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking
cessation plan with the client.

871 A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client’s signs and
symptoms are not compatible with: Inflammation Degenerative disease Infection Recent injury B Redness, heat, and
swelling are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative disease is accompanied by pain, but there is no redness.
Swelling may or may not occur.

872 A client seeks treatment in the emergency room for a lower leg injury. There is visible deformity to the lower aspect of leg, and the injured leg
appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced a:
Contusion Fracture Sprain Strain B Typical signs and symptoms of a fracture include pain, loss of function in the area,
deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A contusion results from a
blow to soft tissue and causes pain, swelling, and ecchymosis. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include
pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on the muscle. Symptoms include soreness and pain
with muscle use.

873 A client arrives at the emergency room with a chemical burn of the left eye. The first action of the nurse is to immediately: Flush the eye
continuously with sterile solution Apply a cold compress to the injured eye Apply a light bandage to the eye Perform an assessment on the client A
When the client has suffered a chemical burn of the eye, the nurse immediately flushes the site with a sterile solution continuously for 15 minutes. If
a sterile eye irrigation solution is not available, running water may be used. Performing an assessment may be helpful, but is not the priority action. Applying
compresses or bandages are incorrect, because they do not rid the eye of the damaging chemical. Cold compresses are used for blows to the eye, while light
bandages may be placed over cuts of the eye or eyelid.

874 A client tells the nurse about a pattern of getting a strong urge to void, which is followed by incontinence before the client can get to the bathroom.
The nurse formulates which of the following nursing diagnoses for this client? Reflex Incontinence Stress Incontinence Urge Incontinence Total
Incontinence C Urge incontinence occurs when the client has urinary incontinence soon after experiencing urgency. Reflex incontinence
occurs when incontinence occurs at rather predictable times that correspond to when a certain bladder volume is attained. Stress incontinence occurs when the
client voids in increments that are less than 50 mL, and has increased abdominal pressure. Total incontinence occurs when there is an unpredictable and
continuous loss of urine.
875 A 52-year-old male client is seen the physician’s office for a physical examination after experiencing unusual fatigue over the last several weeks.
The client’s height is 5 feet, 8 inches and weight is 220Ib. Vital signs are: temperature 98.6° F orally, pulse is 86 beats/min, and the respirations are 18
breaths/min. The blood pressure (BP) is 184/100 mm Hg. Random blood glucose is 122 mg/dL. Which of the following questions should the nurse ask the
client next? Do you exercise regularly? Are you considering trying to lose weight? Is there a history of diabetes mellitus in your family?
When was the last time you had your blood pressure checked? D The client is hypertensive, which is a known major modifiable risk
factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The
client is overweight, which is a contributing risk factor. The client’s nonmodifiable risk factors are age and gender. Since the client presents with several risk
factors, the nurse places priority of attention on the client’s major modifiable factors.

876 A nurse is instilling and otic solution into an adult client’s left ear. The nurse avoids doing which of the following as part of this procedure?
Warning the solution to room temperature Placing the client in a side-lying position with the ear facing up Pulling the auricle backward and
upward Placing the tip of the dropper on the edge of the ear canal D The dropper is not allowed to touch any object or any part of the
client’s skin. The solution is warmed before use. The client is placed on the side with the affected ear upward. The nurse pulls the auricle backward and upward,
and instills the medication by holding the dropper about 1 cm above the ear canal.

877 A nurse is caring for a client with type 1 diabetes mellitus. Which of the following laboratory results would indicate a potential complication
associated with this disorder? Blood glucose 112 mg/dL Ketonuria Blood urea nitrogen (BUN) 18 mg/dL Potassium 4.2 mEq B
Ketonuria is an abnormal finding in the client with diabetes mellitus indicating ketosis. Ketosis is a metabolic effect from the lack of insulin and
incomplete fat metabolism and occurs in type 1 diabetes mellitus. It is associated with the severe complication of diabetic ketoacidosis (hyperglycemia, ketosis,
and acidosis). Option A, C, and D are all normal laboratory findings.

878 A nurse employed in a diabetes clinic is caring for a client on insulin pump therapy. Which statement, if made by the client, indicates that a
knowledge deficit exists regarding insulin pump therapy? If my blood glucose is elevated, I can bolus myself with additional insulin as ordered.
I’ll need to check my blood glucose before meals in case I need a premeal insulin bolus. Now that I have this pump, I don’t have to worry about
insulin reactions or ketoacidosis ever happening again. I still need to follow a diet and exercise plan even though I don’t inject myself daily anymore. C
Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little
insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject
to the usual complications associated with insulin administration without the use of a pump. Options A, B, and D are accurate regarding the use of the insulin
pump.

879 A client with Graves’ disease has exopthalmos and is experiencing photophobia. Which of the following interventions would best assist the client
with this problem? Administer methimazole (Tapazole) every 8 hours around the clock Lubricate the eyes with tap water every 2 to 4 hours
Instruct the client to avoid straining or heavy lifting since this can increase eye pressure Obtain dark glasses for the client D Medical
therapy for Graves’ disease does not help to alleviate the clinical manifestation of exophthalmos. Since photophobia (light intolerance) accompanies this
disorder, dark glasses are helpful in alleviating the problem. Tap water, which is hypotonic, could actually cause more swelling to the eye since it could pull
fluid into the interstitial space. In addition, the client is at risk for developing an eye infection since the solution is not sterile. There is no need to avoid straining
with exophthalmos.
880 A nurse is caring for a client with pneumonia who suddenly becomes restless and has Pao2 of 60 mm Hg. Which of the following nursing diagnoses
would be most appropriate for this client? Fatigue related to a debilitated state Impaired gas exchange related to increased pulmonary secretions
Ineffective airway clearance related to dilated bronchioles Impaired gas exchange related to pneumonia B Restlessness and a low
Pao2 are hallmark signs of impaired gas exchange. Although many clients with pneumonia experience fatigue, this nursing diagnosis is not the most appropriate
in light of the Pao2 level. Dilated bronchioles would be a goal for treatment and not part of the nursing diagnosis. Pneumonia is a medical diagnosis.

881 A nurse reviews the physician’s orders for a client with Guillain-Barre syndrome. Which order written by the physician should the nurse question?
Assess vital signs every 2 to 4 hours Clear liquid diet Passive range of motion exercises TID Bilateral calf measurements TID B
Clients with Guillain-Barre syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semi-solid foods.
Since clients with Guillain-Barre syndrome are at risk for hypotension or hypertension, bradycardia, and respiratory depression, frequent monitoring of vital
signs is required. Passive range of motion exercises can help prevent contractures, and assessing calf measurements can help detect deep vein thrombosis, for
which they are at risk.

882 A client with myasthenia gravis arrives to the emergency room and crisis is suspected. The physician plans to administer edrophonium (Tensilon) to
differentiate between myasthenic and cholinergic crisis. The nurse prepares to administer which medication if the client is in cholinergic crisis? Atropine
sulfate Morphine sulfate Pyridostigmine bromide (Mestinon) Isoproterenol (Isuprel) A Clients with cholinergic crisis have
experienced over dosage of medication. Tensilon will exacerbate symptoms in cholinergic crisis to the point where the client may need intubation and
mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications. Morphine sulfate and pyridostigmine
bromide would worsen the symptoms of cholinergic crisis. Isuprel is not indicated for cholinergic crisis.

883 A nurse is completing a health history on a client with diabetes mellitus who has been taking insulin for many years. At present, the client describes
experiencing periods of hypoglycemia followed by periods of hyperglycemia. The most likely cause for this occurrence is which of the following?
Injecting insulin at a site of lipodystrophy Adjusting insulin according to blood glucose levels Eating snacks between meals Initiating the
use of the insulin pump A Tissue hypertrophy (lipodystrophy) involves thickening of the subcutaneous tissue at the injection sites. This can
interfere with the absorption of insulin, resulting in erratic blood glucose levels. Since the client has been on insulin for many years, this is the most likely cause
of poor control.

884 A client admitted to the nursing unit from the emergency department has a C4 spinal cord injury. Which of the following assessments should the
nurse perform first when admitting the client to the nursing unit? Take the temperature Assess extremity muscle strength Observe for dyskinesias
Listen to breath sounds D Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory
assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured. Dyskinesias occur in cerebellar
disorder, so are not as important in cord-injured clients, unless head injury is suspected.
885 A nurse is planning to care for a client with pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduces
cardiac workload. The nurse identifies which client action as contributing to this goal? Elevating the legs when in bed Sleeping in the supine position
Using seasonings to improve the taste of food Using a bedside commode for urinary and bowel elimination D Using a
bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client’s legs increases venous return to the heart,
increasing cardiac workload. The supine position increases respiratory effort and decreases oxygenation. This increases cardiac workload. Seasoning are high in
sodium.

886 A nurse is caring for the client who returned to the nursing unit following suprapubic prostatectomy. The nurse monitors the continuous bladder
irrigation to detect which of the following signs of catheter blockage? Drainage that is pale pink Drainage that is bright red Urine leakage
around the three-way catheter at the meatus True urine output of 50 mL/hr C Catheter blockage or occlusion by clots following prostatectomy can
result in urine back-up and leakage around the urethral meatus. This would be accompanied by a stoppage of outflow through the catheter into the drainage bag.
Drainage that is bright red indicates that the irrigant is running too slowly; drainage that is pale pink indicates sufficient flow. A true urine output of 50 mL/hr
indicates catheter patency.

887 A nurse is assigned to a client returning from the postanesthesia care unit following transurethral prostatectomy. The nurse avoids doing which of the
following after this procedure? Reporting signs of confusion Administering a belladonna and opium (B&O) suppository at room temperature
Removing the traction tape on the three-way catheter Monitoring hourly urine output C The nurse would avoid removing the traction
tape applied by the surgeon in the operating room. The purpose of this tape is to place pressure on the prostate and reduce hemorrhage. B&O suppositories,
ordered on a PRN basis for bladder spasm, should be warmed to room temperature before administration. The nurse routinely monitors hourly urine output
since the client has a three-way bladder irrigation running. The nurse also assesses for confusion, which could result from hyponatermia secondary to the
hypotonic irrigant used during the surgical procedure.

888 A nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud’s disease. The nurse assesses for the symptoms
associated with Raynaud’s disease by: Observing for softening of the nails or nail beds Palpating for diminished or absent peripheral pulses
Checking for a rash on the digits Palpating for rapid or irregular peripheral pulse B Raynaud’s disease produces closure of the
small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for
interruption of circulation. The nails grow slowly, become brittle or deformed and heal poorly around the nail beds when infected. Skin changes include hair
loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. Although palpation of peripheral pulses is correct, a rapid or irregular pulse
would not be noted. Peripheral pulses may be normal, absent, or diminished.

889 A client is admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following blood gas results would the
nurse most likely expect to note? Po2 of 68 and Pco2 of 40 Po2 of 55 and Pco2 of 40 Po2 of 70 and Pco2 of 50 Po2 of 60 and Pco2 of
50 D During an acute exacerbation, the arterial blood gases deteriorate with a decreasing Po2 and an increasing Pco2. In early stages of COPD,
arterial blood gases demonstrate mild to moderate hypoxemia with the Po2 in the high 60s to high 70s and a normal arterial Pco2. As the condition advances,
hypoxemia increases and hypercapnia may result.

890 A nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of
the following assessment findings would indicate a deterioration in ventilation? Cyanosis Rapid, shallow respirations Hyperinflated chest
Coarse crackles bilaterally B An increase in the rate of respirations and a decrease in the depth of respirations indicates a
deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present with some clients but not all
clients. A hyperinflated chest (barrel-chest) and hypertrophy of the accessory muscles of the upper chest and neck may normally be found in clients with severe
COPD. During an exacerbation, coarse crackles are expected to be heard bilateral throughout the lungs but do not indicate deterioration in ventilation.

891 A magnetic resonance imaging (MRI) is prescribed for a client with Bell’s palsy. Which nursing action is included in the client’s plan of care to
prepare for this test? Keep the client NPO for 6 hours before the test Remove all metal-containing objects from the client Shave the groin for
insertion of a femoral catheter Instruct the client in inhalation techniques for the administration of gas B In an MRI, radio frequency pulse in
a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, watches, etc, should be removed. In addition, a history should
be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, sharpnel, etc. For an abdominal MRI, the
client is usually NPO. NPO status is not necessary for an MRI of the head. The groin may be shaved for an angiogram. Inhalation of gas is not a component of
an MRI.

892 A nurse is assisting a physician with the insertion of a Miller-Abbott tube. The nurse understands that the procedure puts the client at risk for
aspiration. The nurse implements which action to decrease the risk of aspiration? Inserting the tube with the balloon inflated Instructing the client to
cough when the tube reaches the nasal pharynx Placing the client in a high-Fowler’s position Instructing the client to perform a Valsalva
maneuver if the impulse to gag and vomit occurs C The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine, as in
correcting a bowel obstruction. Initial insertion of the tube is a physician responsibility. The tube is inserted with the balloon deflated in a manner similar to the
proper procedure for inserting a nasogastric tube. The client is usually given water to drink to facilitate passage of the tube through the nasopharynx and
esophagus. A high-Fowler's position decrease the risk of aspiration if vomiting occurs.

893 A nurse is assisting a home health care client in managing cancer pain. To ensure that the client has adequate and safe pain control, the planning
strategy would include: Trying multiple medication modalities for pain relief to get maximum pain relief effect Starting with low doses of
medication and gradually increasing to a dose that relieves pain, not exceeding the maximum daily dose Relying totally on prescription and over-the-
counter medications to relive pain Keeping a baseline level of pain so that the client does not get sedated or addicted B Safe pain
control includes starting with low doses and working up to a dose of medication that relieves the pain. Interventions with multiple medication modalities can be
unsafe and ineffective. Option C does not take into account other nursing interventions that may relieve pain, such as massage, therapeutic touch, or music.
Maintaining a baseline level of pain to avoid sedation or addiction is not appropriate practice, unless the client requests this, and this information has not been
provided in the case situation.
894 A client remains in atrial fibrillation with rapid ventricular response, despite pharmacological intervention. Synchronous cardioversion is scheduled
to convert the rapid rhythm. Which of the following is the most important nursing action to ensure safety and prevent complications of this procedure?
Sedate the client before cardioversion Ensure that emergency equipment is available Ensure that the defibrillator is set on the
synchronous mode Cardiovert at 360 joules C Cardioversion is similar to defibrillation with two major exceptions. The countershock is
synchronized to occur during ventricular depolarization (QRS complex ), and less energy is used for the countershock. The rationale for delivering the shock
during the QRS complex is to prevent the shock from being delivered during repolarization (T wave), often called the vulnerable period. If the shock is
delivered during this period, the resulting complication is ventricular fibrillation. It is crucial that the defibrillator be set on the synchronous mode for successful
cardioversion. Options A and B will not prevent complications. Cardioversion usually begins with 50 to 100 joules.

895 A nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse addresses which most important measure to ensure
client safety? Assessing pain Avoiding over-the-counter medications Administering vasodilatiors Moving slowing from a sitting to a
standing D Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in ortostatics
may lead to falls. Vasodilators are not normally prescribed for the client with cardiomyopathy. Options A and B, although important, are not directly to the issue
of safety.

896 A nurse instructs a client with a diagnosis of valvular disease to use an electric razor for shaving. The nurse tells the client that the important of its
use is that: Any cut may cause infection Electric razors can be disinfected All straight razors contain bacteria Cuts need to be avoided D
Anticoagulants are prescribed for clients with valvular disease to prevent thrombus formation and possible stroke. The importance of using an
electric razor is to prevent cuts and possible bleeding. Options A, B, and C are all unrelated to the issue of bleeding.

897 A nurse is caring for a client during the recovery phase following a myocardial infarction. A cardiac catheterization, using the femoral artery
approach, is performed to assess the degree of coronary artery thrombosis. Which nursing action following the procedure is unsafe for the client? Placing the
client’s bed in the Fowler’s position Encouraging the client to increase fluid intake Instructing the client to move the toes when checking
circulation, motion, and sensation Resuming prescribed precatheterization medications A Immediately following a cardiac catheterization
with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. Placing client in the
Fowler’s position (flexion) increases the risk of occlusion or hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body.
Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. The precatheterization
medications are needed to treat acute and chronic conditions.

898 A multidisciplinary health care team is planning care for a client with hyperparathyroidism. The health care team develops which most important
outcome for the client? Describes the administration of aluminum hydroxide gel Restricts fluids to 1000 mL per day Walks down
the hall for 15 minutes, three times per day Describes the use of loperamide (Imodium) C Mobility of the client with hyperparathyroidism should be
encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids
should not be restricted. Discussing the use of these medications is not the priority in this client.

899 A client being seen in the emergency department with complaints of abdominal pain has a diagnosis of acute abdomen and the cause has not been
determined. The nurse would question an order for which of the following at this time? Insertion of a nasogastric tube Insertion of an intravenous (IV) line
Administration of a narcotic analgesic Institution of an NPO diet status C Until the cause of the acute abdomen is determined and a
decision about the need for surgery is made, the nurse would question an order to give a narcotic analgesic because it could mask the client’s symptoms. The
nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of a nasogastric tube may be helpful to provide decompression
of the stomach.

900 A nurse has been assigned to care for a young man recovering at home from a disabling lung infection. While obtaining a nursing history, the nurse
learns that the infection is probably the result of human immunodeficiency virus (HIV). The nurse informs the client that he /she is morally opposed to
homosexuality and cannot care for him. The nurse them leaves the client’s home. Which of the following is true regarding the nurse’s action? The nurse has
a duty to protect self from client care situations that are morally repellent The nurse has a legal right to inform the client of any barriers to providing care
The nurse has the right to refuse to care for any client without justifying that refusal The nurse has a duty to provide competent care to assigned
clients in a nondiscriminatory manner D The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy
does not apply if it interferes with the rights of the client. There is no legal obligation to inform the client of the nurse’s personal objections to the client.
Refusal to provide care may be acceptable if that refusal does not put the client’s safety at risk, and the refusal is primarily associated with religious objections,
not personal objection to lifestyle or medical diagnosis. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing or allowing
harm to befall the client).

901 A client recovering from cardiogenic shock occasionally becomes disoriented. The most appropriate nursing action to ensure safety for this client
would be to: Raise the head of the bed to 45 degrees Keep the side rails up at all times and the call light within reach Keep the over–the–bed
light on in the client’s room Request that only two visitors visit at a time B Keeping the side rails up prevents the disoriented client from
accidentally falling out of bed. Providing the call light to the client provides access to the health care team when assistance is needed. Raising the head of the
bed will not ensure safety. Keeping the over–the–bed light on may be disruptive. Limiting visitors will not ensure safety.

902 A client with subarachnoid hemorrhage has been placed on subarachnoid (aneurysm) precautions. The nurse ensures that the client is provided with
which of the following? Daily stool softeners Bright lights Television Radio Enemas as needed A Subarachnoid
(aneurysm) precautions include a variety of measures designed to decrease stimuli that could increase the client’s intracranial pressure. These include
instituting dim lighting and reducing environmental noise and stimuli. Enemas should be avoided, but stool softeners should be provided. Straining at stool is
contraindicated because it increases intracranial pressure. Suction equipment and oxygen should be available at the bedside.
903 A nurse is caring for a client immediately following a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the
procedure. In order to provide a safe environment for the client at this time, the nurse plans to: Place a padded tongue blade at the bedside in case of a
seizure Check the bedside to ensure no food or fluid is within the client’s reach to prevent aspiration Connect the client to a bedside ECG to monitor
for dysrhythmias Place a water seal chest drainage set at the bedside in case of pneumothorax B Following this procedure, the client remains
NPO until the cough and swallow reflexes have returned, which is usually in 1 to 2 hours. Once the client can swallow, oral intake may begin with ice chips
and small sips of water. There are data in the question that suggest the client is at risk for a seizure. Even though the client is monitored for signs of any
distress, seizures, would not be anticipated and therefore padded tongue blade would not be placed at the bedside routinely. A pneumothorax could possibly
occur, and the nurse should bear this in mind when monitoring the client for signs of distress. However, a water-seal chest drainage set would not be placed
routinely at the bedside. No data are given to support that the client is at increased risk of cardiac dysrhythmias.

904 A client with a history of silicosis is admitted with respiratory distress and impending respiratory failure. The nurse plans to have which of the
following items readily available to the client’s bedside? Chest tube and drainage system Intubation tray Thoracentesis tray Code cart B
The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures an intubation tray is readily
available. The other items are not needed at the client’s bedside

905 A nurse is preparing to care for a client who has undergone left pneumonectomy. The nurse plans to do which of the following immediately after
transfer from post-anesthesia care unit? Place the IV on a pump Assist the client to sit in the bedside chair Position the client supine
Position the client on the left side A Following pneumonectomy, the fluid status of the client is closely monitored to prevent fluid overload,
since the size of the pulmonary vascular bed has been reduced as a result of the pneumonectomy. Complete lateral turning and positioning is avoided. The
head of bed should be elevated to promote lung expansion. The client should remain on bed rest in the immediate postoperative period.

906 A client being seen in the emergency room is being evaluated for possible pleurisy. A nurse is preparing the client for a chest x-ray examination.
The nurse plans to: Ask the client to remove a neck chain being worn Ask the client about the time of last food intake. Scrub the chest with
betadine Determine whether the client has any metallic implants A If a chest x-ray examination is prescribed, jewelry or metallic objects that might
obstruct the x-ray need to be removed. The client does not need to have food or fluid restricted before a chest x-ray procedure, and skin preparation is not
required. Notation of metallic implants is required before magnetic resonance imaging (MIR), but a MRI is not used to diagnose pleurisy.

907 A nurse is planning to obtain an arterial blood gas (ABG) from a client with chronic obstructive pulmonary disease (COPD). The nurse plans time
for which activity after the arterial blood is drawn? Holding a warm compress over the puncture site for 5 minutes Applying pressure to the puncture
site by applying 2 x 2 gauze for 5 minutes Encouraging the client to open and close the hand rapidly for 2 minutes Having the client keep the radial
pulse puncture site in a dependent position for 5 minutes B Applying pressure over the puncture sites reduces the risk of hemotoma
formation and damage to the artery. A cold compress would aid in limiting the blood flow. Keeping the extremity and out of a dependent position will aid in
the formation of a clot at the puncture site.

908 A nurse is admitting a client to the nursing unit who has an arteriovenous (AV) fistula in the right arm for hemodialysis. The nurse would best plan
to prevent injury to the site by: Putting a large note about the access site on the front of the medical record Applying an allergy bracelet to the right arm,
indicating the presence of the fistula Placing a sign in the bedside: No blood pressure (BP) measurements or venipunctures in the right arm
Telling the client to inform all caregivers who enter the room abut the presence of the access site C There should be no venipunctures or
blood pressure measurements in the limb with a hemodialysis access device. This is commonly communicated to all caregivers by placing a sign at the client’s
bedside. Placing a note on the front of medical record does not ensure that everyone caring for the client will be aware of the access device. An allergy bracelet
is placed on the client with an allergy. The client should not be responsible for informing the caregivers.

909 Regular insulin by continues intravenous (IV) infusion is prescribed for client with a blood glucose level of 700 mg/dL. The nurse plans to:
Infuse the medication via an electronic infusion pump Mix the solution in 5% dextrose Change the solution every 6 hours Titrate the
infusion according to the client’s urine glucose levels. A Insulin is administered via an infusion pump to prevent inadvertent overdose and subsequent
hypoglycemia. Dextrose is added to the IV line once the serum glucose level reaches 250 mg/dL to prevent the occurrence of hypoglycemia. Administering
dextrose to the client with a serum glucose level of 700 mg/dL would counteract the beneficial effects of insulin in reducing the glucose level. Glycosuria is not
a reliable indicator of actual serum glucose levels because there are many factors that affect the renal threshold for glucose loss in the urine. There is no reason
to change the solution every 6 hours.

910 A nurse is developing a care for a client with a diabetic ketoaidosis (DKA). The nurse most appropriately includes which intervention in the plan?
Maintain side rails in the upright position Ambulate the client every 2 hours Assess for fluid overload Limit family visitation
A The client with DKA may experience a decrease in the level of consciousness (LOC) secondary to acidosis. Safety becomes a priority
for any client with decreased LOC, thus requiring the use of side rails to prevent fall injuries. The client may be too ill to ambulate and will experience fluid
loss (dehydration) rather than overload. Family visitation is helpful for both the client and the family to assist with psychosocial adaptation.

911 A well-known individual from the community is admitted to the hospital with a diagnosis of Parkinson’s disease. The nurse gives medical
information regarding the clients condition to a person assumed to be a family member. Later, the nurse discovers that this person is not a family member and
realizes that this is a violation of which legal concept of the nurse-client relationship? Invasion of privacy Lack of experience Teaching/ learning
principles Performing a focused physical assessment A Discussing a client’s condition without client permission violates a client’s rights and places
the nurse in legal jeopardy. This action by the nurse is both an invasion of privacy and affects the confidentiality issue with client rights. Options B, C and D
do not represent violation of the situation presented.

912 A clinic is assessing a client for environment risk factors related to neurological disorders. The nurse understands that which of the following is
least likely associated with neurological disorders? Exposure to fumes, such as paints or bonding agents (glue) Exposure to pesticides
Ventilation in the work area Number of windows in the work area D The nurse would assess for the risk of exposure to
neurotoxic fumes and chemicals. These could include paint, bonding agents, pesticides and many more. The nurse also inquires about the adequacy of
ventilation in the home, and work area. There are many work spaces (such as factories, insurance companies, and operating rooms) which are adequately
ventilated without the use of windows.

913 A nurse has an order to test a client’s stools using hemmocult slides. The nurse would question the order if the client was taking which of the
following medication that could cause false negative results? Ascorbic acid Colchicines Iodine Acetylsalicylic acid A
Ascorbic acid can interfere with the result of occult blood testing, causing false negative findings. Colchicine and iodine can cause false-positive
results. Acetylsalicylic acid would either have no effect on results or could cause a positive result, since aspirin is irritating to the stomach lining.

914 A nurse is assessing a client who has just been measured and fitted for crutches. The nurse determine that the client’s crutches are fitted correctly if:
The elbow is at a 30-degree angle when the hand is on the handgrip The elbow is straight when the hand is on the handgrip The client’s
axilla is resting on the crutch pad during ambulation The top of the crutch is even with the axilla A For optimal upper extremity leverage, the
elbow should be approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two or three fingers widths
lower than the axilla. When crutch walking, all weights needs to be on the hands to prevent nerve palsy from pressure on the axilla.

915 A nurse is assigned to care for a client who is in traction. The nurse prepared a plan of care for the client and includes which of the following
nursing action plan? Monitor the weights to be sure that they are resting on a firm surface Check the weights to be sure that they are off the floor
Make sure that the knots are at the pulleys Make sure that the head of the bed is kept elevated at 45 to 90 degree angle B To achieve
proper traction weights need to be free-hanging with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the
bed is usually kept low provide countertraction.
916 A client who has experienced a cerebrovascular accident has partial hemiplegia of the left leg. The straight leg cane formerly used by the client is
not sufficient to provide support. The nurse interpret that the client could benefit from the somewhat greater support and stability provided by a: Quad-cane
Wooden crutch Lofstrand crutch Wheelchair A A quad-cane may be prescribe for the client requiring greater support
and stability than is provided by a straight leg cane. The quad-cane provides a four-point base of support and is indicated for use by clients with partial or
complete hemiplegia. Neither crutches nor a wheelchair are indicated for use with client such as described in this question. A Lofstrand crutch is useful for
clients with bilateral weakness.

917 A client begins to drain small amounts of bright red blood form the tracheostomy tube 24 hours after supraglottic laryngectomy. The best nursing
action is to: Notify the surgeon Increase the frequency of suctioning Add moisture to the oxygen delivery system Document the character
and amount of drainage A Immediately following laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves
within the first few hours. Otherwise, bleeding that is brought red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a
potential life threat and the surgeon is notified to further evaluate the client and suture or repair the bleed. The other options do not address the urgency of the
problem. Failure to notify the surgeon places the client at risk.

918 A client has an order for a stool culture. The nurse avoids doing which of the following when carrying out this order? Wearing sterile gloves
Using a sterile container Refrigerating the specimen Sending the specimen directly to the laboratory C Storing a
stool specimen is a refrigerator in contraindicated because it can retard the growth of organism. A stool specimen is obtained using sterile gloves and sterile
container. After obtaining the specimen, the stool is sent immediately to the laboratory

919 A client is being transferred to the nursing unit from the post-anesthesia care unit following spinal fusion with Harrington rod insertion. The nurse
prepares to transfer the client from the stretcher to the bed by using: A bath blanket and the assistance of 3 people A bath blanket and the
assistance of 4 people A slider board and the assistance of 2 people A slider board with assistance of 4 people D Following spinal fusion, with or
without instrumentation, the client is transferred from the stretcher to the bed using slider board and assistance of 4 people. This permits optimal stabilization
and support the spine, while allowing the client to move smoothly and gently.
920 A nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome (AIDS) who has had blood-tinged sputum with
previous suctioning. The nurse plans to use which of the following items as part of the universal precautions for this client? Gloves, mask, and
protective eye wear Gloves, gown and mask Gown, mask, and protective eye wear Gloves, gown and protective eye wear. A
Universal precautions include the use of gloves whenever there is actual or potential contact with the blood or body fluids. During procedures that
aerosolize blood, the nurse wears a mask and a protective eyewear, or a face shield. Impervious gowns are worn in those instances when it is anticipated that
there will be contact with a large amount of blood.

921 A nurse is preparing to administer oxygen to client with carbon dioxide narcosis who has a history of chronic airflow limitation(CAL). The nurse
checks to see that the oxygen flow rate is prescribed at: 2 to 3 L/min 4 to 5 L/min 6 to 8 L/min 8 to 10 L/min A
The nurse administers oxygen to the client with carbon dioxide narcosis and CAL very cautiously. This is because the client’s respiratory center is
insensitive to carbon dioxide levels as the respiratory stimulant. If oxygen is given freely, the client loses the respiratory drive and respiratory failure results.
Thus, the nurse checks the flow of oxygen to see that it does not exceed to 3 L/min.

922 A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client’s bedside on arrival from the operating
room? An apnea monitor A blood transfusion warmer A suction unit and oxygen An ampule of phytonadione (Vitamin K) C
Following thyroidectomy, respiratory distress can occur either from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and
suction equipment readily available and in working order if such an emergency were to rise. Apnea is not a problem associated with thyroidectomy, unless the
client experienced respiratory arrest. Blood transfusions can be administered without a warmer if necessary. Vitamin K would not be administered for a client
who is hemorrhaging, unless deficiencies is clotting factors warrant its administration.

923 A nurse places a hospitalized client with active tuberculosis in a private, well-ventilated room. In addition, which of the following actions is of
critical actions is most appropriate for the nurse to do before entering to the client’s room? Wash the hands. Wash the hands and place a HEPA
respirator over the nose and mouth. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose when
coughing or sneezing Wash the hands and wear a gown and gloves B The nurse wears a HEPA respirator when caring for the client with active
tuberculoses. Hands are always thoroughly wash before and after caring for the client. Option A is an incomplete action. Option C is an incorrect statement.
Option D is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing.
924 A client is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, the nurse plans to have which of the
following items available at the bedside? Chest tube and drainage system Intubation tray Portable chest x-ray machine Morphine sulfate
injection. A Complications following pleural biopsy include hemothroax, pneumothorax, and temporary pain form intercostal nerve injury. The nurse
has a chest tube and drainage system available at the bedside for use of hemothrax or pneumothorax develops. An intubation tray is not indicated. The client
should be premedicated before the procedure, or local anesthetic is used. A portable chest x-ray machine would be called for to verify placement of a chest tube
if one was inserted, but it is unnecessary to have at the bedside before the procedure.

925 A nurse preparing to begin hemodialysis on a client with renal failure. Which measures would the nurse avoid during this procedure? Putting on the
mask and giving one to the client to wear during connection to the medicine Wearing full protective clothing such as goggles, mask, apron, and gloves.
Covering the connection site with a bath blanket to enhance extremity warmth. Using sterile technique for needle insertion. C
Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both the nurse
and client are extremely important. It is also imperative that universal precautions be followed, which includes the use of goggles, mask, gloves, and an apron.
The connection site should not be covered and it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the
hemodialysis procedure.

926 A nurse is going to suction an adult client with tracheostomy, who has copious amounts of secretions. The nurse does which of the following to
perform this procedure safely? Hyperoxygenate the client using a manual resuscitation bag Set the suction pressure range between 160 to 180 mm Hg
Occlude the Y-port of the catheter while advancing it into tracheostomy Apply continuous suction in the airway for up to 15 seconds. A
To perform suctioning, the nurse hyper oxygenates the client using a manual resuscitation bag, or the sigh mechanism if the client is on mechanical
ventilator. The safe suction range for an adult is 100 to 120 mm Hg. The nurse advances the catheter into the tracheostomy without occluding the Y-port;
suction is never applied introducing the catheter because it would traumatize mucosa and remove oxygen from the respiratory tract. The nurse uses intermittent
suction in the airway for up to 10 to 15 seconds.

927 A post-myocardial infarction client is scheduled for multigated acquisition (MUGA) scan. The nurse ensures that which item is in place before the
procedure?Signed informed consent Notation of allergies to iodine or shellfish A central venous pressure (CVP) line. A Foley catheter A
MUGA is a radionuclide study used to detect myocardial infarction, decreased myocardial blood flow, and left ventricular function. A radioisotope
is injected intravenously. Therefore, a sign informed consent is necessary. The procedure doesn’t use radiopaque dye. Therefore, allergies to iodine and
shellfish is not a concern. A Foley catheter and CVP line are not required.
928 A nurse is developing a nursing care plan for a client with severe Alzheimer’s disease. The nurse identifies which nursing diagnosis as the priority?
Impaired communication Disturbance in role performance High risk for injury Social isolation C Clients who have
Alzheimer’s disease have cognitive impairment and are therefore at high risk for injury. It is critical for the nurse to maintain safe environment particularly at
the client’s judgment becomes increasingly impaired. Options A,B and D may be appropriate but the highest priority is directed toward safety.

929 A client is being admitted to the hospital after receiving a radium implant for bladder cancer. The nurse takes which of the following priority actions
in the care of this client? Encourages the client to take frequent rest periods. Admits the client to a private room Encourages the family to
visit Places the client on reverse isolation. B The client who has a radiation implant should be placed in the private room, and has limited
visitors. This reduces the exposure of others to the radiation. Frequent rest periods are a helpful general intervention, but is not a priority for the client in this
situation. Reverse isolation is unnecessary.

930 A client is to undergo a weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. The nurse interprets that the client understands
how to manage the urine as a biohazard if the client states: Disinfect the urine and toilet with bleach for 6 hours following a treatment Have one
bathroom strictly set aside for the client’s used for the next 2 months. Purchase extra bottles of scented disinfectant for daily bathroom cleansing
Void into a bedpan and then empty the urine into toilet A After intravesical chemotherapy, the client treats the urine as a biohazard. This
involves disinfecting the urine and the toilet with household bleach for 6 hours following a treatment. Scented disinfectants are of no particular use. The client
does not need to have a separate bathroom for personal use. There is no value in using a bedpan for voiding.

931 A nurse is preparing the bedside for postoperative parathyroidectomy client. The nurse ensures that which piece of medical equipment is at the
client’s bedside? Underwater seal chest drainage Tracheotomy set Intermittent gastric suction Cardiac monitor B Respiratory
distress resulting from hemorrhage and swelling and compression of the trachea is a paramount concern for the nurse managing the care for of a postoperative
parathyroidectomy client. An emergency tracheotomy set is always routinely placed at the bedside of the client with this type of surgery, in anticipation of this
potential complication. Options A, C, and D are not specifically needed with the surgical procedure.
932 A nurse has an order to administer foscarnet (Foscavir) intravenously to a client with acquired immunodeficiency syndrome (AIDS). Before
administering this medication, the nurse plans to; Place the solution on a controlled infusion pump Obtain folic acid as an antidote Ensure that
liver enzyme levels have been drawn as a baseline Obtain a sputum culture. A Foscarnet is an antiviral agent used to treat
cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled
infusion device. It is very toxic to the kidneys, and serum creatinine levels are measured frequently during therapy. Folic acid is not an antidote to the
medication. A sputum culture is not necessary.

933 A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. The nurse develops a plan of care for
the client and includes which of the following? Providing the client with short, frequent walks Measuring the client’s pulse each shift
Eliminating sources of caffeine from meal trays Limiting oral and intravenous fluids. C Sinus tachycardia is often caused by
fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Exercise and fluid restriction will not
alleviate tachycardia. Option B will not decrease the heart rate. Additionally the pulse should be taken more frequently than each shift

934 A nurse has given a subcutaneous injection to a client with Acquired Immunodeficiency Syndrome (AIDS). The nurse disposes the used needle and
syringe by:Placing the uncapped needle and syringe in a labeled, rigid plastic container Recapping the needle and discarding the syringe in the disposal unit
Breaking the needle before discarding it Placing the uncapped needle and syringe in a labeled cardboard box. A Universal
precautions include specific guidelines for handling of needles. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a
labeled impermeable container specific for this purpose. Needles should not be discarded in cardboard boxes, because they are not impervious. Needles
should never be left lying around after use.

935 A nurse is planning care for a client with acute glomerunephritis. The nurse instructs the nursing assistant to do which of the following in the care
of the client? Monitor the temperature every two hours Remove the water pitcher from the bedside Ambulate the client frequently Encourage a
diet that is high in protein B A client with acute gloemerulonephritis commonly experiences fluid volume excess and fatigue. Interventions
include fluid restriction, as well as monitoring weight and intake and output. The client may be placed on bed rest, or at least encouraged to rest. This is
because there is direct correlation between proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is
unnecessary to monitor the temperature as frequently as every two hours.
936 A nurse is caring for a client with C6 spinal cord injury during the spinal shock phase. The nurse implements which of the following when preparing
the client to sit in a chair. Teach the client to lock the knees during the pivoting stage of the transfer Administer a vasodilator in order to improve
circulation of the lower limbs Raise the head of the bed slowly to decrease orthostatic hypotensive episodes Apply knee splints to stabilize the joints during
transfer C Spinal shock is often accompanied by vasodilatation of the lower limbs, which results in a fall in blood pressure on rising. The client can
have dizziness and feel faint. The nurse should provide for a gradual progression in a head elevation while monitoring the blood pressure. A vasodilator would
exacerbate the problem. Clients with cervical cord injuries cannot lock their knees, and use of splints would impair the transfer.

937 A nurse observing a second nurse who is performing hemodialysis on a client. The second nurse is drinking coffee and eating doughnut next to the
hemodialysis machine, while talking with the client about the events of the client’s week. The first nurse should: Appreciate what a wonderful
therapeutic relationship this nurse and client have. Get a cup of coffee and join the conversationAsk the client if he or she would like a cup of coffee also.
Ask the nurse to refrain from eating and drinking in that area. D A potential complication with hemodialysis is the acquisition of
dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with client and with environment
surfaces), and staff (who may acquire the virus from contact with the client’s blood.). This risk is minimized by the use of universal precautions, appropriate
hand washing and sterilization procedures, and prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. The first nurse should
ask the second nurse to stop and drinking in the work area.

938 A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which of the following preprocedure assessments by the
nurse would be of highest priority? Allergy to iodine or shellfish Ability of the client to remain still during the procedure Whether the client has
any remaining questions about the procedureWhether the client wishes to void before the procedure. A Because of the risk of allergy to contrast to
medium, the nurse places highest priority of assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the
test, tells the client about the need to remain still during the procedure, and encourages the client to void before the procedure for comfort.

939 A client with possible rib fracture has never had chest x-ray examination. The nurse plans to tell the client which of the following about the
procedure?The x-ray stimulates a small amount of pain It is necessary to remove jewelry and any other metal objects The client will be ask to breathe in
and out during the x-ray procedure. The x-ray technologist will stand next to the client during the x-ray procedure B An x-ray film is a
photographic image of a part of the body on a special film, which is used to diagnose a wide variety of conditions. The x-ray itself is painless, and any
discomfort would arise from repositioning a painful part for filming. The nurse may premedicate a client, if prescribed, who is at risk of pain. Any radiopaque
objects such as jewelry or other metal must be removed. The client is ask to breathe in deeply, and then hold the breath while the chest x-ray is taken. To
minimize the risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the
gonads.

940 A nurse is planning discharge teaching for a client with a spinal cord injury. To provide for a safe environment regarding home care, which of the
following would be the priority in the plan of care? What the physician has indicated needs to be taught Follow-up laboratory and diagnostic tests
Assisting the client to deal with long-term care placement Including the significant others in the teaching session. D Involving the
client’s significant others is discharge teaching is a priority in planning for the client with spinal cord injury. The client will need the support of the significant
others. Knowledge and understanding of what to expect will help both the client and significant others deal with client’s limitations. A physician’s order is not
necessary for discharge planning and teaching; this is an independent nursing action. Laboratory and diagnostic testing are not priority discharge instructions
for this client. Long-term placement is not the only option for a client with spinal cord injury

941 A nurse observes a client wringing his hands and looking frightened. The client reports feeling out of control. Which approach by the nurse
approach by the nurse is most appropriate to maintain a safe environment? Administer the ordered PRN anti-anxiety medication immediately Move the
client to a quiet room and talk about his feelings Isolate the client in a time-out room Observe the client in an ongoing manner but do not
intervene B The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet room decreases
environmental stimulus. Talking provides the nurse an opportunity to assess the cause of the client’s feelings and to identify appropriate interventions.
Isolation is appropriate if a client is a danger to self or others. Medication is used only when other noninvasive approaches have been unsuccessful.

942 A client with urolithiasis is schedule for extracorporeal shock wave lithotripsy. The nurse assesses to ensure that which of the following items are in
place or maintained before sending the client for the procedure. Signed informed consent, clear liquid restriction, Foley catheter Signed informed
consent, NPO status, IV line IV line, clear liquid restriction, Foley catheter IV line, NPO status, Foley catheter B
Extracorporeal shock wave lithotripsy is done with the client under epidural or general anesthesia. The client must sign an informed consent for the
procedure and must be NPO for the procedure. The client needs an IV line for the procedure as well. A Foley catheter is not needed.

943 A nurse is assisting at a code and the physician is going to defibrillate the client. Of the following items, which is the only one that the nurse does
not need to remove from the bedside just before the client is defibrillated? Backboard Oxygen Nitroglycerin patch Ventilator A Flammable
materials and metal devices or liquids (that are capable of carrying electricity) are removed from the client and bed before discharging the paddles of the
defibrillator. The nitroglycerin patch has a metallic backing and should be removed.
944 A physician is about to defibrillate a client with ventricular fibrillation, and says in a loud voice “CLEAR” the nurse immediately Shuts of the
infusion going into the client’s arm Shuts off the mechanical ventilator Steps away from the bed and makes sure that all others have done the
same Places the conductive gel pads for defibrillation on the client’s chest C For the safety of all personnel, when the defibrillator
paddles are being discharged, all personnel must stand back and clear of all contact with the client or the client’s bed. It is the primary responsibility of the
person defibrillating to communicate the “clear” message loudly enough for all to hear, and ensure their compliance. All personnel must immediately comply
with this command. The gel pads should have been placed on the client’s chest before the defibrillator paddles were applied. A ventilator is not in use during a
code, rather than an Ambu (resuscitation) beg is used. Shutting off the infusion has no useful purpose. Stepping back from the bed prevents the nurse or others
from being defibrillated along with the client.

945 A client with chronic renal failure has an indwelling catheter in the abdomen for peritoneal dialysis. The client spills water on the dressing while
bathing. The nurse plans to immediately: Reinforce the dressing Change the dressing Flush the peritoneal dialysis catheter Scrub the
catheter with povidone iodine solution B Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a
conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe
practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine solution is done at the
time of connection or disconnection of peritoneal dialysis.

946 A client is scheduled for electivecardioversion to treat chronic high rate atrial fibrillation. The nurse determines that the client is not yet ready for
the procedure after noting that the: Client’s digoxin (Lanoxin) has been withheld for the last 48 hours Client has received a dose of midazolam
intravenously Client is wearing a nasal cannula delivering oxygen at 2 liters per minute Defibrillator has the synchronizer turned on and is set at
50 joules C Digoxin may be withheld for up to 48 hours before cardioversion, because it increase ventricular irritability and may cause ventricular
dysrhythmias post countershock. The client typically receives a dose of an IV sedative or antianxiety agent. The defibrillator is switched to synchronizer mode
to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level is
typically set at 50 to 100 joules. During the procedure, any oxygen is removed temporarily, because oxygen supports combustion. And a fire could result from
electrical arcing

947 A nurse is assisting in the care of a client who is to be cardioverted. The nurse plans to set the defibrillator to which of the following starting energy
range levels, depending on the specific physician order?50 to 100 joules 150 to 200 joules 250 to 300 joules 350 to 400 joules A
When a client is cardioverted, the defibrillator is charged to the energy level ordered by the physician. Cardio version is usually started at 50 to 100
joules. Option B, C and D are incorrect.
948 A nurse has an order to get the client out of bed to a chair on the first postoperative day following total knee replacement (TKR). The nurse plans to
do which of the following to protect the knee joint? Apply a knee immobilizer before getting the client up, and elevate the client’s surgical length while
sitting Apply a compression dressing, and put ice on the knee while sitting. Lift the client to the bedside chair leaving the continuous passive
motion (CPM) machine in place Obtain a walker to minimize weight bearing by the client on the affected leg. A The nurse assists the client to get
out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The surgeon orders the weight-bearing limits
on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema. Ice is not used unless prescribed. A compression dressing
should already be in place on the wound. A CPM machine is used only while the client is in bed. Ambulation is not started until the second postoperative day.

949 A nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillation has
interpreted the rhythm to be ventricular fibrillation. The nurse should: Orders any personnel away from the client, charges the machine and defibrillates
through the console Performs cardiopulmonary resuscitations (CPR) for one minute before defibrillating Charges the medicine and immediately pushes
the discharge buttons on the console Administer rescue breathing during the defibrillation. A If the AED advices to defibrillate, the nurse
or rescuer orders all persons away from the client, charges the capacitor, and pushes both of the discharge buttons on the console at the same time. The charge
is delivered through the patch electrodes, and this method is known as “hands off” defibrillation, which is safer for the rescuer. The sequence of charges (up to
three consecutive attempt at 200, 300, 360 joules) is similar to that of conventional defibrillation. Option D is contraindicated for the safety of any rescuer.
Performing CPR delays the defibrillation attempt.

950 A nurse is planning care for a client diagnosed with deep vein thrombosis (DVT) of the left leg. Which intervention would the nurse avoid in the
care of this client? Application of moist heat to the leg Administration of acetaminophen (Tylenol) Elevation of the leg Ambulation in the hall
once per shift D Standard management of the client with deep vein thrombosis includes bed rest for 5 to 7 days; limb elevation, relief of
discomfort with warm moist heat and analgesics as needed; anticoagulant therapy; and monitoring for the signs of pulmonary embolism. Ambulation is
contraindicated because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism.

951 A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. The nurse plans to
teach the client that it is important to: Drive at times when the client does not feel dizzy Go to the bedroom and lie down when vertigo is
experienced Remove throw rugs and clutter in the home Turn the head slowly when spoken to C The client with chronic vertigo
should avoid driving and using public transportation. The sudden movements involve in each could precipitate an attack. To further prevent vertigo attacks,
the client should change position slowly, and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should
immediately sit down or grasp the nearest piece of furniture. The client should maintain the home in a state that is free of clutter and have throw rugs removed,
since the effort of trying to regain balance after slipping could trigger the onset vertigo.

952 A client who is immunosuppressed is being admitted to the hospital and will be placed on neutropenic precautions. The nurse plans to ensure that
which of the following does not occur in the care of the client? Placing a mask on the client if the client leaves the room Removing a vase with
fresh flowers left by a previous client Admitting the client to a semi - private room Placing a precaution sign on the door to the room C
The client who is on neutropenic precautions is immunosuppressed, and is admitted to a single ( private ) room on the nursing unit. A precaution
sign should be placed on the door to the client's room. Removal of standing water and fresh flowers is done to decrease the microorganism count. The client
should wear a mask whenever leaving the room to be protected from exposure to microorganisms.

953 A client who received a dose of chemotherapy 12 hours ago is incontinent of urine while in bed. The nurse wears which of the following when
cleaning the client? Mask and gloves Gown and gloves Mask,gown and gloves Gown, gloves and eyewear B The client
who has received chemotheraphy within the previous 48 hours will have an antineoplastic agents or their metabolities in body fluids and excreta. For this
reason, the nurse should wear protection for likely sources of contamination. In caring for the incontinent client, the nurse should wear gloves and a gown, to
protect the hands and uniform from contamination.

954 A nurse receives a call that a client is being admitted who will undergo implantation of a sealed internal radiation source. The nurse contacts the
admission office clerk to ensure that which of the following rooms is selected for the client? A single room at the distant end of the hall. A single
room near the nurse's station A semiprivate room between two isolation rooms A semiprivate room near the nurse's station A The client
receiving an implantation of a sealed internal radiation source should be placed in a single room in an area that reduces the risk of exposure to others. For this
reason, rooms are often used that are at the end of the hall.

955 A nurse is assessing the corneal reflex on an unconscious client. The nurse would use which of the following as the safest stimulus to touch the
client's cornea? Wisp of cotton Sterile drop of saline solution Sterile glove Tip of a 1-mL syringe with the needle removed B
The client who is unconscious is at great risk for corneal abrasion. For this reason, the safest way to test the corneal reflex is by using a drop of
sterile saline. Use of the items in options A,C,and D can cause injury to the cornea.
956 A nurse is caring for a client who has an order for dextroamphetamine (Dexedrine) 25 mg PO daily. The nurse collaborates with the dietician to
limit the amount of which of the following items on the client’s dietary trays? Starch Caffeine Protein Fat B Dextroamphetamine is a
central nervous system (CNS) stimulant. Caffeine is a stimulant also, and should be limited in the client taking this medication. The client should be taught to
limit their caffeine intake as well. Option A, C, and D are acceptable dietary items.

957 A nurse is planning preoperative care of a client scheduled for insertion of an inferior vena cava (IVC) filter. The nurse questions the physician about
withholding which regularly scheduled medication on the day before surgery? Furosemide (Lasix) Potassium Chloride (K-Dur) Docusate (Colace)
Warfarin sodium (Coumadin) D In the preoperative period, the nurse consults with the physician about discontinuing warfarin sodium to
avoid the occurrence of hemorrhage. Furosemide is a diuretic, potassium chloride is a supplement, and docusate is a stool softener.

958 A hospitalized patient with hypertension has been started on captopril (Capoten). The nurse ensures that the client does which of the following
specific to this medication? Eats foods that are high in potassium Takes in sufficient amounts of high fiber foods Moves from a sitting to a
standing position slowly Drinks plenty of water C Orthostatic hypotension is a concern for client taking antihypertensive
medications. Clients are advised to avoid standing in one position for lengthy amounts of time, to change position slowly, and avoid extreme warmth (showers,
bath,weather). Clients are also taught to recognize the symptoms of orthostatic hypotension, including dizziness, lightheadedness, weakness and syncope.
Options A, B and D are not specific to this medication.

959 The physician’s order reads heparin sodium 25,000 units in 250 mL 5% dextrose in water to run continuously at a rate of 800 units per hour by IV.
The nurse sets the intravenous pump how many mL per hour? 8 32 40 80 A Use the formula for calculating
milliliters per hour with the use of an infusion pump. Desired: 800 units/hour, Available:25,000 units/250 mL 5% dextrose in water. First divide the 25,000
units by the 250 mL to yield a concentration of 100 units per mL. Next, 800 units/hour is divided by 100 units/mL. The nurse would set the pump at 8 mL per
hour.
960 A client receiving lisinopril (Prinivil) has a white blood cell (WBC) count of 3800/mm3. The nurse plans to do which of the following in the care of
this client? Follow aseptic technique diligently Request prophylactic antibiotics from the physician Place the client on respiratory isolation
Use antibacterial soap when bathing the client A The client taking angiotensin-converting enzymes (ACE) inhibitors, such as
lisinopril, is at risk of developing neutropenia. These clients require the use of strict aseptic technique by all who care for the client. The client should also be
taught to report signs and symptoms of infection, such as sore throat and fever to the physician. The WBC count with differential may be monitored monthly
for up to 6 months in clients deemed at risk

961 A nurse is caring for a client with cervical cancer who has an internal radiation implant. Which of the following items would the nurse ensure is kept
in the client’s room during this treatment? A bedside commode A lead apron Long-handled forceps and a lead container A number 16 Foley
catheter C In the case of dislodgment of an internal radiation implant, the radioactive source is never touched with the bare hands. It is retrieved
with long-handled forceps and placed in the lead container kept in the client’s room. In many situations, the client has a Foley catheter inserted and is on bed
rest during treatment to prevent dislodgment. A lead apron, although one may be in the room, is not required item. Nurses wear a dosimeter badge while in the
client’s room to measure the exposure to radiation.

962 A 24-year-old female with a familial history of heart disease presents to the physician’s office asking to begin oral contraceptive therapy for birth
control. The nurse would next inquire whether the client: Has taken oral contraceptives before Exercises regularly Eats low cholesterol diet
Is currently a smoker D Oral contraceptive use is a risk factor for heart disease, particularly when it is combined with cigarette smoking.
Regular exercise and keeping total cholesterol levels under 200 mg/dL are general measures to decrease cardiovascular risk.

963 A charge nurse is supervising a new registered nurse (RN) providing care to a client with end-stage heart failure. The client is withdrawn, reluctant
to talk, and show little interest in participating in hygienic care or activities. Which statement if made by the new RN needs further teaching in the use of
therapeutic communication techniques? "Many client with end-stage heart failure fear death." "Why don’t you feel like getting up for your bath?"
"What are your feelings right now?" "These dreams you mentioned what are they like?" B When the nurse asks a “why”
questions of the client, the nurse is requesting an explanation for feeling and behaviors when the client may not know the reason. Requesting an explanation is a
nontherapeutic communication technique. In option A, the nurse is using the therapeutic communication technique of giving information. Imparting the
common fear of death of client’s with end-stage heart failure may encourage the client to voice concern. In option C, the nurse is encouraging verbalizaton of
emotions or feeling, which is a therapeutic communication technique of exploring. Exploring is asking the client to describe something in more detail or to
discuss it more fully.
964 A client seeks treatment in an ambulatory care center for symptoms of Raynaud’s disease. The nurse instructs the client to: Wear
protective items, such as gloves and warm socks as necessary Alternate exposures to both heat and cold Decrease cigarette smoking by half
Continue activity during vasospasm for more rapid relief of symptoms A Treatment for Raynaud’s disease includes avoidance of
precipitating factors such as cold or damp weather, stress, and cigarettes. The client should get sufficient rest and sleep, protect the extremities by wearing
protective clothing, and stop activity during vasospasm.

965 A client diagnosed with angina pectoris, appears to be very anxious and sates, “So I had a heart attack, right?” Which of the following is the best
response for a nurse to make? "No, and we will see to it that you do not have a heart attack." "Yes, that is why you are here." "No, but the doctor
wants to monitor you and control or eliminate your pain." "Yes, but there is minimal damage to your heart." C Angina pectoris is pain
that occurs as a result of inadequate blood supply to the myocardium. A myocardial infarction refers to a heart attack. Option A provides false reassurance.
Neither the nurse the physician can guarantee that a heart attack will not occur.

966 A client in the coronary care unit is about to have a pericardiocentesis done for a rapidly accumulating pericardial effusion. The nurse could best
plan to alleviate the apprehension of the client by: Staying beside the client and giving information and encouragement during the procedure Talking to the
client from the foot of the bed to be available to get added supplies Telling the client that the nurse will take care of another assigned client at this time, so as to
be available once the procedure is complete Telling the client to watch television during the procedure as a distraction A Clients who develop
sudden complications are in situational crisis and need therapeutic intervention. Staying with the client, and giving information and encouragement is part of
building and maintaining trust in the nurse-client relationship. Options C and D distance the nurse from the client in the psychosocial as well as physical sense.
The nurse should ask another care giver to be available to get extra supplies if needed.

967 A client is being discharged to home after angioplasty using the right femoral area as the catheter insertion site. The nurse instructs the client that
which of the following signs and symptoms may be expected after the procedure? Coolness or discoloration of the right foot Temperature as high as
101°F Large area of bruising in the right groin area Mild discomfort in the right groin area D The client may feel some mild discomfort at
the catheter insertion site following angioplasty. This is usually well relieved by analgesics such as acetaminophen (Tylenol). The client is taught to report to
the physician any neurovascular changes to the affected leg, bleeding or bruising at the insertion site, and signs of local infection, such as drainage at the site or
increased temperature.
968 A client is to have arterial blood gases drawn. While nurse is performing the Allen test, the client says to the nurse, “What are you doing? No one
else has done that!” The most therapeutic nursing response would be: "This is a routine precautionary step that simply makes certain your circulation is
intact before obtaining a blood sample." "Oh? You have questions about this? You should insist that they all do this procedure before drawing up your
blood." "I assure you that I am doing the correct procedure. I cannot account for what others do." "This step is crucial to safe blood withdrawal. I could not
let anyone take my blood until they did this." A The Allen test is perform to assess collateral circulation in the hand before drawing a radial
artery blood specimen. The most therapeutic response provides information to the client. Option B is aggressive and controlling as well as nontherapeutic in its
disapproving stance. Option C is defensive and nontherapeutic in offering false reassurance. Option D identifies client advocacy, but is overly controlling and
quite aggressive and undermining of treatment.

969 A client newly diagnosed with angina pectoris asks the nurse how to prevent future angina attacks. The nurse plans to incorporate which of the
following instructions in a teaching session? Eat fewer, larger meals for more efficient digestion Plan all activities for early in the morning, when the client
is mot rested Adjust medication doses freely until symptoms do not recur Dress appropriately in very cold or very hot weather D
Anginal episodes are triggered by events such as eating heavy meals, straining during bowel movements, smoking, overexertion, and experiencing
emotional upset, or temperature extremes. Medication therapy is monitored and regulated by the physician.

970 A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests
that the client is in the denial phase of grieving, and a nursing diagnosis of grieving is still applicable for the client? Requests a sedative for sleep at
10:00 p.m. Expresses hesitancy to leave the hospital Walks up and down three flights of stairs unsupervised Consumes 25% of foods and fluids for supper
C Ignoring activity limitations and avoidance of lifestyle changes are signs of denial in the stages of grieving. Walking three flights of stairs
should be a supervised activity during this phase of the recovery process. Option A is an appropriate client action on the evening before discharge. Option B,
expressing hesitancy to leave, may be a manifestation of anxiety or fear, not of denial. Option D, anorexia, is a manifestation of depression not denial.

971 A client superficial varicose veins says to the nurse, "I hate these things. They’re so ugly, I wish I could get them to go away.” The nurse’s best
response would be: "You should try sclerotherapy. It’s great." "What have you been told about varicose veins and their management?" "There’s not
much you can do once you get them." "I understand how you feel, but you know, they really don’t look too bad." B The client is expressing
distress about physical appearance, and has a risk for Body Image Disturbance. The nurse assesses self-management of the condition as a means of empowering
the client, and helping in adapting to the body change, Options A, C, and D are nontherapeutic.
972 A client was just told by her primary care physician that she will have an exercise stress test to evaluate the client’s status after recent episodes of
more severe chest pain. As a nurse enters the examining room, the client states, "maybe I shouldn’t bother going. I wonder if I should just take more medication
instead." The nurse’s best response would be: "Can you tell me more about how you’re feeling?" "Don’t worry. Emergency equipment is
available if it should be needed." "Most people tolerate the procedure well without any complications." "Don’t you really want to control your heart
disease?" A Anxiety and fear are often present before stress testing. The nurse should explore a client’s feelings if concerns are expressed. Options B,
C and D are inappropriate statements and limit communication. Option A is open ended and is the only one of the options that is phrased to engender trust and
sharing of concerns by the client.

973 A client was started on oral anticoagulant therapy while hospitalized. The client is now being discharged to home and is intermittently confused. The
nurse would evaluate that the client has the best support system for successful anticoagulant therapy monitoring if the client: Has a good friend living
next door who would take the client to the doctor Has a home health aide coming to the house for 9 weeks Was going to stay with a daughter in
the daughter’s home. Was going to have blood work drawn in the home by a local laboratory C The client taking anticoagulant therapy should
be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply
with the medication regimen, the continuance of the regime should be questioned. Clients may need support systems in place to enhance compliance with
therapy. Option A facilitates medical care, option B facilitates reminding blood work only.

974 A client who has undergone successful femoral-popliteal bypass grafting to the leg says to the nurse, “I hope everything goes well after this, and I
don’t lose my leg. I’m so afraid that I’ll have gone through this for nothing.” The nurse’s best response would be: "I can understand what you mean.
I’d be nervous too, if I were in your shoes." "Stress isn’t helpful for you. You should probably just relax and try not to worry unless something actually
happens." "Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about." "This surgery is so
successful, that I wouldn’t be concerned at all if I were you." C Clients frequently fear that they will ultimately lose a limb or become debilitated
in some other way. Option A feeds into the client’s anxiety and is not therapeutic. Option D gives false reassurance. Option B is meant to be reassuring but
offers no suggestions to empower the client. Option C acknowledges the client’s concerns, and empowers the client the risk of complications.

975 A client who is scheduled for implantation of an automatic internal defibrillator-cardioverter (AICD) asks the nurse why there is a need to keep a
diary, and what to put in it. In formulating a reply, the nurse understands that the primary purpose of the diary is to: Provide a count of the number of
shocks delivered. Document events that precipitate a countershock Record a variety of data useful for the physician in medical management
Analyze which activities to avoid C The client with an AICD maintain a log or diary of a variety of data. This includes recording date,
time, activity before the shock and any symptoms experienced, number of shocks delivered, and how the client felt after the shock. The information is used by
the physician to adjust the medical regimen, especially medication therapy, which must be maintained after AICD insertion.

976 A client with angina pectoris is extremely anxious after being hospitalized for the first time. The nurse plans to do which of the following to
minimize the client’s anxiety? Admit the client to a room as far as possible from the nursing station Provide care choices to the client
Encourage the client to limit visitors to as few as possible Keep the door open and hallway lights on at night B General
interventions to minimize anxiety in a hospitalized client include providing information, social support, and control over choices related to care, as well as
acknowledging the client’s feelings. Being far from the nursing station is likely to increase anxiety for this client. Limiting visitors reduces social support, and
leaving the door open with hallway light on may keep the client oriented, but may interfere with sleep and increase anxiety.

977 A client with atherosclerosis asks the nurse about dietary modifications to lower the risk of heart disease. The nurse instructs the client to eat which
of the following foods? Baked chicken with skin Fresh cantaloupe Broiled cheeseburger Mashed potato with gravy B To
lower the risk of heart disease, the diet should be low in saturated fat with the appropriate number of total calories. The diet should include fewer red meats and
more white meat, with the skin removed. Dairy products used should be low in fat, and foods with high amounts of empty calories should be avoided.

978 A client with cardiomyopathy stops eating, takes long naps, and turns away from the nurse when the nurse talks to the client. The nurse interprets
that this client is most likely experiencing: Activity intolerance Intractable pain Noncompliance Depression D Depression is
a common problem related to clients who have long-term and debilitating illness. Options A, B, and C are not related to the symptoms present ion the question
and therefore are not appropriate interpretations.

979 A client with chronic arterial leg ulcers complains of pain and tells the nurse, "I’m so discouraged, I have had this pain for over a year now. The pain
never seems to go away. I can’t do anything, and I feel as though I’ll never get better." The nurse would formulate which of the following nursing diagnosis for
this client? Acute Pain related to the effects of leg ischemia Chronic Pain related to the non-healing arterial ulcerations Fatigue related to lack of
sleep and frustration with illness Ineffective Individual Coping related to chronic illness B The major focus of the client’s complaint id the experience
of pain. Pain that has a duration of greater than 6 months is defined as chronic pain, not acute pain. The North American Nursing Diagnosis Association
(NANDA) defines Fatigue as “a sense of exhaustion and decreased capacity for physical and mental work.” NANDA defines Ineffective Individual Coping as
“impairment of adaptive behavior and abilities of a person in meeting life’s demands and roles.”
980 A client with peripheral arterial disease has received instructions from the nurse about how to limit progression of the disease. The nurse determines
that the client needs further instructions if which of the following statements was made by the client?"I should walk daily to increase the circulation to my legs"
"A hot heating pad on my leg will help to soothe the leg pain." "I need to take special care of my feet to prevent injury." "I need to eat
a balanced diet." B Long –term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise),
promote vasodilatation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of heat directly to the extremity is
contraindicated. The limb may have decreased sensitivity and be more at risk for burns. Additionally, direct application of heat raises oxygen and nutritional
requirements of the tissue even further.

981 A client with premature ventricular contractions says to the nurse, “I’m so afraid something bad will happen.” Which action by the nurse would be
of most immediate help to the client? Giving reassurance that nothing will happen to the client Telephoning the clients family Having a staff
member stay with the client Using television to distract the client C When a client experiences fear, the nurse can provide a calm, safe
environment by offering appropriate reassurance, the therapeutic use of touch, and by having someone remain with the client as much as possible. Option A
provides false reassurance. Options B and D do not address the client’s fear.

982 A client with Raynaud’s disease tells the nurse that she has a stressful job and does not handle stressful situations well. The nurse most appropriately
guides the client to: Change jobs Consider a stress management program Seek help from a psychologist Use earplugs to minimize
environmental noise B Stress can trigger the vasospasm that occurs with Raynaud’s disease, so referral to stress management programs or the use of
biofeedback training may be helpful. Option A is unrealistic. Option C is not necessarily required at this time option D does not specifically address the issue.

983 A female client is being discharged from the hospital to home with an indwelling urinary catheter following surgical repair of the bladder following
trauma. The nurse evaluates that the client understands the principles of catheter management if the client states to: Cleanse the perineal area with soap
and water once a day Keep the drainage bag lower than the level of the bladder Limit fluid intake so the bag won’t become full so quickly
Coil the tubing and place under the thigh when sitting to avoid tugging on the bladder B The perineal area should be cleansed twice
daily and following each bowel movement with soap and water. The drainage bag should be lower than the level of the bladder, and the tubing should be free
of kinks and compression. Adequate fluid intake is necessary to prevent infection and to provide natural irrigation of the catheter from increased urine flow.
984 A home care nurse has given instructions to a client recently discharged from the hospital with an arterial ischemic leg ulcer. The nurse determines
that further instruction is needed if the client made which of the following statements? I should wear shoes and socks. I should cut my toenails straight
across. I should raise my legs above the level of my heart periodically. I should inspect my feet daily. C Foot care instructions for the client
with peripheral arterial ischemia are the same instructions given to the client with diabetes mellitus. The client with arterial disease, however, should avoid
raising the legs above heart level, unless instructed to do so as part of an exercise program (such as Buerger-Allen exercise), or unless venous states is also
present. Options A, B, and D are accurate client statements.

985 A home care nurse provides self-care instructions to a client with chronic venous insufficiency due to deep vein thrombosis. Which statement by the
client indicates a need for further instructions? I can cross my legs at the knee, but not the ankle. I need to elevate the foot of the bed during
sleep. I need to avoid prolonged standing or sitting. I should continue to wear elastic hose for at least 6 to 8 weeks. A Clients with
chronic venous insufficiency are advised to avoid crossing the legs, sitting in chairs where the feet don’t touch the floor, and wearing garters or sources of
pressure above the legs (such as girdles). The client should wear elastic hose for 6 to 8 weeks, and in some situations for life. The client should sleep with the
foot of the bed elevated to promote venous return during sleep. Venous problems are characterized by insufficient drainage of blood from the legs returning to
the heart. Thus, interventions need to be aimed at promoting flow of blood out of the legs and back to the heart.

986 A nurse determines that a client recovering from a myocardial infarction is exhibiting signs of depression when the client: Reports insomnia at
night Consumes 25% of meals and shows little interest during client teaching Ignores activity restrictions and does not report the experience of
chest pain with activity Expresses a apprehension about leaving the hospital and requests that someone stay at night B Signs of
depression include withdrawal, lack of interest, crying, anorexia, and apathy. Insomnia may be a sign of anxiety or fear. Ignoring symptoms and activity
restrictions is a sign of denial. Apprehension is a assign of anxiety.

987 A nurse enters room of a client with myocardial infarction (MI) and finds the client crying quietly. After determining that there is no physiological
reason for the client’s distress, the nurse replies: "Do you want me to call your daughter?" "Can you tell me a little about what made you so upset?"
"I understand how you feel. I’d cry too if I had a major heart attack." "Try not to be so upset. Psychological stress is bad for your heart." B
Clients with an MI often have a nursing diagnosis of Anxiety or Fear. The nurse allows the client to express concerns by showing genuine interest
and concern, and by facilitating communication using therapeutic communication techniques. Option B provides the client an opportunity to express concerns.
Options A, C, and D do not address the client’s feelings or promote client verbalization.
988 A nurse has provided discharge instructions regarding nitroglycerin therapy to the client with angina. Which statement by the client indicates
understanding of home use of the nitroglycerin? "When I have chest pain, I should put a tablet under my tongue. If I have a burning sensation, I should
call my doctor immediately." "When I experience chest pain, I can continue what I’m doing. If it doesn’t go away in 10 minutes, I should use a
nitroglycerin." "When I have pain, I should lie down and place a tablet under my tongue. If the pain is unrelieved in 5 minutes, I should take another
tablet." "If I use a nitroglycerin tablet and the pain does not subside in 15 minutes, I should go to the hospital." C The client taking
sublingual nitroglycerin should be down after taking the medication, because lightheadedness and dizziness may occur as a result of postural Hypotension. The
client should use up to three tablets at 5-minutes intervals before seeking medical attention. Options A, B and D are incorrect regarding the use of nitroglycerin.
A burning sensation is a common side effect of nitroglycerin. Nitroglycerin should be used with the onset of anginal pain. The client should repeat
nitroglycerin if relief is not obtained with the first or second dose.

989 A nurse has provided instructions to a client being discharged from the hospital to home after an abdominal aortic aneurysm (AAA) resection. The
nurse determines that the client understands the instructions if the client stated that an appropriate activity would be to: Lift objects up to 30lb Walk as
tolerated, including stairs and out of the lawn Mow the lawn Play a game of 18-hole golf B The client can walk as tolerated
after repair or resection of an AAA, including climbing stairs and walking outdoors. The client should not lift objects that weight more than 15 to 20 lb for 6 to
12 weeks, or engage in any activities that involve pushing, pulling, or straining. Diving is also prohibited for several weeks.

990 A nurse is giving a client with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, “What’s the use? I’ll
never remember all of this, and I’ll probably die anyway!” The nurse interprets that the client’s response is most likely the result of: The teaching strategies
used by the nurse Anger about the new medical regimen Insufficient financial resources to pay for the medications Anxiety about the ability
to manage the disease process at home D Anxiety and fear often develop after heart failure and can further tax the failing heart. The client’s
statement is made in the middle of receiving self-care instructions. There is no evidence in the question to support options A, B, or C.

991 A nurse is assessing a 39-year-old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, total cholesterol of 190
mg/dL, and a fasting blood glucose level of 114 mg/dL. The nurse would place priority on which risk factor for coronary artery disease (CAD) in this client?
Age Hyperlipidemia Hypertension Glucose intolerance C Hypertension, cigarette smoking, and hyperlipidemia are
major risk factors for CAD. Glucose intolerance, obesity, and response to stress are also contributing factors. Age greater than 40 is a nonmodifiable risk factor.
A cholesterol level of 190 mg/dL and a blood glucose level of 114 mg/dL, are within the normal ranges. The nurse places priority on major risk factors that
need modification.
992 A nurse is caring for a client with acute pulmonary edema. The nurse should include strategies for which of the following in the care of the client?
Decreasing cardiac output Increasing fluid volume Promoting a positive body image Reducing anxiety D When cardiac
output falls as a result of acute pulmonary edema, the sympathetic nervous system is stimulated. Stimulation of the sympathetic nervous system results in the
flight of fight reaction, which further impairs cardiac function. The goal of treatment is to increase cardiac output and decrease fluid volume. An alteration in
body image is not a common problem experienced by client with acute pulmonary edema.

993 A nurse is developing a teaching plan for a client with Raynaud’s disease. The nurse plans to tell the client that the symptoms may improve with: A
high-protein diet, which will minimize tissue malnutrition Vitamin K administration, which will prevent tendencies toward bleeding Keeping the
hands and feet warm and dry, which will prevent vasoconstriction Daily cool baths, which will provide an analgesic effect C Use of measures to
prevent vasoconstriction are helpful in managing Raynaud’s disease. The hands and feet should be kept dry. Gloves and warms fabrics should be worn in cold
weather, and the client avoid exposure to nicotine and caffeine. Avoidance of situations that trigger stress is also helpful. Options A, B and D are not
components of the treatment for this disorder.

994 A nurse is evaluating a hypertensive client’s understanding of dietary modifications to control the disease process. The nurse would evaluate the
client’s understanding as satisfactory if the client made which of the following meal selections? Scallops, French fries, salad with blue cheese dressing
Corned beef, fresh carrots, boiled potato Hot dog in a bun, sauerkraut, baked beans Turkey, baked potato, salad with oil and vinegar D
The client with hypertension should avoid foods high in sodium. Foods from the meat group that are higher in sodium include bacon, hot dogs,
luncheon meat, chipped or corned beef, Kosher meat, smoked or salted meat or fish, peanut butter, and a variety of shellfish.

995 A nurse is implementing measures to maintain adequate peripheral tissue perfusion in a postcardiac surgery client. The nurse avoids which of the
following in giving care to this client? Range-of-motion (ROM) exercises to the feet Application of compression stockings Leg elevation
while sitting in chair Use of the knee gatch D After surgery, measures are taken to prevent venous stasis. They include applying elastic stockings or
leg wraps, use of pneumatic compression boots, discouraging leg crossing, avoiding use of the knee gatch, performing passive and active ROM exercise, and
avoiding the use of pillows in the political space. Leg evaluation while sitting will promote venous drainage and help prevent postoperative edema.
996 A nurse is performing a cardiovascular assessment. Which of the following items would the nurse assess to obtain information about the client’s
right-sided heart function? Status of breath sounds Presence of peripheral edema Presence of dyspnea Rate of respiration B
The client with heart failure may present difference symptoms, depending on whether the right or the left side of the heart is failing. Options A, C
and D identify assessment for left sided heart failure. Assessment of breath sounds provides information about right-sided heart function.

997 A nurse is planning care for a client who is experiencing anxiety following a myocardial infarction. Which nursing intervention should be included
in the plan of care? Provide detailed explanations of all procedures Administer cyclobenzaprine (Flexeril) to promote relaxation Limit family
involvement during the acute phase Answer questions with factual information D Accurate information reduces fear, strengthens the nurse-
client relationship, and assists the client to deal realistically with the situation. Providing detailed information, may increase the client’s anxiety. Information
should be provided simply and clearly. Flexeril is a skeletal muscle relaxant and is used in the short-term treatment of muscle spasms. Limiting family
involvement may or may not be helpful. The client’s family may be a source support for the client.

998 A nurse is planning to teach a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which of the following
explanations would the nurse use to best describe the reasoning for this therapy? Because of this dysrhythmia, blood backs up in the legs, and puts you
at risk for blood clots, also called deep vein thrombosis. The antidysrhythmic medications you are taking cause blood clots as a side effect, so you need this
medication to prevent them. Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which could
then loosen and travel to the lungs or brain. This dysrhythmia decreases the amount of blood flow coming from the heart, which can lead to blood clots
forming in the brain. C A severe complication of atrial fibrillation is the development of mural thrombi. The blood stagnates in the “quivering” atria,
due to the loss of organized atrial muscle contraction and “atrial kick.” The blood that pools in the atria can then clot, which increases the risk of pulmonary
and cerebral emboli.

999 A nurse is planning to teach a client with hypertension about nonfood items that contain sodium and develops a written list for the client. The nurse
avoids placing which of the following items on the list? Demineralized water Antacids Laxatives Toothpaste A Water that is bottled, distilled
deionized, or demineralized may be used for drinking and cooking because it contains no sodium. Sodium intake can be increased by the use of several types
of products, including toothpaste and mouthwashes over-the-counter medications such as analgesics, antacids, cough remedies, laxatives, and sedatives; and
softened water, as well as some mineral waters. Clients are highly advised to read labels for sodium content.
1000 A nurse is providing home care discharge instructions to a client who had varicose vein stripping and ligation and is being discharged from the
ambulatory care unit. The nurse tells the client to: Maintain bed rest for the first 3 days Ambulate for 5 to 10 minutes twice a day beginning the
day after surgery Elevate the foot of the bed while in bed Remove elastic hose after 24 hours. C Standard postoperative care
following vein ligation and stripping consists of bed rest for 24 hours with ambulation for 5 to 10 minutes every 2 hours thereafter. Continuous elastic
compression of the leg is maintained for 1 week following the procedure, followed by long-term use of elastic hose. The foot of the bed should be elevated to
promote venous drainage.

1001 A nurse is providing home care instructions to a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. The
nurse teaches the client to: Avoid sexual intercourse for at least 4 months Replace sublingual nitroglycerin tablets yearly Recognize
the side effect of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss Participate in an exercise program that includes overhead lifting and
reaching C After an acute MI, many clients are instructed to take one aspirin daily. Side effects include tinnitus, hearing loss, epigastric distress,
gastrointestinal bleeding, and nausea. In regard to option A, sexual intercourse may be resumed in 4 to 8 weeks after an MI if the physician agrees. Clients
should be advised to purchase a new supply of nitroglycerin tablets every 6 to 9 months. Expiration dates on the medication bottle should be checked.
Activities that include lifting and reaching over the head should be avoided, because they reduce cardiac output.

1002 A nurse is providing instructions about foot care to a client with chronic arterial insufficiency. The nurse tells the client to: Wear shoes that are
snugly fitting Clean the feet daily, drying them well Apply moisturizer to feet, especially between toes Cut the toenails very short to
prevent scratching B Foot care for the client vascular disease is the same as for clients who have diabetes mellitus. This includes daily cleansing of
the feet; drying well especially between the toes applying lotion to dry areas except between the toes; wearing shoes that fit well without pressure areas; and
keeping the toenails trimmed short.

1003 A nurse is reviewing assessment data on a clinic client. Which assessment data would be most important for the client to modify to lessen the risk
for coronary artery disease (CAD)? Elevated high-density lipoprotein (HDL) levels Elevated low-density lipoprotein (LDL) levels
Elevated triglyceride levels Elevated serum lipase levels B LDL is more directly associated with CAD than other lipoproteins.
LDL levels, along with cholesterol, have a higher predictive association for CAD than triglycerides. Additionally, HDL is inversely associated with the risk of
CAD. Lipase is a digestive enzyme that breaks down ingested fats in the gastrointestinal tract.
1004 A nurse is teaching a client with hypertension to recognize the signs and symptoms that may occur during periods of an elevated blood pressure
(BP). The nurse avoids telling the client that which of the following will occur? Early morning headaches Epistaxis Feeling of fullness in the
head Blurred vision C Cerebrovascular symptoms of hypertension include early morning headaches, occipital headaches, blurred vision,
lightheadedness and vertigo, dizziness, and epistaxis. The client should be aware of these symptoms and report them if they occur. The client should also be
taught self-monitoring of blood pressure. Feelings of fullness in the head is more likely associated with a sinus condition.

1005 A nurse is teaching dietary modification to a client with hypertension. The nurse instructs the client to eat which of the following snacks foods?
Cheese and crackers Honeydew melon slices Frozen pizza Canned tomato soup B Sodium should be avoided by a
client with hypertension. Fresh fruits and vegetables are naturally low in sodium. Hypertensive clients are also advised to keep fat intake to less than 30% of
total calories as part of prudent heart living. Each of the incorrect options contain increased amounts of sodium, and options A and C are likely to be also
higher in fat.

1006 A nurse notes that an assigned client is lying tense in bed staring at the cardiac monitor. The client states “There sure a lot of wires around there. I
sure hope we don’t get hit by lightning.” The most appropriate nursing response is which of the following? "Would you like a sedative to help you relax?"
"Oh, don’t worry-the weather supposed to be sunny and clear today." "Yes, all those wires must be a littlie scary. Did someone explain what
the cardiac monitor was for?" "Your family can stay tonight if they wish." C The nurse should initially the client’s concern and then assess the
client’s knowledge regarding the cardiac monitor. This gives the nurse an opportunity to do the client education if necessary. Options A, B, and D do not
address the client’s concern. Additionally, pharmacological interventions should be considered only if necessary.

1007 A nurse reviews the client’s electrocardiogram (ECG) rhythm strip. The ECG shows that the rate is 90 beats/min. The nurse most appropriately tells
the client that: The rate is normal There is no need to worry Medication specific to the problem will be prescribed A slower heart rate is
preferred A A normal adult resting pulse rate ranges between 60 and 100 beats/min.
1008 A rehabilitation nurse witnessed a postoperative coronary artery bypass graft client and his spouse arguing after a rehabilitation session. The most
appropriate statement by the nurse in identifying the feelings of the client would be; "You seem upset." "You shouldn’t get upset. It’ll affect your
heart." "Oh, don’t let this get you down." "It will seem better tomorrow, smile." A Acknowledging the client’s feeling without
inserting your own value or judgments is a method of therapeutic communications. Therapeutic communication techniques assist the flow of communication
and always focus on the client to verbalize, which give the nurse a direction or clarification of the true feeling. Options B, C, and D don’t encourage
verbalization by the client

1009 A spouse of a client scheduled for an insertion of an automatic implantable cardioverter-defibrillator (AICD) expresses anxiety about what would
happen if the device discharges during physical contact. The nurse tells the spouse that: Physical contact should be avoided whenever possible A warning
device sounds before countershock so there is time to move away The spouse would not feel or be harmed by the countershock The shock would be felt,
but it would not cause the spouse any harm B Anxiety is common in the client with the need for pacemaker insertion. This can be related to fear of
life-threatening dysrhythmias, or related to the surgical procedure. Options A and C are closed-ended and not exploratory. Option D is not indicated because it
asks about the family, and deflects attention away from the client’s concerns. Option B is open-ended and uses clarification as a communication technique to
explore the client’s concerns.

1010 According to standard coronary care unit (CCU) orders, a client with an uncomplicated myocardial infarction (MI) may begin progressive activity
after three days. The client who experienced an infarction 4 days ago refuses to dangle at the bedside saying, “If my doctor tells me to do it I will. Otherwise I
won’t.“ The nurse determines that the client is likely displaying: Anger Denial Dependency Depression C Clients may
experience numerous emotional and behavioral responses following an MI. Dependency is one response that may be manifested by the client’s refusal to
perform any tasks or activities unless approved by the physician. There are no data in the question to support denial or depression. Although the client’s
statement may express anger to some degree, it most specifically addresses dependency.

1011 An elderly client who has never been hospitalized before is to have a 12 electrocardiogram (ECG). The nurse could best plan to alleviate the client’s
anxiety about the test by giving which of the following explanations? The ECG can give the doctor information about what might be wrong with your
heart. It’s important to lie still during the procedure. It should take only about 20 minutes to complete the ECG tracings.The ECG electrodes are
painless and will record the electrical activity of the heart. D The ECG uses painless electrodes, which are applied to the chest and limbs. It
takes less than 5 minutes to complete, and requires the client to lie still. The ECG measures the heart’s electrical activity to determine rate, rhythm, and a
variety of abnormalities. Options A and B factual statements and are not stated to reduce anxiety.
1012 Both the client who had cardiac surgery and the client’s family express anxiety about how to cope with the recuperative process once they are home
alone after discharge. The nurse plans to tell the client and family about which available resource? Local library United Way American
Hearth Association Mended Hearts Club American Cancer Society Reach for Recovery C Most clients and families benefit from knowing
there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon,
cardiologist, and nurse; postcardiac surgery sponsored cardiac rehabilitation programs; and community support groups such as the American Heart Association
Mended Hearts Club (a nationwide program with local chapters). The United Way provides a wide variety of services to people who might otherwise not afford
them. The American Cancer Society Reach for Recovery helps women recover after mastectomy.

1013 Family members of a client with a myocardial infarction complicated by cardiogenic shock are visibly anxious and upset about the client’s
condition. A nurse would plan to do which of the following to provide the best support to the family? Insist they go home to sleep at night to keep up their own
strength Provide flexibility with visiting times according to the client’s condition and family needsOffer them coffee and other beverages on a regular basis
Ask the hospital chaplain to sit with them until the client’s condition stabilizes B The use of flexible visiting hours meets the needs of both
the client and family in reducing the anxiety levels of both. Insisting that the family go home is nontherapeutic. Offering the family beverages does not provide
support. Although the chaplain may provide support, it is unrealistic for the chaplain to stay until the client stabilizes.

1014 In planning care for the client with thromboangiitis obliterans (Buerger’s disease), the nurse incorporates measures to help the client cope with the
lifestyle changes needed to control the disease process. The nurse can best accomplish this by recommending a: Smoking cessation program Pain
management clinic Consult with a dietician Referral to a medical social worker A Smoking is highly detrimental to the client with
Buerger’s disease, and clients are recommended to stop completely. Since smoking is a form of chemical dependency, referral to a smoking cessation program
may be helpful for many clients. For many clients, symptoms are revealed or alleviated once physiology associated with this condition.

1015 A client with diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic hyperosmolar nonketotic syndrome
(HHNS). The nurse develops a discharge teaching plan for the client and identifies which of the following as the priority? Exercise routines Signs and
symptoms of dehydration The need to keep follow-up appointments How to control dietary intake B Clients at risk of HHNS should
immediately report signs and symptoms of dehydration to health care providers. Dehydration can be severe and may rapidly. Although options A, C and D are
a component of the teaching plan, in the client with HHNS, dehydration is the priority.
1016 A client is diagnosed with hypothyroidism and is to begin on thyroid supplements. The nurse instructs the client about the medication. Which of the
following statements, if made by the client, would indicate the need for further education? "I need to take my daily dose every night at bedtime." "I
need to call my physician if I develop any chest pain?" "I need to speak to my physician when I begin to plan for parenthood." "My appetite may
increase because of the medication." A The client is instructed to take the medication in the morning to prevent insomnia. If the client
experiences any chest pain it may indicate overdose and the physician needs to be notified. The dose needs to be adjusted if the client is pregnant or plans to
get pregnant. Gastrointestinal complaints from thyroid supplements include increased appetite, nausea, and diarrhea.

1017 A client newly diagnosed with diabetes mellitus has a nursing diagnosis of Altered Health Maintenance related to anxiety regarding the self-
administration of insulin. Initially, the nurse should plan to: Teach the family member to give the client the insulin Use an orange for the client to inject
into until he or she is less anxious Insert the needle and have the client push in the plunger and remove the needle Give the injection until
the client feels confident enough to do so by himself or herself C Some clients find it difficult to insert a needle into their own skin. For these
clients, the nurse might assist by selecting the site and inserting the needle. then, as first step in self-injection, the client can push in the plunger and remove the
needle. Options A and D place the client into a dependent role. Option B is not realistic, considering the issue of the question.

1018 A client with aldosteronism has developed renal failure and says to the nurse, “This means that I will die very soon.” The most appropriate nursing
response is: "What are you thinking about?" "You will do just fine." "You sound discouraged today." "I read that death is a beautiful
experience" C Option C uses the therapeutic communication technique of reflection, and clarifies and encourages further expression of the
client’s feelings. Option A requests an explanation and does not encourage expression of feelings. Options B and D denies the client’s concerns and provides
false reassurance.

1019 A client with diabetes mellitus has expressed frustration in learning the diabetic regimen and insulin administration. The home health care nurse
would initially: Identify then cause of the frustration Continue with diabetic teaching, knowing that the client will overcome any frustrations
Call the physician to discuss termination from home health care services Offer to administer the insulin on a daily basis until the client is ready
to learn A The home health care nurse must determine what is causing the client’s frustration. Continuing to teach may only further block the
learning process. Terminating the client from home care services achieves nothing and is considered abandonment unless other follow-up care is arranged.
Administering insulin only provides a short-term solution.
1020 A client with diabetes mellitus has received instructions about foot care. Which of the following statements would indicate that the client needs
further instruction? The best time to cut my nails is after bathing. Cotton stockings should be worn to absorb excess moisture. The cuticles
of my nails must be cut to prevent overgrow. My feet should be inspected daily using a mirror. C Trimming or cutting the cuticles of the nails
can lead to injury to the foot by scratching the skin. Even small injuries can be dangerous to the client with diabetes mellitus who has decreased peripheral
vascular circulation. A manicure stick can be used to gently push the cuticle back under the nail. Nails can be ct straight across, and after a bat is the best time,
since the nails are softest then. White cotton stockings are best, and the client needs to inspect the feet daily.

1021 A client with newly diagnosed type 1 diabetes mellitus has been seen for 3 consecutive days in the emergency department for hyperglycemia.
During the assessment the client says to the nurse, "I'm sorry to keep bothering your everyday, but I just can't give myself those awful shots." The nurse best
response is: "You must learn to give yourself the shots." "I couldn't give myself a shot either." "I'm sorry you are having trouble with your
injections. Has someone given you instructions on them?" "Let me see if the door can change your medication." C It is important to
determine and deal with a client’s underlying fear of self-injection. The nurse should determine whether a knowledge deficit exists. Demanding a behavior or
skill is inappropriate (option A). Positive reinforcement is necessary instead of focusing on negative behaviors (option B). The nurse should not offer a change
in regimen that can’t be accomplished (option D).

1022 A client with the diagnosis of hyperparathyroidism says to the nurse, “I can’t stay on this diet. It is too difficult for me.” When intervening in this
situation, the nurse should respond: "It is very important that you stay on this diet to avoid forming renal calculi." "It really isn’t difficult to stick to
this diet. Just avoid milk products." "Why do you think you find this diet plan difficult to adhere to?" "You are having a difficult time staying on this
plan. Lets discuss this." D By paraphrasing the client’s statement, the nurse can encourage the client to verbalize emotions. The nurse also
sends feedback to the client that the message was understood. An open-ended statement or question such as this, prompts a lengthy response from the client.
Option A is giving advice, which blocks communication. Option B devalues the client’s feelings. Option C is requesting information that the client may not be
able to express.

1023 A client with type 2 diabetes mellitus was recently hospitalized for hyperglycemic-hyperosmolar nonketotic syndrome (HHNS). Upon discharge
from the hospital, the client expresses concern about the recurrence of HHNS. Which statement by the nurse is the most therapeutic? "Don’t worry, your
family will help you." "I’m sure this won’t happen again." "You have concerns about the treatment for your condition?" "I think you might need
to go to the nursing home." C The nurse should provide time and listen the client’s concerns. In option C, the nurse is attempting to clarify the
client’s feelings. Options A and B provide inappropriate false hope. In addition, a nurse does not tell a client not to worry. Option D is not an appropriate
nursing response, disregards the client’s concerns, and gives advice.
1024 A clinic instructs a client with diabetes mellitus about how to prevent diabetic ketoacidosis (DKA) on days when the client is feeling ill. Which
statement, if made by the client, indicates a need for further education.? I need to stop my insulin if I am vomiting. I need to call my physician if I am
ill for more than 24 hours. I need to eat 10 to 15 g of carbohydrates every 1 to 2 hours. I need to drink small quantities of fluid every 15 to 30
minutes. A The client needs to be instructed to take insulin even if they are vomiting and unable to eat. It is important to self monitor blood glucose
more frequently during illness (every 2 to 4 hours). If the premeal blood glucose is greater than 250 mg/dL, the client should test for urine ketones and contact
they physician. Options A, C and D are accurate interventions.

1025 A female client who was admitted to the hospital for recurrent thyroid storm is preparing for discharge. The client is anxious about her illness and at
time emotionally labile. Which of the following approaches would be most appropriate for the nurse to include in the discharge plan of care for this client?
Avoid teaching the client anything about the disease until she is emotionally stable. Assist the client in identifying coping skills, support
systems, and potential stressors Reassure the client that everything will fine once she is the home environment Confront the client and explain that she must
control her anxiety if she wants to go home B It is normal for clients who experience thyroid storm (hyperthyroidism) to continue to be anxious and
emotionally labile at the time of discharge. Confrontation in option D will only heighten their anxiety. In addition, options A and C block communication by
either avoiding the issue or providing false reassurance. The best intervention is to help the client cope with these changes in behavior and anticipate potential
stressors so that symptoms will not be as severe.

1026 A husband of a client with Graves’ disease expresses concern regarding his wife’s health, because during the past 3 months she has been
experiencing burst of temper, nervousness, and inability to concentrate, even on trivial tasks. Based on this information, which of the following nursing
diagnoses would be the most appropriate for the client? Ineffective Individual Coping Alteration in Sensory Perception Social Isolation Grieving A
A client with Graves’ disease may become irritable or depressed, especially on discharge from the hospital. The signs and symptoms in the question
does not support options B, C, and D.

1027 A male client is admitted with diabetic ketoacidosis (DKA). His daughter says to the nurse, “My mother died last month, and now this. I’ve been
trying to follow all of the instructions from the doctor; what have I done wrong?” The nurse’s best response would be: "Maybe we can keep your father in
the hospital for a while longer to give you a rest." "An emotional stress, such as your mother’s death, can trigger DKA, even though you are following the
prescribed regimen." "You should talk to the social worker about getting you someone at home who is more capable in managing a diabetic’s care."
"Tell me what you think you did wrong." B Environment, infection, or an emotional stressor can initiate the physiological mechanism of
DKA. Option A is not a cost effective intervention. Option C and D substantiate the daughter’s feelings of guilt and incompetence.
1028 A nurse develops a plan of care for an elderly client with diabetes mellitus. The nurse plans to first: Teach with videotapes showing insulin
administration to ensure competence Assess the client’s ability to read label markings monitoring equipment Structure menus for adherence to
diet Encourage dependence to prepare the client for the chronicity of the disease B The nurse first assess the client’s ability to care for self.
Allowing the client “hands on” experience rather than teaching with videos is more effective. Independence should be encouraged. Structuring menus for the
client promotes dependence.

1029 A nurse has taught a client about the signs and symptoms of hyperglycemia. Which statement by the client best reflects accurate understanding.? "I
may become diaphoretic and faint." "I need to take an extra diabetic pill if my blood glucose level is greater than 300." "I may notice signs of
fatigue, dry skin, and increased urination and thirst." "I should restrict my fluid intake if my blood glucose level is greater than 250mg." C
Fatigue, dry skin, polyuria and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from inability of the
body to utilize glucose. Dry skin occurs secondary to dehydration related to the polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated
with hypoglycemia. Client should not take extra oral hypoglycemic agents to reduce an elevated blood glucose level. Rather, Regular insulin is used for its
rapid response to reduce hyperglycemia. A client with hyperglycemia become dehydrated secondary to the osmotic effect of elevated glucose. Therefore the
client must increase fluid intake.

1030 A nurse in an outpatient diabetes clinic is monitoring a client with type 1 diabetes mellitus. Today’s blood work reveals a glycosylated hemoglobin
(HbA1c) of 10%. The nurse interprets this blood work as indicating which of the following? A normal value, indicating that the client is managing
blood glucose control well A low value, indicating that the client is not managing blood glucose control very well. A high value, indicting that the
client is not managing blood glucose control very well The value does not offer information regarding client management of their disease C
Glycosylated hemoglobin is a measure of glucose control during the past 6 to 8 weeks before the test. It is a reliable measure to determine the
degree of glucose control in diabetic clients over a period of time and is not influenced by good glucose or dietary management a day or two before the test is
done. The normal range for HbA1c is 4% to 7% with elevated levels indicting poor glucose control.

1031 A nurse is admitting to the hospital a client who recently had a bilateral adrenalectomy. Which of the following interventions is essential for the
nurse to include in the client's plan of care? Prevent social isolation Discuss changes in body image Consider occupational therapy Avoid stress-
producing situations and procedures D Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential in maintaining
homeostasis in response to stressors. Options A, B and C are not essential intervention specific to this client’s problem.
1032 A nurse is assessing a client with Addison’s disease for signs of hyperkalemia. The nurse expects to note which of the following if hyperkalemia is
present? Polyuria Dry mucous membranes Cardiac dysrhythmias Prolonged bleeding time C The inadequate production of
aldosterone in Addison’s disease causes inadequate excretion of potassium and results in hyperkalemia. The clinical manifestation of hyperkalemia are the
result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function. Options A, B and D are not manifestation
associated with Addison’s disease or hyperkalemia.

1033 A nurse is assessing the status of the prenatal client. Following the assessment, the nurse determines that which piece of data places the client into
the high-risk category for contracting human immuno-deficiency virus (HIV)? Living in an area where HIV infections are minimal A history of IV drug use
in the past year A history of one sexual partner within the past 10 years A spouse who is heterosexual and had only one sexual partner in the past 10
years. B HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure of infected blood, and transmission from an
infected woman to her fetus. Women who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted
disease those with a history of multiple sexual partners, and those who have used IV drugs. A heterosexual partner, particularly a partner who has had only one
sexual partner in 10 years, is not a high risk factor for developing HIV.

1034 A nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which
of the following statements by the client would indicate an understanding of the nurse’s instructions? "I will definitely have to continue taking antithyroid
medications after this surgery." "I need to place my hands behind my neck when I have to cough or change positions." "I need to turn my head and neck
front, and laterally every hour for the first 12 hours after surgery." "I expect to experience some tingling of my toes, fingers and lips after surgery." B
The client is taught that tension needs to be avoided on the suture line; otherwise, hemorrhage may develop. One way of reducing incisional
tension is to teach the client how to support their neck when coughing or being repositioned. Likewise, during the postoperative period, the client should avoid
any unnecessary movement of the neck. That is why sandbags and pillows are frequently used to support the head and neck. Removal of the thyroid does not
mean that the client will be taking antithyroid medications postoperatively. If a client experiences tingling in the fingers, toes, and lips, it is probably due to
injury to the parathyroid gland during surgery resulting in hypocalcemia. These signs and symptoms need to be reported immediately.

1035 A nurse is caring for a client with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, the nurse teaches the client to:
Omit the evening NPH insulin if the client is exercising Monitor the urine for acetone Access for signs of drowsiness and coma Keep
glucagons subcutaneously available D Glucagon is administered subcutaneously or intramuscularly to release glycogen stores and raise blood
glucose levels in hypoglycemia. This medication is useful if the client loses consciousness and is unable to take glucose by mouth. Family members can be
taught to administer this medication and possibly prevent an emergency room visit. The nurse would not instruct a client to omit insulin. Acetone in the urine
may indicate hyperglycemia. Although signs of hypoglycemia need to be taught to the client, drowsiness and coma are not the initial and key signs of this
disorder.

1036 A nurse is caring for a male client with newly diagnosed type 1 diabetes mellitus. To develop an effective teaching plan, it would be most important
for the nurse to assess the client for: Knowledge of the diabetic diet Expressions of denial of having diabetes Fear of performing insulin
administration Feelings of depression about lifestyle changes B When diabetes mellitus is first diagnosed, the client may go through
the phases of grief-denial, fear, anger, bargaining, depression and acceptance. Denial is the phase that is more detrimental to the teaching/learning process. If the
client is denying the fact he has diabetes, the client probably will not listen to discussions about the disease or how to manage it. Denial must be identified
before the nurse can develop a teaching plan. Adult Health / Endocrine

1037 A nurse is instructing a client with diabetes mellitus regarding hypoglycemia. Which of the following statements, if made by the client, would
indicate a need for further education? Hypoglycemia, can occur at any time of the day or night. If hypoglycemia occurs, I need to take my
Regular insulin as prescribed. If I feel sweaty or shaky I might be experiencing hypoglycemia. I can drink 8 oz of 2% milk of hypoglycemia occurs. B
If a hypoglycemia reaction occurs, the client will need to consume 10 to 15 g of carbohydrate. Tremors and diaphoresis are signs of mild
hypoglycemia. Insulin will lower the blood glucose. Hypoglycemia reactions can occur at anytime of the day or night.

1038 A nurse is instructing a client with type 1 diabetes mellitus about management of hypoglycemic reactions. The nurse instructs the client that
hypoglycemia most likely occurs during what time interval after insulin administration? Onset Peak Duration Anytime B Insulin
reactions are most likely to occur during the peak time of the insulin, when the medication is at its maximum action. Peak action depends on the type of
insulin, the amount administered, the injection site, and other factors.

1039 A nurse is planning the discharge of a young, newly diagnosed male client with type 1 diabetes mellitus. The client tells the nurse that he is
concerned about self-administering insulin while in school with other students around. Which statement by the nurse best supports the client’s need at this time?
"You could contact the school nurse who could provide a private area for you to administer your insulin." "You could leave the school early
and take your insulin at home." "You shouldn’t be embarrassed by your diabetes. Lots of people have this disease." "Oh, don’t worry about that! You’ll
do fine!" A In planning this client’s role transition, the nurse functions in the role of a problem solver in assisting the client to adapt to his illness. In
option A the nurse offers information that addresses the client to reach a decision that optimizes a sense of well-being. Option A requires a change in lifestyle.
Options C and D are inappropriate statements and are similar in that they are both blocks to communication.
1040 A nurse is preparing to teach a client newly diagnosed with diabetes mellitus about blood glucose monitoring. The nurse plans to teach the client to
report glucose levels that exceed: 150mg/dL 200mg/dL 250mg/dL 350mg/dL C The client should be taught to report blood glucose levels that exceed
250 mg/dL, unless otherwise instructed by the physician. Options A and B are levels that do require physician notification. Option D is a high value.

1041 A nurse is reviewing home care instructions with an elderly client who has type 1 diabetes mellitus and a history of diabetic ketoacidosis (DKA).
The client’s spouse is present when the instructions are given. Which of the following statements, if made by the spouse, indicates that further teaching is
necessary? "If the grandchildren are sick they probably shouldn’t come to visit." "I should call the doctor if he has nausea and/or abdominal pain
lasting for more than 1 or 2 days." "If he is vomiting I shouldn’t give him any insulin." "I should bring him to the physician’s office if he develops
a cough." C Infection and stopping insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be
reported, because these signs may be indicative of DKA.

1042 A nurse provides home care instructions to a client with Cushing’s syndrome. The nurse determines that the client understands the hospital
discharge instructions if the client makes which of these statements? I need to eat foods low in potassium. I need to take aspirin rather than
Tylenol for a headache. I need to check the color or my stools. I need to check the temperature of my legs. C Cortisol stimulates the
secretion of gastric acid and this can result in the development of peptic ulcers and gastrointestinal bleeding. Potassium rich food should be encouraged to
correct hypokalemia that occurs in this disorder. Aspirin can increase the risk for gastric bleeding and skin bruising. Cushing ‘s syndrome does not affect
temperature changes in lower extremities.

1043 A nurse requests that a client with diabetes mellitus ask their significant other(s) to attend an educational conference on self-administration of
insulin. The client questions why significant others need to be included. The nurse’s best response would be: Client’s and families often work together to
develop strategies for the management of diabetes. Family members can take you to the doctor. Family members are at risk of developing diabetes.
Nurses need someone to call and check on a client’s progress. A Families and/or significant others may be included in diabetes
education to assist with adjustment to the diabetic regimen. Although option B and option C may be accurate, they are not the most appropriate response.
Option D devalues the client and disregards the issue of independence and promotes powerlessness.
1044 A client in a long-term facility had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon the client’s
return to the long-term-care facility, the priority nursing assessment should focus on: Level of consciousness Act tolerance Hydration
and nutrition status Comfort level C Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with
laxatives and enemas) prior to testing. In addition, the client is most often NPO prior to and during the testing period. Because the studies may be done over a
period exceeding 24 hours, the client may become dehydrated and/ or malnourished. Although options A, B and D may be components of the assessment,
option C is the priority.

1045 A client who is scheduled for an abdominal peritoneoscopy, states to the visiting nurse, “The doctor told me to restrict food and liquids for at least 8
hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?” Which of the
following is the most therapeutic response by the nurse? "Any invasive procedure brings risk with it. You need to report any shoulder pain
immediately." "There are relatively few problems, especially if you are having local anesthesia, but any bleeding should be reported immediately."
"Trouble? There is never any trouble with this procedure. That’s why the surgeon will use local anesthesia." "You seem to understand the
preparation very well. Are you having any concerns about the procedure?" D Abdominal peritoneoscopy is performed to directly visualize the liver,
gallbladder, spleen and stomach after the insufflation of nitrous oxide. During the procedure, a rigid laparoscope is inserted through a small incision in the
abdomen. A microscope in the endoscope allows visualization of the organs and provides a ways to collect a specimen for biopsy or to remove small tumors.
The most therapeutic response is the one that facilitates the client’s expression of feeling. Option B may increase the client’s anxiety. In option C, the nurse
states that there are no problems associated with this procedure. This is an absolute and is incorrect. Although option b contains accurate information, the word
immediately can increase the client’s anxiety.

1046 A client with a colostomy complaints to the nurse of appliance odor. The nurse recommends that the client take in which of the following
deodorizing foods? Yogurt Mushrooms Cucumbers Eggs A Foods that help to eliminate odor with a colostomy include
yogurt, buttermilk, spinach, beet greens, and parsley. Foods that cause odor are many, and include alcohol, beans, turnips, radishes, asparagus, onions,
cucumbers, mushrooms, cabbage, asparagus, eggs, and fish.

1047 A client with hiatal hernia asks the nurse for something to drink. The nurse offers the client which of the following items stocked in the nursing unit
kitchen? Tomato juice Orange juice Grapefruit juice Apple juice D Substances that are irritating to the client with
hiatal hernia include tomato products and citrus fruits, which should be avoided. Since caffeine stimulates gastric acid secretion, beverages that contain
caffeine, such as coffee, tea, cola and cocoa, are also eliminated from the diet.
1048 A home health care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the
client. Which of the following statements, if made by the client, indicates a need for further education? "I will take acetaminophen (Tylenol) if I get a
headache." "I will obtain adequate rest." "I do not need to restrict fat in my diet." "I should monitor my weight on regular basis." A
Tylenol is avoided, it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. Fat restriction is not
necessary and the diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000. The client’s weight should be monitored on a
regular basis.

1049 A home health nurse visits a client with a diagnosis of cirrhosis and ascites. The nurse provides dietary instructions and tells the client to:
Decrease fat intake Decrease carbohydrate intake Restrict calories to 1500/day Restrict sodium intake D If the client
has ascites, sodium and possibly fluids should be restricted in the diet. Fat restriction is not necessary. Total daily calories should range between 2000 and
3000. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The diet should provide ample protein to rebuild tissue but not
enough protein to precipitate hepatic encephalopathy.

1050 A nurse assesses a client who has nasogastric tube (NG) in place and connected to suction after abdominal surgery. Which
observation by the nurse indicates most reliably that the tube is functioning properly? The suction gauge reads low intermittent suction The distal
end of the NG tube is pinned to the client’s gown The client indicates that pain is a 3 on a scale of 1 to 10 The client denies nausea and has 250 mL of
fluid in the suction collection container D An NG tube connected to suction is used postoperatively to decompress and rest the bowel. The
gastrointestinal tract lacks peristaltic activity as a result of manipulation during surgery. Although the nurse makes pertinent observation of the tube to ensure
that it is secure and connected to suction properly, the client is assessed for the effect. The client should not experience symptoms of ileus (nausea and
vomiting) if the tube is functioning properly. A pain indicator of C is an expected finding in a postoperative client.

1051 A nurse caring for the client with hepatic encephalopathy assess for asterixis. To appropriately test for asterixis the nurse: Asks the client to extend
an arm, dorsiflex the wrist, and extend the fingers Checks the stools for clay-colored pigmentation Asks the client to sign his or her name on a
piece of paper and not for any deterioration in hand movements Reviews laboratory serum levels of bilirubin and alkaline phosphatase for elevation A
Asterixis is an abnormal muscle tremor often associated with hepatic Encephalopathy. Asterixis is sometimes called “liver flap.” Options B, C and
D are associated with hepatitis but are not signs of asterixis.

1052 A nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates correct cutting of the appliance by
making the circle how much larger than the client’s stoma? 1/6 inch 1/8 inch ¼ inch ½ inch B The size of the opening for the
application is generally cut 1/8 inch larger than the size of the client’s stoma. This minimizes the amount of exposed skin, but does not cause pressure on the
stoma itself. Option A is an extremely small size that would cause irritation to the stoma. Options C and D leave too much skin area exposed for possible
irritation by gastrointestinal contents.
1053 A nurse is giving instructions to a client with peptic ulcer disease about symptom management. The nurse tells the client to: Eat slowly
and chew food thoroughly Eat large meals to absorb gastric acid Limit the intake of water Use acetylsalicylic acid (aspirin) to relieve
gastric pain A The client with a peptic ulcer is taught to eat smaller, more frequent meals to help keep the gastric secretions neutralized. The
client should eat slowly and chew thoroughly to prevent excess gastric acid secretion. The client should consume fluids of 6 to 8 glasses of water per day to
dilute gastric acid. The use of aspirin is avoided, because it is irritating to gastric mucosa.

1054 A nurse is instructing a client with hepatitis about measures to control fatigue. The nurse avoids telling the client to: Plan rest periods after
meals Rest in-between activities Perform personal hygiene if not fatigued Complete all daily activities in the morning when the client is most
rested D A client with hepatitis has tremendous metabolic demands that lead to fatigue and interfere with activities of daily living (ADLs). The
nurse encourage ADLs unless they cause excessive fatigue. The client is advised to plan rest periods after activities, such as meals. Activities should be spaced
throughout the day with frequent planned rest periods. Clients who engage in excessive activity too early in the recover stage may experience a relapse.

1055 A nurse is providing dietary instruction to a client hospitalized for pancreatitis. Which of the following foods would the nurse instruct the client to
avoid? Lentil soup Bagel Chili Watermelon C The client needs to avoid alcohol, coffee and tea, spicy foods, and
heavy meals, which stimulate pancreatic secretions and produces attacks of pancreatitis. The client is instructed in the benefit of eating small frequent meals
that are high in protein, low in fat, and moderate to high in carbohydrates.

1056 A nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the
client understands when the tube will be removed in the postoperative period when the client states: "When my gastrointestinal (GI) system is healed."
"When I can tolerate food without vomiting." "When my bowels begin to function again, and I begin to pass gas." "When the
doctor says so." C NG tubes are discontinued when normal function returns to the GI tract. The tube will be removed before GI healing. Food
would not be administered unless bowel function returns. Although the physician determines when the NG tube will be removed, option D does not determine
effectiveness of teaching.

1057 During the admission assessment of a client admitted to the hospital for esophageal varices, the client says, “I deserve this. I brought it on myself.”
The nurse’s most appropriate response is: "Would you like to talk to the chaplain?" "Not all esophageal varices are caused by alcohol." "Is there
some reason you feel you deserve this?" "That is something to think about when you leave the hospital." C Ruptured esophageal varices are
often a complication of cirrhosis of the liver and the most common type of cirrhosis caused by chronic alcohol abuse. It is important to obtain an ashamed or
embarrassed, he or she may not respond accurately. Option C is open-ended and allows the client to discuss feelings about drinking. Option A blocks the nurse /
client communication process. Option B and D are somewhat judgmental.
1058 The husband of a client who has Sengstaken-Blakemore tube state to the nurse, “I thought having this tube down her nose the first time would
convince my wife to quit drinking.” The most appropriate response by the nurse is: "Alcoholism is a disease that affects the whole family." "You sound
frustrated in dealing with your wife’s drinking problem." "Have you discussed this subject at the ‘Al-Anon meetings?" "I think you are a good
person to stay with your wife." B In option B, the nurse uses the therapeutic communication techniques of clarifying and focusing in assisting the
client (the husband) to express feelings concerning the wife’s chronic illness. Stereotyping (option A), changing the subject (option C), and showing approval
(option D) are nontherapeutic techniques and block communication.

1059 A client who is to be discharged to home with a temporary colostomy, says to the nurse, “I know I’ve changed this once but I just don’t know how
I’ll do it by myself when I’m home alone. Can’t I stay here until the doctor puts it back?” Which of the following is the most therapeutic nursing response?
"So you’re saying that while you’ve practiced changing your colostomy bag once, you don’t feel comfortable on your own yet?" "Well, your
insurance will not pay for a longer stay just to practice changing your colostomy so you’ll have to fight it out with them." "Going home to care for yourself
still feels pretty overwhelming? I will schedule you for home visits until you’re feeling more comfortable." "This is only temporary but you need to hire a
nurse companion until your surgery." C The client is expressing feelings of fear and helplessness. Option C assists in meeting this need. Option
A is restating, but this response could cause the client to feel more helpless because the client’s fears are reflected back to the client. Option B provides what is
probably accurate information but the words just to practice can be interpreted by the client as belittling. Option D provides information that the client already
knows and then problem solves by using a client-centered action, which would probably overwhelm the client.

1060 A client who recently had a gastrostomy feeding tube inserted refuses to participate in the plan of care, will not make eye contact, and does not speak
to the family or visitors. The nurse assesses that the client is using which type of coping mechanism? Self-control Problem solving Accepting
responsibility Distancing D Self-control is demonstrated by stoicism and hiding feelings. Problem solving involves making plans and
verbalizing what will be done. Accepting responsibility places the responsibility for a situation on one’s self. Distancing is an unwillingness or inability to
discuss events.

1061 A postoperative client has been vomiting, has absent bowel sounds, and paralytic ileus has been diagnosed. The physician orders insertion of a
nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, “I’m not sure I can take any
more of this treatment.” The most appropriate response by the nurse is: "It is your right to refuse any treatment. I’ll notify the physician." "You are
feeling tired and frustrated with your recovery from surgery?" "If you don’t have this tube put down, you will just continue to vomit." "Let’s just put
the tube down so you can get well." B In option B, the nurse uses empathy. Empathy, comprehending and sharing a client’s frame of reference
constitute an important component in a nurse-client relationship. They assist clients to express and explore feelings, which can lead to problem solving. The
other options are examples of barriers to effective communication including defensiveness (option A), showing disapproval (option C), and stereotyping (option
D).

1062 A 22-year-old woman has recently been diagnosed with polycystic kidney disease. A nurse has a series of discussions with the client, which are
intended to help her adjust to the disorder. The nurse plans to include which of the following items as part of these discussions? Ongoing fluid restriction
Depression about massive edema Risk of hypotensive episodes Needs for genetic counseling D Adult polycystic kidney disease is a
hereditary disorder that is inherited as an autosomal dominant trait. Because of this, the client should have genetic counseling, as should the extended family.
The client is likely to have hypertension, not hypotension. Massive fluid restriction is unnecessary.
1063 A client diagnosed with cancer of the bladder has nursing diagnosis of “Fear related to the uncertain outcome of the upcoming cystectomy and
urinary diversion.” The nurse assesses that this diagnosis still applies if the client makes which of the following statements? "I’m so afraid I won’t
live through all this." "What if I have no help at home after going through this awful surgery?" "I’ll never feel like myself if I can’t go to the bathroom
normally." "‘I wish I’d never gone to the doctor at all.’" A For fear to be an actual diagnosis, the client must be able to identify the object of fear. In
this question, the client is expressing a fear of death related to cancer. The statement in option B reflects risk for impaired home maintenance management.
Option C reflects body image disturbance. Option D is vague and nonspecific. Further exploration would be required to associate the statement in option D with
a nursing diagnosis.

1064 A client has urinary calculi composed of uric acid. The nurse is teaching the client dietary measures to prevent further development of urolithiasis.
Which of the following statements would indicates that the client understands these dietary measures? I would avoid milk and dairy products. I
would avoid foods, such as spinach, chocolate and tea. I would avoid foods, such as fish with fine bones and organ meats. I need to drink cranberry juice. C
With a uric acid stone, the client should limit intake of foods high in purines. Organs meats, sardines, herring, and other high-purine foods are
eliminated from the diet. Foods with moderate levels of purines, such as red and white meats and some seafood, are also limited. Options A and B are
recommended dietary changes for calculi composed of calcium phosphate to calcium oxalate. Cranberry juice is commonly recommended to help lower the pH
of urine, rendering it more acid to prevent the development of urinary tract infections. However, uric acid stones form most readily in acid urine, and cranberry
juice would be contraindicated in this client with uric acid stone formation.

1065 A client who has been diagnosed with chronic renal failure has been told that hemodialysis will be required. The client becomes angry and
withdrawn, and states, “I’ll never be the same now.” The nurse formulates which of the following nursing for this client? Altered Thought Disturbance
Body Image Disturbance Anxiety Noncompliance B A client with a renal disorder, such as renal failure, may become
angry and depressed due to the performance of the alternation. Due to the physical change in lifestyle that may be required to manage a severe renal condition,
the client may experience Body Image Disturbance. Anxiety is not appropriate because the client is able to identify the cause of concern. The client is not
cognitively impaired (option A) or stating refusal to undergo therapy (option D).

1066 A client who has never been hospitalized before is having trouble initiating the stream of urine. Knowing that there is no pathological reason for this
difficulty, the nurse avoids which of the following as the least helpful method of assisting the client? Running top water in the sink Instructing the client to
pour warm water over the perineal area Assisting the client to a commode behind a closed curtain Closing the bathroom door and instructing the
client to pull the call bell when done C Lack of privacy is a key issue that may inhibit the ability of the client to void in the absence of known
pathology. Using a commode behind a curtain may inhibit voiding in some people. Use of a bathroom is preferable, and may be supplemented with the use of
running water, or pouring water over the perineum as needed.

1067 A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. The client is very shy and modest. The nurse interprets that this
client would be most likely benefit from increased support and teaching about the procedure because: Radiopaque contrast is injected into the
bloodstream Radioactive material is inserted into the bladder The client must lie on an x-ray table in a cold, barren room The client
must void while the voiding process is filmed D Having to void in the presence of others can be very embarrassing for clients, and may
actually interfere with the client’s ability to void. The nurse teaches the client about the procedure to try to minimize stress from lack of preparation, and gives
the client encouragement and emotional support. Screens may be used in the radiology department to try to provide an element of privacy during this procedure.
1068 A client with acute renal failure (ARF) is having trouble remembering information and instructions as a result of altered laboratory values. The nurse
avoids doing which of the following when communicating with this client? Giving simple, clear directions Explaining treatments using understandable
language Including the family in discussions related to care Giving thorough, complete explanations of treatment options D The client
with ARF may have difficulty remembering information and instructions due to anxiety and due to altered laboratory values. Communications should be clear,
simple, and understandable. The family is included whenever possible. It is the physician’s responsibility to explain treatment options.

1069 A client with chronic renal failure is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of
hemodialysis treatments. The nurse’s response is based on an understanding that the typical schedule is: 5 hours of treatment 2 days/week 3 to 4 hours
of treatment 3 days/week 2 to 3 hours of treatment 5 days/week 2 hours of treatment 6 days/week B The typical schedule for
hemodialysis is 3 to 4 hours of treatment 3 days per week. Individual adjustments may be made according to variables, such as the size of the client, type of
dialyzer, the rate of blood flow, personal client preferences, and others.

1070 A client with nephrotic syndrome asks the nurse, “Why should I even bother trying to control my diet and edema? It doesn’t really matter what I do,
if I can never get rid of this kidney problem anyway!” The nurse selects which of the following most appropriate nursing diagnoses. Powerlessness
Ineffective individual coping Anxiety Body image disturbance A Powerlessness is used when the client believes that
personal actions will not affect an outcome in any significant way ineffective individual coping is used when the client has impaired adaptive abilities or
behaviors in meeting the demands or roles expected. Anxiety is used when the client has a feeling of unease when there is an alteration in the way the client
perceives body image.

1071 A client with nephrotic syndrome needs dietary teaching about how diet can help counteract the effects of altered renal function. The nurse plans to
include which of the following statements in instructions to the client? Plan to drink at least 10 to 12 glasses of water a day. Add salt during cooking
to replace sodium lost in the urine. Increase your intake of fish, meat, and eggs. Increase your intake of fatty foods to prevent protein loss. C
The client with nephrotic syndrome is limited in sodium. This is done to help control edema, which is a predominant part of the clinical picture.
Fluids are not limited unless hyponatremia is present. On the other hand, the client is not encouraged to force fluids. Protein is increased, unless the glomerular
filtration rate is impaired. This helps to replace protein lost in the urine, and ultimately helps in controlling edema also. A part of the clinical picture in
nephritic syndrome is hyperlipidemia, which results from the liver’s synthesis of lipoproteins in response to hypoalbuminemia. Increasing fatty food intake
would not be helpful in this circumstance.

1072 A client with nephrolithiasis arrives at the clinic for a follow-up visit. The laboratory analysis of the stone that the client passes 1 week ago indicates
that the stone is composed of calcium oxalate. Based on this analysis, the nurse tells the client to avoid. Lentils Spinach Lettuce Pasta B
Many kidney stones are composed of calcium oxalate. Food that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate,
wheat bran, nuts, beets, and tea.

1073 A client with pyelonephritis is being discharged from the hospital. The nurse provides the client with discharge instructions to prevent recurrence.
The nurse determines that the client understands the information that was given if the client states an intention to: Report signs and symptoms of
urinary tract infection (UTI) if they persist for more than 1 week Take the prescribed antibiotics until all symptoms subside Return to the physician’s
office for scheduled follow-up urine cultures Modify fluid intake for the day based on the previous day’s output C The client with pyelonephritis
should take the full course of antibiotic therapy that has been prescribed, and return to the physician’s office for follow-up urine cultures if so instructed. The
client should learn the signs and symptoms of UTI, all measures that are used to prevent cystitis, which includes forcing fluids to 3 liters per day.
1074 A home care nurse has given instructions to a female client with cystitis about measures to prevent recurrence. The nurse determines that the client
needs further instruction if the client verbalizes an intention to: Take bubble baths for more effective hygiene Wear underwear made of cotton or
with cotton panels Drink a glass of water and void after intercourse Avoid wearing pantyhose while wearing slacks A Measures to
prevent cystitis include increasing fluid intake 3L/day eating an acid-ash diet; wiping front to back after urination; taking showers instead of tub baths; drinking
feminine hygiene sprays, or perfumed toilet tissue or sanitary pads; and wearing clothes that “breathe” (cotton pants, no tight jeans, no pantyhose under slacks).
Other measures include teaching pregnant women to void every 2 hours, and teaching menopausal women to use estrogen vaginal creams to restore vaginal pH.

1075 A nurse has given instructions to a client with chronic renal failure about reducing pruritis from uremia. The nurse evaluates that the client needs
further information if the client states to use which of the following items for skin care? Mild soap Oil in the bath water Alcohol cleansing pads
Lanolin-based lotion C The client with chronic renal failure often has dry skin, accompanied by itching (pruritis) from uremia. The client
should use mild soaps, lotions, and bath water oils to reduce dryness without increasing skin irritation. Products that contain perfumes or alcohol increase
dryness and pruritis and should be avoided.

1076 A nurse has completed client teaching with a hemodialysis client about self monitoring of fluid status between hemodialysis treatments. The nurse
determines that the client best understands the information given if the client states to record which of the following on a daily basis? Pulse and respiratory
rate Intake and output and weight Blood urea nitrogen and creatinine levels Activity log B The client on hemodialysis should
monitor fluid status between hemodialysis treatments. This can be done by recording intake and output, and measuring weight on a daily basis. Ideally, the
hemodialysis client should not gain more than 0.5 kg of weight per day. Options A, C and D are not necessary.

1077 A nurse has completed instruction on diet and fluid restriction for the client with chronic renal failure. The nurse would evaluate that the client best
understands the information presented if the client selected which of the following desserts from the dietary menu? Angel food cake Ice cream
Sherbet Jell-O A Dietary fluid includes anything that is liquid at room temperature. This includes items such a ice cream, sherbet,
and Jell-O. With clients on a fluid restricted diet, it is helpful to avoid “hidden” fluids to whatever extent is possible. This allows the client more fluid for
drinking, which can help alleviate thirst.

1078 A nurse has given a client with a nephrostomy tube instructions to follow after hospital discharge. The nurse determines that the client understands
the instructions if the client verbalizes to drink at least how many glasses of water per day? 2 to 4 6 to 8 10 to 12 14 to 16 B
The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus, and to provide good
mechanical flushing of the kidney and tube. The nurse encourages the client to take in at least 2000 mL of fluid per day, which is an inadequate amount.
Options C and D are amounts that could distend the renal pelvis.
1079 A nurse has performed a nutritional assessment on a client with cystitis. The nurse tells the client to consume which of the following beverages to
minimize recurrence of cystitis? Coffee Tea Water White wine C Caffeine and alcohol can irritate the bladder. Therefore,
alcohol and caffeine containing beverages such as coffee, tea, and cocoa are avoided to minimize risk. Water helps flush bacteria out of the bladder, and an
intake of 6 to 8 glasses per day is encouraged.

1080 A nurse is admitting a client to the hospital who is to undergo ureterolithotomy for urinary calculi removal. The nurse understands that is
unnecessary to assess which of the following in determining the client's readiness for surgery? Understanding of the surgical procedure Knowledge
of postoperative activities Feelings or anxieties about the surgical procedure Need for a visit from a support group D
Ureterolithotomy is removal of a calculus from the ureter using either a flank or abdominal incision. Since there is no urinary diversion created
during this procedure, the client has no need for a visit from a member of a support group. The client should have an understanding of the same items as for any
surgery, which includes knowledge of the procedures, expected outcome, and postoperative for any concerns or anxieties before surgery.

1081 A nurse is caring for a client following prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation
(CBI). The nurse determines that the flow rate is adequate if the urinary drainage is: Red Concentrated yellow Clear as water Slightly pink
D The bladder irrigant is not infused at a preset rate, but rather the rate is increased or decreased to maintain urine that is a clear pale yellow
color, or that has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored (red) or if clots are seen. Correspondingly, the
rate can be slowed down slightly if the returns are as clear as water.

1082 A nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). The nurse determines that which of the
following is a priority in the postprocedure care of this client? Encouraging increased intake of oral fluids Ambulating the client in the hallway
Encouraging the client to try to void frequently Maintaining the client on bed restA After IVP, the client should take in increased
fluids to aid in clearance of the dye used for the procedure. It is unnecessary to void frequently after the procedure. The client is usually allowed activity as
tolerated, without any specific activity guide lines.

1083 A nurse is evaluating the effects of care for a client with nephrotic syndrome. The nurse determines that the client showed the least amount of
improvement if which of the following information was obtained serially over 2 days of care? Initial weight 208 pounds, down to 203 pounds
Daily intake and output record of 2100 mL intake and 1900 mL output, and 2000 mL intake and 2900 mL output Blood pressure 160/90
mm Hg down to 140/80mm Hg Serum albumin 1.9 g/dL up to 2.0 g/dL D The goal of therapy in nephritic syndrome is to heal the leaking
glomerular membrane. This would then control edema by stopping the loss of protein in the urine. Fluid balance and albumin levels are monitored to determine
the effectiveness of therapy Option A represents a loss of fluid that slightly exceeds 2 liters and represents a significant improvement. Option B represents a
total fluid loss of 700 mL over the 2 days, which is also helpful. Option C show improvement because both symbolic and diastolic blood pressures are lower.
The least amount of improvement is in the serum albumin level, since the normal albumin level is 3.5 to 5.0 g/dL.
1084 A nurse is giving a client with polycystic kidney disease instructions in replacing elements lost in the urine as a result of impaired kidney function.
The nurse instructs the client to increase intake of which of the following in the diet? Sodium and potassium Sodium and water Water and
phosphorus Calcium and phosphorus B Clients with polycystic kidney disease waste sodium rather than retain it, and therefore need
an increase in sodium and water in the diet. Potassium, calcium, and phosphors need no special attention.

1085 A client has an initial positive result of an enzyme-linked immunosorbent essay (ELISA) test for human immunodeficiency virus (HIV). The client
begins to cry, and asks the nurse what this means. the nurse is able to provide support to the client by using knowledge that:The client is HIV positive, but the
disease has been detected early The client is HIV positive, but the client’s CD4 cell count is high There is a high rate of false-positive result with this test,
and more testing needed before diagnosing the client’s status as HIV positive There are occasional false-positive readings with this test, which can be cleared
up by repeating it C If the client’s test results are positive with the ELISA, the test is repeated. If the results are positive a second time, the Western
blot (a more specific test) is done to confirm the finding. The client is not diagnosed as HIV positive unless result pf the Western blot test are positive. (Some
laboratories also run the Western blot a second time with a new specimen before making a final determination.) the ELISA is fast and relatively inexpensive,
but it carries a high false-positive rate. This is because it is not a specific, although it is a very sensitive test.

1086 A client with acquired immunodeficiency syndrome (AIDS) gets recurrent Candida infections (thrush) of the mouth. The nurse has given
instructions to the client to minimize the occurrence of thrush, and evaluates that the client understands the materials if which of the following statements is
made by the client? I should brush my teeth and rinse my mouth once a day. I should used a strong mouthwash at least once a week. Increasing red meat in
my diet will keep this from recurring. Eating 8 oz of yogurt that contains live cultures helps to control this. D Candida infections can
be controlled by eating 8 oz of yogurt that contains live cultures (Lactobacillus acidophilus). Careful routine skin and mouth care are also helpful in preventing
recurrence. Red meat will not prevent thrush. In options A and B the timeframes for oral hygiene are too infrequent.

1087 A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Altered Nutrition: Less Than Body Requirements. The nurse
has instructed the client about methods to maintain and increase weight. The nurse determines that the client would benefit from further instruction if the client
states: Eat low-calorie snacks between meals Eat small, frequent meals throughout the dayConsume nutrient-dense foods and beverages
Keep easy-to-prepare foods available in the home B The client should eat small, frequent meals throughout the day. The client also
should take in nutrient-dense and high-calorie meals and snacks. The client is encouraged to eat favorite foods to keep intake up, and plan meals that are easy
to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in.

1088 A client with acquired immunodeficiency syndrome (AIDS) is being treated for tuberculosis with isoniazid (INH). The nurse plans to teach the client
which of the following regarding the administration of the medication? Administer with an antacid to prevent gastrointestinal (GI) distress Administer at
least 1 hour before administering an aluminum containing antacid to prevent a medication interaction Administer with food to prevent rapid
absorption of INH Administer with a corticosteroid to potentiate the effects of INH B Aluminum hydroxide, a common ingredient in antacids,
significantly decreases INH absorption. INH should be administered at least 1 hour before aluminum-containing antacids. Food affects the rate of absorption of
rifampin (Rifadin), not INH. INH administration with a corticosteroid decreases INH’s effects and increases the corticosteroids effects.
1089 A client with acquired immunodeficiency syndrome (AIDS) shares with the nurse feelings of social isolation since the diagnosis was made. The
nurse plans to suggest which of the following strategies as the most useful way to decrease the client’s stated loneliness? Using the internet on the computer
to facilitate communication Use of the television and newspapers to maintain a feeling of being in touch with the world Contacting a support
group available in the local region for client with AIDS Reinstituting contact with the client’s family, who live in a distant city C The nurse
encourages the client to maintain social contact and support, and assists the client in reducing barriers to social contact. This can include education the client’s
family about the disease and transmission, and suggesting utilization of community resources and support groups. Options A and B will not decrease the client’s
loneliness. Option D, although feasible, is a solution that is less likely to address the client’s current feeling of loneliness

1090 A nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse instructs the client to
avoid acquiring infection from food by avoiding which of the following items? Raw oysters Pasteurized milk Products with sorbitol
Bottled water A The client is taught to avoid raw or undercooked seafood, meat, poultry, and eggs. The client should be also avoid
unpasteurized milk and dairy products. Fruits that the client peels are safe, as are bottled beverage. The client may be taught to avoid sorbitol, but this is to
diminish diarrhea, and has nothing to do with food bone illnesses.

1091 A prenatal client has been told during a physician office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was
significantly distressed regarding this news. Which of the following nursing diagnoses would these data best support? Pain Noncompliance
High Risk for Infection Anticipatory Grieving D A life-threatening diagnosis such as HIV will stimulate the anticipatory grief
response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important
changes in her life, frequently resulting form inability to achieve life goals.

1092 A clinic nurse reads the chart of a client who was seen by a physician and notes that the physician has documented that the client has Lyme disease,
stage III. On assessment of the client, which of the following clinical manifestations would the nurse expect to note? A generalized skin rash A
cardiac dysrhythmia Enlarged and inflamed joints Palpitations C Stage III develops within a month to several months after initial
infection. It is characterized by arthritic symptoms, such as arthralgias and enlarged or inflamed joints, which can persist for several years after the initial
infection. Cardiac and neurological dysfunction occurs in stage. A rash occurs in stage I.

1093 A nurse is caring for a client with a burn injury who has sustained thoracic burns and smoke inhalation, and is at risk for Impaired Gas Exchange.
The nurse avoids which of the following actions in caring for this client? Reposition the client from side to side every 2 hours Position the client on the
bank with the head of the bed at a 45-degree angle only Suction the airway PRN Provide humidified oxygen and incentive spirometry B
Aggressive pulmonary measures are used to prevent respiratory complications in the client who has Impaired Gas Exchange as a result of a burn
injury. These include turning and repositioning, positioning for comfort, using humidified oxygen, providing incentive spirometry, and suctioning the client on
an as needed basis. This will ultimately lead to atelectasis and possible pneumonia.
1094 A client has been experiencing muscle weakness over a period of several months. The physician suspects polymyositis. Which statement, if made
by the client, correctly identifies a confirmation of test results and this diagnosis? "The physicians said if the muscle fibers were thickened, I would
have polymyositis." "If I have polymyositis, there will be a decrease in elastic tissue." "I will know I have polymyositis if the muscle fibers are inflamed."
"The physicians said there would be more fibers and tissue with polymyositis." C In polymyositis, necrosis and inflammation is
seen in muscle fibers and myocardial fibers. Options A is an opposite of what is noted in this disorder. Options B refers to the decreased elastic tissue in the
aorta seen in Marfan’s syndrome. Options D refers to increased fibrous tissue seen in ankylosis.

1095 A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the
following nursing diagnoses for this client? Diversional Activity Deficit Powerlessness Self-Care Deficit Impaired Physical Mobility A
A major defining characteristic of Diversional Activity Deficit is expression of boredom by the client. The question does not identify difficulties
with coordination, range of motion, or muscle strength, which would indicate Impaired Physical Mobility. The question also does not identify client feelings of
inability to perform activities of daily living (Self-Care Deficit) or lack of control (Powerlessness).

1096 A client is fearful about having an arm cast removed. Which of the following actions by the nurse would be the most helpful? Telling the
client that the saw makes a frightening noise Reassuring the client that no one had an arm lacerated blades Stating that the hot cutting blades have rarely
caused burns Showing the client the cast cutter and explaining how it works D Clients may be fearful of having a cast removed because if
the cast-cutting blade. The nurse should show the cast cutter to the client before it is used, and explain that the client may feel heat, vibration, and pressure. The
cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw, but instead cuts the
cast by vibrating side to side. Options A, B, and C are inappropriate and may increase the client’s fear.

1097 A client with right-sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:
Left hand, and placing the cane in front of the left foot Right hand, and placing the cane in front of the right foot Left hand, and 6 inches
lateral to the left foot Right hand, and 6 inches lateral to the right foot C The client is taught to hold the cane on the opposite side of the
weakness. This is because, with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the
fifth toe.

1098 A client with several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg,
which is very edematous. The nurse formulates which of the following nursing diagnoses for the client? Body Image Disturbance Activity
Intolerance Risk for Impaired Physical Mobility Social Isolation A The client is at risk for Body Image Disturbance related to
a change in the structure and function of the affected leg. These are no data in the question to support a diagnoses f (actual) Activity Intolerance or Social
Isolation. The client has an actual (not a risk for) Impaired Mobility because of the fixation device.
1099 A client with a compound fracture of the radius has a plaster of Paris cast applied in the emergency room. The nurse provides discharge
instructions and instructs the client to seek medical attention if which of the following occurs? The cast feels heavy and damp after 24 hours of
applicationNumbness and tingling occur in the fingers Any bloody drainage is noted on the cast during the first 6 hours after application If the entire
cast feels warm in the first 24 hours after application B A limb encased in a cast is at risk for nerve damage and diminished circulation from
increased pressure due to edema. Signs of increased pressure from the cast include numbness tingling, and increased pain. A plaster of Paris can take up to 48
hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.

1100 A female client with a long leg cast has been using crutches to ambulate for 1 week. She comes to the clinic with complaints of pain, fatigue, and
frustration with crutch walking. She states, “I feel like I have a crippled leg.” Which of the following responses by the nurse is most appropriate? "I know how
you feel; I had to use crutches before, too." "Just remember, you’ll be done with the crutches in another month." "Why don’t you take a couple of
days off work and rest." "Tell me what is bothersome for you." D Option D is the therapeutic communication technique of clarification
and validation and indicates that the nurse is dealing with the client’s problem from the client’s perspective. Option A devalues the client’s feelings and thus
blocks communication. Option B provides false reassurance because the client may not be done with the crutches in another month. In addition, it does not
focus on the present problem. Option C gives advise and is a communication block.

1101 A home care nurse is visiting a client who is in a body cast. The nurse is performing an assessment, including the psychosocial adjustment of the
client to the cast. In this regard, the nurse would most appropriately assess for: The type of transportation available for follow-up care The ability to perform
activities of daily living The need for sensory stimulation The amount of home care support available C A psychosocial assessment of a
client who is immobilized would most appropriate include the need for sensory stimulation. This assessment should also include such factors as body image,
past and present coping skills, and the coping methods used during the period of immobilization. Although transportation, home care support, and the ability to
perform activities of daily living are components of an assessment, they are not as specifically related to psychosocial adjustment, as is the need for sensory
stimulation.

1102 A nurse has given instructions to a client returning home following an arthroscopy of the knee. The nurse determines that the client understands the
instructions if the client stated to: Stay off entirely for the rest of the day Resume strenuous exercise the following day Refrain from eating food
for the remainder of the day Report fever or site inflammation to the physician D After arthroscopy, the client can usually carefully on the
leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and
symptoms of infection should be reported to the physician.

1103 A nurse has developed a plan of care for a client who is in traction and documents a nursing diagnosis of Self-Care Deficit. The nurse evaluates the
plan of care and determines that which of the following observations indicates a successful outcome?The client allows the nurse to complete the care on a daily
basis The client allows the family to assist in the care The client refuses care The client assists in self-care as much as possible D
A successful outcome for the nursing diagnosis of Self-Care Deficit for the client to do as much of the self-care s possible. The nurse should
promote independence in the client and allow the client to perform s much self-care as is optimal, considering the client’s condition. The nurse would
determine that the outcome is unsuccessful if the client refused care or allows others to do the care.
1104 A nurse has given the client with nonplaster (fiberglass) leg cast instructions on cast care at home. The nurse determines that the client needs further
instruction if the client makes which of the following statements? "I should avoid walking on wet, slippery floors." "It’s OK to wipe dirt off the top of
the cast with a damp cloth." "I’m not supposed to scratch the skin underneath the cast." "If the cast gets wet, I can dry it with a hair dryer turned to
the warmest setting." D The client is instructed to avoid walking on wet, slippery floors to prevent falls. Surface soil on a cast may be removed with a
damp cloth. If the cast get wet, it can be dried with a hair dryer set to a cool setting. If the skin under the cast itches, cool air from a hair dryer may be used to
relieve it. The client should never scratch under a cast due to the risk of skin breakdown and infection.

1105 A nurse has provided dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the
recommended changes if the client verbalized to increased intake of which foods? Rice Yogurt Sardines Chicken B The major
dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium may also added to certain products, such as orange
juice, which are then advertised as being ‘fortified’ with calcium. Calcium supplements are available and recommended for those with typically low calcium
intake, Rice, sardines, and chicken are not high calcium foods.

1106 A nurse has taught a client with a below-the-knee amputation about prosthesis and stump care. The nurse determines that the client has understood
the instructions if the client stated an intention to: Wear a clean nylon stump sock every day Toughen the skin of the stump by rubbing it with alcohol
Prevent cracking of the skin of the stump by applying lotion daily Use a mirror to inspect all areas of the stump each day D The client
should wear a clean woolen stump stock each day. The stump is cleaned daily with a gentle soap and water, and is dried carefully. Alcohol is avoided, because
it could cause drying or cracking of the skin. Oils and creams are also avoided, because they are too softening to the skin for safe prosthesis use. The client
should inspect all surfaces of the stump daily for irritation, blisters, or breakdown.

1107 A nurse is ambulating a client with a right leg fracture who has an order for partial weight-bearing status. The nurse determines that the client
demonstrates compliance with this restriction if the client: Does not bear weight on the right leg Allows the right leg to touch the floor only
Puts 30% to 50% of the weight on the right leg Puts 60% to 80% of the weight on the right leg C The client who has
partial weight-bearing status places 30% to 50% of the body weight on the affected limb. Full weight-bearing status is placing full weight on the limb. Non-
weight-bearing status does not allow the client to let the limb touch the floor. Touch-down weight-bearing allows the client to let the limb touch the floor, but
not bear weight. There is no classification for 60% to 80% weight-bearing status.

1108 A nurse is caring for a client who is scheduled for a diagnostic test requiring the use of a contrast medium. Which of the following actions by the
nurse has the highest priority? Determining the presence of client allergies Telling the client that frequent ambulation will be required during the procedure
Asking if the client has any last minute questions Telling the client to try to move the bowels before leaving the unit A Because of
the risk of allergy to contrast medium, the nurse places highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse
reinforces information about the test and reminds the client that he or she will most likely need to remain still during the procedure. There is no special need to
ensure that the bowel is empty before the procedure, but it is helpful to have the client void before the procedure for comfort.
1109 A nurse is conducting a health screening clinic for osteoporosis. The nurse determines that which of the following clients seen in the clinic is at
greatest risk of developing this disorder? A 36-year-old man who has asthma A 25-year-old woman who jogs A sedentary 65-year-old woman
who smokes cigarettes A 70-year-old man who consumers excess alcohol C Risk factors for osteoporosis include being female,
postmenopausal, of advanced age, low calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids,
anticonvulsants, and furosemide (Lasix) also increases the risk.

1110 A nurse is developing a plan of care for a client in Buck’s traction regarding measures to prevent complications. The nurse determines that the
priority nursing diagnosis to be included in the plan is which of the following?Diversional Activity Deficient related to bed rest Self-Care Deficit related
to the need for traction Impaired Physical Mobility related to traction Potential for infection at pin sites C The priority nursing
diagnosis for the client in Buck’s traction is Impaired Physical Mobility. Options A and B may also be appropriate for the client in traction, but immobility
presents the greatest risk for the development of complications. Buck’s traction is a skin traction, and there are no in sites.

1111 A nurse is developing a plan of care for a client with a hip spica cast. In the planning, the nurse includes measures to limit complications of
prolonged immobility. The nurse includes which essential item in the plan to prevent this complication? Provide a daily fluid intake of 1000 mL
Monitor for signs of low serum calcium Maintain the client in a supine position Limit the intake of milk and milk products D
Daily fluid should be 2000 mL or greater. The nurse should monitor for signs and symptoms of hypercalcemia, such as nausea, vomiting,
polydipsia, polyuria, polyuria and lethargy. A supine position increases urinary stasis; therefore it should be limited or avoided. Limiting milk and milk
products is the best measure.

1112 A nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which of the following items would the nurse consider to
be most helpful for this client? Television Reading materials Overhead trapeze Fracture bedpan C The use of overhead trapeze is
extremely helpful in assisting a client to move about in bed, and to get on and off the bedpan. This device has the greatest value in increasing overall bed
mobility. A fracture bedpan is useful in reducing discomfort with elimination. Television and reading materials are helpful in reducing boredom and providing
distraction.

1113 A nurse is planning to teach a client with a below-the-knee amputation about skin care to prevent breakdown. Which of the following points would
the nurse include while developing the teaching plan? A stump sock must be worn at all times and changed twice a week The residual limb (stump) is washed
gently and dried every other day The socket of the prosthesis is washed with a harsh bactericidal agent daily The socket of the prosthesis must be dried
carefully before using it D A stump sock must be worn at all times to absorb perspiration and is changed daily. The residual limb is washed
dried, and inspected for breakdown twice each day. The socket of the prosthesis is cleansed with a mild detergent, and rinsed and dried carefully each day. A
harsh bactericidal agent would not be used.
1114 A nurse is providing care to a client after a bone biopsy. Which of the following actions would the nurse take as part of aftercare for this procedure?
Keep the area in a dependent position Monitor vitals signs once per day Monitor the site for swelling, bleeding, or hematoma formation
Administer intramuscular narcotic analgesics C Nursing care after bone biopsy includes monitoring the site for swelling,
bleeding, or hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours of 24 hours. The
client usually requires mild analgesics, more severe pain usually indicates that complication are arising.

1115 A nurse is teaching a client how to stand on crutches. The nurse tells the client to place the crutches: 8 inches to the front and side of the toes 3
inches to the front and side of the toes 20 inches to the front and side of the toes 15 inches to the front and side of the toes A The classic
tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the side of the
client’s toes, depending on the client’s body size. This provides a wide enough base of support to the client and improves balance.

1116 A nurse provides discharge instructions to a client with rheumatoid arthritis (RA). The instructions focus on measures to lessen discomfort and
provide joint protection and the nurse tells the client to: Change position every hour Lift items rather than sliding them Perform prescribed
exercises even if the joints are inflamed Avoid stooping, bending, or overreaching D The client with RA should avoid remaining in one position
and should change positions or stretch every 20 minutes. To reduce efforts by joints, the client’s should slide objects rather than lift them. The client should
avoid exercises and activities other than gentle range of motion when the joints are inflamed. The client is instructed to avoid stooping, bending or
overreaching.

1117 A nurse provides home care instruction to a client with multiple sclerosis (MS). The nurse tells the client to: Avoid pregnancy Restrict fluid
intake to 1000 mL/day Maintain a low-fiber diet Avoid taking hot baths or showers D Because fatigue can be precipitated
b warm temperatures, the client is instructed to take cool baths and maintain a adequate fluid intake of 2000 mL. Daily is encouraged to prevent alteration in
elimination and bowel patterns. The client should not be told to avoid decisions regarding pregnancy.

1118 A nurse receives a telephone call from the emergency room and is told that a client in leg traction will be admitted to the nursing unit. The nurse
prepares for the arrival of the client and asks a certified nursing assistant to obtain which of the following items that will be essential for helping the client move
in bed while in the leg traction? An electric bed A bed trapeze Extra pillows A foot board B A trapeze is essential to
allow the client to lift straight up while being moved, so that the amount of pull exerted on the limb in traction is not altered. Either an electric bed or a manual
bed can be used for traction but does not specifically assist the client to move in bed. A foot board and extra pillows do not facilitate moving.
1119 A nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client’s arm may be broke. Which action
would the nurse take as the highest priority before moving the client? Tell the client that there is no permanent damage Immobilize the arm
Take a set of vital signs Call the radiology department B When a fracture is suspected, it is imperative that the area is splinted
before the client is moved. Emergency help should be called for if the client is external to a hospital, and a physician is called if the client is hospitalized. The
nurse should remain with the client and provide realistic reassurance. The client would not be told that there is no permanent damage.

1120 A nurse teaches a client preparing for discharge from the hospital about home care measures following a total hip replacement. Which of the
following statements, if made by the client, would indicate a need for further education? I need to place a pillow between my knees when I lie down. I
need to wear a support stocking on my unaffected leg. I should not sit in one position for longer than 4 hours. I cannot drive a car for 6 weeks. C
The client needs to be instructed not to sit continuously for longer than 1 hour. The client should be instructed to stand, stretch, and take a few steps
periodically. The client cannot drive a car for 6 weeks after surgery unless allowed by a physician. A support stocking should be worn on the unaffected leg
and an Ace bandage on the affected leg until there is no swelling in the legs and feet, and until full activities are resumed. The legs are abducted by placing a
pillow between then when the client lies down.

1121 An elderly client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. A nurse obtains which of the
following as a priority item to manage this problem? Bed cradle Sheepskin Trapeze Draw sheet B The reddened heels results from
pressure of the foot against the mattress. The nurse obtains a sheepskin, heel protectors, or an alternating pressure mattress. The bed cradle is unnecessary in
managing this problem. A draw sheet and trapeze are of general use for this client but are not specific in dealing wit reddened heel.

1122 An English-speaking Hispanic male with a newly applied long leg cast has a right proximal fractured tibia. During rounds that night, the nurse finds
the client restless, withdrawn, and quiet. Which of the following initial nurse statements would be most appropriate? "Are you uncomfortable?"
"Tell me what you are feeling?" "I’ll get you pain medication right away." "You’ll feel better in the morning." B Option B is
open-ended and makes no assumptions about the client’s psychological or emotional state. Option A is incorrect because males in traditional standard Hispanic
cultures practice “machismo,” in which stoicism is valued, so this client may deny any pain when asked. Option C is incorrect because an assessment is
necessary before administering medication for pain. False reassurance is never therapeutic, which makes option D incorrect.

1123 A client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse reviews the hospital procedures for
developing a plan of care for clients with altered thought processes. The nurse develops which psychosocial outcome that has the highest priority in the
individualized care plan? Improved sleep patterns Increased ability to concentrate and make decisions Meets self-care needs independently
Reduced family fears and anxietyB The client needs to be able to concentrate and make decisions. Once the client is able to do that, the
nurse can work with the client to achieve the other outcomes. The client is the center of the nurse’s concern. Options A and C addresses physiological needs.
Option D is a secondary need.
1124 A male client is in a hip spica cast because of a fracture of the hip. On the day after the cast was applied, the nurse finds the client surrounded by
papers from his briefcase and planning a phone meeting. The nurse’s interaction with the client should be based on the knowledge that: Setting limits
on a client’s behavior is a mandated nursing role Not keeping up with his job will increase his stress level Immediate involvement in his job
will keep him from becoming bored while on bed rest Rest is an essential component in bone healing D Rest is an essential component of
bone healing. Nurses can help clients understand the importance of rest and find ways to balance work demands to promote healing. Nurses cannot demand
these changes but need to encourage clients to choose them. It may be stress relieving to do work; however, in the immediate postcast period it may not be
therapeutic. Stress should be kept at a minimum to promote bone healing. Setting limits on a client’s behavior is not a mandated nursing role.

1125 A nurse is caring for an elderly client who has been placed in Buck’s extension traction following a hip fracture. On assessment, the client is
disoriented. The most appropriate nursing intervention is to: Ask the family to stay with the client Apply restraints to the client Ask the
laboratory to perform electrolyte studies Reorient the client frequently and place a clock and calendar in the client’s room D An inactive
elderly person may become disoriented from lack of sensory stimulation. The most appropriate nursing intervention would be to frequently reorient the client
and to place objects such as a clock and a calendar in the client’s room to maintain orientation. The family can assist with orientation of the client, but it is not
appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies. Restraints may cause further
disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restrains.

1126 An elderly client has been admitted to the hospital with a hip fracture. The nurse prepares a plan of care for the client and identifies desired
outcomes related to the alternations in immobility. Which statement by the client most appropriately supports a positive adjustment to the alternations
experienced in mobility? "I wish you nurse’s would leave me alone! You are always telling me what to do!" "What took you so long. I called for
you 30 minutes ago." "Hurry up and go away I want to be alone." "I find it difficult to concentrate since the doctor talked with me about the surgery
tomorrow" D Option A demonstrates acting out by the client. Option B is demanding response. Option C demonstrates withdrawal behavior.
Demanding, acting out, and withdrawn clients have not coped or adjusted with the injury or disease. Option D is reflective of an individual with moderate
anxiety by their difficulty to concentrate. It most appropriately supports a positive adjustment.

1127 A client has undergone surgery for cataracts. The nurse instructs the client to call the physician for which of the following complaints? A
sudden decrease in vision Eye pain relieved by acetaminophen (Tylenol) Small amounts of dried matter on the eyelashes after sleep
Gradual resolution of eye rednessA The client should report a noticeable or sudden decrease in vision to the physician. The client is taught
to take acetaminophen, which is usually effective in relieving discomfort. The eye may be slightly reddened postoperatively, but this should gradually resolve.
Small amounts of dried material may be removed with a warm facecloth.

1128 A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the client? Wound healing usually takes 12
weeks Expect that vision will be permanently impaired A shield or eye patch should be worn to protect the eye The sutures are removed after 1
week C After ocular surgery, the client should wear an eye patch or eyeglasses for protection of the eye. Healing takes place in about 6 weeks.
Once the postoperative inflammation subsides, the client’s vision should return to the preoperative level of acuity. Sutures may be either absorbable or
nonabsorbable, but in either case, they are not removed.
1129 A client is admitted to the hospital with a leaking cerebral aneurysm and is scheduled for surgery. A nurse implements which of the following during
the preoperative period? Encourage the client to be up at least twice per day Allows the client to ambulate to the bathroom Obtains a
bedside commode for the client’s use Place the client on strict bed rest D The client’s activity is kept a minimum to prevent Valsalva maneuver.
Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients
who have bleeding aneurysms in any vessel will have activity curtailed.

1130 A client is admitted to the nursing unit after a left below-the-knee amputation following a crush injury to the foot and lower leg. The client tells the
nurse, “I think I’m going crazy. I can feel my left foot itching.” The nurse interprets the client’s statement to be: A normal response, and indicates the presence
of phantom limb sensation A normal response, and indicates the presence of phantom limb pain An abnormal response, and indicates that the
client needs more psychological support An abnormal response, and indicates that the client is in denial about the limb loss A Phantom limb
sensations are felt in the area of the amputated limb. These can include itching, warmth, and cold. The sensation are due to intact peripheral nerves ion the area
amputated. Whenever possible, clients should be prepared that they may experience these sensations. The client may also feel painful sensations in the
amputated limb, called phantom limb pain. The origin of the pain is less well understood, but the client should be prepared for this, too, whenever possible. This
is not an abnormal response.

1131 A client is being discharged to home without a Foley catheter following prostatectomy. The nurse plans to teach the client which of the following
points as part of discharge teaching? Drink of 15 glasses of water a day to minimize clot formation Mowing the lawn is allowed after 1 week
Notify the physician if fever, increased pain, or inability in void occurs Avoid lifting more than 50 lb for 4 to 6 weeks after surgery C
The client should notify the physician if there are any signs of infection, bleeding, or urinary obstruction. Lifting more than 20 lb is prohibited for 4
to 6 weeks after surgery. Other strenuous activities that could increase intraabdominal tension are also restricted, such as mowing the lawn. The client should
drink 6 to 8 glasses water or nonalcoholic beverages per day to minimize the risk of clot information.

1132 A client is experiencing diabetes insipidus secondary to cranial surgery. The nurse who is caring for the client plans to implement which of these
anticipated therapies? Fluid restriction IV replacement of fluid losses Increased sodium intake Administering diuretics B
The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or release
of antidiuretic hormone (ADH) in conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures
include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin (Pitressin).
Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality. Option D is incorrect.

1133 A client is seen in a health clinic, and a diagnosis of conjunctivitis is made. A nurse provides instructions to the client regarding care for the disorder
while the client is at home. Which of the following statements if made by the client indicates a need for further education? "I do not need to be concerned
about spreading this infection to other in my family" "I should apply a warm compress before instilling antibiotic drops if purulent discharge is present in my
eye." "I should perform a saline eye irrigation prior to instilling the antibiotic drops into my eye if purulent discharge is present." "I can use an ophthalmic
analgesic ointment at nighttime if I have eye discomfort." A Conjunctivitis is highly contagious. Antibiotic drops are usually administered
four time a day. When purulent discharge is present, saline eye irrigation or eye applications of warm compresses may be necessary before instillation of the
medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are
closed.
1134 A client recovering from a cerebrovascular accident (CVA) has become irritable and angry regarding limitations. Which of the following is the best
nursing approach to help the client regain motivation to succeed? Allow longer and more frequent visitation by the spouse Use supportive
statements to correct the client’s behavior Tell the client that the nurses are experienced and know how the client feels Ignore the behavior, knowing that
the client is grieving B CVA clients have many and varied needs. The client may need the behavior pointed out so that correction can take place. It is
also important to support and praise the client for accomplishments. Spouses of a CVA client are often grieving; therefore more visitation may not be helpful.
Additionally, short visits are often encouraged. Stating that the nurse knows how the client feels is inappropriate. The client’s behavior should not be ignored.

1135 A client recovering from a head injury becomes agitated at times. Which action will most likely calm this client? Turn on the television to
a musical program Offer the client a favorite object to hold, such as a stuffed animal Assign the client a new task to master Make the client aware
that the behavior is undesirable B Decreasing environmental stimuli aids on reducing agitation for the head injured client. Option A increases stimuli.
Option C does not simplify the environment, because a new task may be frustrating. Option D may increase the client’s agitation. The correct option helps to
distract the client with motor activity, holding the stuffed animal.

1136 A client who had a cerebrovascular accident (CVA) has episodes of coughing while swallowing liquids. The client has developed a temperature of
101.6º F, oxygen saturation of 91% (down from 98% previously), slight confusion, and noticeable dyspnea. The nurse would take which of the following most
appropriate actions? Administered a bronchodilator ordered on a RPN basis Administer an acetaminophen (Tylenol) suppository Encourage the client to
cough and deep breathe Notify the physician D The client is exhibiting clinical signs and symptoms of aspiration, which include fever,
dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty in managing saliva, and coughing or
choking while eating. Since the client has developed a complication requiring medical intervention, the most appropriate action is to contact the physician.

1137 A client who is in halo traction, says to the visiting nurse, “I can’t get used to this contraption. I can’t see properly on the side and I keep misjudging
where everything is.” The most therapeutic response by the nurse would be: "Halo traction involves many difficult adjustments. Practice scanning with your
eyes after standing up, before you move." "No one ever gets used to that thing! It’s horrible. Many of our sports people who are in it complain vigorously."
"Why do you like this when you could have died from a broken neck? This is the way it is for several months. You need to accept it more, don’t you
think?" "If I were you, I would have had the surgery rather than suffer like this." A In option A, the nurse employs empathy and reflection.
The nurse then offers a strategy for solving the client’s problem, which helps to increase peripheral vision for clients in halo traction. In option B, the nurse
provides a social response that contains emotionally charged language that could increase the client’s anxiety. In option C, the nurse uses excessive questioning
and gives advice, which is nontherapeutic. In option D, the nurse undermines the client’s faith in the medical treatment being employed by giving advice that is
insensitive and unprofessional.

1138 A client who sustained a thoracic cord injury a year ago returns to the clinic with a small reddened area on the coccyx. The client is not aware of
the reddened area. After counseling the client to relieve pressure on the area according to a turning schedule, which action by the nurse is most appropriate?
Ask a family member to assess the skin daily Schedule the client to return to the clinic daily for a skin check Teach the client to feel
for reddened areas Teach the client to use a mirror for skin assessment D The client should be encouraged to be as independent as possible.
The most effective way of skin self-assessment for this client is with the use of mirror.
1139 A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to avoid which of the following to prevent
barotraumas during ascent and descent of the airplane? Sucking hard candy Swallowing Yawning Keeping the mouth motionless D
Clients who are prone to barotraumas should perform any of a variety of mouth movements to equalize pressure in the ear, particularly during ascent
and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, or sucking on hard candy. Valsalva maneuver may also be helpful. The
client should avoid sitting with the mouth motionless during this time because this aggravates pressure build-up behind the tympanic membrane.

1140 A client with a recent complete T4 spinal cord transection tells the nurse that he will walk as soon as the spinal shock resolves. Which of the
following will provide the most accurate basis for planning a response? To speed acceptance, the client needs reinforcement that he will not walk again
The client needs to move through the grieving process rapidly to benefit from rehabilitation The client is projecting by insisting that
walking is the rehabilitation goal Denial can be protective while the client deals with the anxiety created by the new disability D In the
adjustment period during the first few weeks after spinal cord injury, client may use denial as defense mechanism. Denial may decrease anxiety temporarily,
and is normal part of grieving. After the spinal shock resolves, prolonged or excessive use of denial may impair rehabilitation. However, rehabilitation
programs include psychological counseling to deal with denial grief.

1141 A client with a spinal cord injury (SCI) experiences bladder spasm and reflex incontinence. In preparing for discharge to home, the nurse instructs
the client to: Limit fluid intake to 1000 mL in 24 hours Take own temperature every day Catheterize self every 2 hours PRN to prevent spasm
Avoid caffeine in the diet D Caffeine in the diet can contribute to bladder spasms and reflex incontinence. This should be eliminated
in the diet of the client with an SCI. Limiting fluid intake does not prevent spasm, and could place the client at further risk of urinary tract infection. Self-
monitoring of temperature would be useful in detecting infection, but does nothing to alleviate bladder spasms. Self catheterization every 2 hours is too
frequent, and serves no useful purpose.

1142 A client with a spinal cord injury makes the following comments. Which comment warrants additional intervention by the nurse? "I’m so angry
this happened to me." "I know I will have to make major adjustments in my life." "I would like my family members to be here for my teaching
sessions." "I’m really looking forward to going home." A It is important to allow the client with a spinal cord injury to verbalize their feelings. If the
client indicates a desire to discuss feeling, the nurse should respond therapeutically. Options B and C indicate that the client understands changes that will be
occurring and that family involvement is best. There are no data in the question that indicates that the client will not be going home, therefore this comment
does not require further intervention.

1143 A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, “I’m no good to anyone. I might as well
be dead.” The most appropriate response by the nurse is: "It makes me uncomfortable when you talk this way." "I'll ask the psychologist to see you
about this." "You’re not a useless person at all." "You are feeling pretty bad about things right now." D Restraining reflecting
keeps the lines of communications open and encourages the client to expand on current feeling of unworthiness and loss that require exploration. The nurse can
block communication by showing discomfort, disapproval, or by postponing discussion of issues. Grief is a common reaction to loss of function. The nurse
facilitates grieving through open communication
1144 A client with myasthenia gravis is having difficulty with the motor aspects of speech. The client has difficulty forming words, and the voice has a
nasal tone. A nurse would use which of the following communication strategies when working with this client? Repeat what the client said to verify the
message Encourage the client to speak quickly Nod continuously while the client is speaking Engage the client in lengthy discussions to
strengthen the voice A The client has speech that is nasal in tone and dysarthritic because of cranial nerve involvement of the muscles governing
speech. The nurse listen attentively and verbally verifies what the client has said. Other helpful techniques are to ask questions requiring a yes or no response,
and to develop alternative communication methods (letter board, picture board, pen and paper, flash card). Encouraging the client to speak quickly is
inappropriate and counterproductive. Continuous nodding may be distracting and is unnecessary. Lengthy discussions will tire the client rather tan strengthen
the voice.

1145 A client with myasthenia gravis is ready to return home. The client confides that she is concerned that her husband will no longer find her physically
attractive. The nurse would include in the plan of care to: Encourage the client to start a support group Insist that the client reach our and face this fear
Tell the client not to do dwell on the negative Encourage the client to share her feelings with her husband D Sharing
feelings with her husband directly addresses the issue of the question. Encouraging the client to start a support group will not address the client’s immediate and
individual concerns. Options B and C are blocks to communication and avoid the client’s concern.

1146 A client with prostatitis asks the nurse, "Why do I need to take a stool softener? The problem is with my urine, not my bowels!" Which of the
following is the best response by the nurse? Being constipated puts you at more risk for developing complications of prostatitis. This is a standard
medication order for anyone with an abdominal problem. This will keep the bowel free of feces, which will help decrease the swelling inside.
This will help you avoid constipation, because straining is painful with prostatitis. D Stool softeners are ordered for the client with
prostatitis to prevent constipation, which is painful. It has not cause complications of prostatitis. Stool softeners are not standardly prescribed for “anyone with
an abdominal problem.”

1147 A client with thrombotic cerebrovascular accident (CVA) experiences periods of emotional liability. The client alternately laughs and cries, and
intermittently becomes irritable and demanding. A nurse interprets that this behavior indicates. That the problem is likely to get worse before it gets better
That the client is experiencing the usual sequelae of a CVA That the client is not adapting well to the disability That the client is
experiencing side effects of prescribed anticoagulants B After CVA, the client often experiences periods of emotional liability, which are
characterized by sudden bouts of laughing or crying, or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture
for the client with this health problem, although it may be difficult for health care personnel and family members to deal with. The other options are incorrect.

1148 A family member of a client with a brain tumor is distraught and feeling guilty for not encouraging the client to seek medical evaluation earlier. The
nurse would incorporate which of the following items in formulating a response to the family member’s statement? It is true that brain tumors are easily
recognizable The symptoms of a brain tumor may be easily attributed to another cause Brain tumors are never detected until very late in their
course There are no symptoms of a brain tumor B Signs and symptoms of a brain tumor vary, depending on location, and may easily be
attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and change in intellectual abilities or personality. Seizures occur in
some clients. These symptoms can be easily attributed to other causes. The family requires support to assist them in the normal grieving process.
1149 A home care nurse is evaluating a client’s understanding of self-management of trigeminal neuralgia. Which client statement requires further
teaching by the nurse?Wearing a facial sling will help relieve my symptoms. I should chew on my good side. I should use warm mouth wash for oral
hygiene. Taking carbamazepine (Tegretol) will help control my pain. A Facial slings help the paralysis of Bell’s palsy and are not useful with
trigeminal neuralgia. It is recommended that clients chew on the unaffected side and use warm mouth wash or a water for oral hygiene. Medications such as
carbamazepine (Tegretol) help control the pain of trigeminal neuralgia.

1150 A home care nurse is preparing a plan of care for a client with Meniere’s disease who is experiencing severe vertigo. Which nursing intervention
would the nurse include in the plan of care to assist the client in controlling the vertigo? Encouraging the client to increase daily fluid intake Encourage
the client to avoid sudden head movements Instruct the client to cut down on cigarette smoking Instruct the client to increased sodium in the diet B
The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes, such as salt and fluid restrictions,
that reduce the amount of endolymphatic fluid are sometimes prescribed. Clients are advised to stop smoking because of its vasoconstrictive effects.

1151 A home care nurse provides instruction to the client with a halo vest. The nurse tells the client to: Have the spouse use the metal frame to assist
the client to sit up Perform pin care three times a week using hydrogen peroxide or alcohol Loosen the bots once a day for bathing Carry the
correct size wrench to loosen the bolts in an emergency D The metal frame is never used or pulled on for turning or lifting. Pin care should be
performed at least once a day using soap and water with cotton tipped swabs or alcohol swabs. The bolts should never be loosened except in an emergency. In
fact, the physician should be notified if the bolts loosen. The client is instructed to carry the correct size wrench in case of an emergency requiring
cardiopulmonary resuscitation (CPR). In such a situation, the anterior portion of the vest including the anterior bolts will need to be loosened and the posterior
portion should remain in place to provide stability for the spine during CPR.

1152 A home care nurse visits a client with a cerebrovascular accident (CVA) with unilateral neglect who was recently discharged from the hospital. The
nurse provides instructions to the family regarding care and tells the family to: Place personal items directly in front of the client Assist the client from the
affected side Assist the client to groom the unaffected side first Discourage the client from scanning the environment B Unilateral
neglect is pattern of lack of awareness of body parts such as paralyzed arms or legs. Initially, the environment is adapted to the deficit by focusing on the
client’s unaffected side and the client’s personal items are placed on the unaffected side. Gradually, the client’s attention is focused to the affected side. The
client is assisted from the affected side and the client grooms the affected side first. The client needs to scan the entire environment.

1153 A home health nurse visits an elderly client with arthritis. The client complains of difficulty instilling glaucoma eye drops because of shaking hands
due to the arthritis. Which of the following instructions would the nurse provide to the client to alleviate this problem? Keep the drops in the refrigerator so
they will thicken and be easier to instill Lie down on a bed or sofa to instill the eye drops Tilt the head back to instill the eye drops Inform the
client that a family member will have to instill the eye drops B Elderly clients with arthritis or shaking hands have difficulty instilling their own
eye drops. An elderly client is instructed to lie down on a bed or sofa. Tilting the head back can lead to loss of balance. Eye drops should not be kept in a
refrigerator unless specifically prescribed. Eye drop regimen for glaucoma requires accurate timing and it is unreasonable to expect a family member to instill
the drops. Additionally, this discourage client independence.
1154 A nurse assesses the twelfth cranial nerve in the client who sustained a cerebrovascular accident (CVA). When assessing the twelfth cranial nerve,
the nurse asks the client to: Extend the arms Turn the head toward the nurse’s arm Extend the tongue Focus the eyes on the object held by
the nurse C To assess the function of the twelfth cranial (hypoglosal), nerve, the nurse would assess the client’s ability to extend the tongue.
Impairment of the twelfth cranial nerve can occur with CVA, Options A, B and D do not test the function of the twelfth cranial nerve.

1155 A nurse has an order to institute aneurysm precautions for a client with a cerebral aneurysm. Which of the following items would the nurse
document in the plan of care for this client? Instruct the client not to strain with bowel movements Allow the client to read and watch television Limit out-of-
bed activities to twice daily Encourage the client to take his or her own daily bath A Aneurysm precautions include placing the client on bed
rest in a quiet setting. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure (BP) or impedes venous return
from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides all physical care to minimize increases in the BP. For
the same reason, visitors, radio, television, and reading materials are prohibited or limited. Stimulants such as caffeine and nicotine are prohibited. The nurse
documents that the client is instructed to avoid straining with bowel movements.

1156 A nurse has implemented a plan of care for a client with a C5 spinal cord injury. Which of the following client outcomes would indicate
effectiveness of the interventions? Regains bladder and bowel control Performs activities of daily living independently Maintains
intact skin Independently transfer self to and from the wheelchair C A C5 spinal cord injury results in quadriplegia with no sensation below the
clavicle, including most of the arms and hands. The client maintains partial movement of the shoulders and elbows. Maintaining intact skin is an outcome for
spinal cord injury clients. The remaining options are inappropriate for this type of client.

1157 A nurse is assessing a client to determine adjustment to Presbycusis. Which of the following noted by the nurse indicates successful adaptation to
this problem? Denial of a hearing impairment Proper use of a hearing aid Withdrawal from social activities Reluctance to answer the telephone
B Presbycusis occurs as part of the aging process and is a progressive sensorineural hearing loss. Some clients may not adapt well to the
impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing
aid. Clients show adequate adaptation by obtaining and regularly using a hearing aid.

1158 A nurse is assisting in preparing to admit a client from the post-anesthesia care unit who had microvascular decompression of the trigeminal nerve.
The nurse asks a nursing assistant to make sure that which of the following equipment is at the bedside when the client arrives? Flashlight and pulse
oximeter Cardiac monitor and pulse oximeter Padded bed rails and suction equipment Blood pressure cuff and cardiac monitor A
The postoperative care of a client having microvascular decompression of the trigeminal nerve is the same as for a client undergoing craniotomy.
This client requires hourly neurological assessment, as well as monitoring of cardiovascular and respiratory status. Cardiac monitoring and padded bed rails are
not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is done very cautiously and only
when necessary after craniotomy, to avoid increasing the intracranial pressure.
1159 A nurse is caring for a client who begins to experience seizure activity while in bed. The nurse determines that this particular client is risk for
aspiration. Which of the following actions by the nurse would be most helpful to prevent this from occurring? Loosen restrictive clothing Remove the
pillow and raise the padded side raise Raise the head of the bed Position the client on the side if possible, with the head flexed forward D
Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilities drainage of secretions, which could
help prevent aspiration. The nurse would also remove restrictive clothing and the pillow, and raise the padded side rails, but these actions would not decrease
the risk of aspiration. Rather, they are general safety measures to use during seizure activity. The nurse would not raise the head of he client’s bed.

1160 A nurse is caring for a client who is recovering form the signs and symptoms of autonomic dysreflexia (hyperreflexia). The nurse makes which
therapeutic statement to the client? "I’m sure you now understand the importance of preventing this from occurring." "Now that this problem
is taken care of, I’m sure you’ll be fine." "How could your home care nurse let this happen?" "I have some time if you would like to talk about what
happened to you." D Option D encourages the client to discuss feelings. Options A and C show disapproval and option B provides false
reassurance. These are nontherapeutic techniques.

1161 A nurse is caring for a client with an intracranial aneurysm. The nurse interprets that which of the following is related to dysfunction of cranial
nerve III? Mild drowsiness Less frequent spontaneous speech Slight slurring of speech Ptosis of the left eyelid D
Ptosis of the eyelid is due to pressure on and dysfunction of cranial nerve III. Options A, B and C are early signs of a deteriorating level of
consciousness.

1162 A nurse is caring for a client with left-sided Bell’s palsy. Which statement by the client requires further exploration by the nurse? My left eye is
tearing a lot. I have trouble closing my left eyelid. I can’t taste anything on the left side. I don’t know now I’ll live with the effects of
this stroke for the rest of my life..D Bell’s palsy is an inflammatory condition involving the facial nerve (cranial nerve VII). Although it results in facial
paralysis, it is not the same as stroke or cerebrovascular accident (CVA). Many client fear that they have had a CVA when the symptoms of Bell’s palsy appear
and they commonly believe that the paralysis is permanent. Symptoms resolve, although it may take several weeks to months. Options A, B, and C are expected
assessment finding in the client with Bell’s palsy.

1163 A nurse is caring for a client with myasthenia gravis. The client is vomiting and complaining of abdominal cramps and diarrhea. The nurse also
notes that the client is hypotensive and is experiencing facial muscle twitching. The nurse interprets that these symptoms are compatible with: Systemic
infection A reaction to plasmapheresis Cholinergic crisis Myasthenic crisis C Signs and symptoms of cholinergic crisis include nausea,
vomiting, abdominal cramping, diarrhea, blurred vision, pallor, facial muscle twitching, miosis, and hypertension. Cholinergic crisis is due to overmedication
with cholinergic (anticholinesterase) medications and is treated by withholding medications. Myasthenic crisis is exacerbation of myasthenic symptoms and is
caused by undermedication with anticholinesterase medications. There are no data in the question to support options A, B and D.
1164 A nurse is conducting a health screening on a client with a family history of hypertension. Which assessment finding would alert the nurse to the
need for teaching related to cerebrovascular accident (CVA) prevention? Eats two bowls of high-fiber grain cereal with skim milk for breakfast
Works as the manager of a busy medical-surgical unit yet jogs 2 miles daily Uses oral contraceptives and condoms for pregnancy and disease
prevention Has a blood pressure (BP) of 136/86 mmHg and has lost ten pounds recently C Obesity, hypertension, hypercholesterolemia, smoking,
and the use of oral contraceptives are all modifiable risk factors for CVA. Oral contraceptive use is discouraged in some clients due to the side effect of clot
formation. A low-fat diet and stress reduction methods are encouraged and identified in options A and B. Although options D identifies a borderline BP, the
client has made a change in eating habits.

1165 A nurse is conducting a prostate screening clinic. The nurse interprets that a client understands the educational information that was shared if the
nurse overhears the client tell another participant that: Increased intake of green, leafy vegetables is helpful A daily supplement of vitamin E will prevent
prostate problems An annual prostate exam after age 40 is best for early detection Cigarette smoking triples the chance of developing prostate problems
C Increasing age is the major risk factor for developing benign prostatic hyperplasia (BPH). Increased intake of yellow vegetables and
some elements of the Japanese diet may be helpful in reducing risk. Vitamin E and cigarette smoking have no known relationship with BPH. Early detection is
the only method of prevention (and is actually secondary prevention). This is accomplished by an annual prostate exam after the age of 40.

1166 A nurse is discharging a female client from the hospital who has a diagnosis of T11 fracture with cord transaction. The nurse has reinforced home
care instructions with the client. Which of the following would indicate the need for further discharge teaching?The client state she will have to be careful not
to eat as many dairy products The client states she will wash her hands, perineum, and catheter with soap and water before performing self-catheterization
The client jokes about no longer needing to worry about birth control The client verbalizes the need to eat her meals close to the same time
every day C Female spinal cord trauma in their reproductive years remain fertile. Contraception is necessary for these clients who are sexually active.
Oral contraceptives may increase the risk for thrombophlebitis. Client with paralysis should avoid dairy products to control the formation of urinary calculi.
Clients who lack bladder control are taught to self-catheterize using clean technique. Meals should be at the same time every day and include fiber and warm
solid and liquid foods to promote evacuation of the bowel.

1167 A nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which of the following approaches would the nurse
use to help the family cope with this situation? Enforce adherence to visiting hours to ensure the client’s rest Encourage the family not to give in
to their feelings of grief Discourage the family from touching the client Explain equipment and procedures on an ongoing basis D
Families often need assistance to cope with the sudden severe illness of a loved one. The nurse should explain all reinforce information given by the
physician. The family should be encouraged to touch and speak to the client and to become involved in the client’s care in some way if they are comfortable
with this. The nurse should allow the family to stay with the client whenever possible. The nurse also encourages the family to eat properly and to obtain
enough sleep to maintain their strength.

1168 A nurse is observing a nursing assistant talking with a client whose hearing is impaired. The nurse would intervene if which of the following were
performed by the nursing assistant during communication with the client? The nursing assistant is facing the client when speaking The nursing assistant is
speaking clearly to the client The nursing assistant is speaking directly into the impaired ear The nursing assistant is speaking in normal tone C
When communication with a hearing impaired client, the nursing assistant should speak in a normal tone to the client and should not shout. The
nursing assistant should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nursing
assistant should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but the nursing assistant
needs to avoid talking directly into the impaired ear.

1169 A nurse is obtaining a history on a client admitted to the hospital with a thrombotic cerebrovascular accident (CVA). The nurse assess the client,
knowing that prior to the CVA, the client most likely experienced: Transient hemiplegia and loss of speech Throbbing headaches Unexplained episodes of
loss of consciousness No symptoms at all A Cerebral thrombosis does not occur suddenly. In the few ours or days preceding a thrombotic CVA, the
client ma experience a transient loss of speech, hemiplegia, or paresthesias CVA vary, but may include dizziness, cognitive changes, or seizures. Headache is
rare, and loss of consciousness is not likely to occur.

1170 A nurse is performing a neurological assessment on a client with dementia and is assessing the function of the frontal lobes of the brain. Assessment
of which of the following items by the nurse would yield the best information about this area of functioning. Level of consciousness Insight,
judgment, and planning Feelings or emotions Eye movements B Insight, judgment, and planning are part of the function of the frontal
lobe. Level of consciousness is controlled by the reticular activating system. Feeling are the control of cranial nerves III, IV and VI.

1171 A nurse is providing instructions to a client and family regarding home care following left eye cataract removal. The nurse would plan to teach the
client which of the following pieces of information about positioning in the postoperative period? Lower the head between the knees three times a day
Bend below the waist as frequently as able Do not sleep on the left side Sleep only on the left side C Following cataract
surgery, the client should not sleep on the side of the body that was operated on. The client should also avoid bending below the level of the waist or lowering
the head, because these actions will increase intraocular pressure.

1172 A nurse is receiving a client in transfer from the emergency room; the client has a diagnosis of Guillain-Barre syndrome. The client’s chief
complaint is an ascending paralysis that has reached the level of the waist. The nurse plans to have which of the following items available for emergency use?
Cardiac monitor and intubation tray Blood pressure cuff and flashlight Nebulizer and pulse oximeter Flashlight and incentive
spirometer A A client with Guillain-Barre syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be
available for emergency use. Another complication of this syndrome is cardiac dysrhythmias, the risk of which necessitates cardiac monitoring

1173 A nurse is teaching a client with acute renal failure (ARF) to include proteins in the diet that are considered high quality. Which of the following
foods would the nurse discourage, since it is a low-quality protein source? Eggs Broccoli Chicken Fish B High-quality proteins
come from animal sources, and include such foods as eggs, chicken, meat, and fish. Low-quality proteins derive from plant sources and include vegetables and
foods made from grains. Since a renal diet is limited in protein, it is important that the proteins ingested are of high quality.
1174 A nurse makes a home care visit to a client with Bell’s palsy. Which of the following statements by the client requires clarification by the nurse? "I
have been wearing a facial sling during the daytime." "I wear dark glasses when I go out." "I have started to actively exercise my face a few times a
day." "I am staying on a liquid diet." D It is not necessary for a client with Bell’s palsy to stay on a liquid diet. These clients should be
encouraged to chew on the unaffected side. Options A, B, and C identify accurate statements related to managing Bell’s palsy.

1175 A nurse teaches a client with a spinal cord injury about measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following
statements made by the client would indicate the need for additional teaching? "I need to pay close attention to how frequently my bowels move." "It is best if I
avoid tight clothing and lumpy bed clothes." "I should watch for headache, congestion, and flushed skin." "Symptoms I should watch for include fever
and chest pain." D Symptoms of autonomic dysreflexia include headache congestion, flushed skin above the injury and cold skin below it
diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.

1176 A scleral buckling procedure is performed on a client with retinal detachment and the nurse provides home care instructions to the client. Which
statement by the client indicates a need for further instructions? "I need to clean the eye daily with sterile water and a clean washcloth." "I need to
wear an eye shield during naps and at night.""I need to avoid vigorous activity." "I need to avoid heavy lifting." A In a scleral buckling
procedure, the sclera is compressed from the outside by Silastic sponges or silicone bands that are sutured in place permanently. In addition, an intraocular
injection of air or a gas bubble, or both, may be used to apply pressure on the retina from the inside of the eye to hold the retina in place. If an air or gas bubble
has been injected, it may take several weeks to absorb. Vigorous activities and heavy lifting is avoided. An eye shield or glasses should be worn during the da
and a shield should be worn during naps and at night. The client is instructed to clean the eye with warm tap water using a clean wash cloth.

1177 A young adult male client with a spinal cord injury (SCI) tells the nurse, “It’s so depressing that I’ll never get to have sex again.” The nurse replies
in a realistic way by making which of the following statements to the client? "You’re young, so you’ll adapt to this more easily than if you were older." "It
must feel horrible to know you can never have sex again." "It is still possible to have a sexual relationship, but it is different." "Because of body
reflexes, sexual functioning will be no different than before." C It is possible to have a sexual relationship after an SCI, but it is different from
what the client experienced before the injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm.
Sexual counseling may help the client to adapt to changes in sexuality after an SCI.

1178 An adult client seeks treatment in an ambulatory care clinic for complaints of a left earache, nausea, and a full feeling in the left ear. The client as an
elevated temperature. A nurse first question the client about: A history of a recent brain abscess A history of a recent upper respiratory infection
(URI) Whether acetaminophen (Tylenol) relieves the pain Whether hearing is magnified in that ear B Otitis media in the adult is typically
one sided, and presents as an acute process with earache, nausea and possible vomiting fever, and fullness in the ear. The client may complain of diminished
hearing in that ear. The nurse takes a client complain of diminished hearing in that ear. The nurse takes a client history first, assessing whether the client has
had a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client if anything relieves the pain, but ear infection pain
is usually not relieved until antibiotic therapy is initiated.
1179 The family of a client with Parkinson’s disease tells a nurse that the client is having difficulty adjusting to the disorder and that they do not know
what to do to help. The nurse advises the family that which of the following would be the most therapeutic in assisting the client to cope with the disease?
Encourage and praise client efforts to exercise and perform activities of daily living (ADLs) Cluster activities at the end of the day, when
the client is restless and bored Plan only a few activities for the client during the day Assist the client with ADLs as much as possible A
The client with Parkinson's disease has a tendency to become withdrawn and depressed, which can be limited by encouraging the client to be an
active participant in his or her own care. The family should also give the client encouragement and praise for perseverance in these efforts. The family should
plan activities intermittently throughout the day to inhibit daytime sleeping and boredom.

1180 A nurse is caring for a client with terminal cancer of the throat. The family approaches the nurse and tells that nurse that they have spoken to the
physician regarding taking their loved one home. The nurse plans to coordinate discharge planning. Which of the following services would be most supportive
to the client and family? American Cancer Society Lung Association Hospice care Local religious and social organizations C
Hospice care provides an environment that emphasizes caring rather than curing. The emphasis is on palliative care. One of the major goals of
hospice care is that the client is free of pain and other symptoms that do not allow clients to maintain the quality of their lives. A interdisciplinary approach is
utilized. Option A, B, and D would be helpful but are not the most supportive of the options provided.

1181 A client had a laryngectomy for throat cancer and has started oral intake. A nurse concludes that the client has tolerated the first stage of dietary
advancement if the client takes which of the following types of diet without aspiration or choking? Bland Clear liquids Full liquids
Semisolid foods D Oral intake after laryngectomy is started with semisolid foods. Once the client can mange this type of food, liquids
may be introduced. Thin liquids re not given until the risk of aspiration is negligible. A bland diet is not appropriate. The client may not be able to tolerate the
texture of some of the solid foods that would be included in a bland diet.

1182 A client has terminal cancer and is using narcotic analgesic for pain relief. The client is concerned about becoming addicted to the pain medication.
The home health care nurse allays the client's anxiety by: Explaining to the client that his or her fears are justified but should be of no concern in the
final stages of care Encouraging the client to hold off as long as possible between doses of pain medication Telling the client to take lower doses of
medications even though the pain is not well controlled Explaining to the client that addiction rarely occurs in individuals who are taking medication to relieve
pain D Clients who are receiving narcotics often have well-founded fears about addiction, even in the face of pain. The nurse has responsibility
to provide correct information about the likelihood of addiction while still remaining adequate pain control. Addiction is rare for individuals who are taking
medication to relieve pain. Allowing the client to be in pain, as in options B and C, is not acceptable nursing practice. Option A is only partially correct in that it
acknowledges the client's fear.

1183 A client is admitted to a surgical unit with a diagnosis of cancer. The client is scheduled for surgery in the morning. When a nurse enters the room
and begins surgical preparation, the client states, “I’m not having surgery, you must have the wrong person! My test results were negative. I’ll be going home
tomorrow.” The nurse recognizes that the ego defense mechanism that may be operating here is: Psychosis Denial Delusions Displacements B
By definition, ego mechanisms are operations outside of a person’s awareness that the ego calls into play to protect against anxiety. Denial is the
defense mechanism that blocks out painful or anxiety-inducing events or feelings. In this case, the client cannot deal with the upcoming surgery for cancer and
therefore denies the illness. Psychosis and delusions are not defense mechanisms. Displacement is the discharging of pent-up feelings on persons less dangerous
than those who initially aroused the feelings.
1184 A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy. The physician inserts a Miller-Abbott tube. After
the procedure the client asks the nurse, "Do you think this is worth all this trouble?" The most appropriate action or response by the nurse is: To stay with
the client and be silent Are you wondering whether you are going to get better?Let's give this tube a chance. I remember a case similar to yours,
and the tube relieved the obstruction. B The nurse uses therapeutic communication tools to assist a client with a chronic terminal illness to
express feelings. The nurse listens attentively to the client and uses clarifying and focusing to assist the client in expressing their feelings. Responding with
inappropriate silence (option A), changing the subject (option C), and offering false reassurance (option D) are nontherapeutic communication techniques.

1185 A client is receiving a course of chemotherapy on an outpatient basis for the diagnosis of lung cancer. Which of the following home care
instructions would the nurse provide to the client? A bathroom can be shared with any members of the family Urinary and bowel excreta is not
considered contaminated Disposable plates and plastic utensils must be used during the entire course of chemotherapy Contaminated linens
should be washed separately and then washed a second time with other laundry if necessary D The client may excrete the chemotherapeutic
agent for 48 hours or more after administration, depending on the medication administered. Blood, emesis, and excreta may be considered contaminated during
this time. The client should not share a bathroom with children or pregnant women during this time. Any contaminated linens or clothing should be washed
separately and then washed a second time with other laundry if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of
as hazardous waste.

1186 A client with cancer is placed on permanent total parental nutrition (TPN). The nurse includes psychosocial support when planning care for this
client, because: Death is imminent TPN requires disfiguring surgery for permanent port implantation The client will need to adjust to the idea of
living without eating by the usual route Nausea and vomiting occur regularly with this of treatment and will prevent the client from engaging in social
activities C Permanent TPN is indicated for clients who can no longer absorb nutrients via the enteral route. These clients will no longer take
nutrition orally. Options, A, B, and D are inaccurate. There is no indication in the question that death is imminent. Permanent port implantation is not
disfiguring. TPN does not cause nausea and vomiting.

1187 A client with leukemia receives a course of chemotherapy. The home care nurse scheduled to visit the client receives a telephone call from the
client’s physician. The physician informs the nurse that the neutrophil count is 600/mm³. Which of the following instructions will the nurse provide to the
client during the home care visit? Avoid eating any raw fruits or vegetables Avoid aspirin or medications containing aspirin Avoid straining at bowel
movements Use an electric shaver for shaving A Neutrophil counts should range between 3000 and 5800/mm³. A low neutrophil
count places the client at risk for infection. When the client is at risk for infection, the client should avoid exposure to individuals with cold or infections. All
live plants, flowers, or objects that harbor bacteria should be removed from the client’s environment. The client should be on a low bacteria diet and avoid
eating any raw fruits and vegetables. Option B, C and D are measures that would be implemented if the client was at risk for bleeding.

1188 A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious
about whether dialysis will ultimately be a necessity. The nurse would plan to use which of the following information in discussions with client? There is
absolutely no chance of needing dialysis due to the nature of the surgery Dialysis could become likely, but it depends on how well the client complies
with fluid restriction after surgery One kidney is adequate to meet the needs of the body as long as it has normal function There is a strong
likelihood that the client will need dialysis within 5 to 10 years C Fears about having only one functioning kidney are common in client who must
undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body’s
metabolic needs, as long as it has normal function.

1189 A community health nurse provides an educational session on the risk factors of cervical cancer to the women in a local community. The nurse
determines that further teaching is needed if a woman attending the session identifies which of the following as a risk factor of this type of cancer?
Caucasian race Early age of first pregnancy Prostitution Sexually transmitted disease A Risk factors for cervical
cancer include African American and Native American individuals, prostitution, early first pregnancy, untreated chronic cervicitis, sexually transmitted
diseases, postpartum lacerations, partners with a history of penile or prostate cancer, and infection with human papilomavirus. Options B, C and D identify risk
factors.

1190 A community health nurse provides an educational session to members of the local community regarding breast self-examination (BSE). Which
statement, if made by a client, indicates a need for further education? I should perform the BSE when I have my period. It is easiest to perform
when I am in the shower when my hands are soapy. I need to perform the BSE every month. I’ll use the pads of my three middle fingers to feel for
lumps and thickening. A The best time to perform BSI (not during) the monthly period when the breasts are not tender and swollen. Options B, C, and
D identify accurate information regarding this self-examination.

1191 A home care nurse visits a client with bowel cancer who recently received a course of chemotherapy. The client has developed stomatitis. The
nurse avoid telling the client to: Drink foods and liquids that are cold Eat foods without spices Maintain a diet of soft foods Drink juices
that are not citrus A Stomatitis is a term used to describe inflammation and ulceration of the mucosal lining of the mouth. Dietary modifications
for this condition include avoiding extremely hot or cold foods, spices, and citrus fruits and juices. The client should be instructed to eat soft foods and take
nutritional supplements as prescribed.

1192 A home health care nurse is caring for a client with acute cancer pain. The most appropriate assessment of the client’s pain would include which of
the following? The client’s pain rating The nurse’s impression of the client’s pain Verbal and non-verbal cues from the client Pain relief
after appropriate nursing intervention A The client’s perception of pain is the hallmark of pain assessment. Usually noted by the client rating on
a scale of 1 to 10,the assessment is documented and followed with appropriate medical and nursing intervention. The nurse’s impression and the verbal and
nonverbal is appropriate but relates to evaluation.

1193 A nurse has completed discharge teaching for a client who had surgery for lung cancer. The nurse determines that the client has not understood all
of the essential elements of home management if the client verbalizes to: Sit up and lean forward to breathe more easily Deal with any increase
in pain independently Avoid exposure to crowds Call the physician for increased temperature or shortness of breath B Health teaching includes
using positions that facilitate respiration, such as sitting up and leaning forward. Health teaching also includes avoiding exposure to crowds or persons with
respiratory infections; and reporting signs and symptoms of respiratory infection or increases in pain. The client should not be expected to deal with increases
in pain independently.
1194 A nurse is caring for a client with cancer who has a nursing diagnosis of Body Image Disturbance related to alopecia. The nurse plans to teach the
client which of the following related to this nursing diagnosis? Proper dental hygiene with the use of a foam toothbrushThe importance of rinsing the
mouth after eating The use of wigs, which are often covered by insurance The use of cosmetics to hide drug-induced rashes C The
temporary or permanent thinning or loss of hair, known as alopecia, is common in clients with cancer receiving chemotherapy. This often causes a body image
disturbance that can be easily addressed by the use of wigs, hats, or scarves. Option A, B, and D are all unrelated to alopecia.

1195 A nurse is caring for a client with Hodgkin’s disease who will be receiving radiation and chemotherapy. Which statement by the client indicates a
positive coping mechanism to be used during these treatments? "I have selected a wig, even though I will miss my own hair." "I know losing mg hair
won’t bother me." "I will not leave the house bald." "I will be one of the few who doesn’t lose their hair." A A combination of radiation and
chemotherapy often causes alopecia in Hodgkin’s disease clients. In order to use positive coping mechanisms, the client must identify personal feelings and
positive interventions to deal with side effects. Options B, C, and D are not positive coping mechanisms.

1196 A nurse is caring for a young woman dying from breast cancer. The nurse determines that a defining characteristic of anticipatory grief is present
when the woman: Verbalizes unrealistic goals and plans for the future Discusses thoughts and feeling related to loss Has prolonged emotional
reactions and outbursts Ignores untreated medical conditions that requires treatment B The nurse can determine the client’s stage of
grief by observing the client’s behavior. This is extremely important, because the appropriate nursing diagnoses need to be developed so that the plan of care is
appropriate. Options A, C, and D are examples of dysfunctional grieving.

1197 A nurse is preparing a client with a diagnosis of multiple myeloma for discharge. The nurse tells the client to: Restrict fluid intake to 1500mL/day
Maintain bed rest Maintain a high-calorie, low-fiber diet Notify the physician if anorexia and nausea persist D Clients with
multiple myeloma need to be taught to monitor for signs of hypercalcemia and to report them immediately to the physician. Anorexia, nausea, vomiting,
polyuria, weakness and fatigue, constipation, and signs of dehydration are signs of moderate hypercalcemia. A fluid intake of 3000 mL/day is required to
dilute the calcium overload and prevent protein from precipitating in the renal tubules. Activity is encouraged. Although a high calorie diet is encouraged, a
diet low in fiber can lead to constipation.

1198 A nurse is providing home care instruction to a client recovering from a radical vulvectomy. Which statement by the client indicates a need for
further instructions? I need to take showers rather than tub baths. I need to wipe from front to back after a bowel movement. I need to monitor for
foul-smelling perineal discharge. I need to notify the physician if swelling of the groin or genital area persists for longer than 1 week. D The physician
needs to be notified if any swelling of the groin or genital area occurs. The client should not wait 1 week before notifying the physician. Options A,B and C
are accurate instructions. Additionally, the client should monitor for pain, redness, or tenderness in the calves and for any signs of infection.
1199 A nurse is taking a history from a client suspected of having testicular cancer. Which of the following data will be most helpful in determining risk
factors of this type cancer? Number of sexual partners Age and race Geographic location Marital status and number of children B
Two basic but important risk factors for testicular cancer are age and race. The disease occurs mot frequently in Caucasian males between the ages
of 18 and 40 years. Other risk factors include a history of undescended testis and a family history of testicular cancer. Marital status and number of children do
not pose a risk factor for males and cancer.
1200 A
nurse provides discharge instruction to the client who had a mastectomy and axillary lymph node dissection. The nurse tells the client to: Avoid the use
of insect repellent Cut cuticles on the nails carefully using clean cuticle scissors Wear protective gloves when doing the dishes Avoid the use
of lanolin hand cream on the affected arm C Following axillary node dissection, the affected area may swell and is less able to fight infection. The
client needs to be instructed in the several measures required to prevent complications, such as using insect repellent to avoid bites and stings; never picking at
or cutting cuticles; applying lanolin hand cram a few times daily; and wearing protective gloves while doing dishes and cleaning.

1201 A nurse provides instructions to a client who received cryosurgery for a local stage 0 cervical tumor. The nurse tells the client: To call the
physician if a watery discharge occurs To call the physician if the discharge remains odorous in 1 week To avoid tub baths That pain indicates a
complication of the procedure C Mild pain may occur and continue for several days following this procedure. A clear watery discharge is expected.
For about 14 days, this is followed by discharge containing debris, which may be malodorous. If the discharge continues longer than 8 weeks, an infection is
suspected. Healing takes about 10 weeks. Showers or sponge baths should be taken during this time. Tub baths and sitz baths need to be avoided.

1202 During the nurse assessment, the client says, “My doctor just told me that my cancer has spread and that I have less than 6 months to live.” Which of
the following nursing responses would be most therapeutic? "I know it seems desperate, but there have a lot of breakthroughs. Something might come
along in a month or so to change your status drastically." "I hope you’ll focus on the fact that your doctor says you have 6 months to live and that
you’ll think of how you’d like to live." "I am sorry. There are no easy answers in times like this, Are there?" "I am sorry. Would you like to
discuss this with me some more?" D The client has received very distressing news. The client is most likely still in the stage of shock and
denial. In the correct option, the nurse invites the client to ventilate. Option A provides a social communication and false hope. Option B is patronizing and
stereotypical. Option C is social and expresses the nurse’s feelings rather than the client’s feelings.

1203 In planning for care of a client dying of cancer, one of the goals was that the client would verbalize acceptance of impending death. Which of the
following statements indicates to the nurse that this goal has been reached? "I’ll be ready to die when my children finish school." "I just want to live until
my one-hundredth birthday." "I want to go to my daughter’s. Then I’ll be ready to die." "I’d like to have my family here when I die."D
Acceptance is often characterized by plans for death. Often the client wants loved ones near. Options A, B, and C all reflect the bargaining stage of
coping, wherein the client tries to negotiate with God or fate.
1204 Two months after a right mastectomy for breast cancer, the client comes to the office for a follow-up appointment. The client was told, after the
diagnosis of cancer in the right breast, that the risk for cancer in the left breast existed. When asked about her breast self-examination (BSE) practices since the
surgery, the client replies, “I don’t need to do that any more.” The nurse interprets that this response may indicate: Change in body image
Change in role patternDenial Grief and mourning C The coping strategy of denying or minimizing a health problem is manifested as
anxiety, producing health situations that may be life-threatening. Denial can lead to avoidance of self-care measures such as taking medications or performing
BSE. Options A, B, an D are unrelated to the client’s statement.

1205 A client being mechanically ventilated after experiencing a fat embolus is visibly anxious. The nurse should: Encourage the client to sleep until
arterial blood gas results improve Ask a family member to stay with the client at all times Ask the physician for an order for succinylcholine Provide
reassurance to the client and give small doses of intravenous morphine sulfate as prescribed D The nurse always speaks to the client calmly
and provides reassurance to the anxious client. Morphine sulfate is often prescribed for pain and anxiety for the client receiving mechanical ventilation. In
option A, the nurse does nothing to reassure or help the client. It is not beneficial to ask the family t take on the burden of remaining with the client at all times.
Succinylcholine is a paralyzing agent, but has no antianxiety properties.

1206 A client has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse interprets that which
of the following items should now be limited, which was previously useful in minimizing the client’s anxiety? Radio Television Family visitors
Antianxiety medications D Antianxiety medications and narcotic analgesics are used cautiously in the client being weaned from a
mechanical ventilator. This medication may interfere with the weaning process by suppressing the respiratory drive. The client may exhibit anxiety during the
weaning process as well for a variety of reasons, and therefore distractions such as radio, television, and visitors are still very useful.

1207 A client had arterial blood gases drawn. The results are as follows: pH of 7.34, Paco2 of 37 mm Hg, Pao2 of 79,HCO3 of 19mEg/L. A nurse
interprets that the client is experiencing: Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis C Metabolic
acidosis occurs when the pH falls before 7.35 and the bicarbonate level falls below 22 mEq/L. With respiratory acidosis, the pH drops below 7.35 and the
carbon dioxide level rises above 45 mm Hg. With respiratory alkalosis, the pH rises above 7.45 and the carbon dioxide level falls before 35 mmHg. With
metabolic alkalosis, the pH rises above 7,45 and the bicarbonate level rises above 26 mEq/L.

1208 A client has two chest tubes inserted in the right pleural space following thoracic surgery, which are attached to Pleurevac drainage systems. The
nurse instructs the client in measures that will promote optimal respiratory functioning and plans to: Milk and strip the chest tubes once a shift Maintain the
client on bed rest until the chest tubes are removed Position the client only on the back and on the right side Encourage the client to cough and
deep breathe every hour D The client who has chest tubes following thoracic surgery should be encouraged to cough and deep breathe every 1
to 2 hours after surgery. This helps to facilitate the drainage of fluid from the pleural space, as well as facilitate the clearance of secretions from the respiratory
tract. Milking and stripping of the chest tube is done only when there is an occlusion, such as with a small clot. Even then, it is done only with a physician’s
order or when allowed by agency policy. The client is maintained in semi-Fowler’s position, and may lie on the back or on the non-operative side. The client
may be allowed to lie on the operative side according to surgeon preference, but care must taken not to compress the chest tube or attached drainage tubing.
Ambulation is generally allowed within a day or two, and also facilitate optimal respiratory function.

1209 A client is being discharged from the hospital following a bronchoscopy that was performed yesterday. In performing the discharge planning, the
client makes all of the following statements to the nurse. Which statement would the nurse identify that will indicate a need for further teaching? I can expect
to cough up bright red blood I will stop smoking my cigarettes I will get help immediately if I start having trouble breathing. I will use the throat
lozenges as directed by the physician until my sore throat goes away. A After the procedure, the client should be observed for signs of
respiratory distress, including dyspnea, changes in respiratory rate, use of accessory muscles, and changes in or absent lung sounds. Expectorated secretions are
inspected for hemoptysis. The client needs to avoid smoking. A sore throat is common and lozenges would be helpful to alleviate the sore throat.

1210 A client is being discharged to home with a Heimlich (flutter) valve. The nurse teaches the client that if the valve needs to be changed, it is done:
On inspiration On expiration During a Valsalva maneuver Between inspiration and expiration C A Heimlich
valve is a one-way valve that is used instead of underwater chest drainage in some clients. The client is taught to change the valve during a Valsalva maneuver
while the stopcock is turned off. The client is also instructed how to do dressing changes, to keep the dressing and tubing airtight, and to recognize the signs of
infection.

1211 A client is experiencing difficulty using an incentive spirometer. The nurse teaches the client that which of the following may interfere with
effective use of the device? Breathing through the nose Forming a tight seal around the mouthpiece with the lips Inhaling slowly
Removing the mouthpiece to exhale A Incentive spirometry is not effective breathes through the nose. The client should exhale,
form a tight seal around the mouthpiece, inhale slowly, hold to the count of 3, and remove the mouthpiece to exhale. The client should repeat the exercise
approximately 10 times every hour for best results.

1212 A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home
health nurse visits the client and most importantly plans teaching strategies that are designed to: Encourage the client to become a more active person
Improve oxygenation and minimize carbon dioxide retention Identify irritants in the home that interfere with breathing Promote
membership in support groups B Improving oxygenation and minimizing carbon dioxide retention is the primary objective. The other options are
interventions that will help to achieve this primary goal.
1213 A client is very anxious about receiving chest physical therapy (CPT) for the first time at home. In planning for the client's care, the home health
care nurse proceeds in reassuring the client that: There are no risks associated with this procedure CPT will resolve all the client's respiratory
symptoms CPT will assist in mobilizing secretions to enhance more effective breathing CPT will assist the client to cough more effectively C
There are risks associated with CPT and these include cardiac, gastrointestinal, neurological, and pulmonary. CPT is an intervention to assist in
mobilizing and clearing secretions and enhance more effective breathing. It will not resolve all respiratory symptoms. CPT will assist the client to cough, if the
secretions have been mobilized and the cough stimulus is present.

1214 A client newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolations for at lest 2 weeks. Which of the following
would be most important in preventing psychosocial dis-important in preventing psychosocial distress in the client? Remove the calendar and clock in
room so that the client will not obsess about time. Note whether the client has visitors Give the client a roommate with (TB) who persistently
tries to talk Instruct all staff not to touch the client B The nurse should note whether the client has visitors and social contacts, since
the presence of others can offer positive stimulation. The calendar and clock are needed to promote orientation to time. A roommate who insists on taking could
create sensory overload. Additionally, the client in respiratory isolating should be in a private room. Touch may be important order to help the client feel
socially acceptable.

1215 A client scheduled for pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and
radiation exposure. The nurse provides a response to the client that provides reassurance, based on the understanding that: The procedure is somewhat painful,
but there is minimal exposure to radiation Discomfort may occur with needle insertion, and there is minimal exposure to radiation must be used to get
accurate results There is absolutely no pain, although a moderate amount of radiation must be used to get accurate results There is very mild pain
throughout the procedure, and the exposure to radiation is negligible. B Pulmonary angiography involves minimal exposure to radiation. The
procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. Options A, C, and D are
incorrect.

1216 A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate the use
of the device, expecting that the client is: Not forming a tight seal around the mouthpiece Inhaling too slowly Not resting adequately between
breaths Exhaling too slowly C If the client does not breathe normally between incentive spirometer breaths, then hyperventilation and fatigue can
result. Hyperventilation is the most common cause of respiratory alkalosis, which is characterized by lightheadedness and dizziness. Options A, B and D
would not be a cause of lightheadedness and dizziness.
1217 A client who is to undergo thoracentesis is afraid of not being able to tolerate the procedure. The nurse interprets that the client needs honest support
and reassurance, which can best be accomplished by which of the following statements? "The procedure takes only 1 to 2 minutes, so you might try to get
through it by mentally counting up to 120." "The needle is a little uncomfortable going in, but this is controlled by rhythmically breathing in and out. I’ll be
with you to coach your breathing." "The needle hurts when it goes in and you must remain still. I’ll stay with you throughout the entire procedure and
help you hold your position." "I’ll be right by your side, but the procedure will be totally painless as long as you don’t move." C The needle
insertion for thoracentesis is painful for the client. The nurse tells the client how important is to remain still during the procedure, so the needle doesn’t injure
visceral pleura or lung tissue. The nurse reassures the client during the procedure and helps the client hold the proper position.

1218 A client with a history of pulmonary emboli is scheduled for insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the
physician has explained the procedure and obtained consent from the client. The client is lying in bed, wringing his hands, and say to the nurse, “I’m not sure
about this. What if it doesn’t work, and I’m just as bad off as before?” the nurse formulates which of the following nursing diagnoses for the client?
Fear related to the potential risks and outcome of surgery Anxiety related to the fear of death Ineffective individual Coping
related to the treatment regimen Knowledge Deficit related to the surgical procedure A The north American Nursing Diagnosis Association
(NANDA) defines fear as “a feeling of dread related to an identifiable source that the person validates.” This client identified the surgical procedure and its
outcome as the object of fear. Anxiety is used when the client cannot identify the source of the uneasy feelings. Ineffective individual coping is appropriate
when the client is not making needed adaptations to deal with daily life. Knowledge deficit is characterized by a lack of appropriated information

1219 A client with active pulmonary tuberculosis (TB) has been receiving multi-drug chemotherapy for the past month. The client is being prepared for
discharge from the hospital to home. The nurse determines respiratory isolation is no longer required and that medication therapy has been effective when:
Nausea and vomiting has stoppedThe Mantoux test (PPD) is negative Sputum cultures are negative Stools are clay colored C
The primary diagnostic tool for pulmonary tuberculosis is a sputum culture. A negative culture indicates effectiveness of treatment. Nausea and
vomiting and clay-colored stools are side effects of the medication used to treat tuberculosis. Their presence or absence does not measures the therapeutic
effectiveness of the medication. The Mantoux test is a screening tool, not a diagnostic test for tuberculosis. Since the Mantoux test indicates exposure to the
organism but not active disease, the test results will remain positive.

1220 A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which of
the following methods for communication may be easiest for the client? Have the family interpret needs Use a picture or wood board Use a pad and
pencil Devise a system of hand signals B The client with an endotracheal tube in place cannot speak. The nurse devices an alternative
communication system with the client. Use a picture or word board is the simplest method of communication, because it requires only pointing at the word or
object. A pad and pencil is an acceptable alternative, but it requires more client effort and more time. The use of hand signals may not be a reliable method,
because it may not meet all needs, and is subject to misinterpretation. The family does not need to bear the burden of communicating the client’s needs, and
they may not understand them either.

1221 A client with chronic airflow limitation (CAL) is admitted to the hospital with exacerbation, and has a nursing diagnosis of Ineffective Airway
Clearance. The nurse assesses the client with regard to which of the following pre-hospitalization factors that could have contributed most to this nursing
diagnosis? Anxiety level Amount of sleep Fat intake Fluid intake D The client with Ineffective Airway Clearance has
ineffective coughing and excess sputum in the airway. The nurse assesses for contributing factors, such as dehydration and lack of knowledge of proper
coughing techniques. Reduction of these factors help to limit exacerbations of the disease. Options A, B, and C are not directly associated with this nursing
diagnosis.
1222 A client with chronic obstructive pulmonary disease (COPD) has a knowledge deficit related to positions used to breathe more easily. The nurse
plans to teach the client to: Lie on the side with the head of the bed at a 45-degree angle Sit bolt upright in bed with the arms crossed over the chest
Sit on the edge of the bed with the arms leaning on an overbed table Sit in a reclining chair tilted slightly back with the feet elevated C
Proper positioning can decrease episodes of dyspnea in a client. These include sitting upright while leaning on an overbed table, sitting upright in a
chair with the arms resting on the knees, and leaning against a wall and while standing. Option A restricts expansion of the lateral wall of the lungs. Option B
restricts movement of the anterior and posterior walls. Option D restricts posterior lung expansion.

1223 A client with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the
client which of the following methods to best interrupt the dyspnea-anxiety-dyspnea cycle? Relaxation and breathing techniques Biofeedback
and coughing techniques Guided imagery and limiting fluids Distraction and increased dietary carbohydrates A The anxious
client with dyspnea should be taught interventions to decrease anxiety, which include relaxation, biofeedback, guided imagery, and distraction. This will stop
the escalation of feelings of anxiety and dyspnea. The dyspnea can be further controlled by teaching the client respiratory techniques are more effective.
Limiting fluids will thicken secretions and increased dietary carbohydrates will increase production of CO2 by the body.

1224 A client with emphysema is to undergo decortications to remove the inflamed tissue, pus, and debris. The nurse offers emotional support to the client
based on the understanding that: The client is likely to be in excruciating pain after surgery The client will probably have chronic dyspnea after the
surgery Chest tubes will be in place after surgery for some time, and the healing process is slow This problem may decrease the client’s life expectancy C
The client undergoing decortication to treat emphysema needs ongoing support by the nurse. This is especially true because the client will have chest
tubes in place after surgery, which must remain until the former pus-filled space is completely obliterated. This usually takes a considerable amount of time, and
may be discouraging to the client. Progress is monitored by chest x-ray. Options A, B, and D are not accurate.

1225 A client with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out the medically prescribed order. Which approach should
the nurse plan to best meet the needs of the client in a holistic manner? Leave the client alone while gathering required equipment and medications
Give the client the call bell and encourage its use if the client feels worse Ask a family member to stay with the client Stay with the client and
ask another nurse to gather equipment and supplies not already in the room D Pulmonary edema is accompanied by extreme fear and anxiety. Since
the client typically experiences a sense of impending doom, the nurse should remain with the client as much as possible. Options A and B do not provide for the
psychological needs of the client in distress. Family members (option) can emotionally support the client but are not able to respond to physiological needs and
symptoms. In fact, they are typically in psychological distress themselves.
1226 A community health nurse reviewed information on the population I a local community. The nurse determines that there are groups in the
population that are at high risk for infection with tuberculosis (TB). The nurse targets which of the following groups for screening? White, Anglo-Saxon
Americans Adolescents 13 to 17 years of age French Canadians in rural America Elders in long-term care facilities D Elderly
persons, particularly those in long-term care facilities, are at high risk for infection with TB. Almost half of all new cases of tuberculosis occur in this are group.
Other people at malnourished, immunosuppressed, and /or economically disadvantaged; foreign born persons, and persons of a minority race who formerly
lived in a place where TB is common, such as Asia and the Pacific Islands.

1227 A nurse determines that the result of a Mantoux tuberculin skin test is positive. In order to most accurately diagnose tuberculosis (TB), the nurse
plans to consult with the physician to follow up the skin test with a: Chest x-ray Computed tomography scan of the chest Sputum
culture Complete blood cell count C Although the findings of a chest x-ray examination are important, it is not possible to make a diagnosis
of TB solely on the basis of this examination. This is because other disease can mimic the appearance of TB. The demonstration of tubercle bacilli
bacteriological is essential for establishing a diagnosis. Microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of
the presence f tubercle bacilli. Options B and D will not diagnose TB.

1228 A nurse has been preparing a client with chromic obstructive pulmonary disease (COPD) for discharge to home. Which statement by the client
indicates a need for further teaching in relation to nutrition? I will certainly try to drink 3 L of fluid every day. It’s best to eat three large meals a
day so I will get all my nutrients. I will not eat as much cabbage as I once did. I will rest a few minutes before I eat. B Adequate fluid intake
helps to liquefy pulmonary secretions. Large meals distend the abdomen and elevate the diaphragm, which may interfere with breathing. Gas forming foods
may cause bloating, which interferes with normal diaphragmatic breathing. Resting before eating may decrease the fatigue that is often associated with COPD.

1229 A nurse has conducted teaching with a client who has experienced pulmonary embolism about methods to prevent recurrence after discharge from
the hospital. The nurse evaluates that the instructions have been effective if the client states an intention to: Continue to wear supportive hoe Limit intake
of fluids Cross the legs only at the ankle, but not at the knees Sit down whenever possible A Recurrence of pulmonary embolism can be
minimized by wearing elastic supportive hose, enhances venous return. The client can also enhance venous return by avoiding crossing the legs at the knees of
ankles, interspersing periods of sitting with walking, and performing active foot and ankle exercise. The client should also take in sufficient fluids to prevent
hemoconcentration and hypercoagulability.

1230 A nurse has given the postoperative thoracotomy client instructions about how to perform arm and shoulder exercises after discharge from the
hospital. The nurse evaluates that the client has not learned the proper techniques if the client is observed doing which of the following movements on the
affected side? Moving the arm up over the head and back down. Holding the hands crossed in front and raising them over the head. Holding the
upper arm straight out while moving the forearm up and down Making circles with the wrist D A variety of exercise that involve moving the
shoulder and elbow joints are indicated after thoracotomy. These include shrugging the shoulders and moving them back and forth; moving the arms up and
down, forward, and backward; holding the hand crossed in front of the waist and then raising them over the head; and holding the upper arm straight out while
moving the lower arm up and down. Exercises that move only the wrist joint are of no use after this surgery.
1231 A nurse has taught a client with silicosis about situations to avoid to prevent self-exposure to silica dust. The nurse evaluates that the client
understands the instructions if the client verbalizes giving up or wearing a mask for which of the following hobbies? Pottery making
Woodworking Painting Gardening A Exposure to silica dust occurs with activities such as pottery making and doing stone
masonry. Exposure to finely ground silica, such as is used with soaps, polishes, and filters, is also dangerous. Silica is not a pesticide and is not found in the
average soil. Silica is not inhaled in fumes, such as in woodworking or painting.

1232 A nurse in an ambulatory clinic administers a Mantoux skin test to a client on a Monday. The nurse plans to have the client return to the clinic to
have results read on: Tuesday or Wednesday Wednesday or Thursday Thursday or Friday The following Monday B
The Mantoux skin test for tuberculosis is read in 48 to 72 hours. The client should return to the clinic on Wednesday or Thursday.

1233 A nurse is caring for a client who has just experienced a pulmonary embolism. The client is restless and very anxious. The nurse uses which
approach in communicating with this client? Explaining each treatment in great detail Having the family reinforce the nurse’s directions Giving
simple clear directions and explanations Speaking very little to the client until the crisis is over C The client who has suffered pulmonary
embolism is fearful and apprehensive. The nurse effectively communicates with this client by staying with the client, providing simple, clear, and accurate
information, and displaying in a calm, efficient manner. Options A, B, and D will produce more anxiety for the client and family.

1234 A nurse is caring for a young adult diagnosed with sarcoidiosis. The client is angry and tells the nurse there is no point in learning disease
management, since there is no possibility of ever being cured. The nurse formulates which of the following nursing diagnoses for this client? Impaired
Thought Processes Altered Health Maintenance Anxiety Powerlessness D The client with powerlessness expresses feelings of having
no control over a situation or outcome. Altered Health Maintenance involves the inability to seek out help that is needed to maintain health. Anxiety is a vague
sense of unease. Impaired Thought Processes involves disruption in cognitive abilities or thought.

1235 A nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the
site. Which intervention by the nurse would be the best to relieve the client’s anxiety? Encouraging the client to cough and deep breathe Staying with
the client Interpreting the arterial blood gas report Distracting the client with television B Staying with the client has a twofold benefit.
First it relieves the client’s anxiety. In addition, the nurse must stay with the client to observe respiratory status after application of the occlusive dressing. It is
possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax resulting in a sudden decline in respiratory status and
mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Coughing and deep breathing have no immediate benefit for
the client who is in distress. Option D is nontherapeutic.
1236 A nurse is conducting a health screening clinic. The nurse interprets that which of the following clients participating in the screening has the
greatest need for instruction to lower the risk of developing respiratory disease? A 50-year-old smoker with cracked asbestos lining on basement pipes
in the home A 40-year-old smoker who works in a hospital A 36-year-old who works with pesticides A 25-year-old whose hobby is
woodworking A Smoking enhances the client’s risk of developing some form of respiratory disease. Other risk factors include exposure to
harmful chemicals, airborne toxins, and dust or fumes. The client at greatest risk has two identified risk factors, one of which is smoking.

1237 A nurse is interviewing a client with chronic obstructive pulmonary disease (COPD), who has a respiratory rate of 35 breaths/min and is
experiencing extreme dyspnea. Which if the following nursing diagnoses would be most appropriate for this client? Impaired Verbal Communication
related to a physical barrier Ineffective individual coping related to the client’s inability to handle a situational crisis Altered Body Image related to
neurological deficit Knowledge deficit related to COPD A A client may suffer physical or psychological alterations that impair
communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration affecting speech.
There are no data in the question that support options B, C, and D.

1238 A nurse is planning to assist in obtaining a set of arterial blood gases on a client. In addition to sending the specimen to the laboratory immediately,
the nurse plans to provide which of the following items to optimally maintain the integrity of the specimen? A syringe containing a preservative A
syringe containing a preservative and a bag of ice A heparinized syringe and a preservative A heparinized syringe and a bag of ice D
The arterial blood gas sample is obtaining by using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory
immediately. A preservative is not used.

1239 A nurse is preparing a client with pneumonia for discharge to home. Which statement by the client would alert the nurse to the fact that the client is
in need of further discharge teaching? I will take all my antibiotics, even if I do feel 100% better. I understand that it may be weeks before my
usual sense of well-being returns. It is a good idea for me to take a nap every afternoon for the next couple of weeks. You can toss out that incentive
spirometry as soon as I leave for home. D Deep breathing and coughing exercises and use of incentive spirometry should be practiced for 6 to 8
weeks after the client is discharged from the hospital to keep the alveoli expanded and promote the removal of lung secretions. If the entire regimen of
antibiotics is not taken, the client may suffer a relapse. Adequate rest is needed to maintain progress toward recovery. The period of convalescence with
pneumonia is often lengthy and it may be weeks before the client feels is a sense of well-being.

1240 A nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib
fractures. The goal is that the client will exhibit normal respiratory functioning. The nurse provides instructions to assist the client toward this goal. Which
statement by the client indicates to the nurse that further instructions are needed? I will let you know at once if I have trouble breathing. I will lie on
the affected side for an hour. I can expect a chest x-ray to be done shortly. I will notify you if feel a crackling sensation on my chest. B
Use the process of elimination, noting the key words further instructions are needed. Focus on the issue: postprocedure care following thoracentesis.
Note that options B states “the affected side for an hour.” Recall that facilitating lung expansion is important. Noting the words affected side in option B will
direct you to this option. Review postprocedure care for a thoracentesis if you had difficulty with this question.

1241 A nurse is teaching a client with histoplasmosis infection about prevention of future exposure to infections sources. The nurse evaluates that the
client needs further instruction if the client states that potential infectious sources include:Grape arbors Mushroom cellars Floors of chicken houses
Bird droppings A A client with histoplasmosis is taught to avoid exposure to potential sources of the fungus, which includes bird
droppings (especially starlings and blackbirds), floors of chicken houses and bat caves, and mushrooms cellars.

1242 A nurse is teaching a client with pulmonary sarcoidosis about long-term ongoing management. The nurse plans to include which of the following in
the instructions? Need for daily corticosteroid therapy Usefulness of home oxygen equipment Need for follow-up chest x-ray evaluation
every 6 months Importance of using incentive spirometer daily C The client with pulmonary sarcoidosis needs to have follow-up chest
x-rays every 6 months to monitor disease progression. If an exacerbation occurs, treatment is initiated with systemic corticosteroids, which tend to provide
rapid improvement in symptoms. Home oxygen and ongoing use of incentive spirometer are not indicated.

1243 A nurse taught a client with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood
the instructions if the client states an intention to: Try to take only small, shallow breaths Splint the chest wall during coughing and deep breathing
Lie as much as possible on the unaffected side Take as much pain medication as possible B The client with pleurisy should
splint the chest wall during coughing and deep breathing. The client may also lie on the affected side to minimize movement of the affected chest wall. Taking
small, shallow breaths promotes atelectasis. The client should take medication prudently so that adequate coughing and deep breathing is performed and an
adequate level of comfort is maintained.

1244 A nurse teaches a client which a rib fracture to cough and deep breathe. The client resists directions by the nurse because of the pain. The nurse
most appropriately: Continues to give the client gentle encouragement Requests that the physician perform a nerve block to deaden the pain
Explains in detail the potential complications resulting from lack of coughing and deep breathing Premedicates the client and assists the client to
splint the area during the coughing and deep-breathing exercises. D The shallow respirations and splinting that occur with rib fracture predispose the
client to developing a telectasis and pneumonia. It is essential that the client perform coughing and deep breathing to prevent these complications. The nurse
accomplishes this most effectively by premedicating the client with pain medication and assisting the client with splinting during the exercises.
1245 A physician orders a follow-up home care visit for an older adult client with emphysema. When the home health nurse arrives, the client is smoking.
Which of the following statements made by the nurse would be most therapeutic? "Well, I can see you never got to the Stop Smoking clinic!" "I
notice that you are smoking. Did you explore to Stop Smoking Program at the Senior Citizens?" "I wonder if you realize that you are slowly killing
yourself? Why prolong the agony? You can just jump of the bridge!" "I’m glad I caught you smoking! Now that your secret it out, let’s decide what
your are going to do?"B Emphysema clients need to avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a
client should not make judgmental comments and should explore an adaptive strategy with the client without being overly controlling. This will place the
decision making in the client’s hands, and provide an avenue for the client to share what may be expressions of frustration at an inability to stop what is
essentially a physiological addiction. Option A is an intrusive use of sarcastic humor that is degrading to the client. In option C, the nurse preaches and is
judgmental. Option D is a disciplinary remark and places a barrier between the nurse and client within the therapeutic relationship.

1246 A 22-year-old male client with AIDS signs a do not resuscitate (DNR) order when he is admitted to the hospital. When respiratory arrest occurs 3
weeks later the client is not resuscitated. A true statement about the legal aspects of a DNR order would be: Age is an important factor in the decision not to
resuscitate The decision not to resuscitate resides with the client's physician The status of the DNR order is contingent on the policies of the institution
Once the order has been signed, it remains in force for the entire hospitalization C Policies relative to DNR orders vary among
hospitals and the nurse must adhere to the policies of the institution

1247 A 26-year-old homosexual is diagnosed with AIDS. The primary nurse reports to the nursing team that the client wept when told of the diagnosis.
One of the nursing assistants responds, "I don't feel sorry for him. He made his bed, and now he can lie in it." This comment is most likely a result of the
nursing assistant's: Values and beliefs about sexual life-styles Anger and mistrust of homosexual males in general Discomfort with men who are
unable to control their emotions Hostility over having to care for someone with a sexually related disease A This statement reflects values and
beliefs regarding homosexuality as being bad and deserving of punishment.

1248 A 75-year-old female client tells the nurse that she read about a vitamin that may be related to aging because of its relationship to the structure of
cell walls and wonders whether she should be taking it. The nurse should recognize that the client is probably referring to: Vitamin A Vitamin C Vitamin E
Vitamin B1 C Vitamin E hinders oxidative breakdown of structural lipid membranes in body tissues caused by free radicals in the
cells.

1249 A 79-year-old client is admitted for dehydration, and an IV infusion of normal saline at 125 ml/hr is started. One hour later the client begins
screaming, "I can't breathe." The nurse should: Call the physician to order a sedative Discontinue the IV and call the physician Elevate the
head of the bed and obtain vital signs Assess the client for allergies and change the IV to a heparin lock C Verbalization indicates the client is
breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm; checking the vital signs after this is the first step in
assessing the cause of the distress.

1250 A back brace is prescribed for a client who had a laminectomy. The nurse should include in the teaching plan instructions to: Use the brace
when the back feels tired Apply the brace before getting out of bed Put the brace on while in the sitting position Wear the brace when performing
twisting exercises B This is done while in the supine position before the body is subjected to the force of gravity in a vertical position; anatomic
landmarks are easier to locate for correct application of the brace, and intraabdominal organs have not shifted toward the pelvic floor by gravity.

1251 A chronically ill, elderly female client tells the home care nurse that the daughter with whom she lives seems run-down and disinterested in her own
health as well as the health of her children, ages 2, 5, 7, and 12. The client tells the nurse that her daughter coughs a good deal and does a lot of sleeping. In this
situation the nurse should pursue the daughter's condition for potential case finding because: Children younger than 12 are very susceptible to
tuberculosis Deaths from tuberculosis have been generally on the decrease Tuberculosis has been dramatically rising in the general population
Aging clients with chronic illness are most adversely affected by tuberculosis D The client's chronic illness and increased age increase
vulnerability; the daughter's condition should be explored in more detail.

1252 A client appears very anxious, with respirations that are shallow and very rapid (40 per minute). The client complains of feeling dizzy and light-
headed and having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client's complaints are probably related to:
Eupnea Hyperventilation Kussmaul's respirations Carbon dioxide intoxication B The client is hyperventilating and
blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis.

1253 A client arrives at the emergency room after being bitten by a stray dog. The bite involved tearing of skin and deep soft tissue injury. The client says
the dog was foaming at the mouth and afterward ran away. The first nursing action is to: Ask the client about horse serum allergy Notify the police
department to capture the dog Assess the client's injury, vital signs, and past history Inoculate the client with human rabies immune globulin C
To make effective decisions, baseline information on the client's condition, extent of injury, and significant past health history are needed.

1254 A client comes to the clinic after being bitten by a raccoon in the woods in an area where rabies is endemic. The nurse recalls that rabies is:
An acute bacterial infection characterized by encephalopathy and opisthotonos An acute bacterial septicemia that results in convulsions
and a morbid fear of water A nonspecific immunoresponse to organisms deposited under the skin by an animal bite An acute viral infection,
characterized by convulsions and difficult swallowing, that affects the nervous system D This is a viral infection that enters the body through a
break in the skin and is characterized by convulsions and choking
1255 A client complains of urinary problems. Cholinergic medications are prescribed. The nurse is aware that this type of medication is prescribed to
prevent: Kidney stones A flaccid bladder A spastic bladder Urinary tract infections B Cholinergics intensify and prolong
the action of acetylcholine, which increases the tone in the genitourinary tract, preventing urinary retention.

1256 A client has a chest tube for pneumothorax. The nurse finds the client in respiratory difficulty with the chest tube separated from the drainage
system. The nurse should: Obtain a new sterile drainage system Clamp the drainage tubing with two clamps Reconnect the client's tube to the
drainage system Place the client in the high-Fowler's position immediately C To prevent further possibility of pneumothorax, the nurse
should immediately reconnect the tube.

1257 A client has a femoral-popliteal bypass graft. When the vital signs are assessed, the client's blood pressure is 200/110 mm Hg. The nurse should
notify the physician immediately because the: Graft could rupture Client is anaphylactic Client is hypervolemic Graft may be occluded
A Hypertension increases pressure on the suture lines of the graft.

1258 A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks (TIAs). The nurse understands that TIAs are:
Temporary episodes of neurologic dysfunction Transient attacks caused by multiple small emboli Periods of alternating exacerbations
and remissions Ischemic attacks that result in progressive neurologic deterioration A Narrowing of arteries supplying the brain causes
temporary neurologic deficits that last for a short period; between attacks the neurologic examination is normal.

1259 A client has a permanent sigmoid colostomy because of cancer. The physician orders daily colostomy irrigations. The nurse should explain to the
client that the primary purpose of these irrigations is to: Prevent straining at passage of stool Establish a regular elimination schedule Decrease the
amount of flatus in the bowel Limit the amount of fluid lost from the intestine B Irrigations regulate the bowel to function at a specific time
for the convenience of the client.
1260 A client has a Swan-Ganz catheter inserted for monitoring cardiovascular status. With the Swan-Ganz catheter the most accurate measurement of the
client's left ventricular pressure would be the: Right atrial pressure Cardiac output by thermodilution Pulmonary artery diastolic pressure
Pulmonary capillary wedge pressure D Pulmonary capillary wedge pressure is an indirect measure of left ventricular end diastolic
pressure, an indication of ventricular contractility.

1261 A client has a tentative diagnosis of primary biliary cirrhosis. Symptoms include jaundice, ascites, and peripheral edema. When performing the
physical assessment, the nurse would expect to observe the skin change known as: Vitiligo Hirsutism Melenosis Telangiectasis D
This is a vascular lesion associated with cirrhosis; it is thought to be related to elevated estrogen levels.

1262 A client has a tumor of the cerebellum. In view of the functions of this structure, the nurse should expect to observe an: Unconscious state
Inability to execute voluntary movements Absence of the knee-jerk and other reflexes Inability to execute smooth, precise movements D
The cerebellum is involved in the synergistic control of muscle action. Below the level of consciousness it functions to produce smooth, steady,
coordinated, and efficient movements.

1263 A client has been in a coma for 2 months and is maintained on bed rest. The nurse understands that to prevent the effects of shearing force, the head
of the bed should be at an angle of: 30 degrees 45 degrees 60 degrees 90 degrees A Shearing
force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and cause this
phenomenon

1264 A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and
excesses should be corrected. A nutritional assessment should be conducted to determine whether the client: Is deficient in vitamins A, D, and K
Eats adequate amounts of dietary fiber Consumes excessive amounts of protein Has excessive levels of potassium and folic acid A
Bile promotes the absorption of the fat-soluble vitamins; an obstruction of the common bile duct limits the flow of bile to the duodenum.
1265 A client has decided to become a total vegetarian (vegan) and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse
should instruct this client to: Add milk to grains to provide complete proteins Use eggs with plant foods to provide essential amino acids
Plan a careful mixture of plant proteins to provide a balance of amino acids Add cheese to grains and beans to increase the quality of protein
consumed C Complementary mixtures of essential amino acids in plant proteins provide complete dietary protein equivalents.

1266 A client has emergency surgery for a ruptured appendix. After assessing that the client is manifesting symptoms of shock the nurse should:
Prepare for a blood transfusion Notify the physician immediately Elevate the head of the bed 30 degrees Administer the oxygen
prescribed postoperatively B Peritonitis and shock are potentially life-threatening complications following abdominal surgery; prompt, rigorous
treatment is necessary.

1267 A client has just been diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" The nurse's
best response would be: "Most individuals with your disease live a normal life span" "Is your family here? I would like to explain your disease
to all of you" "The prognosis is variable; most individuals experience remissions and exacerbations" "Why don't you speak with your physician who
can give you more details about your disease" C This is a truthful answer that provides some realistic hope.

1268 A client in thyroid storm tells the nurse, "I know I'm going to die. I'm very sick." The best response by the nurse would be: "You must feel very sick
and frightened" "Tell me why do you feel you are going to die?" "I can understand how you feel, but people do not die from this problem" "If
you would like, I will call your family and tell them to come to the hospital" A This reflects the client's feelings and encourages a further exploration
of concerns.

1269 A client is admitted to the hospital for abdominal surgery for cancer of the pancreas. Before surgery, meperidine hydrochloride (Demerol) is ordered
for pain. The nurse recognizes that morphine sulfate is contraindicated for this client because it: Causes respiratory excitement Stimulates pancreatic
duct secretion Causes spasm of the pancreatic ducts Stimulates the sympathetic nervous system C Morphine sulfate increases spasm of
smooth muscle and is contraindicated in all conditions in which there is obstruction of smooth muscle ducts
1270 A client is admitted to the hospital for an acute episode of rheumatoid arthritis. During the initial assessment the nurse observes that the client's
finger joints are swollen. The nurse understands that this swelling is most likely related to: Urate crystals in the synovial tissue Inflammation
in the joint's synovial lining Formation of bony spurs on the joint surfaces Escaped fluid from the capillaries, increasing interstitial fluids B
This is caused by inflammation of the synovium, resulting in vascular congestion, fibrin exudate, and cellular infiltrate.

1271 A client is admitted to the hospital with diabetic ketoacidosis. The nurse understands that the elevated ketone level present with this disorder is
caused by the incomplete oxidation of: Fats Protein Potassium Carbohydrates A Incomplete oxidation of fat results in fatty
acids that further break down to ketones.

1272 A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. A lithotripsy is scheduled. The initial
nursing action should be to: Strain all urine output Increase the oral fluid intake Obtain a urine specimen for culture Administer
the prescribed analgesic D The pain of renal colic is excruciating; unless relief is obtained the client is unable to cooperate with other therapy.
"

1273 A client is admitted to the hospital with the diagnosis of acute salmonellosis. The nurse would expect that the client will be receiving: Antacids
Electrolytes Antidiarrheics Antispasmodics B Fluids of dextrose and normal saline and electrolytes are administered
to prevent profound dehydration caused by an excessive loss of water and electrolytes through diarrheal output.

1274 A client is admitted to the hospital with weakness in the right extremities and a slight speech problem. Vital signs are normal. During the first 24
hours the nurse should give priority to: Checking the client's temperature Evaluating the client's motor status Monitoring the client's
blood pressure Obtaining a urine specimen from the client B This assessment would indicate whether there is a progression of symptoms or
improvement and assist the physician in determining the diagnosis.
1275 A client is admitted to the intensive care unit with a diagnosis of adult respiratory distress syndrome. When assessing this client the nurse should
expect to find: Hypertension Tenacious sputum An altered mental status A slowed rate of breathing C This is
secondary to cerebral hypoxia, which accompanies ARDS; cognition and level of consciousness are reduced.

1276 A client is admitted to the intensive care unit with pulmonary edema. When performing the admission assessment, the nurse should expect: A
decreased blood pressure Radiating anterior chest pain A pulse that is weak and rapid Crackles at the base of each lung D Crackles are
the sound of air passing through fluid in the alveolar spaces; in pulmonary edema, fluid moves from the intravascular compartment into the alveoli.

1277 A client is being prepared for discharge from an ambulatory surgical unit following a cataract removal with an intraocular lens implant. The
statement by the client that suggests to the nurse that discharge teaching was effective is: "I'm driving home since I feel so good." "I can't wait until I get
home to wash my hair." "I can expect to see bright flashes of light for awhile." "I'll call the surgeon if the analgesic doesn't relieve the pain." D
Postoperatively the client must check daily for signs of rejection, which include redness, irritation, discomfort, or vision loss; the surgeon should be
notified if any of these appear; pain following a cataract extraction may indicate infection or hemorrhage and should be reported to the physician immediately. "

1278 A client is brought to the emergency room after an automobile accident. The client's blood pressure is 100/60 mm Hg, and the physical assessment
suggests a ruptured spleen. Based on this information, the nurse should assess the client for an early sign of decreased arterial pressure, such as: Warm,
flushed skin Confusion and lethargy Increased pulse pressure Reduced peripheral pulses D Hypovolemia results in a
decreased cardiac output and a decreased arterial pressure, which are reflected by a feeble, weak peripheral pulse.

1279 A client is cautioned to avoid vitamin D toxicity while increasing protein intake. The nurse would know that the teaching was understood when the
client states, "I must increase my intake of: Tofu products. Fruit and eggnog. Powdered whole milk. Cottage cheese custard. A
Tofu products increase protein without increasing vitamin D because, unlike milk products, tofu does not contain vitamin D.
1280 A client is diagnosed as having a peptic ulcer. The nurse would expect that the client's pain: Occurs 1 to 3 hours after meals Is intensified
when vomiting occurs Increases when fatty foods are ingested Begins in the epigastrium and radiates to the abdomen A Pain occurs
after the stomach empties; eating stimulates gastric secretions, which act on the gastric mucosa of an empty stomach, causing gnawing pain.

1281 A client is diagnosed as having non-insulin-dependent diabetes mellitus and the physician prescribes glyburide (Micronase). While taking this
medication, the client should be taught to observe for: Ketonuria Weight loss Ketoacidosis Hypoglycemia D Oral
hypoglycemic agents decrease serum glucose levels.

1282 A client is diagnosed with tuberculosis associated with HIV infection. The test results that are crucial for the nurse to review before starting
antitubercular pharmacotherapy are: Liver function studies Pulmonary function studies Electrocardiogram and echocardiogram
White blood cell counts and sedimentation rate A Antitubercular drugs such as isoniazid (INH), rifampin (Rifadin), and
aminosalicylate sodium are hepatotoxic.

1283 A client is on a ventilator. One of the nurses asks what should be done when condensation resulting from humidity collects in the ventilator tubing.
The best response to this question would be to: Notify the respiratory therapist. Empty the fluid from the tubing. Decrease the amount of humidity.
Measure the fluid and record it on the I&O. B This is necessary to prevent flooding of the trachea with fluid; some systems have
receptacles attached to the tubing to collect the fluid and others have to be temporarily disconnected while emptying the fluid.

1284 A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for evidence of: Negative nitrogen balance
Excessive loss of potassium ions Excessive retention of sodium ions Elevation of the urine-specific gravity B Lasix is a
potent diuretic used to provide rapid diuresis in pulmonary edema; it acts in the loop of Henle and causes depletion of electrolytes such as potassium and
sodium.
1285 A client is scheduled for a bone scan to determine the presence of metastases. The nurse is aware that teaching prior to a scheduled bone scan was
effective when the client states that: "X-rays will be taken to identify where I may have lost calcium from my bones." "A portion of my bone
marrow will be removed and examined for cell composition." "A radioactive chemical will be injected into my vein that will destroy cancer cells present
in my bones." "A substance of low radioactivity will be injected into my vein, and my body inspected by an instrument to detect where it is deposited."
D A bone scan reflects the uptake of a bone-seeking radioactive isotope; an increased uptake is seen in metastatic bone disease,
osteosarcoma, osteomyelitis, and certain fractures.

1286 A client is scheduled for a transurethral resection of the prostate. As part of the preoperative teaching, the nurse should explain that after surgery:
Urinary control may be permanently lost to some degree The client's ability to perform sexually will be permanently impaired
Urinary drainage will be dependent on a urethral catheter for 24 to 48 hours Frequency and burning on urination will last while the cystotomy
tube is in place C An indwelling urethral catheter is used because surgical trauma can cause urinary retention, leading to further complications
such as bleeding.

1287 A client is scheduled for an arthroscopy of the knee in the morning and asks the nurse about the procedure. The statement by the nurse that best
describes the procedure would be: "You will be anesthetized and not remember anything about the procedure." "It is a direct visualization of the
joint to diagnose the extent of the knee injury." "It is a radiologic procedure that will help diagnose the extent of the knee injury." "The
procedure will determine the type of treatments the physician will prescribe." B This is a truthful description of arthroscopy; the physician uses a
scope to visualize the knee structures to determine the extent of injury.

1288 A client is scheduled to have a thyroidectomy for cancer of the thyroid. When providing preoperative teaching for the postoperative period, the nurse
should teach the client to: Cough and deep breathe every 2 hours Perform range-of-motion exercises of the head and neck Support the
head with the hands when changing position Apply gentle pressure against the incision when swallowing C This relieves tension on
the incision and limits the risk of dehiscence.

1289 A client is suspected of having thrombophlebitis of the left lower extremity. During the initial assessment the nurse should specifically observe the
client for: Edema of the left leg Mobility of the left leg A positive left-sided Babinski's reflex Presence of peripheral arterial pulses A
Swelling of the extremity is indicative of thrombophlebitis.
1290 A client is taught how to change the dressing and how to care for a recently inserted nephrostomy tube. On the day of discharge the client states, "I
hope I can handle all this at home; it's a lot to remember." The best response by the nurse would be: "I'm sure you can do it!" "Oh, a family member
can do it for you." "You seem to be nervous about going home." "Perhaps you can stay in the hospital another day" C Reflection
conveys acceptance and encourages further communication.

1291 A client is to be discharged following a laser laparoscopic cholecystectomy. The nurse would recognize that the discharge instructions were
understood when the client states: "I can change the bandages every day." "I should remain on a full liquid diet for 3 days." "I should not
bathe the surgical sites for a week." "I may have mild shoulder pain for about a week." D Mild shoulder pain is common up to 1 week
after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity
during surgery.

1292 A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?"
From this statement the nurse ascertains that the client is most likely experiencing: Fear Depression Dependency Ambivalence
A Fear of recurrent myocardial infarct or sudden death is common when the client's environment is to be changed to one that appears less
vigilant.

1293 A client is to receive doxorubicin (Adriamycin) as part of a chemotherapy protocol. The major life-threatening side effect of Adriamycin that the
nurse should assess the client for is: Cardiotoxicity Pancytopenia Pulmonary fibrosis Ulcerative stomatitis A Congestive
heart failure and dysrhythmias are the only life-threatening toxic effects unique to Adriamycin.

1294 A client returns from surgery with a hip prosthesis. An abductor splint is in place. The nurse should remove the splint: When the client gets up
in a chair When the client needs a change of position Once the client's operative pain has ceased To administer skin care and physical therapy D
Until the order is written to discontinue the abduction splint, it is only removed for mobility such as physical therapy and hygiene; adduction to or
beyond the midline is not permitted for 2 to 3 months.
1295 A client sustains a vertebral fracture at the T1 level as a result of diving into shallow water. On admission to the emergency room, a detailed
neurologic assessment is performed. The nurse should expect to find: Inability to move the lower arm Normal biceps reflexes in the arm
Loss of pain sensation in the hands Difficulty breathing and a flaccid diaphragm B The nerves for arm innervation are
above the injury level at C4.

1296 A client undergoes pituitary surgery by the transsphenoidal route. After surgery the nurse should instruct the client to avoid food such as:
Celery Shellfish Grapefruit Aged cheese A Because roughage such as celery can irritate the surgical wound and lead to
hemorrhage, this type of food is contraindicated in the postsurgical period of transsphenoidal surgery.

1297 A client who had previously signed a consent for a liver biopsy has a change of mind and no longer wants the procedure. The best initial response by
the nurse would be: "Why did you originally sign the consent?" "Can you tell me why you decided to refuse the procedure?" "You are obviously
afraid about something concerning the procedure" "Although the procedure is very important, I understand why you changed your mind" B
This attempts to explore why the client is refusing the procedure and promotes communication.

1298 A client who has been hospitalized for thrombophlebitis asks how future attacks can best be prevented. The nurse should teach the client to:
Follow the program of exercises Take prophylactic anticoagulants Apply warm soaks to the legs daily Apply elastic stockings before
arising D This provides support and promotes venous return; applying stockings while legs are horizontal before arising ensures that stockings are
applied before dependent edema occurs.

1299 A client who had a kidney transplant develops leukopenia 3 weeks after surgery. The nurse should be aware that the leukopenia is probably caused
by: A bacterial infection High creatinine levels Rejection of the kidney The antirejection medications D The WBC
count can drop precipitously; if leukocytes are less than 3,000/mm3, the drug should be stopped to prevent irreversible bone marrow depression.
1300 A client who has a long leg cast applied is to be discharged. When discussing pain management, the nurse should advise the client to take the
prescribed prn Tylenol with Codeine: Just as a last resort Before going to sleep When the discomfort begins As the pain becomes intense C
Pain is most effectively relieved when the analgesic is administered at the onset of pain, before it becomes intense; this prevents a pain cycle from
occurring.

1301 A client who has a myocardial infarction experiences a noticeably decreased pulse pressure. The nurse should immediately recognize this as a
possible indication of: Increased blood volume Hyperactivity of the heart Increased cardiac sufficiency Decreased force of
contraction D A direct relationship exists between the systolic blood pressure and the force of left ventricular contraction.

1302 A client who has had a subtotal thyroidectomy does not understand how hypothyroidism could develop when the problem was hyperthyroidism. The
nurse should base a response on the knowledge that: Hypothyroidism is a gradual slowing of the body's function There will be a decrease in pituitary
thyroid-stimulating hormone There is less thyroid tissue to supply thyroid hormone after surgery Atrophy of tissue remaining after surgery
reduces secretion of thyroid hormones C After a thyroidectomy the thyroxine output is usually inadequate to maintain an appropriate metabolic
rate.

1303 A client who had a transurethral resection of the prostate is to be discharged from the outpatient surgical department. The nurse understands that
discharge teaching was effective when the client states: "I will enjoy a bowl of hot chili for supper." "I am going to enjoy driving myself back home." "I
will drink 4 to 5 glasses of water during the day." "I will notify my physician if persistent bleeding occurs." D Intermittent bleeding is
expected; however, if persistent bleeding occurs, the surgeon should be notified.

1304 A client who has recently had an abdominoperineal resection and colostomy accuses the nurse of being uncomfortable during a dressing change
because the "wound looks terrible." The nurse recognizes that the client is using the defense mechanism known as: Projection Sublimation
Intellectualization Reaction formation A Projection is the attribution of unacceptable feelings and emotions to others.
1305 A client who is newly diagnosed with multiple myeloma asks the physician what treatment will be necessary. The nurse should expect the physician
to reply: Human leukocyte interferon therapy Radiotherapy on an outpatient basis Surgery to remove the lesion and lymph nodes
Chemotherapy employing a combination of drugs D This is the treatment of choice; a variety of drugs affects rapidly dividing cells at
different stages of cell division.

1306 A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. In preparation for this activity the client should be
taught: Leg lifts to prevent hip contractures Push-ups to strengthen arm muscles Balancing exercises to promote equilibrium Quadriceps-
setting exercises to maintain muscle tone B Arm strength is necessary for transfers and activities of daily living and for the use of crutches or a
wheelchair.

1307 A client who is scheduled to have surgery to remove an aldosterone-secreting adenoma wonders what will happen if he refuses to have the surgery.
The nurse would base a response on the fact that: The tumor must be removed to prevent heart and kidney damage Surgery will prevent the tumor from
metastasizing to other organs Radiation therapy can be just as effective as surgery if the tumor is small Chemotherapy is as reliable as surgery to treat
adenomas of this type in some cases A Renal and cardiac complications will occur if the hypertension caused by the tumor is not arrested.

1308 A client who is taking an oral hypoglycemic daily for non-insulin-dependent diabetes mellitus (NIDDM) develops the flu and is concerned about the
need for special care. The nurse should advise the client to: Skip the oral hypoglycemic pill, drink plenty of fluids, and stay in bed Avoid food,
drink clear liquids, take a daily temperature, and stay in bed Eat as much as possible, increase fluid intake, and call the office the next day Take the oral
hypoglycemic pill, drink warm fluids, and perform a finger stick for glucose ac and hs D Physiologic stress increases gluconeogenesis, requiring
continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring serum glucose levels permits early intervention if necessary.

1309 A client who is to begin continuous ambulatory peritoneal dialysis (CAPD) asks the nurse what this treatment entails. The explanation should
include information that: Peritoneal dialysis is done in an ambulatory care clinic There is continuous hemodialysis and peritoneal dialysis
There is continuous contact of dialysate with peritoneal membrane About a quarter of a liter of dialysate is maintained intraperitoneally C
Dialysate is introduced into the peritoneal cavity where fluids, electrolytes, and wastes are exchanged through the peritoneal membrane.
1310 A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." The best response by the nurse
would be: It will be no worse than a sunburn A localized skin reaction usually occurs Have they had experience with this type of radiation?
Daily application of an emollient will prevent the burn B Radiodermatitis occurs 3 to 6 weeks after the start of treatment.

1311 A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first
48 hours after the client's admission will be to: Monitor the client's vital signs Increase the client's fluid intake Improve the client's nutritional
status Identify the client's reasons for drinking A A client's vital signs, especially the pulse and temperature, will rise before the client
demonstrates any of the more severe symptoms of withdrawal from alcohol.

1312 A client with a coronary occlusion is experiencing chest pain and distress. The nurse should administer oxygen to: Prevent dyspnea
Prevent cyanosis Increase oxygen concentration to heart cells Increase oxygen tension in the circulating blood C
Administration of oxygen increases the transalveolar O2 gradient, which improves the efficiency of the cardiopulmonary system. This increases the
oxygen supply to the heart.

1313 A client with a distal femoral shaft fracture is at risk for developing a fat embolus. A distinguishing sign that is unique to a fat embolus is:
Oliguria Dyspnea Confusion Petechiae D At the time of a fracture or orthopedic surgery fat globules may move from the bone marrow
into the bloodstream; also, elevated catecholamines cause mobilization of fatty acids and the development of fat globules; in addition to obstructing vessels in
the lung, brain, and kidneys with systemic embolization from fat globules, petechiae are noted in the buccal membranes, conjunctival sacs, hard palate, chest,
and anterior axillary folds; these adaptations only occur with a fat embolism.

1314 A client with a hiatal hernia asks the nurse how to best prevent esophageal reflux. The nurse's best response would be: Increase your intake of
fat with each meal. Lie down after eating to help your digestion. Reduce your caloric intake to foster weight reduction. Drink several glasses of fluid during
each of your meals. C Weight reduction decreases intra-abdominal pressure, thereby decreasing the tendency to reflux into the esophagus.
1315 A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the
physician will order: A glass of water every hour until hydrated Small frequent intake of juices, broth, or milk Short-term NG replacement of
fluids and nutrients A rapid IV infusion of an electrolyte and glucose solution B This would provide gradual replacement of both fluid and
electrolytes without overloading the intravascular compartment.

1316 A client with a history of hypertension and left ventricular failure arrives for a scheduled clinic appointment and tells the nurse, "My feet are killing
me. These shoes got so tight." The nurse's best initial action would be to: Weigh the client Notify the physician Take the client's pulse rate
Listen to the client's breath sounds A Shoes that become too tight indicate pedal edema, which is a sign of fluid retention; 2.2
pounds is equal to 1 liter of fluid.

1317 A client with a history of hypertension develops pedal edema and demonstrates dyspnea on exertion. The nurse recognizes that the client's dyspnea
on exertion is probably: Caused by cor pulmonale A result of left ventricular failure A result of right ventricular failure
Associated with wheezing and coughing B The failing left ventricle cannot accept blood returning from the lungs; this results in
increased vascular pressure in the lungs.

1318 A client with a history of hypertension is admitted to the hospital with aphasia. A bruit is heard over the left carotid artery, and the pulse is irregular.
The nurse is aware that complete occlusion of the branches of the middle cerebral artery resulting in aphasia may occur because of: A history of hypertensive
disease Emboli associated with atrial fibrillation Developmental defects of the arterial wall Inappropriate paroxysmal neural discharge B
Emboli, occurring from atrial fibrillation, cause complete occlusion of vessels; usually middle cerebral arteries are involved; the infarct may cause
hemiplegia, aphasia, or spatial perceptual deficits.

1319 A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. An appropriate postoperative intervention on the day
after surgery would be to: Keep the client on bed rest Have the client sit in a chair Assist the client with ambulation Encourage the client to
keep the legs elevated C Mobility will reduce venous stasis and edema as well as promote arterial perfusion and healing.
1320 A client with a long history of bilateral varicose veins questions the nurse about the brownish discoloration of the skin of the lower extremities. The
nurse should explain that this is probably the result of: An inadequate arterial blood supply Delayed healing of tissues after an injury Leakage of
RBCs through the vascular wall Increased production of melanin in the area C Increased venous pressure alters the permeability of the veins,
allowing extravasation of RBCs; lysis of RBCs causes brownish discoloration of the skin.

1321 A client with a partial-thickness burn complains of chilling. To limit this adaptation, the nurse should: Limit the occurrence of drafts
Keep the room temperature more than 90 degrees F Maintain the room humidity at less than 40% Place a sterile top sheet over the
client A Clients with burns are sensitive to environmental changes; loss of the skin's microcirculation in the burned areas decreases the ability to
retain body heat.

1322 A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should:
Apply suction while inserting the catheter Hyperoxygenate with 100% oxygen before and after suctioning Use short, jabbing movements of
the catheter to loosen secretions Suction two to three times in quick succession to remove all secretions B Suctioning also removes oxygen,
which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client prior to and after suctioning.

1323 A client with a tentative diagnosis of myasthenia gravis is scheduled for a Tensilon test. When teaching about this test, the nurse should explain to
the client that the response to the medication that will confirm the diagnosis of myasthenia gravis will be a: Brief exaggeration of symptoms Prolonged
symptomatic improvement Symptomatic improvement in ptosis only Rapid but brief symptomatic improvement D Tensilon acts
systemically to increase muscle strength, with a peak effect in 30 seconds which lasts several minutes.

1324 A client with a transplanted kidney is taught the signs of rejection. The nurse would know that the teaching was effective when the client says that a
sign of rejection would be: Weight loss A subnormal temperature An elevated blood pressure An increased urinary output C
Hypertension is caused by a return of hypervolemia because of the failure of the new kidney.
1325 A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. Following the procedure the nurse should assess
the client for esophageal perforation, which is indicated by: Faintness and feelings of fullness Diaphoresis and cardiac palpitations
Increased heart rate and abdominal pain Increased blood pressure and urinary output C An increased heart rate is related to an
autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux.

1326 A client with AIDS comments to the nurse, "There are so many rotten people around. Why couldn't one of them get AIDS instead of me?" The nurse
could best respond: "It seems unfair that you should be so ill" "I can understand why you're afraid of death" "Have you thought of speaking with
a minister?" "I'm sure you really don't wish this on someone else" A The client is in the anger or "why me" stage; encouraging the
expression of feelings will help the client resolve them and move toward acceptance.

1327 A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. This electrolyte
deficiency can best be corrected by: A low-residue diet Hyperalimentation Intravenous therapy An oral electrolyte solution C
This ensures a rapid, well-controlled technique for electrolyte (chloride) replacement.

1328 A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to
observe for: A rapid, thready pulse Decreased peristalsis Respiratory congestion An increase in temperature A
Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia; a rapid, thready pulse is a compensatory response
to this shift.

1329 A client with cancer is receiving a multiple chemotherapy protocol. Included in the protocol is leucovorin calcium (Wellcovorin). The nurse
recognizes that this drug is administered to: Potentiate the effect of alkylating agents Diminish the toxicity of folic acid antagonists Limit the
occurrence of nausea and vomiting associated with chemotherapy Interfere with cell division at a different stage of cell division than the other drugs B
Leucovorin calcium limits toxicity of folic acid antagonists, such as methotrexate sodium, by competing for transport into cells.
1330 A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO2 of 60 mm Hg. These blood gases require nursing
attention because they indicate: Metabolic acidosis, Metabolic alkalosis Respiratory acidosis Respiratory alkalosis C The pH indicates
acidosis; CO2 is the parameter for respiratory function; normal PCO2 is 40 mm Hg.

1331 A client with chronic renal failure is accepted for a kidney transplant and attends a group educational program for potential transplant candidates.
The client asks the nurse which kidney will be removed. The nurse's best response would be: Neither of your kidneys will be removed unless they are
infected. It is up to the surgeon as to which kidney is replaced with the new one. The kidney that is the most diseased is removed and replaced with the
new one. Your right kidney will be removed because it has a longer renal vein making transplant easier. A The recipient's own kidneys are not
removed unless a chronic infection is present.

1332 A client with diabetes mellitus develops ketoacidosis. The arterial blood gas report that is representative of diabetic ketoacidosis is: PCO2 49,
HCO3 32, pH 7.50 PCO2 26, HCO3 20, pH 7.52 PCO2 54, HCO3 28, pH 7.30 PCO2 28, HCO3 18, pH 7.28 D Low pH and bicarbonate
values reflect metabolic acidosis; a low PCO2 value indicates compensatory hyperventilation

1333 A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin complains of tingling and numbness of the fingers and toes and
shortness of breath. The cardiac monitor shows the appearance of a U wave. The nurse should recognize that these symptoms indicate: Hypokalemia
Hyponatremia Hypoglycemia Hypercalcemia A These are classic signs of hypokalemia that occur when potassium
levels are reduced as potassium reenters cells with glucose.

1334 A client with expressive aphasia becomes frustrated and upset when attempting to communicate with the nurse. To help alleviate this frustration the
nurse should: Limit the client's contact with others to limit the frustration Anticipate needs so that the client does not have to ask for help
Face the client and speak loudly so that the client can see and hear better Allow plenty of time so that the client does not have to respond under
pressure D Giving adequate time to respond and employing a calm, accepting, deliberate, and interested manner will reduce the client's anxiety and
tension as well as increase self-esteem.
1335 A client with HIV-associated Pneumocystis carinii pneumonia is to receive pentamidine isethionate IV once daily. To ensure client safety the nurse
should: Mix the drug with sterile saline without a preservative Administer the drug over a period of 20 to 30 minutes Monitor the blood pressure for
hypertension during therapy Assess blood glucose levels daily during therapy and several times after therapy D Pentamidine can cause
either hypoglycemia or hyperglycemia even after therapy is discontinued, and therefore blood glucose levels should be monitored. "

1336 A client with Hodgkin's disease enters a remission period and remains symptom-free for 6 months, when a relapse occurs. The client is diagnosed at
stage IV. The therapy option the nurse should expect to be implemented at this time is: Radiation therapy Combination chemotherapy Radiation
with chemotherapy Surgical removal of the affected nodes B A protocol consisting of three or four chemotherapeutic agents that attack the
dividing cells at various phases of development is the therapy of choice at this stage; alternating courses of different protocols may be used.

1337 A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. After the angiogram the nurse
should: Elevate the foot of the bed Have the client void within 2 hours Keep the client in the high-Fowler's position Perform a
neurovascular assessment of the affected extremity D Because of the trauma associated with the insertion of the catheter during the procedure, the
involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus could occur.

1338 A client with insulin-dependent diabetes is placed on an insulin pump. The most appropriate short-term goal in teaching this client to control the
diabetes is: The client will: Adhere to the medical regimen. Remain normoglycemic for 3 weeks. Demonstrate the correct use of the insulin
pump. List three self-care activities necessary to control the diabetes. C This is a short-term goal, client-oriented, necessary for the client to
control the diabetes, and measurable when the client performs a return demonstration for the nurse.

1339 A client with insulin-dependent diabetes mellitus receives NPH insulin (Humulin N) every morning at 8:00 A.M. The nurse recognizes that the client
understands the action of this insulin when the client says, "I should be alert for signs of hypoglycemia between: 10 am and noon 2 pm and 4
pm 4 pm and 6 pm 8 pm and 10 pm C NPH insulin's onset of action is 1 to 2 hours, peak action is 8 to 12 hours, and duration of
action is 18 to 24 hours; if hypoglycemia were to occur, it would happen between 4 pm and 8 pm.. "
1340 A client with lower back pain is tentatively diagnosed as having a herniated intervertebral disc. When assessing this client's back pain, the nurse
should ask: "Is there any tenderness in the calf of your leg?" "Have you had any burning sensation on urination?" "Do you have any
increase in pain during bowel movements?" "Does the pain begin in your flank and move around to the groin?" C The Valsalva maneuver raises
cerebrospinal fluid pressure, thereby causing pain.

1341 A client with metastatic melanoma is being treated with Interferon. The nurse is aware that the teaching about this drug is understood when the client
states: I will increase my fluid intake to 2 to 3 liters daily I need to discard any reconstituted solution at the end of the week I can continue driving
my car as before, as long as I have the stamina I should be able to continue my usual activity while taking this medication A This helps
flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment.

1342 A client with multiple myeloma is scheduled to have a chest x-ray examination and a bone scan. For this client, the primary responsibility of the
nursing and radiology staff is to: Explain the procedure and its purpose Observe the client for shortness of breath Provide for rest periods during the
procedure Handle the client with supportive movements D Because of bone erosion, pathologic fractures are a common complication of
multiple myeloma.

1343 A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?"
The nurse's best response would be: "Tell me about your fears regarding pain." "Analgesics will be ordered to control the pain." "Let's make a
list of the things you need to ask your physician." "Pain is not a characteristic symptom of this disease process." D This is a truthful answer
that provides hope for the client.

1344 A client with myasthenia gravis has been receiving pyridostigmine bromide (Mestinon). Because of inadequate symptomatic control, the physician
begins long-term steroid therapy. When this type of therapy is being initiated, it is especially important to: Increase the client's sodium intake
Place the client on protective isolation Decrease the client's fluid intake to 1000 ml daily Observe the client for an exacerbation of
symptoms D Exacerbation of myasthenia may occur within 2 weeks of steroid therapy, causing respiratory embarrassment and dysphagia.
1345 A client with myasthenia gravis has increased difficulty in swallowing. The nurse would be most effective in preventing the aspiration of food by:
Placing an emergency tracheostomy set in the client's room Changing the client's diet order from soft foods to clear liquids Assessing the
client's respiratory status before and after meals Coordinating the client's meal schedule with peak effect of pyridostigmine bromide D
Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing probability of aspiration.

1346 A client with myasthenia gravis improves and is discharged from the hospital. The discharge medications include pyridostigmine bromide
(Mestinon) 10 mg every 6 hours. The nurse would know that the drug regimen was understood when the client says, "I should: Take milk with each
dose of Mestinon. Take the Mestinon on an empty stomach. Set my alarm clock to take my medication. Take my pulse and respirations before taking
the drug. C Mestinon is a vital drug that must be taken on time; missed or late doses can result in severe respiratory and neuromuscular consequences
or even death.

1347 A client with myasthenia gravis is admitted to the emergency room in crisis. To distinguish between myasthenic crisis and cholinergic crisis, the
nurse should expect the physician to administer: Atropine sulfate Protamine sulfate Naloxone (Narcan) Edrophonium chloride (Tensilon)
D A positive response to the administration of Tensilon indicates myasthenic crisis, whereas an increase in the severity of symptoms
indicates cholinergic crisis.

1348 A client with non-insulin-dependent diabetes mellitus (NIDDM) is taking 1 glyburide (Micronase) tablet daily. The client asks whether an extra pill
should be taken before exercise. The nurse should reply: You will need to decrease your exercise. An extra pill will help your body use glucose
correctly. Your diet and medicine will not be affected by exercise. No, but observe for signs of hypoglycemia while exercising. D Exercise
improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia.

1349 A client with oat cell lung cancer is scheduled for a mediastinoscopy with biopsy. The nurse should: Tell the client that chest tubes will be present
after the procedure Explain that the procedure will visualize the lungs and the chest cavity Advise the client of the NPO status after midnight the
night before the test Inform the client that some pleural fluid will be removed during the procedure C To prevent aspiration during the
procedure, clients are required to be NPO for at least 8 to 12 hours prior to the procedure.

1350 A client with osteomyelitis of the leg is to have a debridement of the infected
bone. When planning for postoperative care the nurse knows that: Frequent range-of-motion exercises will be needed Septicemia is a common
postoperative complication The client's leg will be immobilized in a cast or splint The client will be allowed out of bed after the first day C
 The infected bone is placed at rest in a cast, splint, or traction to reduce pain and limit the spread of infection.

1351 The nurse is assessing a client who desires an effective contraceptive method. Which assessment finding would contraindicate the use of an oral
contraceptive by the client? Anemia Age 24 Irregular menstrual cycles History of thrombophlebitis D For clients with a history
of thrombophlebitis, oral contraceptives are contraindicated because they may alter clotting functions and increase the risk of thrombus formation. Because
oral contraceptives typically reduce the duration of menstrual periods, they frequently improve anemia. They are an appropriate contraceptive method for
healthy women under age 40 and commonly are prescribed to promote more regular menstrual cycles.

1352 A pregnant client's last normal menstrual period began on July 30. Using Nagele's rule, what is her estimated due date? 23-Apr 30-Apr 7-
May 37399 C To apply Nagele's rule correctly, subtract 3 months from the first day of the last normal menstrual period (July 30 - 3 months
= April 30) and then add 7 days (April 30 + 7 days = May 7). The other answer options do not apply all parts of the rule correctly.

1353 A client, gravida 1, para 0, is 9 weeks pregnant. She states, "I can't believe I'm pregnant. I just got a new job!" What is the most accurate
evaluation of this statement? She desires an abortion. She is expressing ambivalence. She is depressed about the pregnancy. She may have
difficulty bonding with the neonate. B Feelings of ambivalence normally occur in the first trimester of pregnancy. At this stage, therapeutic
nursing interventions include nonjudgmental acceptance and exploration of the client's feelings. Assessment for depression or the desire for an abortion may
follow. Early expressions of ambivalence do not prevent the mother from bonding with her neonate.

1354 When assessing a pregnant client for exposure to potential teratogens, the nurse should examine which factor most critically? Type of
teratogen Duration of teratogen exposure Weeks of gestation at the time of exposure Client's physical condition at the time of exposure C
Although the nurse should consider all of these factors, the most critical one is the gestational age of the fetus at the time of exposure. The fetus is
most susceptible to teratogenic effects between 2 and 8 weeks' gestation, when the organs are forming.

1355 During a prenatal visit, the nurse should consider which of these assessment findings to be normal? Fetal heart rate of 170 beats/minute at 20
weeks' gestation Maternal report of quickening at 12 weeks' gestation Engagement without lightening at 24 weeks' gestation Fundal height palpable
midway between the umbilicus and symphysis pubis at 16 weeks' gestation D At 16 weeks' gestation, the fundus should be easily palpated midway
between the symphysis pubis and umbilicus. The normal fetal heart rate ranges from 120 to 160 beats/minute. Quickening - the client's first perception of fetal
until 18 to 20 weeks' gestation. Engagement with or without lightening typically occurs between weeks' 36 and 40.

1356 When teaching a client about the complications of pregnancy, the nurse should make sure that she recognizes which of these as a sign of a
complication? Nausea with occasional vomiting in the first trimester Maternal fatigue, especially in the late afternoon Blurred or double vision
upon arising Constipation in the second trimester C Vision changes frequently are associated with pregnancy-induced hypertension
and require investigation. The other options are normal discomforts of pregnancy.

1357 The nurse is attempting to confirm a pregnancy of approximately 8 weeks. After taking the client's history and assessing her, the nurse should
expect to find which presumptive sign of pregnancy? Breast enlargement and increased vascularity Maternal reports of backache and leg cramps
New striae over the lower abdomen Braxton Hicks contractions A In early pregnancy, elevated estrogen and progesterone
levels cause breast enlargement and increased vascularity, which are presumptive signs of pregnancy. Backache and leg cramps may result from pregnancy or
from various other conditions. Striae over the lower abdomen may result from pregnancy or excessive weight gain in a nonpregnant client. Braxton Hicks
contractions occur much later in pregnancy and are considered a probable sign of pregnancy.

1358 Which nursing diagnosis is most appropriate for an adolescent client undergoing a routine nonstress test to assess fetal well-being at 39 weeks'
gestation? Fear related to stimulated uterine contractions during the test Pain related to maternal positioning during the test Anxiety related to the
invasive nature of the test Knowledge deficit related to the test procedure D Before beginning the nonstress test, the nurse should
explain its purpose and procedure to the client. By offering this information, the nurse corrects a knowledge deficit related t the test procedure. The nonstress
test does not induce contractions, allows the client to remain in a comfortable position, and is not invasive.

1359 A pregnant client who had rheumatic fever as a child currently has Class 2 heart disease and develops shortness of breath and chest discomfort with
moderate exertion. Which condition would increase her risk for further complications of pregnancy? Anemia Nocturia Heartburn Supine hypotension A
A client with Class 2 heart disease and anemia is at increased risk for infection, and infection would compromise her heart condition further because
normal physiological changes in blood volume and weight gain during pregnancy have already increased the cardiac work load. Nocturia and heartburn,
although common discomforts of pregnancy, should not compromise the client with cardiac problems. Supine hypotension should not compromise the heart
and can be treated by altering the client's position when lying down.
1360 During pregnancy, a client with type 1 diabetes should receive which instruction? Restrict weight gain to 5 lb (2.3 kg) each trimester.
Continue to take tolbutamide (Orinase) daily. Restrict fluid intake to 1 liter per day. Attend all scheduled prenatal visits. D
A pregnant client with diabetes should attend regular prenatal visits so her insulin requirements may be adjusted to compensate for the changes that
occur during pregnancy. She should gain more than 5 lb (an average of 1 lb [0.4 kg] per week) in the second and third trimesters. Oral hypoglycemic agents,
such as tolbutamide (Orinase), should not be used during pregnancy because their teratogenic effects are still being researched and may cause prolonged
hypoglycemia in the fetus. Instead, dietary management and insulin injections are used to control diabetes during pregnancy. The recommended fluid intake
during pregnancy is 3 liters per day.

1361 A client with pregnancy-induced hypertension (severe pre-eclampsia) is receiving magnesium sulfate intravenously. Her hourly assessment reveals
the following: blood pressure remaining at 130/90 mm Hg; urine output, 60 ml/hour; deep tendon reflexes, 2+; and respirations, 10 breaths/minute. What
action should the nurse take? Notify the physician that the client is not responding to the medication because her blood pressure remains elevated.
Notify the physician that the client is exhibiting signs of magnesium sulfate toxicity as evidence by 2+ deep tendon reflexes. Notify the
physician that the client's urine output is inadequate based on expected output during magnesium sulfate administration. Discontinue magnesium sulfate and
notify the physician that the client is exhibiting magnesium sulfate toxicity based on her respiratory rate. D Because the adverse effects of
magnesium sulfate include respiratory paralysis, and because a respiratory rate of 10 breaths/minute signals magnesium sulfate toxicity, the nurse should
discontinue the drug and notify the physician. The client's blood pressure appears stable because it has not significantly increased or decreased in the last hour.
Deep tendon reflexes of 2+ are normal. Urine output of at least 40 ml/hour is expected.

1362 A client has been in labor with her first child for 12 hours. Vaginal examination reveals an increase in cervical dilation from 4 to 6 cm in the last
hour. Fetal station has remained at -2 since admission 4 hours ago. Moderate contractions are occurring every 5 minutes and lasting for 60 seconds. What is
the nurse's best evaluation of this labor pattern? Arrested fetal descent Early transitional labor Prolonged latent phase of labor Hypertonic
uterine contractions A The lack of change in fetal station indicates arrested fetal descent, which may be caused by cephalopelvic disproportion.
Cervical dilation is progressing normally (at least 1.2 cm per hour). Transitional labor occurs when the cervix dilates from 8 to 10 cm; the latent phase, from 0
to 4 cm. Hypertonic contractions are not present because the contractions are moderate, occur every 5 minutes, and last only 60 seconds.

1363 The nurse recognizes fetal distress during labor. To improve fetal oxygenation, the care plan should include which of these measures? Notify the
physician or nurse-midwife. Increase the client's oral fluid intake. Administer oxygen at 3 to 5 liters/minute. Turn the client to a left lateral
position. D Placing the client in a left lateral position increases placental perfusion and decreases contraction frequency, which increases fetal
oxygenation. The nurse should notify the physician or nurse-midwife, but this action does not improve oxygenation. Intravenous, rather than oral, fluids are
indicated to increase fluid volume and therefore placental perfusion. Oxygen should be administered, but at a rate of at least 7 liters/minute.
1364 For a client in active labor who requests pain medication, the nurse obtains an order for morphine sulfate, 1 mg I.V. when administering an I.V.
narcotic, which action should the nurse take? Inject the drug slowly at the beginning of several consecutive contractions. Add the drug to 50 ml of
normal saline and infuse it over 30 minutes. Administer the drug quickly during one contraction. Administer the drug slowly between contractions. A
Because blood flow to the uterus and fetus decreases during contractions, slow injection at the beginning of several consecutive contractions
decreases the amount of drug that reaches the fetus. Narcotic administration over 30 minutes, quickly during one contraction, or slowly between contractions
increases the amount of drug that reaches the fetus.

1365 A client in latent labor has not prepared for labor. Although the client is comfortable now, she and her partner have heard many stories about labor
and are anxious. Which intervention is most appropriate at this time? Encourage the client to sleep and have her partner go home until labor becomes
active. Tell the client that she may have pain medication as soon as she begins active labor. Clarify misconceptions and teach simple breathing
patterns and coping techniques. Obtain an order for a sedative from the physician or nurse-midwife. C Because the client is still in latent
labor and comfortable, this is an ideal time to clarify misconceptions about labor and teach breathing patterns and coping techniques. Having the partner leave
may increase the client's anxiety and inability to cope with labor. Pain medication may be appropriate later, but the client needs coping techniques now and
after medication administration. A sedative may be ordered, but only if the client's anxiety cannot be decreased with support and education.

1366 After 10 hours of labor, a client's contractions are 3 to 4 minutes apart and she is using a modified, paced-breathing technique. Her skin is warm and
diaphoretic. The nurse-midwife orders ice chips only. Which nursing diagnosis should be included in this client's plan of care? Anxiety related to
increasing contractions Knowledge deficit related to the labor process Impaired physical mobility related to labor discomfort High risk for
fluid volume deficit related to fluid restriction and increased fluid output D Because the client is consuming only ice chips and is sustaining
insensible fluids loss through fast breathing and diaphoresis, she is at high risk for fluid volume deficit. The other options may be appropriate; however, the
data supplied in the situation do not support any of these nursing diagnosis at this time.

1367 A client is being admitted to the labor unit. Because the client is well advanced in labor, the nurse must prioritize the admission questions. Which
information is most important to obtain when birth is imminent? Duration of previous labor Frequency of contractions Presence of bloody show
Expected due date D Because birth is imminent, the most important information is expected due date because it will help the health care
team prepare to meet the special needs of a preterm or post-term infant. The duration of previous labor, frequency of contractions and presence of bloody show
are not significant because birth is imminent and these factors do not affect the provision of safe care during childbirth.
1368 A client is receiving I.V. oxytocin (Pitocin) to induce labor. The nurse observes three contractions that last 100 seconds each and notes incomplete
uterine muscle relaxation between these contractions. How should the nurse respond? Maintain the oxytocin infusion at the current rate. Increase the
infusion rate according to protocol. Discontinue the oxytocin infusion. Prepare for immediate delivery. C Oxytocin infusion may
cause tetanic uterine contractions with inadequate relaxation of uterine muscles. When such contractions occur, the nurse should discontinue the oxytocin
infusion immediately to prevent complications, such as fetal distress, ruptured uterus, or rapidly progressing labor. Maintaining or increasing the infusion rate
could lead to complications. The nurse should prepare for delivery based on cervical changes, not necessarily contraction patterns.

1369 How should the nurse determine the frequency of uterine contractions? Time from the beginning of one contraction to the beginning of the
next contraction. Time from the beginning of one contraction to the end of the same contraction. Time from the peak of one contraction to the
peak of the next contraction. Time from the end of one contraction to the beginning of the next contraction. A The nurse determines contraction
frequency by timing from the beginning of one contraction to the beginning of the next contraction; contraction duration, from the beginning of one contraction
to the end of the same contraction. Answer options C and D are incorrect techniques for assessing labor contractions.

1370 A client is about to be discharged from the labor unit after 2 hours of observation, resulting in a diagnosis of false labor. The nurse teaches her about
home care. Which statement by the client indicates a need for further instruction? "I'll return if any bleeding occurs." "I'll return if my
membranes rupture." I'll return if my contractions are 5 minutes apart." "I'll won't eat or drink anything in case I come back in labor." D
The client should continue to eat and drink, because true labor may not begin for several days or longer. Bleeding, a sign of complications, is a
reason to return to the hospital Membrane rupture and regular contractions are signs of true labor and also are reasons to return to the hospital.

1371 A client is admitted to the labor unit in latent labor with spontaneous rupture of membranes. During a vaginal examination, the nurse discovers
umbilical cord prolapse. The nurse should make which goal the highest priority? Promote client comfort. Decrease client anxiety.
Relieve umbilical cord compression. Prepare the client for cesarean birth. C The top priority is to relieve umbilical cord
compression - and thus improve fetal oxygenation - by putting pressure against the presenting part and using maternal positions, such as the knee-chest
position, to relieve pressure on the cord. Comfort promotion, anxiety reduction, and preparation for cesarean birth are important goals but do not take top
priority because oxygen is vital to the fetus's life.
1372 A client is admitted in labor. Which statement by the client indicates a risk factor? "The baby keeps moving. I didn't think it was supposed to
move during labor." "I was surprised when my water broke. I didn't think it would be green." "I didn't realize my back would ache during contractions."
"That bloody show so much mucus in it!" B Green amniotic fluid indicates the passage of meconium, which suggests fetal distress and
an increased risk of meconium aspiration syndrome. Fetal movement before and during labor is normal; decreased or increased fetal movement may be a sign
of fetal distress. Contractions may be felt in the back, lower abdomen, or both. Bloody show usually contains blood and mucus from the dislodged cervical
mucus plug.

1373 A postpartal client states, "At least I won't have to worry about getting pregnant while I'm breast-feeding my baby." How should the nurse respond
to this statement? "Although you may not have normal menstrual periods while you breast-feed, breast-feeding is not an effective contraceptive method."
"To ensure contraception, you should resume taking birth control pills before leaving the hospital if you're breast-feeding." "Breast-feeding prevents
ovulation and provides contraception as long as you continue to breast-feed at least once per day." "Breast-feeding is very effective in preventing pregnancy
as long as you experience no menstrual cycles." A Although many women do not ovulate while breast-feeding, breast-feeding does inhibit
ovulation and is not an effective contraceptive method. Most oral contraceptives are contraindicated during breast-feeding and are not prescribed to breast-
feeding clients during postpartal hospitalization. One breast-feeding per day goes not inhibit ovulation. Some women ovulate even though normal menstrual
periods have not returned, making pregnancy possible.

1374 When caring for a postpartal client who has tested positive for the human immunodeficiency virus (HIV), the nurse should discourage which
practice by the client? Bottle-feeding the neonate with formula Frequency holding of the neonate to promote bonding Consuming a high-protein to
promote healing. Breast-feeding to ensure the transfer of passive immunity D Breast-feeding is not recommended for HIV-positive
clients because HIV appears in breast milk and can be transmitted to the neonate through breast-feeding. Because breast-feeding is not advisable, the HIV-
positive client should prepare and use formula appropriately during bottle-feeding. The client should be given frequent opportunities to hold her neonate so that
bonding can occur. Consumption of a high-protein diet promotes healing and is especially important for an HIV-positive client.

1375 For a client who is hospitalized with HELLP syndrome, the nurse should report which assessment finding immediately to the physician?
Nausea and vomiting. Increased urine outputPetechiae on extremities and joints Liver enzyme levels slightly below normal C In
HELLP syndrome, the client has hemolysis, elevated liver enzymes, and a low platelet count. Petechiae suggest a coagulation disorder, such as disseminated
intravascular coagulation, which is a common complication of HELLP syndrome. The nurse should report this finding to the physician immediately so that
management can begin. Nausea and vomiting are not associated with HELLP syndrome. Decreased - not increased - urine output may indicate a renal
complication of HELLP syndrome. Liver enzyme levels typically are elevated in HELLP syndrome, reflecting liver involvement in the disease.
1376 Four hours ago, a client gave birth to a 9 lb (4.0 kg) boy. The nurse formulated the following nursing diagnosis for her plan of care. Which
diagnosis should receive top priority? Pain related to the episiotomy Decrease cardiac output related to hemorrhage High risk for infection
related to the episiotomy Altered parenting related to unmet expectations about childbirth B Because the neonate is large for gestational
age, it increases the mother's chance for hemorrhage due to uterine overdistention; because hemorrhage is life-threatening, it takes top priority. The other
nursing diagnoses are valid parts of the plan of care, but do not take top priority, especially in the immediate recovery period when a life-threatening
hemorrhage is most likely to occur.

1377 On a client's first postpartal day, the nurse's assessment reveals the following: vital signs within normal limits, a boggy uterus, and perineal pad
saturation with lochia rubra. What should the nurse do first? Reassess in 1 hour. Administer oxytocin. Massage the uterus gently. Notify the
physician or nurse-midwife. C When the uterus is relaxed (boggy), the nurse's first action is to gently massage it to stimulate contraction
(involution). Fifteen minutes later, the nurse should reassess the client to ensure that the massage was effective. If the uterus does not respond to massage, then
the nurse administers oxytocin (Pitocin). If the uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse
or decreased blood pressure, the nurse should notify the physician or nurse-midwife.

1378 Postpartal psychosocial adaptation includes the dependent (taking in) phase. Which client action best demonstrates this phase? Recalling
events of labor and birth Asking about neonatal care techniques Planning the neonate's acceptance Planning for home management A
Postpartal psychosocial adaptation begins with the dependent phase. In this phase, the client is concerned with herself and the birth experience,
typically reviewing the events of labor and birth. In the dependent-independent (taking hold) phase, the client expresses concern about her neonate and
mothering skills, typically asking about neonatal care techniques. In the interdependent (letting go) phase, the client gains confidence in her mothering skills
and interdependence with her family typically planning for home care and acceptance of the neonate into the family.

1379 A client is concerned that her 2 day old breast-feeding neonate is not getting enough milk. The nurse tells the client how to evaluate breast-feeding.
Which of the following is a sign of effective breast-feeding? One to two voidings every 24 hours Breast-feeding four times in 24 hours
Weight loss of 10% to 15% of birth weight Latching on to areola and audible swallowing D Breast-feeding is effective if the
neonate is properly latched on the areola and if swallowing is heard. Neonates should void at least 6 to 8 times per day and should breast-feed every 2 to 3
hours. Weight loss of 5% to 10% is acceptable for a neonate.
1380 The nurse is teaching a breast-feeding client how to care for engorged breasts. Which statement indicates that the client has not understood the
information? "I'll use massage to help soften my breasts." "I'll use warm packs or a warm shower to ease engorgement.' "If the baby only feeds
on one side, I'll express milk from the other side." "If my breasts are uncomfortable, I'll limit the time I breast-feed the baby." D Engorgement
results from fullness in the breast veins and alveolar engorgement with milk. If insufficient breast milk is removed (as when feeding sessions are limited), the
milk volume will exceed the alveolar storage capacity, causing pain. Breast massage, heat application, and milk expression from the breasts can minimize
engorgement.

1381 The nurse shows a primiparous client how to bathe her neonate. Which statement by the client indicates a lack of understanding? "I'm going to
bathe the baby in the kitchen. It's nice and warm there." "I have all kinds of pretty, scented soaps and lotions to use." "I'll sponge-bathe the
baby until the cord area is healed." "I'll wash the baby's eyes and face first." B Scented and medicated soaps and lotions are not
recommended because they may alter skin pH and impair the skin's ability to protect against infection. Selecting a warm environment, sponge bathing until the
cord area heals, and washing the face first are appropriate activities and indicate an understanding of neonatal bathing.

1382 When performing a postpartal assessment, which precautions should the nurse plan to take? Hand washing only Handwashing, gloves
Hand washing, gloves and barrier gown Hand washing, gloves, barrier gown and eye protection B During a postpartal assessment, the
nurse is likely to touch blood or body fluids, especially during perineal assessments. Therefore, the nurse should wash the hands and wear gloves. Hand
washing alone is not adequate protection and does not comply with universal precautions. The nurse should wear eye protection and a gown when splashing is
likely, such as during childbirth. During a postpartal assessment, splashing is not likely to occur.

1383 In the nursery, the nurse should expect to see which of these signs in a neonate whose mother used heroin during the latter half of the pregnancy?
Lethargy at age 2 days Irritability and weak sucking Flattened nose, small eyes, and thin lips Congenital defects, such as limb
anomalies B Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer
supplied. Signs of heroin withdrawal include irritability, restlessness, and poor sucking patterns. Lethargy is not associated with heroin addiction in neonates.
A flattened nose, small eyes, and thin lips are signs of fetal alcohol syndrome. Heroin use during pregnancy has not been linked with specific congenital
anomalies.
1384 Which finding is most common among neonates whose mothers smoked during pregnancy? Post-term birth Large for gestational age
Small for gestational age Appropriate size for gestational age C Two factors cause the neonates of mothers who smoke to
be small for gestational age: the nicotine in tobacco products causes vasoconstriction, which reduces blood flow -- and nutrient transfer -- to the fetus and
smokers are at greater risk for poor nutrition. Women who smoke are more likely experience preterm, rather than post-term, birth because of vasoconstriction.
A large-for-gestational-age neonate results from increased nutrient transfer to the fetus, such as when a fetus receives excessive glucose from a diabetic mother.

1385 At 1 minute after birth, a neonate has an Apgar score of 7. What should the nurse do? Administer oxygen via nasal prongs Begin
cardiopulmonary resuscitation (CPR) Stimulate breathing by rubbing the neonate's back Encourage the mother to hold the neonate close to her C
An apgar score of 5 to 7 ( out of 10) indicates mild respiratory depression. The nurse can stimulate breathing by gently but firmly slapping the soles
of the feet or rubbing the neonate's back. The nurse also administers oxygen through a bag and face mask-- not nasal prongs-- at 100% concentration. The
nurse performs CPR only if the neonate's Apgar score is between 0 and 2. The neonate must be stabilized before being held by the mother.

1386 A 1-hour-old neonate is being held by the parents. The nurse assesses the neonate and documents the following findings: axillary temperature, 95.8º
F (35.8º C); apical pulse, 110 beats/minute; and respirations, 64 breaths/minute. Which nursing diagnosis takes top priority? High risk for altered
body temperature related to heat loss Altered parenting related to the addition of a new family member High risk for fluid volume deficit related to
insensible fluid loss High risk for infection related to transition to the extrauterine environment. A The neonate's temperature should range from
96ºF (35.5ºC) to 97.7ºF (36.5ºC) and respirations should be less than 60 breaths/minute. (The respiratory rate increases as hypothermia develops.) Correcting
hypothermia is the top priority for this neonate, because cold stress can lead to respiratory distress and hypoglycemia. The other nursing diagnoses may be
appropriate, but do not take precedence over altered body temperature, which could be life-threatening.

1387 The nurse places a neonate with hyperbilirubinemia under a phototherapy lamp with eye and gonad protection. What is the goal of phototherapy? To
prevent hypothermia To promote respiratory stability To decrease the serum level of conjugated bilirubin To decrease the serum level of unconjugated
bilirubin D The goal of phototherapy is to reduce the serum level of unconjugated bilirubin because a high level may lead to bilirubin
encephalopathy (kernicterus). Phototherapy does not prevent hypothermia or promote respiratory stability. It has no effect on conjugated bilirubin, which is a
water-soluble substance that is excreted easily in urine and stool.

1388 In a 1 day old neonate, which assessment finding indicates that oxygen needs are not being met by current treatments? Respirations of 54
breaths/minute Abdominal breathing Nasal flaring Acrocyanosis C Signs of respiratory distress include respirations over 60
breaths/minute, labored respirations, grunting, nasal flaring, generalized cyanosis, and retractions. Abdominal breathing is normal finding in neonates.
Acrocyanosis (bluish hands and feet is normal during the first day of life.
1389 A neonate begins to gag and turn a dusky color. What should the nurse do first? Calm the neonate. Notify the physician. Provide
oxygen using a face mask. Aspirate the nose and mouth with a bulb syringe. D The nurse's first action should be to clear the airways with
a bulb syringe. After the airways are clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or if the
neonate's color does not improve readily, the nurse should notify the physician. The nurse should not administer oxygen unless the airway is cleared because it
would be ineffective.

1390 On assessing a 1 day old neonate, the nurse obtains the following data: axillary temperature, 98ºF (36.6ºC); birth weight of 7 lbs 3 oz (3.3 kg);
current weight of 7 lb (3.2 kg); breast-feeding once every 2 to 3 hours; and slightly yellow sclerae. Which nursing diagnosis should the nurse add to the plan of
care? Altered nutrition: less than body requirements, related to inadequate feeding Hypothermia related to immature temperature regulation
Fluid volume deficit related to insensible fluid loss High risk for injury related to hyperbilirubinemia D Yellow sclerae indicate
bilirubin deposits and possibly hyperbilirubinemia. The assessment findings do not support a nursing diagnosis of altered nutrition because neonates normally
breast-feed every 2 to 3 hours. An axillary temperature of 98ºF (36.6ºC) is within normal limits for neonates, which eliminates hypothermia as a nursing
diagnosis. The assessment findings also do not support a nursing diagnosis of fluid volume deficit because a weight loss of up to 10% of birth weight is normal
in neonates.

1391 During an assessment of a perinatal client with a history of left-sided heart failure, a nurse notes that the client is experiencing unusual episodes of a
nonproductive cough on minimal exertion. The nurse interprets that this finding may be the first indicator of which important cardiac problem? Orthopnea
Decreased blood volume Right-sided heart failure Pulmonary edema D Pulmonary edema from heart failure may first
be manifested as a cough. The cough occurs in response to fluid filling the alveolar spaces. Pulmonary edema develops as a result of left ventricular failure or
acute fluid overload. Orthopnea is an assessment finding. Increased rather than decreased blood volume occurs in heart failure. Peripheral edema and
organomegaly are signs of right-sided heart failure.

1392 A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which findings would the nurse expect to note
on assessment of the clients? Absence of any signs and symptoms Pain, itching, and vaginal discharge Proteinuria,hematuria, edema, and
hypertension Costovertebral angle pain B Clinical manifestations of a Candida infection include pain, itching,and a thick,white vaginal
discharge.Proteinuria, hematuria,edema, hypertension, and costovertebral angle pain are clinical manifestations associated with urinary tract infections
1393 A pregnant client is suspected of having iron deficiency anemia (IDA). Which of the following would the nurse expect to note regarding the client's
status? A low hemoglobin and hematocrit level A high hemoglobin and hematocrit level Fluid volume excess Fluid volume deficit A
When the hemoglobin level is below 11 mg/dL, iron deficiency is suspected. An indirect index of the oxygen-carrying capacity is the packed red
blood cell volume or hematocrit level. Pathological anemia of pregnancy is primarily caused by iron deficiency. Options C and D are nursing diagnoses and
not noted in IDA.

1394 A nurse is caring for a postpartum client. Which finding would make the nurse suspect endometritis in this client? Fever over 38º C,
beginning 3 days postpartum Lochia rubra on the second day postpartum Elevated white blood cell count Breast engorgement A Fever on the
third or fourth day postpartum should raise concerns about possible endometritis until proven otherwise. A woman with endometritis normally presents with a
temperature higher than 38o C. Lochia rubra on the second day postpartum is a normal finding. The white blood cell count of a postpartum woman is
normally increased. Thus this method of detecting infection is not of great value in the puerperium. Breast engorgement is also a normal response and is not
associated with endometritis.

1395 A nurse is performing an assessment on a postmature neonate. Which physical characteristic would the nurse expect to observe? Vernix that
covers the body in a thick layer Desquamation over the body Smooth soles without creases Lanugo covering the entire body B A postmature
neonate exhibits dry, peeling, cracked, almost leatherlike skin over the body, which is called desquamation. A preterm neonate (24 to 37 weeks) exhibits thick
vernix covering the body, smooth soles without creases, and lanugo covering the entire body.

1396 A nurse is performing an admission assessment on a small for gestational age (SGA) term infant. The nurse observes tachypnea, grunting,
retractions, and nasal flaring. The nurse interprets that these symptoms are most likely the result of: Hypoglycemia Meconium aspiration
syndrome Respiratory distress syndrome Transient tachypnea of the newborn B Tachypnea, grunting, retractions, and nasal flaring are
symptoms of respiratory distress related to meconium aspiration syndrome. The SGA infant is most prone to meconium aspiration syndrome. In utero,
hypoxia can cause relaxation of the anal sphincter, with passage of meconium into the amniotic fluid. The fetus also gasps in response to hypoxia, which can
result in aspiration of meconium in utero or with the first breaths after birth. Transient tachypnea of the newborn is primarily found in infants delivered via
cesarean section. Respiratory distress syndrome is a complication of preterm infants. These symptoms are unrelated to hypoglycemia.
1397 A nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that
the neonate’s respiratory status is improving? Presence of systolic murmur Respiratory rate between 60 to 70 breaths/min Edema of the
hands and feet Urine output of 1 to 3 mL/kg/hr D Increased urination is an early sign that the neonate’s respiratory condition is improving.
Lung fluid, which occurs in RDS, moves from the lungs into the blood stream as the condition improves and the alveoli open. This extra fluid circulates to the
kidneys, which results in increased voiding. Systolic murmurs usually indicate the presence of a patent, ductus arteriosus, which is a common complication of
RDS. Respiratory rates above 60 breaths/min are indicative of tachypnea, which is a sign of respiratory distress. Edema of the hands and feet occurs within
the first 24 hours as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the
tissues.

1398 A nurse is caring of a term newborn. Which assessment finding would alert the nurse to suspect the occurrence of jaundice in this newborn? A
negative result to a direct Coomb’s test Birth weight of 8 lb 6 oz Presence of a cephalhematoma Infant blood type of O negative C
Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the
cephalhematoma resolves and is absorbed into the circulatory system. A negative result to a direct Coombs' test indicates that there are no maternal antibodies
on fetal erythrocytes. The birth weight in option B is within the acceptable ranges for a term newborn and therefore does not contribute to an increased
bilirubin level. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus or newborn.

1399 A nurse is performing an assessment on a client with pregnancy-induced hypertension (PIH) who is in labor. The nurse most likely expects to note:
Decelerations and increased variability of the fetal heart rate Increased blood pressure Decreased brachial reflexes Increased
urine output B The major symptoms of PIH is elevated blood pressure. As the disease progresses, it is possible that increased brachial
reflexes, decreased fetal heart rate and variability and decreased urine output will occur, particularly during labor.

1400 A nurse is performing an assessment on a female client who is suspected of having mittelschmerz. Which of the following would the nurse expect to
note on assessment of the client? Client complains of pain at the beginning of the menstruation Profuse vaginal bleeding Sharp pain located on
the right side of the pelvis Pain that occurs during intercourse C Mittelschmerz ( middle pain ) refers to pelvic pain that occurs
midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle
and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right side or left side of the pelvis. It
generally lasts one to three days, and slight vaginal bleeding may accompany the discomfort.
1401 A client has been seen in the health care clinic and has been diagnosed with endometriosis. The client asks the nurse to describe this condition. The
nurse tells the client that endometriosis: Is the presence of tissue outside the uterus that resembles the endometrium Is pain that occurs during ovulation
Is also known as primary dysmenorrhea Causes the cessation of menstruation A Endometriosis is defined as the presence of
tissue outside the uterus that resembles the endometrium in both structure and function. The response of this tissue to the stimulation of estrogen and
progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology.
Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods, and amenorrhea is the cessation of menstruation for a period of at least 3
cycles or 6 months in a woman who has established a pattern of menstruation and can result from a variety of causes.

1402 A client calls the physician's office to schedule an appointment because a home pregnancy test was performed and the results were positive. A nurse
determines that the home pregnancy test identified the presence of which of the following in the urine? Estrogen Progesterone Human
chorionic gonadotropin ( hCG ) Follicle stimulating hormone ( FSH ) C In early pregnancy, hCG is produced by trophoblastic cells that
surround the developing embryo. This hormone is responsible for positive pregnancy tests. Options A, B and D are incorrect.

1403 A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which of the
following would the nurse anticipate to be prescribed? Repeat hepatitis screen Retesting the mother in 1 week Administration of hepatitis vaccine
and hepatitis B immune globulin to the neonate within 12 hours after birth Administration of antibiotics during pregnancy C A hepatitis B
screen is performed to detect the presence of antigens in maternal blood. If antigens present, the neonate needs to receive the hepatitis vaccine and hepatitis B
immune globulin within 12 hours after birth Options A, B and D are incorrect.

1404 A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in the calf when
she walks. Which of the following would be the most appropriate nursing action? Tell the client that this is normal during pregnancy Instruct the
client to avoid walking Assess the presence of Homans' sign Instruct the client to elevate the legs consistently throughout the day C
If a woman complains of calf pain during walking, it could be an indication of venous thrombosis of the lower extremities. The most appropriate
nursing action would be to assess for Homan's sign, which would assist in determining the presence of venous thrombosis. It is not appropriate to tell the
mother that this is normal during pregnancy. Ambulation is a necessary exercise and the woman should be encouraged to ambulate during pregnancy. Although
it is important to elevate the legs during pregnancy, elevating the legs consistently is not the appropriate nursing action.
1405 A clinic nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first
day of the last menstrual period ( LMP ) was and the client reports February 9,2002. Using Nagele's rule, the nurse determines that the estimated date of
confinement is: October 16,2002 November 16,2002 October7,2002 November 7,2002 B Accurate use of Nagele's rule
requires that the woman have a regular 28 - day menstrual cycle. To calculate the estimated date of confinement, the nurse would add 7 days to the first day of
the LMP, subtract 3 months, and then add 1 year. First day of last menstrual period: February 9,2002, add 7 days: February 16,2002, subtract three months:
November 16,2001, and add 1 year November 16,2002

1406 A nurse is measuring the fundal height of a client who is at 36 weeks' gestation. In preparing to perform the procedure the nurse would:
Turn the client onto her left side Instruct the client to lie in a prone position Place the client in a prone position with the head of the bed elevated
Have the client stand for the procedure A When measuring fundal height, the nurse has the client lie in a supine position and instructs
the women to turn onto her left side, or the nurse can elevate the left buttock by placing a pillow under the area. Options B, C and D are incorrect client
positions for measuring fundal height.

1407 A nurse is performing a measurement of fundal height on a client who is at 36 weeks' gestation. During the measurement the client begins to feel
lightheaded. Based on the nurse's knowledge of the physiological occurrences of pregnancy, the nurse determines that this is most likely the result of:
Emotional instability Compression of vena cava A full bladder Insufficient iron intake B Compression of the
inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the woman turn onto her left side or elevating the
left buttock during fundal height measurement will correct or prevent the problem. Options A, C, and D are unrelated to this syndrome.

1408 A nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client most closely for which complication
that is most likely associated with a twin pregnancy? Maternal anemia Postterm labor Hemorrhoids Gestational diabetes A
Maternal anemia often occurs in twin pregnancies because of a greater demand for iron by fetuses. Option B is incorrect because twin pregnancies
often end in prematurity. Hemorrhoids occur in pregnancy but are not the most likely occurrence associated with a twin pregnancy. Option D is not a
complication of a twin pregnancy.
1409 A nurse is conducting a clinic visit with a prenatal client with heart disease. The nurse carefully assesses the client's vital signs, weight, and fluid and
nutritional status to detect complications caused by: Hypertrophy and increased contractility of the heart The increase in circulating blood volume
Fetal cardiomegaly Rh incompatibility B Pregnancy taxes the circulating system of every woman because both the blood volume and
cardiac output increase. Options A, C and D are not directly associated with pregnancy in a client with cardiac condition.

1410 A postpartum nurse is reviewing the records of the new mothers admitted to the postpartum unit. The nurse determines that which of the following
mothers would be at least risk for developing a puerperal infection? A mother with a history of previous infections A mother who
experienced prolonged rupture of the membranes A mother who had an excessive number of vaginal examinations A mother who underwent a vaginal
delivery of the newborn D Risk factors associated for puerperal infection include a history of previous infections, cesarean births,
trauma,prolonged rupture of the membranes, prolonged labor, excessive number of vaginal examinations, and retained placental fragments.

1411 A nurse in the delivery room is assisting with the delivery of a newborn infant. Following delivery, the nurse prepares to prevent heat loss in the
newborn infant from conduction by: Wrapping the newborn in a blanket Closing the doors to the delivery room Drying the newborn with
a warm blanket Placing a warm pad on the crib before placing the newborn in the crib D Hypothermia caused by conduction occurs
when the newborn infant is on a cold surface, such as cold pad or mattress. Warming the crib pad will assist in preventing hypothermia by conduction.
Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn infant dry by drying the wet newborn infant at birth will
prevent hypothermia via evaporation. Convection occurs as air moves across the newborn infant's skin from an open door and heat is transferred to the air.
Radiation occurs when heat from the newborn infant radiates to a colder surface.

1412 A nurse provides a class to new mothers on newborn care. In teaching good care, the nurse tells the mother: If triple dye has been applied to the
cord, it is not necessary to do anything else to it To apply alcohol to the cord, ensuring that all areas around the cord are cleaned two or three times a
day To apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause the newborn infant pain All that is necessary is to
wash the cord with antibacterial soap, allowing it to air dry one time a day B The umbilical cord and base should be cleaned two or three times per
day using alcohol or other agents. These steps are to lift the cord, wipe around the cord starting at the top, clean the base of the cord, and hold the diaper below
the cord to allow the cord to air dry and to prevent contamination from urine. Continuation of cord care is necessary until the cord falls off within 7 to 14 days.
The cord needs to be cleansed with alcohol thoroughly. The infant does not feel pain in this area. Water and soap are not necessary, and in fact the cord should
be kept from getting wet.
1413 A nurse is monitoring a preterm newborn infant for signs of respiratory distress syndrome ( RDS ). The nurse monitors the infant for: Cyanosis,
tachypnea, retractions, grunting respirations, and nasal flaring Acrocyanosis, apnea, pneumothorax, and grunting Barrel-shaped chest, hypotension,
and bradycardia Acrocyanosis, emphysema, and interestitial edema A The newborn infant with respiratory distress syndrome may present
with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall reactions, or audible grunts. Acrocyanosis is the bluish discoloration of the hands
and feet, is associated with immature peripheral circulation, and is not uncommon in the first few hours of life. Options B, C, and D do not indicate clinical
signs of RDS.

1414 A nurse is preparing to assess the apical heart rate of a newborn infant in the newborn nursery. The nurse performs the procedure and notes that the
heart rate is normal if which of the following is noted? A heart rate of 90 beats / min. A heart rate of 140 beats / min. A heart rate of 180 beats / min A
heart rate of 190 beats / min. B The normal heart rate in a newborn infant is 100 to 170 beats / min. Options A, C and D are incorrect. Option A
indicates bradycardia and options C and D indicate tachycardia.

1415 A childbirth educator teaches a class of expectant parents that it is standard routine to instill a medication into the eyes of a newborn infant as a
preventive measure against opthalmia neonatorum. The educator tells the class that the medication currently used for the prophylaxis of opthalmia neonatorum
is: Erythromycin opthalmic eye ointment Neomycin opthalmic eye ointment Penicillin opthalmic eye ointment Vitamin K
injection A Opthalmic erythromycin 0.5% ointment is a broadspectrum antibiotic and is used prophylactically to prevent opthalmia neonatorum, an
eye infection acquired from the newborn infant's passage through the birth canal. Infection from these organisms can cause blindness or serious eye damage.
Erythromycin is effective against Neisseria gonorrhea and Chlamydia trachomatis. Vitamin K is administered to the newborn infant to prevent abnormal
bleeding and to promote liver formation of the clotting factors II, VII, IX, and X. Options B and C are incorrect.

1416 A nurse is developing a teaching plan for the mother of a newborn infant who is human immunodeficiency virus ( HIV ) - positive. Which specific
instruction should be included in the teaching plan? Instruct the mother to provide meticulous skin care of the newborn infant and to change the infant's
diaper after each voiding or stool. Instruct the mother to feed the newborn infant in an upright position with the head and the chest tilted slightly back
to avoid aspiration Instruct the mother to feed the newborn infant with a special nipple and bubble the infant frequently to decrease the tendency to swallow
air Instruct the mother to check the anterior fontanel for bulging and for sutures for widening each day. A Meticulous skin care helps protect
the HIV - infected newborn infant from secondary infections. Feeding the newborn in an upright position, using a special nipple, and bulging fontanels are
unrelated to the pathology associated with HIV.
1417 A client in labor has a concurrent diagnosis of sickle cell anemia. Because the client is at high risk for sickling crisis, which nursing action is the
priority to assist in preventing a crisis from occurring during labor? Reassure the client Administer oxygen as ordered throughout labor
Maintain strict asepsis Prevent bearing down B During the labor process, the client with sickle cell anemia is at high risk for
being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Options A and C are appropriate actions
but are unrelated to sickle cell crisis. Option D is inappropriate.

1418 A nurse is caring for a client in active labor. The nurse performs which of the following to best prevent fetal heart rate decelerations?
Increases the rate of the oxytocin (Pitocin) infusion Encourages upright or side-lying maternal positions Monitors the fetal heart rate every
30 minutesPrepares the client for a Cesarean delivery B Side-lying and upright positions like walking , standing, and squatting can improve
venous return and encourage effective uterine activity. The nurse should discontinue an oxytocin infusion in the presence of fetal heart rate decelerations,
thereby reducing uterine activity and increasing uteroplacental perfusion. Monitoring the fetal heart rate every 30 minutes will not prevent fetal heart rate
decelerations. There are many nursing actions to prevent fetal heart rate decelerations, without necessitating surgical intervention.

1419 A client with diabetes mellitus is at 36 weeks' gestation. The client has weekly nonstress test for the last 3 weeks, and the results have been
reactive. This week the nonstress test was nonreactive after 40 minutes. Based on these results the nurse would anticipate the client will be prepared for:
Immediate induction of labor Hospitalization with continuous fetal monitoring A return appointment in 2 to 7 days to repeat the nonstress
test A contraction stress test D A nonreactive test needs further assessment. There is not enough data in the question to indicate that
the procedures in options A and B are necessary at this time. To send the client home for 2 to 7 days may put the fetus in jeopardy. A contraction stress test is
the next test needed to further assess the fetal status.

1420 A clinic nurse prepares to assess the fundal height of a client in the second trimester of pregnancy. When measuring the fundal height, the nurse will
most likely expect the measurement to: Correlate with gestational age Be greater than gestational age Be less than gestational age Have no
correlation to gestational age A Up until the third trimester the measurement of fundal height will, on average, correlate with the gestational age.
Options B,C, and D are incorrect.
1421 A pregnant client tells a nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum
and notes the presence of the umbilical cord. The nurse’s initial action is to: Notify the physician Monitor the fetal heart rate Transfer the client to the
delivery room Place the client in trendelenburg position D On inspection of the perineum, if the umbilical cord is noted, the nurse
immediately places the client into Trendelenburg position while pushing the presenting part upward to relieve the cord compression. This position is maintained
and the physician is notified. The nurse monitors the fetal heart rate. The client is transferred to the delivery room when prescribed by the physician.

1422 A nurse admits a newborn infant to the nursery. On assessment of the infant, the nurse palpates the anterior fontanel and notes that it feels soft. The
nurse determines that this finding indicates: Increased intracranial pressure Dehydration Decreased intracranial pressure A normal finding D
The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-shaped. It can be described as soft, which is normal, or full
and bulging, which could be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the infant is dehydrated.

1423 A nurse is preparing to assess the respirations of a newborn infant just admitted to the nursery. The nurse performs the procedure and determines that
the respiratory rate is normal if which of the following are noted? A respiratory rate of 20 breaths/min A respiratory rate of 40 breaths/min A
respiratory rate of 90 breaths/min A respiratory rate of 100 breaths/min B Normal respiratory rate varies from 30 to 80 breaths/min when the
infant is not crying. Respirations should be counted for 1 full minute to ensure an accurate measurement because the newborn infant is a periodic breather.
Observing and palpating respirations while the infant is quiet promotes accurate assessment. Palpation aids observation in determining the respiratory rate.
Option A indicates bradypnea, and options C and D indicate tachypnea.

1424 A client is in her second trimester of pregnancy. During her routine prenatal visit, she states that she frequently has calf pain when she walks. Which
of the following should the nurse assess to assist in identifying the origin of the discomfort? Chadwick’s sign Leopold’s sign Homan’s sign
Kernig’s sign C Homan’s sign tests for venous thrombosis of the lower extremity. Pain in the calf during walking could indicate
venous thrombosis. Chadwick’s sign is a cervical change and is a probable sign of pregnancy. Leopold’s sign is a fictitious term. Leopold’s maneuvers are a
series of abdominal palpation maneuvers that provide information regarding fetal presentation, position, presenting part, attitude, and descent. Kernig’s sign test
for meningeal irritability.
1425 A pregnant woman who is at 32 weeks gestation is admitted to the obstetric unit for observation after an automobile accident. The client is
experiencing slight vaginal bleeding and mild cramps. The nurse does which of the following to determine the viability of the fetus? Inserts an intravenous
line and begins an infusion at 125 mL/hr Administers oxygen to the woman via a face mask at 7 to 10 L/min Positions and connects the ultrasound
transducer and the tocotransducer to the external fetal monitor Positions and connects a spiral electrode to the fetal monitor for internal monitoring C
External fetal monitoring will allow the nurse to determine any change in the fetal heart rate and rhythm that would indicate that the fetus is in
jeopardy. Internal monitoring is contraindicated when there is vaginal bleeding of an unstated cause, especially in preterm labor. Since fetal distress has not
been determined at this time, oxygen administration is premature. The amount of bleeding described is insufficient to require intravenous fluid replacement.

1426 A clinic nurse is caring for a client suspected of a diagnosis of pregnancy-induced hypertension (PIH). The nurse assesses the client expecting to
note which of the following if PIH is present? Glycosuria, hypertension, and obesity Edema, ketonuria, and obesity Edema, tachycardia,
and ketonuria Hypertension, edema, and proteinuria D PIH is the most common hypertension disorder in pregnancy. It is
characterized by the development of hypertension, proteinuria, and edema . Glycosuria and ketonuria occur in diabetes mellitus. Tachycardia and obesity are
not specifically related to diagnosing PIH.

1427 A nurse is teaching a pregnant client about nutrition. The nurse includes which information in the client’s teaching plan? The nutritional status of
the mother significantly influences fetal growth and development All mothers are at high risk for nutritional deficiencies Calcium is not important until the
third trimester Iron supplements are not necessary unless the mother has iron deficiency anemia A Poor nutrition during pregnancy can
negatively influence fetal growth and development. Although pregnancy poses nutritional risk for the mother, not all clients are at high risk. Calcium is critical
during the third trimester but must be increased from the onset pregnancy. Intake of dietary iron is insufficient for the majority of pregnant women, and iron
supplements are routinely prescribed.

1428 A nurse is assigned to care for a client with hypertonic labor contractions. The nurse plans to conserve the client’s energy and promote rest by:
Avoiding uncomfortable procedures such as intravenous infusions or epidural anesthesia Assisting the client with breathing and relaxation
techniques Keeping the room rightly lit so the client can watch her monitor Keeping the television (TV) or radio on to provide distraction. B
Breathing and relaxation techniques aid the client in coping with the discomfort of labor and in conserving energy. The use of intravenous or
epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for every
needs. Noise from a TV or radio, and light stimulation does not promote rest. A quiet, dim environment would be more advantageous.
1429 A client is at term pregnancy. The fetal heart rate (FHR) is being monitored for a baseline rate. The nurse is satisfied with the results and tells the
client that the baby’s heart rate is within normal limits. The nurse then documents which FHR finding? 90 beats/min 140 beats/min
180 beats/min 200 beats/min B The normal FHR range is 110 to 160 beats/min; therefore, option B is the only correct
option.

1430 A client who is 15 years old is pregnant and is being treated by a dermatologist for acne. The clinic nurse asks the client about the treatment
prescribed for the acne knowing that which treatment will be avoided? Topical erythromycin Exfoliation Cleansing with antibacterial soap
Oral tetracycline D Tetracycline during pregnancy may lead to discoloration of the child’s teeth when they erupt. This treatment for
acne will be avoided during pregnancy. Options A, B, and D are appropriate treatments.

1431 A woman at 32 weeks’ gestation is brought into the emergency department after an automobile accident. The client is bleeding vaginally, and fetal
assessment indicates moderate fetal distress. Which of the following will the nurse do first in an attempt to reduce the stress on the fetus? Start
intravenous (IV) fluids at a keen open rate Administer oxygen via a facemask at 7 to 10 liters per minute. Elevate the head of the bed to a semi-Fowlers
position Set up for an immediate cesarean section delivery B Administering oxygen will increase the amount of oxygen for transport to the
fetus, partially compensating for the loss of circulating blood volume. This action is essential regardless of the cause or amount of bleeding. IV fluids may be
initiated. The clients will be positioned per physician’s order. There are no data that would indicate an immediate cesarean delivery is necessary.

1432 A nurse is caring for a client with pregnancy-induced hypertension (PIH) who is in labor. The nurse monitors the client closely for which
complication of PIH? Seizures Placenta previa Hallucinations Altered respiratory status. A The major complication of
pregnancy-induced hypertension is seizures. Placenta previa, hallucinations, and altered respiratory status are not directly associated with PH.

1433 A nurse is reviewing the antenatal history of a client in early labor. The nurse recognizes which of the following factors documented in the history
as having the greatest potential for causing neonatal sepsis following delivery? Adequate prenatal care Appropriate maternal nutrition and
weight gain Spontaneous rupture of membranes 2 hours ago. History of substance abuse during pregnancy D Risk factors
for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include low socioeconomic status, poor
prenatal care and nutrition, and a history of substance abuse during pregnancy. Premature rupture of the membranes prolonged rupture of membranes greater
than 18 hours before birth is also a risk factor for neonatal acquisition of infection.

1434 A nurse performs a prenatal assessment on a client in the first trimester of pregnancy. The nurse discovers that the client frequently consumes
alcohol beverages. The nurse initiates interventions to assist the client to avoid alcohol consumption in order to:Promote the normal psychosocial adaptation of
the mother to pregnancy Reduce the potential for fetal growth restriction in utero Minimize the potential for placement abruptions during the
intrapartum period Reduce the risk of teratogenic effects to developing fetal organs, tissues, and structures D The first trimester, or organogenesis
is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this
critical period depend not only on the amount of alcohol consumed, but on the interaction of the quantity, frequency, type of the alcohol, and other drugs that
may be abused during the period by the pregnant woman. Eliminating consumption of alcohol during this time may promote normal fetal organ development.

1435 A nurse is performing a prenatal examination on a client in the trimester. The nurse begins an abdominal examination and performs Leopold’s
maneuvers. The nurse determines which of the following after performing the first maneuver? Fetal lie and presentation Fetal descent
Strength of urine contractions Placenta previa A The first maneuver determines the contents of the fundus (either the fetal head or
breech) and thereby the fetal lie. Leopold maneuvers should not be performed during a contraction. Placenta previa is diagnosed by ultrasound and not by
palpation. Fetal descent is determined with the fourth maneuver.

1436 A new prenatal client is 6 months pregnant. On the first prenatal visit, the nurse notes that the client is gravida 4, para 0, aborta 3. the client is 5’6”
tall, weighs 130 lbs, and is 25 years old. The client states, “I get really tired after working all day and I can’t keep up my housework.” Which factor in the
above data would lead the nurse to suspect gestational diabetes? Fatigue Obesity Maternal age Previous fetal demise D Fatigue is
normal occurrence during pregnancy. A client 5’6” tall and 130 lbs does not meet criteria of 20% over ideal weight. Therefore the client is not obese. To be at
high risk for gestational diabetes, the maternal age should be greater than 30 years. A previous history of unexplained stillbirths or miscarriages puts the client
at high risk for gestational diabetes maternity.

1437 A nurse is caring for a client with pre-eclampsia. The nurse develops a plan of care knowing that if the client progresses from preeclampsia to
eclampsia, the nurse’s first action is to: Administer IV magnesium sulfate Assess the blood pressure and fetal heart tones Clear and
maintain an open airway Administer oxygen by face mask C It is important as a first action to keep an open airway and prevent injuries to the
client. Options A, B, and D are all procedures that should be done but not the first action.
1438 A nurse explains to the mother of a newborn the purpose of giving a vitamin K injection to her newborn. The nurse determines that the mother
understands if the mother states that vitamin K is administered because the newborn: Has low hemoglobin blood levelsCan’t produce vitamin K in the liver
Lacks vitamins Lacks intestinal bacteria D The absence of normal flora needed to synthesize vitamin K in the normal
newborn gut results in low levels of vitamin K and creates a transient blood coagulation deficiency between the second and fifth day of life. From a low point
at about 2 to 3 days after birth, these coagulation factors rise slowly, but do not approach normal adult levels until 9 moths of age later. Increasing levels of
these vitamin K-dependent factors indicate a response to dietary intake and bacterial colonization in the intestines. An injection of vitamin K (Aqua-Mephyton)
is administered prophylactically on the day of birth to combat the deficiency. Options A, B, and C are incorrect.

1439 A nurse in a newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse
obtains equipment to perform which diagnostic test? Indirect and direct bilirubin levels Rh and ABO blood typing Heelstick blood glucose
Serum insulin level C After birth, the most common problem in an LGA infant is hypoglycemia, especially if the mother is diabetic. At
delivery, when the umbilical cord is clamped and cut, the maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin,
which depletes the infant’s blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not performed, the
newborn may suffer central nervous system damage as a result of inadequate circulation of glucose to the brain. Indirect and direct bilirubin levels are usually
ordered after the first 24 hours, since jaundice is usually seen at 48 to 72 hours after birth. There is no rationale for ordering an Rh and ABO blood type, unless
the maternal blood is Rh negative. Serum insulin levels are not helpful, since there is no intervention to decrease these levels to prevent hypoglycemia.

1440 A nurse is caring for a 30 weeks’ gestation client in preterm labor. The physicians orders bethamethasone (Celestone) intramuscularly. The client
asks the nurse why she is receiving corticosteroids. The nurse tells the client that the bethamethasone will: Help the baby’s lungs mature faster.
Prevent the membranes from rupturing Decrease the incidence of fetal infection Help stop the labor contractions A Respiratory
distress syndrome (RDS) is the most common cause of morbidity and mortality in preterm infants. Bethamethasone, a corticosteroid, is administered to
enhance fetal lung maturity in 24- to 34- week gestations. The medication’s optimal benefits begin 24 hours after initial therapy. Bethamethasone does not
prevent rupture of the membranes. Bethamethasone does not decrease the incidence of fetal infection and can mask signs of infection when the client has
premature rupture of the membranes with preterm labor. Even though betamethasone may be given during the time that tocolytic are administered, it does not
inhibit preterm labor.

1441 It has been 12 hours since a client’s delivery of a newborn. A nurse assesses the mother for the process of involution and documents that is
progressing normally when palpation of the client's fundus is noted: At the level of the umbilicus Midway between the umbilicus and symphysis
pubis 1 fingerbreadth below the umbilicus 2 fingerbreadths below the umbilicus A The term involution is used to described the
rapid reduction in size and return of the uterus to a normal condition similar to its prepregnant state. Immediately following the delivery of the placenta, the
uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and umbilicus. Within the 6 to 12 hours
after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then
descends into the pelvis approximately 1 fingerbreadth on each succeeding day.
1442 A nurse teaches a postpartum client about observation of lochia. The nurse determines the client’s understanding when the client says that on the
second day postpartum, the lochia should be: Yellow White Pink Red D The uterus rids itself of the debris that remains
after birth through a discharge called lochia, which is classified according to its appearance and contents. Lochia rubra is dark red. It occurs from delivery to 3
days postpartum and contains epithelial cells, erythrocytes, leukocytes, shreds of deciduas, and occasionally fetal meconium, lanugo, and vernix caseosa.
Lochia serosa is brownish pink discharge that occurs from days 4 to 10. Lochia alba is a white discharge that occurs from days 10 to 14. Lochia should not be
yellow or contain large clots; if it does, the cause should be investigated without delay.

1443 A nurse explains to a mother that her newborn is being admitted to a neonatal intensive care unit with a probable diagnosis of fetal alcohol syndrome
(FAS). The nurse explains the expected effects of FAS to the mother. The nurse evaluates the effectiveness of the explanation when the mother states:
Withdrawal symptoms will occur after 3 days. Mental retardation is unlikely to happen. Withdrawal symptoms are tremors, crying,
seizures, and reflexes that aren’t normal. The reason the child is so large is because of the fetal alcohol syndrome. C The long-term prognosis
for newborns with FAS is poor. Symptoms of withdrawal include tremors, sleeplessness, seizures, abdominal distention, hyperactivity, and uncontrollable
crying. Central Nervous System (CNS) disorders are the most common problems associated with FAS. Because of the CNS disorders, children born with FAS
are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after birth or at the
latest, within the first 3 days of life. Most neonates with FAS are mildly to severely mentally retarded. The newborn is usually growth deficient at birth.

1444 A client at 10 weeks’ gestation is receiving prenatal care at a high-risk clinic. She is an insulin dependent diabetic. The nurse teaches the client about
the early sign of hyperglycemia. The nurse evaluates that teaching is effective when the client states that an early sign of hyperglycemia is: Polyuria
Nervousness Shakiness Hunger A Polyuria is an early sign of hyperglycemia. Other signs can include polydipsia, dry mouth,
increased appetite, fatigue, nausea, hot flushed skin, rapid deep breathing, abdominal cramps, acetone breath, headache, drowsiness, depressed reflexes, oliguria
or anuria, stupor, and coma.

1445 A nurse receives report at the beginning of the shift regarding a client with an intrauterine fetal demise. On assessment of the client, the nurse
expects to note which of the following? Elevated blood pressure, proteinuria, and edema Regression of pregnancy symptoms and absence of fetal
heart tones Uterine size greater than expected for gestational age Intractable vomiting and dehydration B Symptoms of a fetal demise include
a decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. Additionally many symptoms of the pregnancy may
diminish, such as breast size and tenderness. Option A is associated with preeclampsia. Option D is associated with hyperemesis gravidarum.
1446 A client has arrived at the labor and delivery unit in active labor. The nursing assessment reveals a history of recurrent genital herpes and the
presence of lesions in the genital tract. The nurse plans to: Prepare the client for a cesarean delivery Limit visitors and maintain reverse isolation
Prepare the client for a spontaneous vaginal delivery Rupture the membranes artificially, looking for meconium-stained fluid A A
cesarean delivery can reduce the risk of neonatal infection with a mother in labor who has herpetic genital tract lesions. Intact membranes provide another
barrier to transmitting the disease to the neonate. There is no need to limit visitors or maintain isolation, although universal precautions should be maintained.

1447 A clinic nurse teaches a pregnant client with herpes genitalis about the measures that will be implemented during the pregnancy. Which of the
following statements, if made by the client, indicates that teaching was effective? "I must continue to take my Acyclovir (Zovirax)" "I need to
abstain from sexual intercourse during the entire pregnancy" "I need to take sitz baths four times a day" "I may need a cesarean section if the lesions are
present at the time of labor" D For women with active lesions, either recurrent or primary, at the time of labor, delivery should be cesarean;
therefore option D is correct. Acyclovir is used with caution during pregnancy. Clients should be advised to abstain from sexual contact while the lesions are
present. If it is an initial infection, they should continue to abstain until they become culture negative because prolonged vital shedding may occur in such
cases. Option C is incorrect. Keeping the genital area clean and dry will promote healing.

1448 A physician has written an order to administer methylergonovine (Methergine) to a postpartum client with uterine atony. The nurse would contact
the physician to verify the order if which of the following conditions were present in the mother? Excessive lochia Excessive bleeding and saturation
of more than 1 peripad per hour Hypertension Difficulty locating the uterine fundus C Methergine is contraindicated for a
hypertensive woman, individuals with severe hepatic or renal disease, and during the third stage of labor. A uterine fundus that is difficult to locate, excessive
bleeding, and excessive lochia are clinical manifestations of uterine atony indicating the need for Methergine.

1449 A nurse is reviewing the results of the rubella screening (titer) with a 24-year-old pregnant client. The test results are positive and the mother asks if
it is safe for her toddler to receive the vaccine. The most appropriate nursing response is: "You are still susceptible to rubella, so your toddler should receive the
vaccine." "Most children do not receive the vaccine until 5 years of age." "It is not advised for the children of pregnant women to be vaccinated during
their mother’s pregnancy." "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." D
All pregnant women should be screened for prior rubella exposure during pregnancy. All children of pregnant women should receive their
immunizations according to schedule. Additionally there is no definitive evidence that the rubella vaccine virus is transmitted from person to person. A
positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to the rubivirus.
1450 Following delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or
when she plans to care for her infant. The nurse informs the mother that this is necessary to: Minimize the potential of postpartum hemorrhage
Help the mother assume the parenting role Provide an opportunity to the nurse to teach infant care techniques Avoid maternal/infant injury that
may occur because of the potential for syncope or overexertion D The immediate postpartum period is associated with increased risks for the
cardiac client since about 500 ml of additional blood is added to the intravascular volume following placental separation. In addition, hormonal changes and
fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although options B and C are appropriate
nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the potential for cardiac
compromise.

1451 A nurse is assigned to care for a woman with preeclampsia. The nurse plans to initiate which action to provide a safe environment? Turn off the
room lights and draw the window shades Maintain fluid and sodium restriction Take vital signs every four hours Encourage visits from family and
friends for psychosocial support A Clients with preeclampsia are at risk of developing preeclampsia (convulsions). Bright lights and sudden loud
noises may initiate convulsion in this client. A woman with preeclampsia should be placed in a dim lighted, quiet, private room. Visitors should be limited to
allow for rest and prevent over stimulation. Clients with preeclampsia have decreased plasma volume and adequate fluid and sodium intake is necessary to
maintain fluid volume and tissue perfusion. Vital signs need to be monitored more frequently than every 4 hours when preeclampsia is present.

1452 A client is scheduled for a bronchoscopy. The nurse plans for which of the following measures as the highest priority item?Restricting the diet to
clear liquids on the day of the test Asking the client about allergies to shellfish Obtaining informed consent for an invasive procedure
Administration of (No Suggestions) antibiotics prophylactically. C Bronchoscopy requires that informed consent be obtained from the
client before the procedure. The client is kept NPO for at least 6 hours before the procedure. It is unnecessary to inquire about allergies to shellfish before this
procedure, because contrast dye is not injected. There is no need for prophylactic antibiotics.

1453 A clinic nurse is caring for a pregnant client with herpes genitalis. The nurse provides instructions to the mother regarding treatment modalities that
may be necessary for treatment of this condition. Which of the following statements if made by the mother indicates an understanding of these treatment
measures? "I need to abstain from sexual intercourse until after delivery." "I need to use vaginal creams after the douche every day." "I need to
douche and perform a sitz bath three times a day." "It may be necessary to have a cesarean section for delivery." D If a woman has an active
lesion, either recurrent or primary at the time of the labor, delivery should be by cesarean section. Clients are advised to abstain from sexual contact while the
lesions are present. If it is an initial infection, the client should continue to abstain from sexual intercourse until the cultures are negative because prolonged
viral shedding may occur. Douches are contraindicated and the genital area should be kept clean and dry to promote healing.
1454 A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breastfeed the baby as planned after delivery.
Which of the following responses is most appropriate by the nurse? "You will not be able to breastfeed the baby until 6 months after delivery.'
"Breastfeeding is not a problem and you will be able to breastfeed immediately after delivery." "Breastfeeding is allowed if the baby receives
prophylaxis at birth and remains on the scheduled immunization." "Breastfeeding is not advised, and you should seriously consider bottle-feeding the baby."C
The pregnant client who test positive for hepatitis B virus should be reassured that breastfeeding is not contraindicated if their infant receives
prophylaxis at birth and remains on the schedule for immunizations. Options A, B, and D are incorrect.

1455 A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table and the nurse positions the client:
In Trendelenburg position In semi-Fowler’s position Supine position with a wedge under the right hip In the prone position C
Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities, therefore decreasing
cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus
displaced off the abdominal vessels. Positioning for the abdominal surgery necessitates a supine position; however a wedge placed under the right hip provides
displacement of the uterus. Trendelenburg positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and
oxygenation. A semi-Fowler’s or prone position is not practical for this type of abdominal surgery.

1456 A 17-year-old client tells the nurse that her sister had a tubal pregnancy about 3 months ago and had to have her tube removed. The nurse knows that
this young woman needs further explanation when she states: "This kind of thing can happen to my sister again." "I guess I'll have to wait awhile to
become an aunt." "This kind of thing can happen after a pelvic infection." "My sister is lucky because she'll never have a period again." D
Removing the tube does not bring a halt to menses; endometrial proliferation and shedding will occur as long as the ovaries and uterus are present.

1457 A 22-year-old client with a 3-year history of diabetes mellitus controlled by diet alone is now pregnant and has become insulin dependent. The nurse
understands that the client is classified as a: Class A diabetic Class B diabetic Class C diabetic Class D diabetic B Class B
diabetes includes pregnant women with an onset of diabetes mellitus after 20 years of age, with a duration of less than 10 years, and no obvious vascular
disease.
1458 A 26-year-old female, whose sister recently had a mastectomy, calls the local women's health center for an appointment for a mammography. To
prepare for the test, the nurse should teach the client that: The room will be darkened throughout the procedure Each breast will be firmly
compressed between two plates Food and fluid must be avoided for 6 hours before the test She does not need a mammography until she is 50 years
old B Compression of the breast flattens mammary tissue and maximizes the penetration of the breast by x-rays; this is especially important for
the dense breast tissue of adolescents, young nulliparous women, and women with large breasts.

1459 A 39-year-old who is Rh negative is seen by the physician during the first trimester of pregnancy. She has just been told that Rh sensitization is
suspected. The nurse explains that Rho (D) immunoglobin (RhIg) will be given to reduce sensitization. The nurse's teaching is effective if the client understands
that she will receive RhIg at: 12 weeks gestation 28 weeks gestation 36 weeks gestation 40 weeks gestation B RhIg administration
during the 28th week of gestation reduces an active antibody response in an Rh-negative individual exposed to the positive blood; this drug is used during
pregnancy.

1460 A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. The nurse should instruct the client to:
Stop nursing for 2 days to allow the nipple to heal Manually express milk and feed it to the baby in a bottle Use a breast shield to
keep the baby from direct contact with the nipple Nurse the baby on the unaffected breast first until the affected breast heals D The most
vigorous sucking will occur during the first few minutes of nursing when the infant would be on the unaffected breast; later sucking is less traumatic.

1461 A client and her husband are being discharged from the hospital after giving birth of a fetal demise. They ask about the possibility of attending a
bereavement support group in the community. The nurse is aware that this is an indication of: Denial Prolonged sadness Normal grieving
Anger C A perinatal bereavement support group can help the parent’s work through their pain by nonjudgmental sharing of feelings. It
is a necessary part of normal grieving. The parents request is not indicative of denial, prolonged sadness, or anger.

1462 A client arrives in the labor room suite with the caput emerging. The nurse recognizes that delivery is imminent and tells the client to: Push with all
her power Use the pant-breathing pattern Assume the Trendelenburg position Hold her breath and turn to the left side B Panting will
slow the process so the nurse can support the head as it is delivered.
1463 A client asks the nurse about the use of an intrauterine device (IUD) for contraception. When discussing this method with the client, the nurse
includes that a common problem with IUDs is: Expulsion of the device Occasional dyspareunia Perforation of the uterus
Frequent vaginal infections A The IUD may cause irritability of the myometrium, inducing uterine contractions and expulsion of the
device; the presence of the IUD thread should be verified both before menstruation and coitus.

1464 A client asks the nurse for contraceptive information. The nurse, as part of the teaching plan on contraception, tells the client that: The rim of
the condom must be held in place while withdrawing the penis from the vagina Diaphragms are equally effective whether or not the partners choose
to use spermicidal creams No sperm can reach the ovum if the man uses coitus interruptus and withdraws before ejaculation Individuals using
periodic abstinence should have intercourse on days when the woman has a rise in temperature A Unless the condom is held, it can be displaced,
allowing the sperm to enter the vagina.

1465 A client at 16 weeks gestation is to have a sonogram followed by an amniocentesis. Nursing intervention would include directing this client to void:
Just before each procedure is begun After the first sonogram tracing is obtained At least 1 hour before the procedures are scheduled to
begin After the sonogram is completed and before the amniocentesis is begun D A full bladder is required for effective visualization of the
uterine contents during the sonogram; the bladder should be emptied before an amniocentesis to prevent accidental puncture of the bladder during the
procedure.

1466 A client comes to the infertility clinic for a carbon dioxide insufflation test to determine whether her fallopian tubes are patent. As part of the
teaching before the test the nurse tells the client: "You will receive a local anesthetic to lessen the pain of the test." "You will have to rest in bed for 8
hours after the test is completed." "You may have some persistent shoulder pain for 24 hours after the test.' "You may become nauseated during the test,
but the nausea will subside." C This is referred pain from the passage of carbon dioxide through the tubes; this is usually indicative of tubal
patency.

1467 A client enters the hospital for exploratory abdominal surgery. She is 3 months pregnant and has been informed that there are many dangers
involved. The nurse had her sign a consent form for an exploratory laparotomy. Cancer of the uterus is discovered and a hysterectomy is performed. On
returning from surgery the client is informed that her uterus was removed. She sues the hospital, the surgeon, and the nurse. The decision in this case will be
based on the fact that: General consent forms signed on admission are sufficient The client received inadequate information to give consent
The surgeon has the legal right to do what was deemed necessary in surgery Consent for exploratory surgery implies permission for removing
organs if this is justified B Uninformed consent constitutes an artificial consent; sufficient information was not given.
1468 A client expresses a desire to breastfeed her preterm infant who is in the neonatal intensive care nursery. The nurse should: Tell the client this is not
possible because the infant is being fed by gavage Discourage the client because of the time and effort it will take to pump her breasts Instruct the
client that breast milk is inadequate for a preterm infant because it does not contain all the necessary nutrients Support the client's decision and explain that
the infant will initially lose weight due to the energy expended when breastfeeding D Weight loss results from the extra sucking effort required
to obtain milk flow from the breast.

1469 A client has stated she wishes to use the calendar method of birth control. The nurse is aware that the client understands how to calculate the
beginning of the fertile period when she states, "I will: Subtract 11 days from the length of my longest cycle. Subtract 18 days from the length of my shortest
cycle. Abstain from sexual intercourse after the 10th day of my cycle. Abstain from intercourse from the 10th day prior to the middle of my average
cycle. B The fertile period is determined by subtracting 18 days from the length of the shortest cycle to determine the first unsafe day and
subtracting 11 days from the length of the longest cycle to determine the last unsafe day.

1470 A client in active labor is admitted to the birthing room. A vaginal examination reveals a 6 to 7 cm dilation. Based on this finding the nurse should
expect that this client would: Have a profuse bloody show Appear unable to control her shaking legs Be uncomfortable because of nausea and
vomiting Have contractions every 3 to 5 minutes of 60-second duration D This is a description of the contractions during the active portion of
the first stage of labor.

1471 A client in labor has human immunodeficiency virus (HIV) and says to the nurse, “I know I will have a sick looking baby. Which of the following
would be the most appropriate nursing response? "There is no reason to worry. Our neonatal unit offers the latest treatments available." "You have
concern about how HIV will affect your baby?" "You are very sick, but your baby will not be." "All babies are beautiful. I am sure your baby
will be too." B Option B is the most therapeutic response and the response that will elicit the best information. It addresses the therapeutic
communication technique of paraphrasing. Parents need to know that their baby will not look sick from HIV at birth and that there will be a period of
uncertainty before it is known whether the baby has acquired the infection. The client should not be told “there is no reason to worry.” Options C and D provide
false reassurances. Option B is an open-ended response that will provide an opportunity to the client to verbalize concerns.
1472 A client in late active first stage labor has just reported a gush of vaginal fluid. A nurse observes a fetal monitor pattern of variable decelerations
during contractions followed by a brief acceleration. Then there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of
these data, the nurse prepares to initially: Take the vital signs Perform a manual sterile vaginal exam Perform Leopold’s maneuver Test the
vaginal fluid with a nitrazine strip B Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical
manifestation of cold compression resulting from occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in
the vagina, confirming the problem. On the basis of the data in the question, options A, C and D are not initial actions.

1473 A client in the trimester of pregnancy arrives at the clinic and tells the nurse that she frequently has a backache. Which instruction would the nurse
provide to the client to alleviate the backache? Sleep in a supine position and on a firm mattress Wear a maternity girdle Eat small
meals frequently Elevate the legs when sitting B To provide relief from backache, the nurse would advise the client to used good posture and
body mechanics, perform pelvic rock exercises, and to wear flat supportive shoes. The client is also instructed to wear a maternity girdle, avoid overexertion,
and sleep in the lateral position on a firm matters. Back massage is also helpful. Eating small meals would more specifically assist in the relief of dyspnea.
Leg elevation assists the client who has varicosities.

1474 A client is admitted to the hospital in labor 12 hours after her membranes have ruptured. It is important for the nurse to assess the character of the
client's amniotic fluid to prepare for potential: Cord prolapse Placenta previa Maternal sepsis Abruptio placentae C
After 12 hours, amniotic fluid must be assessed for odor and appearance indicating infection for either mother or infant.

1475 A client is admitted to the hospital with uterine tenderness and very minimal, dark red vaginal bleeding. She is diagnosed as having abruptio
placentae. Upon admission, the priority assessment would include vital signs, skin color, urine output, and: Her past obstetric history Fundal height
or abdominal girth The time and amount of last mealFamily history of bleeding disorders B It is vital that a baseline measurement be
obtained because increasing size is a sign of concealed hemorrhage; in abruptio placentae there is bleeding behind the placenta.
1476 A client is in the hospital undergoing therapy for severe pregnancy-induced hypertension. If eclampsia should occur, the nurse's first action should
be to: Assess fetal heart tones Maintain an open airway Protect the client from injury Increase the infusion of magnesium sulfate
immediately C When a client is eclamptic she will be experiencing seizures; protecting the client from injury is always the first priority with
any seizure.

1477 A client is now in her second trimester. While listening to the fetal heart, the nurse hears a heartbeat at the rate of 136 in the right upper quadrant and
also at the midline below the umbilicus. The sources of these sounds are: Heart rates of two fetuses Maternal and fetal heart rates Fetal heart
rate and funic soufflé Uterine souffle and fetal heart rate C The funic souffle is blood rushing through the fetal umbilical cord and is
therefore the same rate as the fetal heart rate.

1478 A client is placed on progesterone oral contraceptives (minipills) and is instructed by the nurse to take 1 pill daily: Throughout the
menstrual cycle During the 5 days surrounding ovulation During the first 5 days of the menstrual cycle Throughout the first 21 days of the
menstrual cycle A Maintenance of serum progesterone levels keeps cervical mucus thick and hostile to sperm at all times.

1479 A client is receiving rehabilitative services during pregnancy for alcohol abuse. The nurse would provide supportive care by: Encouraging
the client to participate in care and identifying supportive strategies that are helpful Avoiding discussion of the alcohol problems and recovery with the
client Minimizing communication with supportive family members Encouraging the client to stop counseling once the infant is born A
The nurse provides supportive care by encouraging the client to participate in care. The nurse should not avoid discussing the client’s problem with
the client, and communication with the family members is important. Counseling needs to continue after the infant is born.

1480 A client is taking oral contraceptives. The nurse should inform the client to stop taking the contraceptive and report to the physician immediately if
she experiences: Vertigo and nausea Weight loss and breast pain Hypotension and amenorrhea Headaches and visual disturbances D
Headaches, either sudden or persistent, may indicate hypertension or a cardiovascular event; visual disorders, such as partial or complete loss of
vision or double vision, may indicate neuroocular lesions, which are associated with the use of oral contraceptives.
1481 A client is to receive a tuberculin test as part of her prenatal workup. Before administering the test, the most important information for the nurse to
collect is whether the client has: Previously had a tuberculin test Ever had a positive tuberculin test A history of tuberculosis in the family
Had any serious respiratory diseases B A tuberculin test should not be administered to a client with a previous positive tuberculin
test because severe reactions can occur at the test site in individuals previously sensitized.

1482 A client second trimester of pregnancy is being assessed at a health care clinic. The nurse performing the assessment notes that the fetal rate is 100
beats per minute. Which of the following nursing actions would be most appropriate? Document the findings Inform the mother that the
assessment is normal and everything is fine Notify the physician Instruct the mother to return to the clinic in 1 week for reevaluation of the fetal heart rate C
The fetal heart rate should be between 120 and 160 beats per minute during pregnancy. A fetal heart rate of 100 beats per minute would require that
the physician be notified and the client be further evaluated. Options A and B are similar and can be eliminated first. Option D an inaccurate nursing action.

1483 A client vaginally delivers a 7 pound, 2 ounce baby and has made the decision to breastfeed the infant. When instructing the client regarding
breastfeeding, the nurse tells the client to expect that: Weight loss will occur rapidly Lochial flow will be increased Uterine involution will be delayed
Use of heat will be contraindicated B Breastfeeding stimulates oxytocin release and uterine contractions, resulting in increased
lochial flow.

1484 A client visits her gynecologist to confirm a suspected pregnancy. During the nursing history the client states that her last menstrual period began on
April 11. The client states that some spotting occurred on May 8. The nurse calculates that the client's due date is: 10-Jan 18-Jan 12-Feb
15-Feb B Using Nagele's rule, subtract 3 months and add 7 days to the first day of the last menstrual period, April 11.

1485 A client who has cervical cancer is hospitalized for internal radiation therapy. After the radiation source has been loaded, the nurse should:
Check the client's voiding and catheterize if necessary Immediately place the client in a high-Fowler's position Ensure that a low-
residue diet has been ordered for the client Stay with the client for half an hour and assess for symptoms of radiation sickness C Clients with
internal radiation for cervical cancer are given low-residue diets and often medications to suppress peristalsis and prevent pressure from BMs.
1486 A client who has just delivered an infant with Down syndrome tells the nurse that she could not possibly take a retarded child home and asks
whether she should plan to place the child in an institution. An appropriate statement by the nurse at this time would be: "I understand how you feel, and I
will notify the nursery personnel of your decision." "At this young age no one is able to predict your baby's ultimate level of functioning." "Give
yourself time to get acquainted and you will see that your baby isn't retarded yet." "You should not make such a hasty decision, as your baby is like any
other baby right now."B This is an accurate and nonjudgmental response.

1487 A client who has just had her second child wishes to breastfeed. When the nurse brings the baby to be breastfed, the mother asks whether she may
drink a small glass of wine to help her relax. The nurse's best response would be: I'm sure that drinking one glass of wine would not cause any harm.
Yes it's relaxing, but I do think you should find another, better way to relax. You seem a little tense. Tell me about your past breastfeeding
experiences. I'm sure a glass of wine would be OK, but you had better check with your physician. C This recognizes the client's feelings,
encourages ventilation, and does not encourage the use of alcohol for relaxation.

1488 A client who has missed one menstrual period thinks she is pregnant. The nurse suggests a pregnancy test. This is possible because in early
pregnancy the urine contains: Prolactin Estrogen Luteinizing hormone Chorionic gonadotropin D Chorionic gonadotropin is present
in the urine during early pregnancy and is the basis for pregnancy tests; since this hormone appears only during early pregnancy, its presence is taken as a sure
sign of pregnancy.

1489 A client who has undergone a cesarean delivery because of the presence of active genital herpes is transferred to the postpartum unit 2 hours after
delivery. The nurse on the unit should plan to institute: Strict isolation Enteric isolation Contact isolation Protective isolation C
Contact precautions include wearing gown and gloves; these protect the nurse from the virus.

1490 A client who is at 34 weeks gestation has been receiving terbutaline (Brethine) IV. Her contractions increase to every 10 minutes, and her cervix
dilates to 4 cm. The Brethine is discontinued. Priority nursing care during this time should be directed toward: Promotion of maternal-fetal well-being during
labor Reduction of anxiety associated with preterm labor Supportive communication with the client and her partner Assisting the family to
cope with the impending preterm birth A Labor is continuing, and the promotion of the well-being of the client and fetus is the most important
priority for nursing care during this period.
1491 A client who is pregnant for the first time and is carrying twins is scheduled for a cesarean delivery. Preoperative teaching should include telling the
client to expect to: Be discharged between 5 to 7 days postpartum Need an enema to have an effective bowel movement Be ambulating whenever
desired the day after surgery Take sponge baths until the incision is completely healed C Early postoperative ambulation helps prevent
many postpartal complications such as thrombophlebitis and constipation.

1492 A client who is to have a uterine aspiration abortion at 10 weeks gestation should be told that: A general anesthetic will be used to insert the
laminaria tent The uterine lining will be scraped after removal of the laminaria tent The laminaria tent will have to be retained in the cervical
canal for 4 to 24 hours An increased amount of bleeding will be present for 3 to 5 hours after the abortion C As the laminaria tent is
left in place for this length of time, it increases in size from absorption of moisture and dilates the cervix 2 to 3 times its original diameter before the suction
procedure is done.

1493 A client who recently delivered a baby is transferred to the postpartum unit by the nurse. To avoid a charge of abandonment, the nurse should first:
Document all aspects of the client's condition and the transfer Orient the client to the new room and explain policies and unit routines
Assess the client and determine that all findings are within normal limits Give a detailed report of the client's condition to the responsible staff
member D Since the nurse is responsible for the client's care until another nurse assumes that responsibility, the nurse should report directly to the
nurse in charge.

1494 A client who was admitted to the hospital for surgery for an ectopic pregnancy asks the nurse why she has shoulder pain. The nurse would base a
response on the fact that the pain is caused by: Anxiety about the diagnosis Cardiac changes from hypovolemia Blood accumulation
under the diaphragm Rebound tenderness from the ruptured tube C Any blood from the rupture will accumulate; pressure from this accumulation
pushing on the diaphragm causes pain.

1495 A client with a high-risk pregnancy is to undergo a contraction stress test (CST). The nurse understands that this test would not be done if the client
had: Blurred vision Vaginal bleeding Sickling of the red cells Increasing hypertension B Bleeding could indicate
placenta previa or abruptio placentae, which would be aggravated by the contractions from the use of Pitocin.
1496 A client with a history of phenylketonuria, who was maintained on a low-phenylalanine diet until 9 years of age, is now pregnant. The nurse teaches
this client that: Reinstitution of the low-phenylalanine diet will protect her baby from PKU The baby will probably be mentally retarded because of
her history of PKU The fetus is at no risk prenatally but will require immediate care at birth to prevent PKU Phenylalanine should be avoided even when
not pregnant so that her body is able to support a pregnancy A The fetus is at risk for retardation prenatally from a buildup of metabolites in the
PKU-affected mother if a prescribed diet is not followed by the mother.

1497 A client with a suspected placenta previa is to have an ultrasonogram to determine the location of the placenta. In preparation for this procedure the
nurse should: Insert an indwelling urinary catheter Cleanse her abdomen with a germicidal soapInstruct her to drink two large glasses of water
Give a cleansing enema of 500 ml normal saline C A full bladder helps to stabilize the uterus during ultrasonography; this allows for
better visualization of the fetus; two full glasses of water, drunk about 1 hour before the test, will fill the bladder.

1498 A client with eclampsia has a generalized seizure. Following the seizure, the client has an elevated temperature of 102º F (39º C). The nurse suspects
that the temperature may be caused by: Excessive muscular activity Development of a systemic infection Dehydration caused by rapid fluid
loss Disturbance of the cerebral thermal center D Increased electric charges in the brain during a seizure may disturb the cerebral
thermoregulation center.

1499 A client with preeclampsia is told that she must remain on bed rest at home. The client starts to cry and tells the nurse that she has two small children
at home who needs her. The nurse's best response would be: "You'll need someone to care for the children." "You are worried about how you
will be able to manage." "You can get a neighbor to help out, and your husband can do the housework in the evening." "You'll be able to fix
light meals, and the children can go to nursery school a few hours each day." A The therapeutic regimen includes bed rest; peace of mind can best be
achieved if the children are adequately cared for.

1500 A client with pregnancy-induced hypertension is being treated on an ambulatory basis, and bed rest for 3 days is prescribed. The nurse
encourages the client to stay in bed and assume the: Supine position Side-lying position Semi-Fowler's position Slight Trendelenburg's
position B The side-lying position improves venous return to the heart and increases stroke volume and cardiac output.
1501 A client with severe preeclampsia is admitted to the hospital. She is a student at a local college and assists on continuing her studies while in the
hospital despite being instructed to rest. The nurse notes she studies about 19 hours a day between numerous visits from fellow students, family, and friends.
The nurse plans to: Instruct the client that the health of the baby is more important than her studies at this time Ask her why she is not complying
with the order of bed rest Include a significant other in helping the client understand the need for bed rest Develop a routine with the client to
balance studies and rest needs D In options A and B, the nurse is judging the client’s opinion and asking probing questions. This will cause a
breakdown in communication. Option C persuades the client’s significant other to disagree with the client’s action. This could cause problems with the
relationship between the client and significant other and also conflict in communication with the decision making.

1502 A client with severe preeclampsia who has a BP of 170/110 mm Hg, a pulse of 108 beats per minute, and respirations of 24 breaths per minute is
placed on IV magnesium sulfate therapy. Eight hours later her BP is 150/110, the pulse is 98, respirations are 14, and there is absence of the knee-jerk reflex.
The nurse should: Eliminate the next dose of magnesium sulfate and notify the physician Administer calcium gluconate as an antidote for the
magnesium sulfate Administer the next dose of magnesium sulfate because the blood pressure is still high Wait 1 hour, monitor the vital signs and
reflexes again, and then administer the next dose A Near-toxic levels of magnesium sulfate are indicated by the disappearance of the knee-jerk
reflex and by depressed respirations (less than 12 per minute).

1503 A client with severe pregnancy-induced hypertension (PIH) who has been admitted to the hospital anxiously asks the nurse, "Will my baby be all
right?" The nurse's most appropriate response would be: "There is no way of telling at this time what the outcome will be." "The baby will probably
be all right; it's protected by the amniotic fluid." "If you do what the doctor tells you to do, everything will progress normally." "We will be constantly
monitoring your baby's condition. Would you like to listen to the baby's heartbeat?" D This reassures the client that her baby is all right at the
moment and that the nurses are aware of and monitoring the baby's status.

1504 A client with worsening preeclampsia is hospitalized and placed in a private room. The nurse knows that this is important because a nonstimulating
environment for a client with increased cerebral irritability: Improves intracellular fluid reabsorption Reduces the severity of frontal headaches
Reduces the probability of grand mal seizures Prolongs the duration of hypotensive medications C Even minimal sensory
stimuli can trigger exaggerated cerebral responses such as convulsions; therefore a nonstimulating environment is therapeutic. ","A non-stimulating
environment has no relation to the length of time antihypertensive drugs must be given. "

1505 A client, 35 weeks gestation, is admitted to the hospital with a small amount of bright red vaginal bleeding without contractions. After placing the
client in bed, the nurse should: Check fetal heart tones Administer a Fleet enema Obtain an amniotomy setup Perform a vaginal
examination A In light of the vaginal bleeding, the priority nursing action is ascertaining whether a viable fetus is present.

1506 A client, who has participated in caring for her infant in the neonatal intensive care unit for several days in preparation for the baby's discharge,
comes to the unit on the last hospital day with alcohol on her breath and slurred speech. The nurse's most appropriate action would be to: Talk with the
mother about her condition and assess her willingness to participate in an alternate discharge plan Speak to the mother about her condition and have her see a
social worker about the baby's discharge to a foster home Continue with the discharge procedure, alerting the home health nurse that immediate
follow-up is needed for the mother Avoid confrontation by asking the mother to wait in the hospital lobby and calling the physician to cancel the
discharge order A Confrontation about the active substance abuse and the mother's diminished ability to safely care for the infant at this time is
necessary to help the mother get help and to also protect the baby.

1507 A client's history and physical assessment reveal that the client has previously received estrogen replacement therapy as a treatment for osteoporosis.
The nurse should recognize that the client has an increased risk of developing: Endometrial cancer Accelerated bone loss Vaginal tissue atrophy A myocardial
infarction A Statistics indicate a relationship between estrogen therapy and an increased incidence of endometrial cancer, although mortality is not
increased.

1508 A clinic nurse is providing instructions to a client in the third trimester of pregnancy regarding relief measures related to heartburn. Which of the
following instructions would the nurse provide to the client? Eat fatty foods only once a day in the morning Avoid milk and hot teat
Take frequent sips of water Use antacids that contain sodium C Measures to provide relief of heartburn include small frequent meals,
and avoiding fatty fried foods, coffee, and cigarettes. Mild antacids can be used if they do not contain aspirin or sodium. Frequent sips of milk, hot tea, or water
is helpful. Gum is also helpful in the relief of heart burn.

1509 A common method of locating the precise position of a fetus and placenta prior to an amniocentesis is: Fetoscopy Fluoroscopy
Sonography X-ray examination C Sonography, based on sound-wave reflection and detection, locates the position of the fetus
and placenta prior to insertion of the needle in amniocentesis; this minimizes the potential for fetal damage during the procedure.

1510 A couple are desirous of using the rhythm (calendar) method of contraception but do not understand how it works. The nurse's explanation to this
couple about when to refrain from intercourse will be based on the fact that ovulation occurs: Fourteen days prior to the onset of menstruation
Seven days before the end of the menstrual cycle Seven days after the completion of the menstrual period Fourteen days after the
completion of the menstrual period A Ovulation is anticipated approximately 14 days prior to menstruation; however, it is more reliable to
avoid using a specific number of days and to calculate on the basis of an individual's cycle rather than an average 28-day cycle.

1511 A disease that can arise from normal microbial flora, especially after prolonged antibiotic therapy, is: Q fever Candidiasis
Scarlet fever Herpes zoster B Candidiasis (Candida infection) arises in certain individuals when local resistance is
decreased through prolonged antibiotic therapy or with certain diseases (e.g., diabetes) and debilitating conditions (e.g., drug addiction).
1512 A female client and her newborn infant have undergone testing for human immunodeficiency virus (HIV) and both clients were found to be positive.
The news is devastating and the mother is crying. Using crisis intervention techniques, which of the following does the nurse interpret that the client needs at
this time? Call an HIV counselor and make an appointment for them Describe the progressive stages and treatments for HIV Examine with the mother
how she got HIV Listen quietly while the mother talks and cries D This client has just received devastating news and needs to have
someone present with her as she begins to cope with this issue. The nurse needs to sit and actively listen while the mother talks and cries. Calling an HIV
counselor may be helpful, but it is not what the client needs at this time. The other options are not appropriate for this stage of coping with the news that both
she and the infant are HIV positive.

1513 A female client with Hodgkin's disease is to start total nodal irradiation. She and her husband have been trying to have a child, and they are quite
concerned when they learn that the radiation therapy includes the pelvic nodal area. When questioned about this, the nurse should refer them to the physician
because the nurse should be aware that: The ovaries can be surgically moved and placed in a shielded area Intense radiation to the area always causes
permanent sterilization The radiation used is not radical enough to destroy ovarian function Ovarian function will be temporarily destroyed
but will return in time A Women in the childbearing years should be informed of all options available to preserve ovarian function.

1514 A few hours after being admitted in active labor, a primigravida becomes very restless, flushed, and irritable and perspires profusely. The client
states that she is going to vomit. The nurse suspects that these symptoms are indicative of: Late stage Third stage Second stage
Transition stage D The physiologic intensification of labor occurring during transition is caused by a greater energy expenditure and
increased pressure on the stomach; this results in feelings of fatigue, discouragement, and nausea. "

1515 A home nurse provides instructions to a postpartum client who has developed breast engorgement. The nurse tells the mother to: Feed the
infant less frequently, every 4 to 6 hours, using bottle feeding in between Apply cool packs to both breasts 20 minutes before a feeding Avoid the use
of a bra during engorgement Gently massage the breast from the outer areas of the nipple during feeding D The client with breast engorgement
should be advised to feed frequently, at last every 21 ½ hours for 15 to 20 minutes per side. Moist heat should be applied to both breasts for about 20 minutes
before a feeding. Between feedings, the mother should wear a supportive bra. During a feeding, it is helpful to gently massage the breast from the outer areas
to the nipple to stimulate the letdown and flow of milk.

1516 A married client, 35 years old, who is to undergo a tubal ligation is assessed by the nurse to determine the client's possible emotional response to the
procedure. A factor in the history that would contribute most to the healthy resolution of any emotional problem associated with sterilization would be that the
client: Has a son and daughter and feels her family is complete Thinks the surgery will relieve her monthly dysmenorrhea Knows that
her husband does not want her to have any more children Has just had a complicated delivery and never wants to undergo another birth again A
Many couples in their 30s, who are happy with their family and feel their family is complete, choose sterilization as their method of contraception.
1517 A mother delivers a male infant at 35 weeks gestation. When visiting her infant in the neonatal intensive care nursery (NICU) for the first time, the
mother asks, "When will I be able to breastfeed my son?" The nurse's most appropriate response would be: "Even though he is preterm, he is stable. You
may try now if you would like. " "Preterm infants should not breastfeed. It takes more calories than bottle-feeding." "Pump your breasts now and then
feed him the milk by bottle to conserve his energy." "He is preterm and sucks weakly so it will be several weeks before you may breastfeed." A A
preterm infant may have a weak suck but usually can be breastfed; the mother may at least attempt it, if the infant's condition is stable.

1518 A mother has just given birth to a baby who has a cleft lip and palate. When planning to talk to the mother, the nurse should recognize that this client
must be allowed to work through which of these emotions before maternal bonding can occur? Anger Grief Guilt Depression B
The mother must first be assisted to grieve for the anticipated child that she did not have. Once this is accomplished, the mother can begin to focus
on bonding with the baby she gave birth to. Options A, C, and D are incorrect, because they are only one component of the grief process.

1519 A mother is breastfeeding her newborn. She asks when she can switch the baby to a cup. The nurse would recognize that the mother understands the
teaching about feeding when she says she will start to introduce a cup when the baby is: 4 months old 6 months old 12 months old 18
months oldB At about 6 months of age, infants are able to swallow independently of sucking and a cup can be introduced.

1520 A mother of an infant with hydrocephalus is concerned about the complication of mental retardation. The mother states to the nurse, “I’m not sure if
I can care for my baby at home.” The most appropriate response by the nurse would be which of the following? "There is no reason to worry. You have a good
pediatrician." "Mothers instinctively know what is best for their babies." "You have concern about your baby’s condition and care?"
"All babies have individual needs." C Paraphrasing is restating the mother’s message in the nurse’s own words. Option c addresses
the therapeutic technique of paraphrasing. In options A and B, the nurse is offering a false reassurance and these types of responses will block communication.
In option D, the nurse is minimizing the social needs involved with the baby’s diagnosis, which is harmful for the nurse-parent relationship.

1521 A mother's laboratory results indicate the presence of cocaine and alcohol. The characteristic in the baby that would indicate to the nurse that the
baby has been affected by fetal alcohol syndrome would be: Cleft lip Polydactyly Umbilical hernia Small upturned nose D
The abnormal facies associated with fetal alcohol syndrome includes a small, upturned nose, which is distinctive in these infants.
1522 A neonatal intensive care nurse is caring for a newborn infant immediately following delivery, the infant has a suspected diagnosis of
erythroblastosis fetalis. The nurse would make which of the following statements to the parents at this time? "You must have many concerns. Please ask me
any questions as I explain your infant’s care." "This is a common neonatal problem; you shouldn’t be concerned." "There is no need to
worry. We have the most updated equipment in this hospital." "Your infant is very sick. The next 24 hours are most crucial." A Parental
anxiety is expected related to the care of the infant with erythroblastosis fetalis. This anxiety is due to a lack of knowledge regarding the disease process,
treatments, and expected outcomes. Parents need to be encouraged to verbalize concerns and participate in care as appropriate.

1523 A neonatal intensive care unit (NICU) nurse teaches Handwashing techniques to parents before the handling of their infant, who is receiving
antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the purpose of Handwashing if they state that this is primarily
done to: Reduce their own fears Minimize the spread of infection to other siblings Reduce the possibility of environmental infection for their
infant Allow them an opportunity to communicate with each other and staff C Appropriate Handwashing by staff and parents has been
effective in the prevention of nosocomial infections in nursery units. This action also promotes parent’s taking an active part in the care of their infant. Options
A and D are not the primary reasons to perform Handwashing. Since the infant has the infection and is the NICU, option B is incorrect.

1524 A neonate is delivered at 29 weeks gestation and weighs 1619 g (3 lb 9 oz ). Based on the weight and gestational age, this neonate would be
classified as: Preterm Immature Nonviable Low-birth-weight infant A Preterm describes a newborn delivered at 37 weeks'
gestation or less, regardless of weight.

1525 A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet needs. The nurse can best respond: Just eat as
you have been doing during your pregnancy. Just drink a lot of milk; you need the calcium to make your own milk. Don't worry about it,
your body will produce the amount of milk your baby needs. You'll need greater amounts of the same foods you've been eating and more fluids. D
Compared with the prenatal diet, the diet for lactation requires an increased intake of all food groups, vitamins and minerals, plus increased fluid to
replace that lost with milk secretion; calories should be increased by 500 daily and protein by 10 to 15 g daily.

1526 A new parent is trying to make the decision whether or not to have her baby boy circumcised. The nurse makes which statement to assist the mother
in making a decision? "I had my son circumcised, and I am so glad!" "Circumcision is a difficult decision, but your physician is the best, and you
know it’s better to get it done now that later!" "Circumcision is a difficult decision. There are various controversies surrounding circumcision. Here,
read this pamphlet that discusses the pros and cons, and we will talk after you read, to answer any questions that you have." "You know they say it prevents
cancer and sexually transmitted diseases, so I would definitely have my son circumcised!" C Informed decision making is the key point in
answering this question. The nurse should provide educational material and answer questions pertaining to the education of the mother. Providing written
information to the mother will give her the information she needs to make an educated and informed decision. The nurse’s personal thoughts and feelings
should not be part of the educational process.
1527 A newborn male infant is diagnosed with an undescended testicle (cryptorchidism). The parents ask questions about the condition. The nurse
responds knowing that if this condition is not corrected, which of the following could have a psychosocial impact? Infertility Malignancy
Feminization Atrophy A Infertility can occur in this condition, because proper function of the testes depends on a temperature
cooler than 98.6° F. The psychological effects of an “empty scrotum” could affect the client’s perception of self and the ability to reproduce. Options B and D
are possible physical consequences. Since all hormones responsible for secondary sex characteristics continue to be secreted directly into bloodstream, option C
is not correct.

1528 A newborn of 30 weeks gestation has a heart rate of 86 beats per minute and has slow irregular respirations. The infant grimaces in response to
suctioning, is cyanotic, and has flaccid muscle tone. The nurse should assign the infant an Apgar score of: 2 3 4 5 B
Heart rate less than 100 beats per minute = slow and irregular respirations = grimaces in response to suctioning = flaccid muscle tone = 0; and
cyanosis = 0; the Apgar score would total 3.

1529 A newborn whose mother has Type I diabetes mellitus has been receiving a continuous infusion of fluids with glucose. When discontinuing the IV
infusion, the nurse should: Slowly decrease the rate Observe for metabolic alkalosis Withhold oral feedings for 4 to 6 hours Check the
urine for glucose every hour A Decreasing IV glucose slowly is necessary to prevent a hypoglycemic response.

1530 A newborn with respiratory distress syndrome is placed on continuous positive-pressure ventilation therapy via an endotracheal tube. The nurse
notes that the infant's breath sounds on the right side are diminished, and the point of maximum impulse (PMI) of the heartbeat is in the left axillary line.
Interpretation of this assessment data should lead the nurse to understand that: These are normal findings because infants with this disorder often have some
degree of atelectasis The inspiratory pressure on the ventilator is probably too low and needs to be increased for adequate ventilation The infant may have a
pneumothorax, and the physician should be contacted immediately so treatment can be instituted The endotracheal tube has probably slipped into the left
main stem bronchus and needs to be pulled back to ventilate both lungs C These are key signs of a pneumothorax, which can occur when an
infant is receiving oxygen by positive pressure.

1531 A newborn's total body response to noise or movement is often distressing to the parents. It is important for the nurse to teach the parents that this
response is: A reflexive response that indicates normal development An involuntary response that will remain for the first year of life An automatic
response that may indicate that the baby is hungry A voluntary response that indicates insecurity in a new environment A This is a
normal Moro reflex, which indicates an intact nervous system.
1532 A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as “two or more fetal heart rate
(FHR) accelerations of 15 beats per minute, lasting 15 seconds, in association with fetal movement.” A nurse interprets these findings as: A reactive
nonstress test A nonreactive nonstress test Unclear for accurate interpretation Unsatisfactory A A reactive nonstress test
(normal/negative) indicates a healthy fetus. It is describes as two or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the
beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive nonstress test (abnormal) is described as
no accelerations or accelerations of less than 15 beats per minute or lasting less than 15 seconds throughout any fetal movement during the testing period. An
unsatisfactory test cannot be interpreted because of the poor quality of the FHR.

1533 A nonstress test is scheduled for a client with pregnancy-induced hypertension. During the nonstress test the nurse should be aware that if
nonperiodic accelerations of the fetal heart rate occur with fetal movement, it most likely indicates: Fetal well-being Head compression
Uteroplacental insufficiency Umbilical cord compression A Nonperiodic accelerations on movement and a baseline variability of
5 to 15 beats indicate fetal well-being.

1534 A nurse continues to assess a client who is in the first stage of labor for progress and fetal well-being. At the last vaginal exam, the client was fully
effaced, 8 centimeters dilated, vertex presentation, and station 1. Which observation would indicate that the fetus was in distress? Vaginal exam continues
to reveal some old meconium staining demonstrates and the fetal monitor demonstrates a U-shaped pattern of deceleration during contractions, recovering to a
baseline of 140 beats per minute. Fresh, thick meconium is passed with a small gush of liquid, and the fetal monitor shows late decelerations with a variable
descending baseline Fresh meconium is found on the examiner’s gloved fingers after a vaginal exam, and the fetal monitor pattern remains essentially
unchanged The fetal heart are slowly drops to 110 beats per minute during strong contractions, recovering to 138 beats per minute immediately afterward B
Meconium staining alone is not a sign of fetal distress. Meconium passages is a normal physiological function, frequent in a fetus over 38 weeks
gestation. Old meconium staining may be the result of prenatal trauma that is resolved. It is not unusual for the fetal heart rate to drop below the 140 to 160
beats per minute range in late labor during contractions, and in a healthy fetus the fetal heart rate will recover between contractions. Fresh meconium in
combination with late decelerations and a variable descending baseline is an ominous signal of fetal distress resulting from fetal hypoxia.

1535 A nurse determines that a gravida 3, para 3 client is beginning to go into shock and is hemorrhaging as a result of a partial inversion of the uterus.
The nurse pages the obstetrician STAT and calls for assistance. The client asks in an apprehensive voice, “What is happening to me? I feel so funny, and I know
I am bleeding. Am I dying?” The nursed responds to the client, knowing that the client is feeling: Panic secondary to shock Fear and anxiety related
to unexpected and ambiguous sensations Anticipatory grieving related to the fear of dying Depression related to postpartum hormonal changes B
Feelings of loss of control are common causes of anxiety. The unknown is the most common cause of fear. Apprehension and feelings of impending
doom are also associated with shock, but the case situation does not suggest panic at this point. Anticipatory grieving occurs when there is knowledge of the
impending loss, but this is not operative in a sudden situational crisis such as this one. It is far too early for the onset of postpartum depression.

1536 A nurse has conducted a class for pregnant clients with diabetes mellitus on signs and symptoms of potential complications. The nurse determines
that the teaching was effective if the client made which of the following statements? "I’m glad I don’t have to worry about developing hypoglycemia while
I am pregnant." "I need to watch my weight for any sudden gains, since I am prone to pregnancy-induced hypertension." "My insulin needs
should decrease in the last 2 months, because I will be using some of the baby’s insulin supply." "I should not have ultrasonography done since I am
diabetic." B Hypoglycemia is a problem during pregnancy and needs to be assessed. A diabetic pregnant client has a higher incidence of pregnancy-
induced hypertension than the nondiabetic pregnant client. Insulin needs will increase during the last trimester because of increased placenta degradation.
Ultrasonography is performed frequently during a diabetic pregnancy to check for congenital anomalies and determine appropriate growth patterns.

1537 A nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify the urine.
Which of the following fluids, if identified by the mother, indicates a need for further education regarding the fluids that will acidify the urine? Apricot juice
Carbonated drinks Prune juice Cranberry juice B Acidification of the urine inhibits multiplication of bacteria. Fluids
that acidify the urine include apricot, plum, prune, and cranberry juice. Carbonated drinks should be avoided because they increase urine alkalinity.

1538 A nurse in a newborn nursery receives a telephone call and is informed that a newborn infant whose mother is Rh negative will be admitted to the
nursery. In the planning of care for the infant’s arrival, the priority nursing action would be to: Obtain the necessary equipment from the blood bank
needed for an exchange transfusion Call the maintenance department and ask for a phototherapy unit to be brought to the nursery Obtain the
newborn infant’s blood type and direct Coombs results from the laboratory Obtain a vial of vitamin K from the pharmacy and prepare to administer an
injection to prevent isoimmunization C To further plan for the newborn infant’s care, the infant’s blood type and direct Coombs must be
known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs test) of the newborn infant.
The nurse should obtain these results from the laboratory. Options A and B are inappropriate at this time, and additional data area needed to determine whether
these actions are needed. Option D is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.

1539 A nurse in a postpartum unit checks the temperature of a client who delivered a healthy newborn infant 4 hours ago. The mother’s temperature is
100.8º F. Which of the following is the most appropriate nursing intervention? Notify the physician Continue hydration and recheck the temperature 4 hours
later Document the temperature Increase the IV fluids A A temperature of greater than 100.4º F in two consecutive readings is considered
febrile, and the physician should be notified. Options B, C and D are inappropriate actions at this time.

1540 A nurse in the newborn nursery is caring for a premature infant. The best way to assist the parents to develop attachment behaviors is to:
Encourage the parents to touch and speak to their infant Place family pictures in the infant’s view Report only positive qualities and progress to
the parents Provide information on infant development and stimulation A Parents’ involvement through touch and voice establishes and initiates
the bonding process in the parent-infant relationship. Their active participation builds their confidence and supports the parenting role. Providing information
and emphasizing only positives are not incorrect, but do not relate to the attachment process. Family pictures are ineffective for an infant.

1541 A nurse instruct a perinatal client about measures to prevent urinary tract infections. Which statement if made by the client would indicate an
understanding of these measures?"I can take a bubble bath as long as the soap doesn’t contain any oils." "I should always use scented toilet paper." "I
can wear my tight-fitting jeans." "I should choose underwear with a cotton panel liner." D Wearing items with a cotton panel liner allows for air
movement in and around the genital area. Bubble bath or other bath oils should be avoided, because these may be irritating to the urethra. Harsh, scented, or
printed toiler paper may cause irritation. Wearing tight clothes irritates the genital area and does not allow for air circulation.

1542 A nurse instructs a client with mild preeclampsia about home care measures. The nurse evaluates that the teaching has been effective concerning
assessment of complications when the client states: "As long as the home health care nurse is visiting me daily I do not have to kept my next physician’s
appointment." "I need to take my blood pressure each morning and alternate arms each time." "I need to check my weight every day at
different times during the day." "I need to check my urine with a dipstick every day for protein and call the physician if it is 2+ or more" D
The client needs to be instructed to report any increases in blood pressure, 2+ proteinuria, weight gain greater than 1 lb per week, presence of edema,
and decreased fetal activity to the physician or health care provider immediately to prevent worsening of the preeclamptic condition. It is important to keep
physician appointments even if the client is receiving visits from a home health care nurse. Blood pressures need to be taken in the same arm, in a sitting
position, every day in order to obtain a consistent and accurate reading. The weight needs to be checked at the same time each day, wearing the same clothes,
after voiding, and before breakfast in order to obtain reliable weights.

1543 A nurse is assessing a client with pregnancy-induced hypertension (PIH) who was admitted to the hospital 48 hours ago. Which of the following
data would indicate that the condition has not yet resolve? Blood pressure reading at prenatal baseline Urinary output is increased Client
complaints of blurred vision Presence of trace urinary protein C Client complains of headache or blurred vision indicate a worsening of the
condition and warrant immediate further evaluation. Options A, B and D are all signs that the pregnancy-induced hypertension is being resolved.

1544 A nurse is assisting in caring for a woman in labor who is receiving oxytocin (Pitocin) by intravenous (IV) infusion. The nurse monitors the client,
knowing that which of the following indicates an adequate contraction pattern? Three to five contraction in a 10 minute period, with resultant cervical
dilation One contraction per minute, with resultant cervical dilatation Four contractions every 5 minutes, with resultant cervical dilatation
One contraction every 10 minutes, without resultant cervical dilatation A The preferred oxytocin dosage is the minimal amount
necessary to maintain an adequate contraction pattern, characterized by three to five contraction in a 10-minute period, with resultant cervical dilatation. If
contractions are more frequent than every 2 minutes, contraction quality may be decreased.

1545 A nurse is caring for a client during a precipitate labor. In assessing the client’s emotional needs, the nurse can anticipate the client having:
Less pain and anxiety than with a normal labor A need for support in maintaining a sense of control Fewer fears regarding the effect on
the infant A sense of satisfaction regarding the quick labor B The client experiencing a precipitate labor may have more difficulty maintaining
control due to the abrupt onset and quick progression of the labor. This may be very different from previous labor experiences; therefore the client needs
support form the nurse to understand and adapt to the rapid progression. The contractions often increase in intensity quickly, adding to the pain, anxiety, and
lack of control. The client may also have an increased amount of concern about the effect of the labor on the baby. Lack of control over the situation combined
with increased pain and anxiety can result in a decreased level of satisfaction with the labor and delivery experience.

1546 A nurse is caring for a client with a precipitate labor. The nurse tells the client that in this type of labor. The labor will last less than 3 hours
A lengthy period of pushing may be necessary The onset of contraction is gradual Induction may be necessary A
Precipitate labor is defined as that which last 3 or fewer hours for the entire labor and delivery. It is usually has an abrupt, not a gradual onset.
Induction, particularly with an oxytocic agent, is contraindicated because of the enhanced stimulatory effects on the uterine muscle and an increased risk for
fetal hypoxia.

1547 A nurse is caring for a postpartum client with thromboembolitic disease. When planning care to prevent the complication of pulmonary embolism,
the nurse prepares specifically to:Administer and monitor anticoagulant therapy as prescribed Assess breath sounds frequently Enforce strict bed rest
Monitor vital signs frequently A The purpose of anticoagulant therapy to treat thromboembolitic disease is to prevent the clot from
moving to another area, thus preventing pulmonary embolism. Although option B, C, and D may be planned for a client with thromboembolitic disease, option
A will specifically prevent pulmonary embolism.

1548 A nurse is caring for a pregnant client hospitalized for stabilization of diabetes mellitus. The client tells the nurse that her husband is caring for their
2-year-old daughter. The nurse develops which short-term psychosocial outcome for the client? Teach the client and family about diabetes and its
implications Provide emotional support and education about altered family processes related to the pregnant woman’s hospitalization Protect from
risk of injury secondary to convulsions Be alert to the risks of early labor and birth B The shot-term psychosocial well-being of the family is at
risk because of the hospitalization of the client. Teaching about diabetes mellitus is a long-term goal related to diabetes. Options C and D are unrelated to
diabetes mellitus and are more related to pregnancy-induced hypertension.

1549 A nurse is caring for a term infant who is 24 hours old and who had a confirmed episode of hypoglycemia at 1 hour of age. Which of the following
observations by the nurse would indicate the need for further evaluation? Blood glucose level of 40mg/dL before the last feeding High-pitched cry; eating
10 to 15 mL of formula per feeding Weight loss of 4 ounces and dry, peeling skin Breast-feeding for 20 minutes or longer; strong sucking B
At 24 hours of age, a term infant should be able to consume at least 1 ounce (30mL) of formula per feeding. A high-pitched cry is indicative of
neurological involvement. Blood glucose levels are acceptable at 40 mg/dL in the first few days of life. Weight loss over the first few days of life and dry,
peeling skin are normal findings for term infants. Breast-feeding for 20 minutes with a strong suck is an excellent finding. Hypoglycemia causes central
nervous system symptoms (high-pitched cry), and also is exhibited by lack of strength to eat enough for growth.

1550 A nurse is checking the fundus in a postpartum woman. The nurse notes that the uterus is soft and spongy. Which of the following nursing actions
is most appropriate initially? Massage the fundus gently until firm Document fundal position an consistency and height Encourage the mother to
ambulate Notify the physician A If the fundus is boggy (soft), the nurse should massage it gently until it is firm, observing for increased bleeding or
clots. Option C is an inappropriate action at this time. The nurse should document fundal position, consistency and height, the need to perform fundal
massage, and the client’s response to the intervention. The physician will need to be notified if uterine massage is not helpful.

1551 A nurse is developing goals for the postpartum client who is at risk for infection. Which of the following goals would be most appropriate for this
client? The client will verbalize a reduction of pain The client will no longer have a positive Homan’s sign The client will report how to treat an infection
The client will be able to identify measures to prevent infection D The uterus is theoretically sterile during pregnancy and until the
membranes rupture. It is capable of being invaded by pathogens after rupture. Options A and B are unrelated to the issue of infection. Option C indicates that
an infection is present. Option D is a goal for the client’s “at risk” for infection.
1552 A nurse is instructing a maternity client how to keep a fetal activity diary. Which of the following instructions would the nurse provide to the client?
Schedule the counting periods about 1 hour before eating Lie on your stomach when you prepare to count the fetal movement.
You should expect the baby to move at least 35 times in 3 hours. You need to contact the physician if the baby’s movements are less than 10 times
in 3 hours. D Most healthy fetuses move at least 10 times in 3 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs
some attention and evaluation. In general, women are advised to count fetal movements for 30 to 60 minutes three times a day usually after meals when the
fetus is more active. The client should lie on the left side during the procedure, because it provides optimal circulation to the uterus-placenta-fetus unit.

1553 A nurse is instructing a pregnant client on measures to prevent a recurrent episode of preterm labor. Which statement by the client indicates a need
for further teaching? "I will report any feeling of pelvic pressure.""I will adhere to the limitations in activity and stay off my feet." "I will avoid sexual
intercourse at this time." "I will limit my fluid intake to three 8-0z glasses of fluid a day." D Risks preterm labor dehydration. A client
should not restrict fluid (except for those containing alcohol and caffeine). A sign of preterm labor may be pelvic pressure, without the perception of a
“contraction.” A decrease in activity and bed rest is often prescribed in an attempt to decrease pressure on the cervix and increase uterine blood flow.
Mechanical stimulation of the cervix during intercourse can stimulate contractions.

1554 A nurse is monitoring a client who is receiving an oxytocin (Pitocin) infusion for the induction of labor. The nurse would suspect water intoxication
if which of the following were noted? Bradycardia Lethargy Tachycardia Fatigue C During an oxytocin infusion, the
woman is monitored closely for water intoxication. Signs of water intoxication include tachycardia, cardiac dysrhythmias, shortness of breath, nausea and
vomiting.

1555 A nurse is observing parents at the bedside of their small-for-gestational-age (SGA) female infant, who is at 27 weeks gestation. The infant’s mother
states, “She is so tiny and fragile. I’ll never be able to hold her with all those tubes.” The nurse interprets the mother’s statements as being relevant to which of
the following nursing diagnoses? Impaired Adjustment Risk for Caregiver Strain Ineffective Family Coping Risk for Altered Parenting D
One of the nursing diagnoses for the parents of a high-risk neonate, such as a preterm SGA infant, is risk for Altered Parenting. Parent-infant
bonding is affected if the infant does not exhibit normal newborn characteristics. Option A involves nonacceptance of a health status change or an inability to
problem solve or set a goal. Option B addresses the strain of a caregiver, which during the initial hospitalization is too early to apply. Option C involves
identification of ineffective coping. At this time, there are inadequate data for these diagnoses, although they may become relevant at a later time.

1556 A nurse is performing an assessment on a pregnant client with a history of cardiac disease and is assessing for venous congestion. The nurse
assesses which of the following body areas, knowing that venous congestion is most commonly noted in this area? Vulva Fingers of the hands
Around the eyes Around the abdomen A Assessment of the cardiovascular system includes observation for venous congestion that
can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the
abdominal area of a client who is pregnant. Although edema ma be noted in the fingers and around the eyes, edema in these areas would not be directly
associated with venous congestion.
1557 A nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a “tearing”
sensation in the lower abdomen, is upset, and expresses concern for the safety of her baby. The most appropriate nursing response would be: "Don’t worry,
you are in good hand." "I can understand that you are fearful. We are doing everything possible for your baby." "You’ll have to talk to your doctor
about that." "I don’t have time to answer questions now. We’ll talk later." B Clients have a concern for the safety of their baby during
labor and delivery, especially when a problem arises. Empathy and a calm attitude with realist reassurances are an important aspect of client care. Dismissing or
ignoring the client’s concern can lead to increased fear and lack of cooperation. Option A uses a cliché and false reassurance. Options C and D attempt to place
the client’s feelings “on hold.”

1558 A nurse is planning care for a client with an intrauterine fetal demise. Which of the following is not an appropriate goal for this client? The woman
and her family will express their grief about the loss of their desired infant The woman and her family will discuss plans for going home without the infant
The woman and her family will contact their Pastor or grief counselor for support following discharge The woman will recognize that
thoughts of worthlessness and suicide are normal following a loss D It is important for the nurse to assess whether the client is undergoing the normal
grieving process. Signs that are a cause for concern and are not part of the normal grieving process include thoughts of worthlessness and suicide.

1559 A nurse is planning interventions for counseling the maternal client newly diagnosed with sickle cell anemia. The most important psychosocial
intervention would be which of the following? Provide all information regarding the disease Allow the client to be alone if she is crying
Provide emotional support Avoid the topic of the disease at all costs C One of the most important nursing functions is providing
emotional support to the client and family during the counseling process. Option A overwhelms the client with information while the client is trying to cope
with the news of the disease. Option B is only appropriate if the client requests to be alone. If this is not requested, the nurse is abandoning the client in time of
need. Option D is similar to option B and is nontherapeutic.

1560 A nurse is preparing a woman in labor for an amniotomy. The nurse would assess which priority data prior to the procedure? Maternal
blood pressure Maternal heart rate Fetal heart rate Fetal scalp sampling C Fetal well-being must be confirmed before and after
amniotomy. Fetal heart rate should be checked by Doppler or by the application of the external fetal monitor. Although maternal vital signs may be assess,
fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.

1561 A nurse is preparing to care for the mother of a preterm infant. The nurse plans to begin discharge planning for the preterm infant: When the
discharge date is set When the parents feel comfortable with and can demonstrate adequate care of their infant When the mother is in labor After
stabilization of the infant in the early stages of hospitalization D Discharge planning begin at admission. Determination of the services, needs,
supplies, and equipment requirements should not be determined on the day of discharge. Option A and B are incorrect, because it is much too late to make the
plans that need to be made. Option C is incorrect, because the outcome of the delivery in not known.
1562 A nurse is teaching a mother with diabetes mellitus who delivered a large for gestational age (LGA) male infant about care of the infant. The nurse
tells the mother that LGA infants appear to be more mature because of their large size, and in reality, these infants frequently need to be aroused to facilitate
nutritional intake and attachment. Which statement, if made by the mother, indicates further teaching is necessary? "I will talk to my baby when he is in
a quiet alert state." "I will watch my baby closely, because I know he may not be as mature in motor development." "I will breastfeed my baby every 2
½ to 3 hours, and will implement arousing techniques." "I will allow my baby to sleep throughout the night, because he needs his rest." D
LGA infants tend to be more difficult to arouse and therefore will need to be aroused to facilitate nutritional intake and attachment opportunities.
These infants also have problems maintaining a quiet alert state. It is beneficial for the mother to interact with the infant during this time to enhance and
lengthen the quiet alert state. Even though the infant is large, motor function is not usually a mature as in the term infant. LGA infants need to be aroused for
feedings, usually every 2 1/2 to hours for breastfeeding.

1563 A nurse is teaching cord care to a new mother. The nurse tells the mother that:Cord care is done only at birth to control bleeding Alcohol is the
best agent used to clean the cord The process of keeping the cord clean and dry will decrease bacterial growth It takes 21 days for the cord to dry up and fall
off C The cord should be kept clean and dry to decrease bacterial growth. The cord should be cleansed 2 to 3 times a day using alcohol or
other agents. Cord care is required until the cord dries up and falls off between 7 and 14 days. Additionally, the diaper should be folded below the cord to keep
urine away from the cord.

1564 A nurse is teaching health education classes to a group of expectant parents and the topic is preventing mental retardation caused by congenital
hypothyroidism. The nurse tells the parents that the most effective means of preventing mental retardation caused by this disorder is by: Adequate
protein intake Limiting alcohol consumption Genetic testing Neonatal screening D Congenital hypothyroidism is the most
common preventable cause of mental retardation. Neonatal screening is the only means of early diagnosis. Newborn infants are screened for congenital
hypothyroidism before discharge from the nursery and before 7 days of life.

1565 A nurse provides instructions to a new mother who is about to breastfeed her newborn infant. The nurse avoids telling the mother to: Turn the
newborn infant on his or her side facing the mother When the newborn opens the mouth, draw the newborn the rest of the way onto the breastTilt up the
nipple or squeeze the areola, pushing it into the newborn’s mouth Place a clean finger in the side of the newborn’s mouth to break the suction before removing
the newborn from the breast. C The mother is instructed to avoid tilting up the nipple or squeezing the areola and pushing it into the newborn’s
mouth. Options A, B and D are correct procedures for breastfeeding.

1566 A nurse teaches a mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of
the care? "I need to check for bleeding every hour for the first 12 hours." "I need to clean the penis every hour with baby wipes." "I need to wrap the penis
completely in dry sterile gauze, making sure it is dry when I change his diaper." "The baby will not urinate for the next 24 hours because of swelling."
A The mother needs to be taught to observe for bleeding and to assess the site hourly for 8 to 12 hours following the circumcision. Voiding
needs to be assessed. The mother should call the physician if the baby has not urinated within 24 hours. Swelling or damage may obstruct urine output. When
the diaper is changed, Vaseline gauze should be reapplied. Frequent changing prevents contamination of the site. Water is used for cleaning, because soap or
baby wipes may irritate the area and cause discomfort.

1567 A perinatal client is admitted to an obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the
client, a nurse would consult with a dietician to ensure which of the following? A low-calorie diet to ensure absence of weight gain A diet low in
fluids and fiber to decrease blood volume A diet high in fluids and fiber to decrease constipation Unlimited sodium intake to increase circulating blood
volume C Constipation can cause the client to use the Valsalva maneuver. This maneuver can cause blood to rush to the heart and overload the
cardiac system. A low-calorie diet is not recommended during pregnancy. Diets low in fluid and fiber can cause a decrease in blood volume that can deprive
the fetus of nutrients. Therefore, adequate fluid intake and high-fiber foods are important. Sodium should be restricted to some degree, as prescribed by the
physician, because it will cause an overload of the circulating blood volume and contribute to cardiac complication.

1568 A perinatal home health nurse has just assessed the fetal status of a client with a diagnosis of partial placental abruption at 20 weeks’ gestation. The
client is experiencing new bleeding and reports less fetal movement. The nurse informs the client that the physician will be contacted for possible hospital
admission. The client begins to cry quietly while holding her abdomen with her hands. She murmurs, “No, no, you can’t go, my little man.” The nurse
recognizes the client’s behavior is an indication of: Pain related to abdominal tetany Cognitive confusion secondary to shock Anticipatory grieving
related to perceived potential lossSituational crisis, death of fetus, related to fear and loss C Anticipatory grieving occurs when a client has knowledge
of an impending loss. Anticipatory grieving is appropriate when signs of fetal distress accelerate. The first stages of anticipatory grieving may be characterized
by shock, emotional numbness, disbelief, and strong emotions, such as tears, screaming, or anger. There are no data that indicate the presence of pain,
confusion, or fetal death.

1569 A petite client, pregnant for the first time, is concerned about regaining her figure after delivery and wishes to diet during pregnancy. The nurse
should advise her that: Dieting is recommended to lessen the incidence of stillbirth Dieting is recommended to make delivery easier since she
is so small Inadequate food intake during pregnancy can cause low-birth-weight infants Inadequate food intake during pregnancy can cause pregnancy-
induced hypertension C The Committee on Maternal Nutrition of the National Research Council recommends a weight gain of at least 25 lb (11.3 kg)
during pregnancy; inadequate nutrition during pregnancy results in underweight babies.

1570 A postpartum client has a nursing diagnosis of High Risk for infection. The following goal has been developed. “The client will not develop an
infection during her hospital stay” Which of the following assessment data would support the conclusion that the goal has been met? Presence of chills
Abdominal tendernessAbsence of fever Loss of appetite C Fever is the first indication of an infection. Chills, abdominal
tenderness, and loss of appetite also indicate the presence of an infection. Therefore, the absence of a fever indicates that an infection not present.

1571 A postpartum client with gestational diabetes is scheduled for discharge. During the discharge teaching the client asks the nurse, “Do I have to worry
about this diabetes any more?” The best response by the nurse is which of the following? "Your blood glucose level is within normal limits now, you will be all
right." "You will only have to worry about the diabetes if you become pregnant again." "You will be at risk for developing gestational diabetes
with your next pregnancy and developing overt diabetes mellitus." "Once you have gestational diabetes, you have overt diabetes and must be treated with
medication for the rest of your life." C The client is at risk for developing gestational diabetes with each pregnancy. The client also has an
increased risk of developing overt diabetes and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for
developing diabetes, such as weight control. A diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing overt
diabetes; however, with proper care it may not develop.

1572 A postpartum nurse has instructed a new mother on how to bathe her newborn infant. The nurse demonstrates the procedure to the mother and on
the following day, asks the mother to perform the procedure. Which observation, if made by the nurse, indicates that the mother is performing the procedure
correctly? The mother cleans the ears and then moves to the eyes and the face The mother begins to wash the newborn infant by starting with the eyes and face
The mother washes the arms, chest, and back, followed by the neck, arms and face The mother washes the entire newborn infant’s body and
then washes the eyes, face, and scalp B Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and the
area behind the ears are cleaned. The newborn infant’s neck should be washed because formula, lint, or breast milk will often accumulate in the folds of the
neck. Hands and arms are then washed. The newborn infant’s legs are washed next, with the diaper area washed last.

1573 A predisposing factor to postpartal hemorrhage is: A short duration of labor A previous cesarean delivery The presence of a
multifetal pregnancy A mother who is 40 years of age or more C Overdistention of the uterus because of a large baby, multiple gestation, or
hydramnios predisposes a woman to uterine atony, which may cause postpartum hemorrhage.

1574 A pregnant client is admitted to the hospital with abdominal pain and severe vaginal bleeding. After assessment, the nurse makes a nursing diagnosis
of decreased cardiac output related to hemorrhage. The first nursing action should be to: Administer oxygen Elevate the head of the bed Draw blood
for Hgb and HCT Give Demerol 50 mg IM for pain A The symptoms indicate loss of blood; to compensate for the decreased cardiac output,
oxygen is needed to maintain the well-being of both the mother and fetus.

1575 A pregnant client is newly diagnosed as having gestational diabetes. She cries during the remaining interview and keeps repeating, “What have I
done to cause this? If I could live my life over.” Which nursing diagnosis should direct nursing care at this time? Self-Concept Disturbance related to
a complication of pregnancy Knowledge Deficit related to diabetic self-care during pregnancy Body image Disturbance related to complications of
pregnancy Risk for injury to the fetus related to maternal distress A The client is putting the blame for the diabetes on herself, lowering her self-
concept or image. She is expressing fear and grief. Knowledge Deficit is an important nursing diagnosis for this client, but not at this time. The client will not
be able to comprehend information at this time. There are no data in question to support the nursing diagnoses in options C and D.

1576 A pregnant client who has a history of heart problems asks how she can relieve her occasional heartburn. As part of the teaching plan, the nurse
should warn against taking antacids containing: Sodium Calcium Aluminum Magnesium A Excess fluid retention is an
undesirable effect of sodium intake.
1577 A pregnant client with diabetes mellitus arrives at the health care clinic for follow-up visit. In this client, the nurse most importantly monitors.
Urine for glucose and ketones Blood pressure, pulse, and respirations Urine for specific gravity For the presence of edema A
The nurse assess the pregnant client with diabetes mellitus for glucose and ketones in the urine at each prenatal visit because the physiological
changes of pregnancy can drastically alter insulin requirements. Assessment of blood pressure, pulse, respiration, urine for specific gravity, and the presence of
edema are more related to the client with pregnancy-induced hypertension.

1578 A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. A nurse performs an assessment on the client and
expects that the client will indicate that which of the following medications is prescribed? Oral intake of 15 mg of warfarin (Coumadin) daily Intravenous
infusion of heparin sodium, 5000 units daily Subcutaneous administration of heparin sodium, 5000 units daily Subcutaneous administration of terbutaline
(Brethine) daily C Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy, since they are at
greater risk for thromboembolic disease during the antenatal, intrapartal and postpartum periods Warfarin (Coumadin) is contraindicated during pregnancy
because it passes the hemorrhagic disorders. Heparin, which does not pass the placental barrier, is safe for anticoagulant therapy during pregnancy and would
be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only.

1579 A pregnant client, interested in childbirth education, asks how the Lamaze method differs from the Read method. The nurse explains that the Lamaze
method: Is a much easier method to teach and learn Requires a good deal of prenatal preparation Forbids the use of pain-relieving drugs during
labor Is a calm, relaxed approach based on childbirth without pain B There is much to be learned and practiced so that the client can vary
the techniques through the stages of labor.

1580 A preterm infant is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for the nurse to:
Hydrate the infant q 15 min Put a hat on the infant's head Keep the O2 concentration at 100% Remove the infant q 15 min for
stimulation B O2 has a cooling effect, and the baby should be kept warm so that metabolic activity and O2 demands are not increased.

1581 A primapara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it
is 190 beats per minute. The most appropriate nursing action would be to: Document the finding Consult with the physician Tell the client that the
FHR is normal Recheck the FHR with the client in the standing position B The fetal heart rate should be 120 to 160 beats per minute
throughout pregnancy. In this situation, the FHR is above the normal range, and the nurse should most appropriately consult with the physician. The FHR
would be documented, but option B is the most appropriate action. The nurse would not tell the client that the FHR is normal because this is not true
information. Option D is an appropriate action.
1582 A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeated verbalized concern regarding safety
of the fetus. Which of the following nursing diagnoses is most appropriate at this time? Pain Impaired Tissue Integrity Urinary Tract Infection
Fear D The primary concern for this client is safety of her fetus, not herself. The priority nursing diagnosis at this time is Fear. Option
C is a medical diagnosis and outside the scope of nursing practice. Pain and Impaired Tissue Integrity are commonly seen in clients experiencing urinary tract
infections, but the question includes no data to support either of the options.

1583 A rectocele and cystocele are usually due to: Injury during childbirth Infection of the bladder Relaxation of
musculature of the pelvic floor Trauma in repair of an episiotomy or laceration C Relaxation of the pelvic musculature causes the uterus to
drop, with a subsequent relaxation of the vaginal walls, most often as a result of childbirth. A rectocele is protrusion of the rectal wall into the vagina, whereas a
cystocele is protrusion of the bladder into the vaginal wall.

1584 A small-for-gestational-age (SGA) newborn, who has just been admitted to the nursery, has a high-pitched cry, appears jittery, and has irregular
respirations. The nurse is aware that these symptoms may be associated with: Hypovolemia Hypoglycemia Hypercalcemia
Hypothyroidism B SGA infants may exhibit hypoglycemia, especially during the first 2 days of life, because of depleted glycogen
stores and inhibited gluconeogenesis.

1585 A stillborn was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. Which statement by the
nurse would further assist the family in their initial period of grief? "I feel so bad. I don’t understand why this happened either." "You can hold the baby
for another 15 minutes; then I need to take the baby away." "What did you name your baby?" You seem upset. Do you need a tranquilizer?" C
Nurses should be able to explore measures that assist the family to create memories of an infant so that the existence of the child is confirmed and
the parents can complete the grieving process. Option C identifies such a measure and also demonstrate a caring and empathetic response. Option A is
inappropriate and reflects a lack of knowledge on the nurse’s part. Option B is uncaring. Option D devalues the parents feelings and is inappropriate.

1586 After a difficult delivery, a neonate is admitted to the nursery with an Apgar of 4. This would most likely indicate that this score includes the fact
that the baby's: Respirations are 35 Muscle tone is flaccid Heart rate is over 100 Body is pink but the extremities are blue B
Flaccid muscle tone is the only abnormal finding; all other choices indicate a normal newborn response and would score higher on the Apgar scale.
1587 After a difficult delivery, an assessment of a full-term newborn reveals an unequal Moro reflex on one side and a flaccid arm in adduction. The nurse
suspects: Brachial palsy Supratentorial tear Fracture of the clavicle Crigler-Najjar syndrome A Brachial palsy results
from excessive stretching of the nerve fibers that run from the neck, through the shoulder, and down toward the arm; the muscles of the upper arm are involved,
and the infant holds the arm at the side with the elbow extended and the hand rotated inward.

1588 After a first-trimester aspiration abortion, the nurse knows that the instructions are understood when the client states: "I will be able to resume
intercourse in 4 to 5 days." "After 24 hours, I can substitute tampons for sanitary pads." "I can expect my menstrual period to resume in 2 to 3
weeks." "I will call the physician if I must change my sanitary pad more than once in 4 hours." D This indicates that the bleeding is excessive
and the physician should be notified.

1589 After a mastectomy or hysterectomy many clients feel incomplete as a women. The statement that should alert the nurse to this feeling in a client
following a total hysterectomy would be: "I can't wait to see all my friends again." "I feel washed out; there isn't much left." "I can't wait to get home
to see my grandchild." "My husband plans for me to recuperate at our daughter's home." B The client's statement infers an emptiness with
an associated loss.

1590 After an unexpected emergency cesarean delivery, the client tells the nurse that she is a "natural childbirth flunkie." The postpartal phase of
adjustment that this statement most closely typifies is: Taking in Letting go Taking hold Working through A By discussing the
experience, the client is bringing it into reality; this is characteristic of the taking-in phase.

1591 After delivery the mother's vital signs are T 99.4º F, PR 80 regular and strong, RR 16 slow and even, and BP 148/92 mm Hg. The assessment the
nurse should continue to monitor is the client's: Pulse Respiration Temperature Blood pressure D This blood
pressure is elevated and exceeds the 140/90 mm Hg designated by the National Institutes of Health as stage I hypertension; intervention may be necessary.

1592 After vaginal delivery of a large-for-gestational-age (LGA) male infant, the nurse wraps the infant in a warm blanket and hands him to his mother.
The mother verbalizes concern over the infant’s facial bruising. To enhance attachment, the nurse makes which therapeutic statement? "Since the bruising is
painful, it is advisable that you not touch the baby’s face." "The bruising is caused by polycythemia, which usually leads to jaundice." "It is a
normal finding in large babies and nothing to be concerned about." "The bruising is temporary and it is important to interact with your infant." D
The mother of an LGA infant with facial bruising may be reluctant to interact with the infant because of concern about causing additional pain to the
infant. The bruising is temporary. Option A advises the mother not to touch the baby’s face, because the bruising is painful. Touch is an important component of
the attachment process. Touching the infant gently with fingertips should be encouraged. The LGA infant may have polycythemia, which can contribute to
bruising, but the bruising is not actually caused by the polycythemia. Option C avoids the mother’s verbalized concerns.

1593 An abandoned infant has been brought to the hospital. Ophthalmia neonatorum is diagnosed. The nurse can estimate the infant's age at: 1
day 2 days About 3 to 4 days Less than 24 hours C Untreated ophthalmia neonatorum becomes apparent on the third or fourth
postnatal day and is evidence that the mother may have had gonorrhea or a chlamydia infection.

1594 As a client watches, the nurse does a nasogastric feeding on the client's preterm infant son who weighs 2350 g. The client asks, "Would it hurt for
my baby to suck on a pacifier during the feeding?" The nurse's most appropriate response would be: "It might tire him out because he's still so small. We don't
want him to use up all his energy." "If he sucks on a pacifier a lot now he may have problems learning how to suck from a bottle later. " "There's no
real benefit in using a pacifier and there is a relationship between the use of a pacifier and buck teeth." "Sucking on a pacifier during tube feedings
may help him associate sucking with food so that he'll adjust better to bottle feedings." D Research has demonstrated that preterm infants who are
allowed to suck on a pacifier during tube feedings take bottle feedings more readily and are discharged sooner. "

1595 Assessment of a newborn reveals congenital cataracts, microcephaly, deafness, and cardiac anomalies. These assessments indicates that, during
pregnancy, the mother may have contracted: Rubella Toxoplasmosis Herpes virus type II Chlamydia trachomatis A Congenital
rubella syndrome results in abnormalities that vary depending on the gestational age of the fetus when maternal infection occurs; the most severe results occur
if the mother is infected during the first trimester when organogenesis is taking place.

1596 At 1 minute after birth the nurse notes that an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps the
arms extended. The nurse should assign this infant an Apgar score of: 4 6 8 10 C A perfect score is 10; 1
point is deducted for lessened muscle tone, the baby's arms do not flex, and 1 point for acrocyanosis, which is manifested by bluish hands and feet.

1597 Aware of the signs of an impending postpartal hemorrhage, the nurse assesses a postpartum client for: A decrease in pulse rate
Continuous trickling of blood Persistent muscular twitching An increase in blood pressure B Blood pressure and pulse may not
change significantly until large amounts of blood have been lost; the trickling of blood indicates continuous bleeding.
1598 Because an infertility workup involves both partners, a male client is to have a semen analysis. As part of his instructions the nurse should tell him
to: Use a condom to collect the semen specimenMake sure that the specimen is collected as soon as he awakens Ejaculate 2 to 3 days before
collection to ensure a pure specimen Refrigerate the specimen until it can be delivered to the laboratory D This is necessary to keep the sperm
viable; if the specimen becomes warm, the sperm will die.

1599 Before administering IV magnesium sulfate therapy to a client with pregnancy-induced hypertension, the nurse should assess the client's:
Urinary glucose, acetone, and specific gravity Temperature, blood pressure, and respirations Urinary output, respirations, and
patellar reflexes Level of consciousness, funduscopic appearance, and knee reflex C An adequate urinary output, an indicator of adequate renal
function, is necessary to prevent toxicity because MgSO4 is excreted by the kidneys; signs of toxicity are reduced respirations and absent patellar reflexes;
therefore, baseline assessments should be done.

1600 Before giving medications to a client who is 6 hours postpartum, the nurse assesses the client and notes the following findings: BP 178/110 mm Hg;
TPR 98/60/18; fundus firm, one finger below umbilicus; episiotomy edematous, red, and approximated; and one Peri-pad saturated with lochia rubra in 6 hours.
In light of these assessment findings, the nurse should contact the physician before administering: Cephradine (Velosef) Hydrocortisone acetate (Epifoam)
Methylergonovine maleate (Methergine) Casanthranol and docusate sodium (Peri-Colace) C Methergine, an oxytocic, is used to
promote uterine contractions; its vasoconstrictive action can also lead to hypertension, and it should not be used when hypertension is already present.

1601 During a class for prepared childbirth, the nurse discusses the importance of the "spurt of energy" that occurs prior to labor. The nurse teaches the
women to conserve this energy because: Fatigue may influence the need for pain medication Energy helps to increase the woman's progesterone level
This energy decreases the intensity of uterine contractions Extra energy is needed to push during the first stage of labor A
Fatigue will influence the successful use of other coping strategies such as distraction; this may lead to the client's requiring pain medication.

1602 During labor a client has an internal fetal monitor applied. The nurse should be concerned about a fetal heart rate that: Did not drop during
contractions Varied from 130 to 140 beats per minute Dropped to 110 beats during a contraction Occasionally dropped to 90 beats unrelated to
contractions D This fetal heart pattern is known as type III dip, or deceleration; it indicates cord compression that may lead to fetal hypoxia.
1603 During labor the nurse must be aware that an early deceleration (type I dip) is evidenced by an FHR of: 80 to 100 beats per minute early in
the contraction 140 to 160 beats per minute early in the contraction 120 to 140 beats per minute early in the contraction 100 to 120 beats per
minute early in the contraction D Early decelerations, with onset before the peak of the contraction and low point at the peak of the contraction, are
due to fetal head compression; FHR rarely drops below 100 beats per minute.

1604 During the physical assessment of a recently delivered newborn, the nurse palpates the infant's femoral pulses. This is done to detect the presence of:
Atrial septal defect Coarctation of the aorta Ventricular septal defect Patent ductus arteriosus B Coarctation
of the aorta results in diminished or absent femoral pulses.

1605 Erosions of the cervix are common when: There has been a long labor The normal acidity of the vagina is altered The cervix is not dilated
completely when delivery occurs The cervix stretches during delivery and there is an unhealed laceration B Changes in the pH of the
vaginal tract cause cellular alteration and destruction.

1606 Following an elective abortion via a hysterotomy, Rho (D) (RhoGAM) is administered intramuscularly to an Rh-negative mother to: Expand the
antibody pool of the mother Prevent antibody formation in the mother Suppress the activity of Rh-negative antibodies Accelerate the mother's
production of immune bodies B Rho(D) globulin attacks fetal red cells that have gained access to the maternal bloodstream at the time of delivery;
it prevents antibody formation.

1607 Following delivery a client is transferred to the postpartum unit. Of the postpartum mothers on the unit, the one the nurse should observe most
closely is: A primipara who has delivered an 8 lb baby A grand multipara who experienced a labor of only 1 hour A primipara who received 100 mg
of Demerol during her labor A multipara who experienced placental separation and delivered in 10 minutes B Increased parity
contributes to an increased incidence of uterine atony because the uterine muscle may not contract effectively, thus leading to postpartal hemorrhage; a 1-hour
labor in a grand multipara is not uncommon.
1608 Following delivery a client wishes to begin nursing her infant. The nurse assists the client by: Positioning the infant to grasp the nipple so as
to express milk Giving the infant a bottle first to evaluate the baby's ability to suck Leaving them alone and allowing the infant to nurse as long as
desired Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex D Stimulating the rooting reflex is effective in making the
infant grasp the nipple.

1609 Four hours after a vaginal delivery, the client still has not voided. The nurse's initial action should be to: Palpate the client's suprapubic area
for distention Encourage voiding by placing the client on a bedpan frequently Place the client's hands in warm water to encourage micturition
Inform the physician of the client's inability to void and await orders A Physical assessment is a form of data collection. It is the
first step in planning care.

1610 If a woman with an untreated chlamydial infection is allowed to deliver vaginally, the infant is in danger of being born with: Thrush
Congenital syphilis Ophthalmia neonatorum Neurologic complications C Chlamydia trachomatis transmitted from the
mother is usually manifested in the infant as an eye infection; it becomes apparent on the third or fourth postnatal day.

1611 If anemia is present with a hemoglobin level of 8 g or lower, a mother with cardiac disease probably will develop: Heart block
Cardiac failure Atrial fibrillation Cardiac compensation B Anemia decreases the capacity of the blood to carry
oxygen and thus increases the demands on the heart.

1612 If the physician plans to do a vaginal examination on a client with a placenta previa, the nurse should have available: One unit of freeze-dried
plasma Vitamin K for intramuscular injection Heparin sodium for intravenous injection Two units of typed and cross-matched blood D A
vaginal examination may result in a sudden, severe hemorrhage because of the location of the placenta near the cervical os; whole blood should be ready for
administration to prevent shock.

1613 In her 32nd week of pregnancy, a client's ultrasonography reveals a low-lying placenta. The nurse is aware that when this client's pregnancy comes
to term and labor begins, the client may first experience: Sharp abdominal pain Painless vaginal bleeding Increased lower back pain
Early rupture of membranes B As the process of effacement occurs in the latter part of pregnancy, placental separation from the uterus
may occur, causing painless bleeding.
1614 In the second hour after delivery a client's uterus is found to be firm, above the level of the umbilicus, and to the right of midline. The appropriate
intervention would be to: Observe for signs of retained secundines Tell the client that this is a sign of uterine stabilization Assist the client to the
bathroom to empty her bladder Massage her uterus vigorously to prevent hemorrhage C A full bladder commonly elevates the uterus and displaces
it to the right; even though the uterus feels firm, it may relax enough to foster bleeding; therefore, the bladder needs to be emptied to increase uterine tone.

1615 Infants whose mothers contracted rubella in the first trimester are frequently born with: Phocomelia Otosclerosis
Hydrocephalus Cardiac anomalies D Heart development occurs between the second and eighth week of gestation.

1616 Laboratory studies reveal that a pregnant client's blood type is O and she is Rh positive. Problems related to incompatibility may develop in her
infant if the infant is: Type A or B Rh negative Delivered preterm Type O, Rh positive A An ABO incompatibility may
develop even in first-born infants under these conditions. The mother has antibodies against the antigens of the A and B blood cells. These antibodies are
transferred across the placenta and produce hemolysis of the fetal RBCs. The infant is AB and an incompatibility may also occur.

1617 Nursing care for an infant with necrotizing enterocolitis includes: Diluting the formula mixture as ordered Measuring abdominal girth every 2
hours Administering oxygen prior to gastric feeding Giving 1/2 strength formula by gavage feeding B Prolonged gastric
emptying occurs when the baby has NEC; an increase in abdominal girth of greater than 1 cm in 4 hours is significant and needs immediate intervention.

1618 Nursing care of an infant with respiratory distress syndrome (RDS) should be directed toward: Maintaining the infant in a warm environment
Turning the infant frequently to prevent apnea Keeping the infant in oxygen concentrations of 40% Stimulating deep breathing by
tapping the infant's toes A This is done because any attempt by the infant to maintain temperature further compromises physical status by
increasing metabolic activity and O2 demands.

1619 On a return visit to the infertility clinic, a client whose temperature charts demonstrate an ovulatory pattern and a normal menstrual cycle despite an
inability to become pregnant requests fertility drugs. The nurse should recognize that the client: Has a right to receive this drug Will require an
endometrial biopsy Has to be scheduled for a culdoscopy Needs to bring her husband's semen in to be examined D Because the client is
ovulating, the infertility may be a result of a seminal factor; the partner's semen should be examined before more extensive studies or treatments are begun with
the woman.

1620 One minute after delivery, a newborn is crying vigorously and has an apical pulse of 110. The nurse notes acrocyanosis and flexion of the
extremities. The baby's Apgar score is: 7 8 9 10 C Apical pulse of 110 = acrocyanois = active motion and
flexion = vigorous cry = effective respiratory effort with crying = total Apgar score = 9.

1621 Prior to the administration of RhIg, the nurse reviews the laboratory data of a pregnant client. RhIg is given to pregnant women who are:
Rh positive and Coombs' positiveRh negative and Coombs' positive Rh positive and Coombs' negative Rh negative and
Coombs' negative D RhIg is given to prevent active formation of antibodies when an Rh-negative individual is at risk for sensitization; if given to
an Rh-positive person, an injection of RhIG would cause hemolysis of RBCs

1622 The blood vessels in the umbilical cord consist of: One artery and one vein One artery and two veins Two arteries and one
vein Two arteries and two veins C Two umbilical arteries arise from the fetus and go to the placenta, where waste products are exchanged
for oxygen and nutrients and then returned via one umbilical vein to the baby.

1623 The client who is scheduled for an amniocentesis states, "I'm glad this test will be able to tell whether my baby is well." The nurse's best response
would be: "This is such a good test and the work in this field is amazing." "A normal amniocentesis is a reliable indicator of a healthy baby." "This test is
useful in detecting potential defects due to chromosomal errors.' "Amniocentesis is a valuable tool for detecting congenital defects in the developing baby."
C Amniocentesis has proven useful in detecting potential defects resulting from chromosomal errors, such as Down syndrome, Tay-Sachs
disease, hemophilia, and thalassemia.

1624 The doctor orders 3 liters of oxygen to be delivered via oxygen hood to a 36-week gestation newborn. The nursery nurse recognizes that this is an
incomplete order and calls the physician to ask for an order for: An oxygen analyzer An oxygen saturation rate Pulse rate, an oxygen analyzer, and
oxygen percentage Pulse oximetry with limits, oxygen analyzer, and oxygen percentage D Oxygen requirements of premature infants
must be closely monitored to prevent blindness, lung, and other tissue damage; oxygenation status determined by all available technology must be used to
individualize and plan care accordingly.
1625 The hormones responsible for the menstrual cycle are: Gonadotropins Estrogen and progesterone Gonadotropins and estrogen
Gonadotropins, estrogen, and progesterone D The gonadotropins, follicle-stimulating hormone and luteinizing hormone, are concerned
with ovarian changes that produce ovulation. Estrogen is increased because of secretion from the developing follicle. Progesterone is higher because of
secretion from the corpus luteum. The hormones work in concert to stimulate the menstrual cycle.

1626 The ischial spines are designated as an important landmark in labor and delivery because the distance between the spines is: The
narrowest diameter of the pelvis The widest measurement of the pelvis A measurement of the floor of the pelvis A measurement of the inlet of the
birth canal A This is the area through which the presenting part must enter; if it is too small it is called cephalopelvic disproportion and
vaginal delivery is not possible.

1627 The major body system affected in tertiary syphilis is the: Reproductive Integumentary Cardiovascular Lower
respiratory C Syphilis is primarily a vascular disease; aortitis, valvular insufficiency, and aortic aneurysms are the most prevalent problems in tertiary
syphilis.

1628 The most appropriate nursing diagnosis for a client with a ruptured ectopic pregnancy would be: Fluid volume excess High risk for infection
Decreased cardiac output Altered health maintenance C This is an appropriate nursing diagnosis; the bleeding is causing a
decreased circulating blood volume and therefore a decreased cardiac output.

1629 The mother who is bottle-feeding her 1-month-old asks the nurse whether any vitamin or mineral supplements are required. The nurse bases the
reply on the knowledge that babies who are bottle-fed with ready-to-use formula require: Iron Fluoride Vitamin K Vitamin B12 B
Unless fluoridated water is used by the manufacturer, fluoride supplementation of 0.25 mg daily is required.

1630 The nurse caring for a 32-week appropriate-for-gestational-age (AGA) neonate establishes the following list of potential interventions for the infant.
The intervention that should receive the highest priority is: Promoting bonding Preventing infection Maintaining respirations Supporting
body temperature C Although bonding is important to the parent-child relationship, without oxygen, life could not be sustained.
1631 The nurse discusses breast care with a mother who is bottle-feeding her infant. The nurse plans further teaching when the client states: "May I have
my medication for the discomfort in my breasts? " "The discomfort I am feeling will go away in a couple of days. " "How should I apply heat to my
breasts to help my milk dry up? " "I must call my husband and ask him to bring my new brassiere." C Heat increases milk flow, and because the
client is not breastfeeding, this is an undesired outcome; application of cold is recommended to restrict milk flow.

1632 The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the
fetal heart rate with: Fetal gestational age Fetal physical activity Maternal blood pressure Maternal uterine contractions B Under normal
conditions the heart rate increases with physical activity; the test looks for accelerations of 10 to 15 beats with fetal movements.

1633 The nurse gently performs Leopold's maneuvers on a client with a suspected placenta previa and expects to find the: Fetal head firmly
engaged Fetal small parts difficult to palpate Uterus hard and tetanically contracted Fetal presenting part high and floating D
With a low-implanted placenta (placenta previa) the presenting part may have difficulty entering the pelvis.

1634 The nurse has just finished reviewing the use of anesthesia during a vaginal delivery with a pregnant cardiac client. The teaching could be
considered effective when the client states that the type of anesthesia she expects to receive is: A pudendal block Spinal anesthesia General
anesthesia A paracervical block A The choice of pudendal block would indicate effective teaching, since forceps could be used to shorten the second
stage of labor.

1635 The nurse is aware that a client could be at increased risk for postpartum hemorrhage if the client: Breastfed in the delivery room Received a
pudendal block for delivery Delivered a baby who weighed 9 lb, 8 oz Had a third stage of labor that lasted 10 minutes C Chances of
postpartal hemorrhage are 5 times greater with large infants because uterine contractions may be impaired after delivery.

1636 The nurse is aware that absorption of drugs taken orally during pregnancy may be altered as the result of: Delayed gastrointestinal emptying
Decreased glomerular filtration rates Developing fetal-placental circulation Increased secretion of hydrochloric acid A
There is reduced GI motility during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and
the intestines laterally and posteriorly; absorption of some drugs, vitamins, and minerals may be increased.
1637 The nurse is aware that during the taking-in phase of the postpartum period, the area of health teaching that the client will be most responsive to is:
Perineal care Infant feeding Infant hygiene Family planning A During the taking-in phase, a woman is
primarily concerned with being cared for and being cared about.

1638 The nurse is aware that in an infant of 32 weeks gestation the: Areola and nipple are barely visible Palms have clearly defined creases
Ear pinna springs back when folded Square window sign shows a 0 degree angle A Breast tissue is not palpable in an infant of less
than 33 weeks gestation.

1639 The nurse is aware that the client most likely to be predisposed to placenta previa would be a: 19-year-old, gravida 1, para 0 25-year-old,
gravida 2, para 1 40-year-old, gravida 2, para 1 30-year-old, gravida 6, para 5 D Multiple past pregnancies tend to make the endometrial
lining more vulnerable to abnormal implantation.

1640 The nurse is aware that the nursing action that would best promote parent-infant attachment behaviors would be: Restricting visitation on
the postpartum unit Supporting rooming-in with parental infant care Encouraging the parents to choose breastfeeding Keeping the new family
together immediately postpartum D Research strongly supports the theory that there is a sensitive period during the first few hours of life that is
extremely important in the promotion of parent-infant attachment.

1641 The nurse is caring for a cardiac client with a history of rheumatic fever who is in labor. The nurse anticipates that after delivery, the client will be
prophylactically placed on: Lasix Heparin Digitalis Ampicillin D Clients who have had rheumatic fever are placed on
prophylactic ampicillin therapy to minimize the development of streptococcal infections.

1642 The nurse is planning for the discharge of a crack-addicted 17-year-old mother and her baby. To best meet the mother's and her baby's needs, the
nurse should attempt to initiate a: Legal aid referral Foster care referral Family court referral Visiting nurse referral D
The nurse, by going into the home, would be able to monitor both the mother's and baby's health, as well as the mother's parenting skills and
evidence of drug rehabilitation.
1643 The nurse knows that a client in early pregnancy understands the need to increase her intake of complete proteins during her pregnancy when she
reports she is eating more: Nuts and seeds Milk, eggs, and cheese Beans, peas, and lentils Whole grains and breads B
These animal proteins are complete proteins containing all eight essential amino acids; plant proteins are incomplete.

1644 The nurse knows that women with diabetes mellitus who become pregnant: Have 30% or more fetal mortality Have decreased insulin
requirements Require intensive and thorough prenatal careShould have their babies by cesarean delivery C There is a constant need
for evaluation of diabetic status, fetal maturity, and placental functioning.

1645 The nurse may best obtain a Moro reflex by: Grasping the infant's hand Stimulating the infant's feet Creating a loud noise
suddenly Changing the infant's equilibrium D Changes in equilibrium stimulate this neurologic reflex in an infant under the age of 6
months; the movements should be bilateral and symmetric; a loud noise causes the same reaction (startle reflex), but using noise as a stimulus really tests
hearing.

1646 The nurse recognizes that a client who, although ambivalent, is seriously considering an abortion because of financial difficulties, is in crisis. The
nurse should intervene to alleviate the crisis by: Understanding the family interaction Helping the mother express her feelings Involving the
father in preparation classes Involving the mother in preparation classes B The ability to express one's feelings is often a first step in the
recognition and resolution of a crisis.

1647 The nurse recognizes that survival in the neonatal period is largely related to: Gestational age and birth weight Reproductive history of the mother
Timing and adequacy of prenatal care Parental health habits and social class A Adaptation to the extrauterine environment is
largely dependent on the functional capacity of vital organ systems, which is established during intrauterine development; this is measurable in terms of
gestational age and weight.

1648 The nurse understands that a positive contraction stress test may be indicative of potential fetal distress because the test demonstrates that during
contractions the fetal heart rate shows: A normal baseline Late decelerations Early decelerations Variable decelerations B The fetus
with a borderline cardiac reserve will show hypoxia by a decreased heart rate when there is minimal stress, making the test positive.
1649 The nurse understands that the effect PKU has on development will depend on: Diagnosis within the first 3 days after birth The level of
phenylalanine in the blood at birth Compliance with a corrective diet and how early it is instituted The presence of phenylpyruvic acid in the urine
at 1 week of age C Adherence to the diet is necessary for optimal physical growth with no adverse effects on mental development; a diet that is
instituted late will not reverse brain damage.
1650 The nurse understands that when a contraction stress test is interpreted as negative it means: The fetus at this time is
likely to tolerate the stress of labor but the test should be repeated weekly The test should be repeated in 24 hours because the examination results indicate
hyperstimulation Immediate delivery should be considered because there is no fetal heart acceleration with fetal movement A trial induction should
be started because fetal heart rate acceleration with movement is indicative of a false result A A negative test implies that placental support is
adequate and the fetus is likely to tolerate the stress of labor should it ensue within the week.

1651 The nurse would know that a client taking oral contraceptives understood the teaching about estrogen when the client indicates that the most
common side effect of the estrogen would be: Amenorrhea Hypomenorrhea Nausea and vomiting Depression and lethargy C
Nausea and vomiting are related to excessive amounts of estrogen; these symptoms can usually be controlled by reducing the dose.

1652 The nurse would know that a pregnant client does not understand the teaching about fetal growth and development when the client states:
The mother must observe proper nutrition. The fetus gets food from the amniotic fluid. There are two umbilical arteries and one vein.
The baby's oxygen needs are provided for by the mother. B The amniotic fluid is a protective environment; the fetus depends on
the placenta, along with the umbilical blood vessels, for obtaining nutrients and oxygen.

1653 The nurse would observe for symptoms of respiratory distress syndrome (RDS) in an infant whose mother: Is a Class A diabetic Had
previously used heroin Had been hypertensive during pregnancy Was preeclamptic during labor and delivery A Infants of Class A
diabetic mothers may be delivered before 38 weeks; therefore these infants would be predisposed to the development of respiratory distress syndrome (RDS,
hyaline membrane disease), which occurs in preterm infants.

1654 The obstetrician hands the neonate to the nurse after delivery. The nurse's first action should be to: Dry and place the infant in a warm
environment Cut the umbilical cord and attach a Hesseltine umbiliclip Administer oxygen by face mask until cyanosis clears Perform an
abbreviated systematic physical assessment A Preventing heat loss conserves the infant's oxygen and glycogen reserves, and this is a first priority.

1655 The outermost membrane that helps form the placenta is the: Amnion Chorion Yolk sac Allantois B The chorion is the
outermost membrane that helps form the placenta. It develops villi and, through its interaction with the endometrium, becomes part of the placenta.

1656 The parents of a male newborn infant who is not circumcised are instructed on how to clean the newborn’s penis. Which statement by the parents
indicates an understanding of the instructions? "I should retract the foreskin to clean the penis." "I should not retract the foreskin to clean the
penis, because this may cause adhesions." "I should retract the foreskin no farther than it will go to clean the penis." "I should retract the foreskin for
cleaning every morning and evening." B In male newborn infants, the prepuce is continuous with the epidermis of the gland and is not
retractable. If retraction is forced, this may cause adhesions to develop. The parents should be told to allow separation to occur naturally, which usually occurs
between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning once a week. Options
A, C, and D identify an action that addresses retraction of the foreskin.

1657 The parents of a newborn infant with congenital hypothyroidism and Down’s syndrome tells the nurse how sad they are that their child was born
with these problems. They had many plans for a normal child, and now these will need to be adjusted. Based on these statements, the nurse plans to address
which nursing diagnosis? Anticipatory Grieving Dysfunctional Grieving Impaired Adjustment Ineffective Family Coping C
Anticipatory Grieving is the intellectual and emotional responses and behaviors by which individuals and families work through the process of
modifying self-concept based on the perception of potential loss. Defining characteristics include expressions of sorrow and distress at potential loss.
Dysfunctional Grieving or Impaired Adjustment are abnormal responses to changes in health status. The nursing diagnosis of Ineffective Family Coping is used
when a usually supportive person is providing insufficient, ineffective, or compromised support, comfort, assistance, or encouragement.

1658 The priority nursing care for a severely preeclamptic client would include: Isolating her in a dark room Maintaining her in a supine position
Encouraging her to drink clear fluids Protecting her against extraneous stimuli D Absolute bed rest, a quiet room, and minimal
stimulation are essential to reducing the risk of a seizure.

1659 The term metrorrhagia refers to: Spotting or staining at time of ovulation Presence of occult blood in vaginal discharge Severe
bleeding during each menstrual period Periods of bleeding in between menstrual periods D Bleeding between periods is abnormal.
Bleeding other than during the menstrual period is known as metrorrhagia.

1660 The test that the physician might perform to determine the underlying cause of uterine pain is: Laparoscopy Estradiol level
Tubal insufflation Endometrial smear A Laparoscopy involves direct visualization of the uterus via fiberoptics. The procedure is
carried out through a transabdominal stab wound.

1661 To best assist new parents to understand the unique characteristics of a newborn, the nurse should discuss with them the: Infant's response to
routine feeding schedules Testing of the normal newborn's auditory acuity Newborn's behaviors and states of wakefulness Importance of
reading about parent-infant bonding C This information assists parents to understand the unique features of their newborn and promotes
interaction and care during periods of wakefulness.

1662 To determine if there is cephalopelvic disproportion, the birth attendant would order a test known as: Pelvimetry Fetal scalp
pH Amniocentesis X-ray examination D X-ray pelvimetry is more definitive than digital pelvimetry, but because of radiation hazards
it should be limited to clients in labor in whom it is clearly essential to the outcome of pregnancy.
1663 To facilitate delivery in a client with cardiac problems, the nurse would expect that the physician will probably: Use Pitocin induction Use forceps
to assist delivery Schedule a cesarean delivery Do nothing and let nature proceed B This will decrease the workload of the heart
during expulsion and permit a vaginal delivery.

1664 To improve hydration, a nurse has been encouraging the intake of oral fluids to a woman in labor. Which of the following indicates a successful
outcome of this action? A urine specific gravity of 1.020 Continued leaking of amniotic fluid during labor Blood pressure of 150/90/mm Hg
Ketones in the urine A Urine specific gravity is an expression of the concentration of the urine. During the first stage of labor, the renal
system has a tendency to concentrate urine. Labor and birth require hydration and caloric intake to replenish energy expenditure and promote efficient uterine
function. An elevated outcomes related to labor and hydration. Once membranes are ruptured, it is expected that amniotic fluid may continue to leak.

1665 To provide preoperative teaching the nurse should know that after a client has a hysterectomy: Menstruation ceases and ovarian hormone
secretion decreases Menopause begins immediately with the cessation of ovarian hormone production The cyclical oscillation of hormones between
the hypophysis and the ovaries continues Ovarian hormone secretion ceases, but the hypophysis continues secretion of gonadotropic hormones C
In a hysterectomy the uterus is removed, but no other female organs. Consequently menstruation ceases but the hypophyseal and ovarian hormone
cycles continue.

1666 Twelve hours after a normal spontaneous delivery, a client's temperature is 100.4º F. This elevation is most likely an indication of: Mastitis
Dehydration Puerperal infection Urinary tract infection B A client's temperature may be elevated to 100.4º F during
the first 24 hours postpartum as a result of dehydration from labor.

1667 Twins are delivered at 30 weeks gestation and are diagnosed as having respiratory distress syndrome. The principle underlying the respiratory
distress of these infants is: Surface tension Pascal's principle Archimedes' principle Second law of thermodynamics A
The physical principle is surface tension; since the lung tissue of the infant lacks the group of detergents known as surfactant, water molecules
strongly interact with each other by hydrogen bonding, and the alveolar sacs and respiratory passages do not easily expand; the result is extremely labored, if
not impossible, breathing.

1668 Upon admission to the hospital, a client 42 weeks gestation, complaining of back pain and fluid leaking from the vagina, is assessed. The findings
are: contractions q 3 to 4 minutes, lasting 30 to 45 seconds; cervix 2 cm dilated and 70% effaced; presenting part floating; fetal heart rate 140 bpm in the RLQ;
streaks of blood from the vagina; and ruptured membranes. The nurse is aware that the finding that indicates that a problem with delivery may occur is that:
The membranes had ruptured The presenting part is floating There are streaks of blood from the vagina Fetal heart tones are 140
beats/minute in the RLQ B A floating fetal head in a primigravida of 42 weeks gestation who is in early labor is suggestive of disproportion
because engagement usually occurs 2 weeks before term in primigravidas.

1669 When a breech presentation is suspected, the nurse should diligently observe the client for: Symptoms of fetal distress, such as a prolapse
of the cord Signs of precipitate labor, such as rapid dilation of the cervix Symptoms of primary uterine inertia, such as cessation of contractions
Signs that normal labor is progressing, such as increased contractions A The feet or buttocks are not effective in blocking the
cervical opening, and the cord may slip through and be compressed.
1670 When a client has a precipitate delivery, it is important for the nurse to observe the client for: Sudden chilling Bleeding and infection
Elevation in blood pressure Respiratory insufficiency in the baby B A precipitate delivery may be injurious to both mother and
infant. The maternal morbidity rate is increased by infection and/or hemorrhage resulting from the trauma of a rapid, forceful delivery in a contaminated field.

1671 When assessing a client, the nurse should be aware that the characteristics of the normal female pelvis include: Flat sacrum, coccyx movable,
spines prominent, pubic arch wide Flat sacrum, coccyx movable, spines prominent, pubic arch narrow Well-hollowed sacrum, coccyx
movable, spines not prominent, pubic arch wide Deeply hollowed sacrum, coccyx immovable, pubic arch narrow, spines not prominent C
Although pure types are unusual, the normal female pelvis is one most favorable for normal delivery; characteristics include well-rounded inlet,
straight side walls, well-formed sacrosciatic notches, good sacral curvature and inclination, movable coccyx, moderately sized ischial spines, and well-rounded
suprapubic arches.

1672 When assessing a newly admitted laboring primigravida, the nurse notes that the fetal heartbeat is loudest in the upper left quadrant. The nurse
suspects that the position of the fetus is probably: Left sacral anterior Left occipital anterior Left mentum anterior Left occipital transverse A
If the heart is heard in the upper left quadrant, the baby must be lying in a breech position with the head upright and the heart uppermost.

1673 When assessing a preterm infant, it is most important for the nurse to know the infant's gestational age and how it compares to the birth weight
because: This information will help identify potential newborn problems This information must be documented on the admission record The infant
will lose 10% of birth weight during the first few days of life Evaluation and classification records are necessary for health insurance A A
preterm, small-for-gestational-age infant is at risk for problems not seen in the term or average-for-gestational-age infant because of immaturity; this
information will help the nurse to anticipate potential problems and aim interventions at prevention.

1674 When caring for a client with a radium implant for cancer of the cervix, the nurse should: Spend time with the client to alleviate her anxiety
Wear a lead-lined apron while administering any care Limit the client's activity so as not to dislodge the radium insert Use disposable sheets
and towels to prevent exposure of laundry personnel C Normal activity must be limited so that the implant will not become dislodged.

1675 When caring for a laboring client with placenta previa, it would be most important for the nurse to: Assess the fetal heart tones by fetoscope
Frequently assess the height of the fundus Evaluate the external blood loss by pad count Perform frequent vaginal and rectal
examinations C This will indicate whether bleeding may be progressing toward maternal and fetal distress.
1676 When changing her infant, a new mother notes a reddened area on the infant's buttock and reports it to the nurse. The nurse should: Have the
nursery staff change the infant's diaper Use both lotion and powder to protect the involved area Notify the pediatrician and request an order for a topical
ointment Encourage the new mother to cleanse and change the infant more often D Proper cleansing and frequent changing will limit the
presence of irritating substances.

1677 When counseling the client with diabetes mellitus who requests contraceptive information, it would be most therapeutic for the nurse to focus on:
Rhythm The IUD A diaphragm Oral contraceptives C This is the preferred method for clients with diabetes because it has
no physiologic side effects.

1678 When discussing dietary needs during pregnancy, a client tells the nurse that milk constipates her at times. The nurse should explain that it is
preferable to: Substitute a variety of cheeses for the milk Substitute skimmed or buttermilk for whole milk Increase her prenatal capsules and
omit the milk Treat constipation in some way other than omitting milk D Unless a lactose intolerance is present, the client should
drink milk; eating dried fruits and high-fiber foods and increasing fluids and activity will aid in lessening constipation.

1679 When discussing immunity with a prenatal client during her first visit to the prenatal clinic, the nurse recalls that active immunity occurs when:
Protein antigens are formed in the blood to fight invading antibodies Protein substances are formed by the body to destroy or neutralize
antigens Blood antigens are aided by phagocytes in defending the body against pathogens Sensitized lymphocytes from an immune donor act as
antibodies against invading pathogens B Active immunity occurs when the individual's cells produce antibodies in response to an agent or its
products; these antibodies will destroy the agent (antigen) should it enter the body again.

1680 When estimating an infant's gestational age, the nurse should take into consideration: Weight and length at birth Presence of a tonic neck
reflex Size of breast tissue and genitalia Condition of skin on the extremities C The breast buds and genitalia develop at a specified rate
and are good indicators of gestational age.

1681 When first seeing her preterm infant in the neonatal intensive care unit (NICU), the mother immediately starts to cry and refuses to touch the baby.
The nurse understands that this behavior represents: A normal detachment behavior An incomplete bonding behavior A normal reaction to the situation
A reaction to the NICU environment C To cry in this situation is a normal response; it is also normal to be frightened about
touching a small preterm infant, but the nurse should provide support and encourage the mother to do so.
1682 When inspecting her newborn after delivery, a mother asks the nurse whether her newborn has flat feet. The nurse recalls that: Flat feet are
common in children and infants This is difficult to assess because the feet are so small Flat feet are associated with major deformities of the bones of the feet
such as clubfoot The arch of the newborn's foot is covered with a fat pad giving the appearance of being flat D The fat pad is present in
newborns and infants; the arch develops when the child begins to walk.

1683 When obtaining the health history from a client who is seeking contraceptive information, the nurse should consider that oral contraceptives are
contraindicated in a client who: Is older than 30 years Smokes a pack of cigarettes per day Has a history of borderline hypertension Has had at
least one multiple pregnancy C Oral contraceptives may cause hypertension and place the client at risk for the development of a CVA.

1684 When performing a physical assessment of a pregnant woman, the nurse should recognize that 40% to 50% of all clients with abruptio placentae also
have: Hydramnios Hypertension Heart disease Diabetes mellitus B Abruptio placentae occurs in about 1% of all
pregnancies; the problem is much more common in women with hypertension; the causative factors are not clear.

1685 When performing breast self-examination a client should be: Squeezing the nipples to check for discharge Using the right hand to examine the
right breast Placing a pillow under the shoulder opposite the side being examined Pressing the palm of the hand against the breast to
compress it to the chest wall A Serous or bloody discharge from the nipple is abnormal.

1686 When preparing a client to breastfeed, the nurse teaches the client that: High levels of progesterone stimulate the secretion of oxytocin
High levels of estrogen stimulate secretions of lactogenic hormones Milk secretion is under the control of hormones and starts
immediately after delivery Suckling stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex D If suckling or
nipple stimulation is discontinued, acinic cells degenerate, regressive changes occur, and lactation ends.

1687 When teaching a client to use a diaphragm to prevent pregnancy, the nurse should tell the client that the diaphragm: May or may not be used
with a spermicidal lubricant to be effective Must be inserted with the dome facing down to be maximally effective Often appears puckered but this will
not interfere with its effectiveness Should remain in place as much as 6 hours after intercourse to be effective D The diaphragm should
remain in place for at least 6 hours after intercourse; if coitus occurs within those 6 hours, additional spermicide should be added and the 6 hour time frame
begins again.

1688 While a client is receiving magnesium sulfate for severe pregnancy-induced hypertension, a primary nursing intervention would be: Limiting her
fluid intake to 1000 ml/24 hours Preparing for the possibility of a precipitate delivery Restricting visitors and keeping the room darkened and quiet
Obtaining magnesium gluconate for use as an antagonist if necessary C A quiet room helps to reduce stimuli, which is essential for
limiting or preventing seizures.
1689 While counseling a prenatal client about her dietary and alcohol drinking habits, a nurse observes that the client has difficulty concentrating and
appears agitated. The nurse should proceed with the assessment by using which guideline? Discussing the possible consequences of drinking alcohol
during pregnancy should be avoided. Women respond negatively to a hopeful message of the potential benefits of drinking during pregnancy A
nonjudgmental approach may help to gain maternal trust Provoking maternal guilt may help a woman recognize her problem and seek support
services C The potential effects of alcohol abuse during pregnancy for both the mother and the fetus have been well documented. The nurse who
express genuine concern for suspected abusers may motivate positive behavioral changes during the prenatal period. The maternal behaviors of lack of
concentration and agitation are frequently seen in childbearing women who are abusing alcohol. Options A, B and D are inappropriate guidelines for the nurse
to follow in this situation, and they do not address a caring approach.

1690 Within minutes after the delivery of a healthy baby, the client displays symptoms of respiratory distress. Amniotic fluid embolism is suspected. In
addition to the respiratory distress, the nurse should assess this client for: Hypertension Uterine atony Thrombophlebitis Uncontrolled
bleeding , D Disseminated intravascular coagulation is associated with amniotic fluid embolism; both problems frequently occur following premature
separation of the placenta.

1691 The nurse is caring for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST? A mother reports that the
umbilical cord of her five-day-old infant is dry and hard to the touch. A mother reports that the soft spot on the head of her four-day-old infant feels
slightly elevated when the baby sleeps. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate. A father
reports that he bumped the crib of his two-day-old infant and she violently extended her extremities and returned to them their previous position. B
fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure

1692 A six-month-old is brought to the clinic for a well-baby check-up. During the exam, the nurse should expect to assess which of the following? A
pincer grasp. Sitting with support. Tripling of the birth weight. Presence of the posterior fontanelle. B six-month-old should sit
with help

1693 The prenatal client at eight-weeks gestation has a positive VDRL. In preparing the teaching plan, which of the following would be MOST
appropriate for the nurse to include? The importance of not taking any medications so as not to damage the fetus. Instructing the client on the
importance of taking the penicillin for the prescribed time. Instructing the client to refrain from sexual activity. Maintaining the confidentiality of
sexual partners or contacts. B physical, vitally important to complete all the penicillin

1694 The nurse cares for a newborn infant with fetal alcohol syndrome. The nurse would expect to see which of the following physical characteristics?
An infant that is large for gestational age (LGA) with craniofacial abnormalities and hydrocephalus. An infant with a small head circumference, low
birth weight, and undeveloped cheekbones. An infant small head circumference, low birth weight, and excessive rooting and sucking behaviors. An infant
with a normal head circumference, low birth weight, and respiratory distress syndrome. B seen with fetal alcohol syndrome
1695 At 32-weeks gestation, a client has an order for an ultrasound. The client indicates an understanding of this procedure if she makes which of the
following statements to the nurse? The results will inform us of the gestational age. This test will evaluate the baby's lungs. The test will
show us if there is any problem in the spinal cord. Early problems with the baby's blood can be identified with this test. A ultrasound
detects the gestational age

1696 A 20-year-old woman arrives at the hospital in active labor. The admitting nurse attaches an internal fetal monitor. The nurse knows the MOST
important reason for the fetal monitor is: to evaluate the progress of the client's labor. to assess the strength and duration of the client's contractions. to
monitor the oxygen status of the fetus during labor. to decide if an oxytocin drip is necessary. C goal is early detection of mild fetal hypoxia

1697 A client, gravida 2 para 1, is admitted with hypertension and complains that her wedding band is tight. The nurse should expect to assess which of
the following with early pre-eclampsia? Blurred vision and proteinuria. Epigastric pain and headache. Facial swelling and proteinuria. Polyuria and
hypertonic reflexes. C may occur due to the chemicals that are used in cutting the drugs by the client or drug dealer

1698 A new mother is taking her infant home. The client asks the nurse when she should start giving her child solid foods. The nurse's response should be
based on which of the following statements? Rice cereal is usually the first solid food and is started around four to five months. Strained fruits are well
tolerated as the first solid food, and infants like them. Introduction of solid foods is not important at this time. Solid foods are usually not started until the
infant is around six months old. A infants are less likely to be allergic to rice cereal than to any other solid food; usually started between four and five
months of age; breast-fed infants may be started on solids even later

1699 The nurse is teaching a parenting class to a group of expectant mothers. The nurse should advise that the breastfeeding mother should increase her
daily caloric intake by how many calories? 200 300 400 500 D milk production requires an increase of 500 calories per
day

1700 Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which
of the following nursing responses would be BEST? SIDS will provide you with this opportunity. SHARE will provide you with this opportunity.
RESOLVE will provide you with this opportunity. CANDLELIGHTERS will provide you with this opportunity. B correct-
SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage
1701 A 21-year-old woman at 16-weeks gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this
procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by this test? Tetralogy of
Fallot. Talipes equinovarus. Hemolytic disease of the newborn. Cleft lip and palate. C Maternal antibodies destroy fetal RBCs;
bilirubin is secreted because of hemolysis

1702 The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome? Prevent iron
deficiency anemia. Decrease touch to prevent overstimulation. Provide feedings via gavage to decrease energy expenditure. Replace vitamins
depleted as a result of poor maternal diet. D frequently, maternal diet is poor, and infant is malnourished; adequate intake of B complex vitamins is
necessary for normal CNS function

1703 Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a
modified radical mastectomy and axillary dissection? Anxiety related to the mastectomy. Impaired skin integrity related to the mastectomy.
Pain related to surgical incision. Self-care deficit related to dressing changes. C immediately after surgery, the priority is optimizing the
client's comfort

1704 During a prenatal visit, a client states: "I have been very nauseated during my first trimester, and I don't understand the reason." Which of the
following responses by the nurse is BEST? "You are nauseated because of the fatigue you are feeling. " "The nausea is due an increase in the basal
metabolic rate." "The nausea is caused by a secondary elevation in the hormones produced by the endocrine system." "If you eat different kinds of foods,
you won't be nauseated. " C during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and HCG from the
endocrine system

1705 The nurse is caring for a multipara client who delivered a female infant one hour ago. The nurse observes that the client's breasts are soft; the uterus
is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following
actions? Perform a straight catheterization. Offer the client the bedpan. Put the baby to breast.Massage the uterine fundus. B
Boggy uterus deviated to right indicates full bladder, encourage client to void

1706 A baby girl weighing 7 lb 4 oz with Apgar scores of 7 and 8 at one and five minutes is admitted to the nursery. Because her mother is a type I
diabetic, the nurse knows the infant is at GREATEST risk for developing: hypovolemia. hypoglycemia. hyperglycemia. cold stress.B
Fetus produces increased insulin to match mother's increased glucose level during pregnancy, infant continues to have high insulin output after birth,
resulting in hypoglycemia

1707 The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive. The mother is Rh-negative, the baby is Rh-positive, and
there is a negative direct Coombs. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative. The mother is Rh-
positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy. B RhoGAM is given to an Rh-negative mother who delivers
an Rh-positive baby when baby has a negative Coombs' test
1708 The nurse is making patient assignments on the obstetrical unit. Which of the following patients should the nurse assign to an RN who has been
reassigned to the obstetrical unit from outpatient surgery? A patient at 16 weeks gestation admitted with hyperemesis receiving IV fluids. A
patient at 26 weeks gestation in premature labor receiving terbutaline (Brethine). A patient at 32 weeks gestation with a placenta previa and ruptured
membranes. A patient at 37 weeks gestation with pregnancy-induced hypertension and epigastric pain. A Monitor IV therapy, administer
antiemetics and nutritional supplements

1709 A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate nursing
diagnosis is high risk for: impaired swallowing. failure to thrive. fluid volume deficit. altered health maintenance. C May become
dehydrated

1710 A 26-year-old woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12. The nurse determines
that her EDC (estimated date of confinement) is" February 1. February 15. February 19. March 14. B When using
the Naegele rule, add seven days to first day of last menstrual period and subtract three months

1711 A 4 lb 10 oz baby boy is delivered at 32 weeks gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. He has
mottling of the skin and acrocyanosis with irregular respirations of 60. The nurse should recognize these findings as signs of: hypoglycemia.
cold stress.birth asphyxia. hypovolemia. B Symptoms describe cold stress

1712 The nurse prepares a 25-year-old woman for a cesarean section. The patient says she had major surgery several years ago and asks if she will receive
a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section
contains a lower overall dosage of medication than is given before general surgery. contains reduced amounts of sedatives and hypnotics than
are given before general surgery. contains reduced amounts of narcotics than are given before general surgery. contains medications similar in type and
dosages to those given before general surgery. C decreased so less narcotic crosses the placental barrier causing respiratory depression in the
infant

1713 A 23-year-old woman at 32 weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate
a possible complication? The client's urine test is positive for glucose and acetone. The client has 1+ pedal edema in both feet at the end of
the day. The client complains of an increase in vaginal discharge. The client says she feels pressure against her diaphragm when the baby moves.
A abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency
1714 A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?
Administer oxygen. Turn her to the right side. Provide adequate hydration. Start antibiotics. C Adequate hydration is a
priority for any client with sickle cell crisis

1715 A woman at 38 weeks gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by
the client, would suggest to the nurse placenta previa as the cause of the bleeding? "I feel fine, but the bleeding scares me." "I've been more
nauseated during the past few weeks." "The bleeding started after I carried 4 bags of groceries." "I've been having severe abdominal cramps."
A Placenta previa is characterized by painless vaginal bleeding

1716 After a client has a positive Chlamydia trachomatis culture, she and her husband return for counseling. It would be MOST important for the nurse to
ask which of the following questions? "Do you have contacts to identify?" "What is your understanding regarding how chlamydia is
transmitted?" "Do you have questions about the culture and its validity?' "Do you have allergies to the medications?" B Means of
transmission of chlamydia may or may not have been made clear to both partners; nurse should assess this first; is a sexually transmitted disease

1717 A client with multiple sclerosis (MS) at 39 weeks gestation is admitted to the labor and delivery unit in active labor. The client's vital signs are: BP
127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the
following interventions? Prepare to administer IV Pitocin to the client. A reduction in the amount of pain medication administered.
Check the client's blood pressure every 5 minutes. Prepare an isolette for the infant. B Less pain medication is required due to overall
decrease in pain perception due to MS

1718 A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14,
para 2 gravida 2, and regular periods every 28 to 30 days. The client is divorced and works full time as a bank teller. The nurse knows the MOST probable
cause of the client's symptom is emotional trauma and stress. the onset of menopause. the presence of uterine fibroids. a possible tubal
pregnancy. B Ovarian function gradually decreases and then stops, usually 45-50 years old

1719 The newborn infant of an HIV-positive mother is admitted to the nursery. Which of the following would the nurse include in the plan of care?
Standard precautions. Testing for HIV. Transfer to an acute care nursery facility. Request AZT from the pharmacy. A Provides
immediate protective care for the staff members

1720 Which nursing interventions would be a priority in preventing complications after a cesarean birth? Turn, cough, and deep breathe. Limit fluid
intake. Supply a high-carbohydrate diet. Evaluate skin integrity. A Represents preventive care for respiratory congestion resulting from
anesthesia and shallow respirations due to the abdominal incision
1721 A nonstress test is scheduled for a client at 34 weeks gestation that developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? Start an intravenous line for an
oxytocin infusion. Obtain a signed consent prior to the procedure. Instruct client to push a button when she feels fetal movement. Attach a
spiral electrode to the fetal head. C Nonstress test is a noninvasive test to evaluate the response of the fetal heart rate to the stress of fetal movement;
response will be reflected on the fetal monitor

1722 The nurse is caring for clients in the antepartal clinic. A client at 34 weeks gestation comes to the clinic for treatment of a sprained ankle. The nurse
should question which of the following orders? ASA (aspirin) 650 mg PO q4h prn for pain. Return to the clinic in two weeks.Ice to sprain for 20
minutes qh for 24h. Teach client 3-gait crutch walking. A Aspirin can cause fetal hemorrhage, do not use during pregnancy

1723 The nurse is caring for a 26-year-old woman immediately after delivery of 8lb 4oz baby girl. The patient's history indicates she was diagnosed with
type I diabetes mellitus (IDDM) at age 12. The nurse would expect which of the following changes to occur in the patient? The blood sugar will fall due to a
sudden decrease in insulin requirements. The blood sugar will rise due to a rapid decrease in circulating insulin. The blood sugar will gradually rise
due to a decreased level of metabolic stress. The blood sugar will gradually fall due to a decrease in food intake. A Hormonal interference in
glucose metabolism during pregnancy causes insulin requirements to increase then decrease after delivery

1724 The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing
intervention would be to discontinue the infusion. turn client to the left side. change the fluids to LR. increase the IV flow rate.
A Will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration

1725 The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's
history would have a direct correlation with her current problem? History of rheumatic fever four years ago. Presence of ventricular septal defect as an
infant. Heart disease in both the maternal and the paternal families. Persistent ear infections and mastoiditis as a child. A Most
common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve

1726 The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest
premature labor at 33 weeks gestation. Based on this result, the nurse would anticipate: administration of ritodrine hydrochloride (Yutopar). initiation of
an oxytocin (Pitocin) drip. delivery of the infant by cesarean section. continuation of bedrest until otherwise indicated. C Because the
lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants
1727 The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?
The client complains of epigastric pain. The client complains of shortness of breath. The client states she has increased rectal pressure.
The client has gained of 33 pounds during her pregnancy. A Is usually indicative of an impending convulsion

1728 A 20-year-old primipara attends a class for women who plan to breastfeed. To prepare for breastfeeding, the nurse should encourage the women to
apply moisturizer to their breasts every day after bathing. expose their breasts to air every day for 20 minutes. wash their breasts with
water and rub with a towel every day. massage their breasts to increase circulation twice daily.C Prepares nipples for stretching action of
sucking during breastfeeding, soap avoided to prevent drying

1729 The nurse is making rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should put the infant to the
woman's breast. encourage the woman to drink warm oral fluids. check the woman's pulse and respirations. continue to monitor the firmness of
the uterus. A Implementation, causes natural surge of oxytocin that results in contraction of uterus

1730 The nurse takes a history from a woman in the prenatal clinic. The nurse identifies that which of the following pregnant women is MOST likely to
have an Rh-incompatibility problem? An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man and never has received
RhoGAM. An Rh-negative woman who conceived with an Rh-positive man who has Rh antibodies. An Rh-positive woman who previously aborted a fetus at
12 weeks gestation and did not receive RhoGAM and now conceived with an Rh-positive man. An Rh-negative woman who never received RhoGAM and
now conceived with an Rh-negative man. B Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus's
blood cells

1731 The nurse is monitoring a 20-year-old woman in active labor who is receiving oxytocin (Pitocin) 1 mU/min IV. The nurse should stop the infusion if:
the contractions occur at 3-minute intervals and last more than 60 seconds. the contractions occur at 2.5-minute intervals and last more than 90
seconds. the contractions occur at 2-minute intervals and last more than 90 seconds. the contractions occur at 2-minute intervals and last more than 60
seconds. C contractions should be less frequent (longer than 2-minute intervals) and should be of shorter duration (less than 90 seconds) allows for
longer resting time between contractions

1732 A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to: avoid
intercourse for 48 hours before the examination. avoid douching for 24 hours prior to her appointment. withhold all foods and fluids 12 hours before
the appointment. save her first voided urine specimen the morning of her appointment. B douching would affect appearance of cells in
vaginal smear, would make test inaccurate
1733 The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching
her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, "I can't stand this anymore!" The nurse
should encourage the husband to instruct his wife to use shallow respirations during the contractions. offer his wife ice chips or sips of water to
distract her from the pain. stroke his wife's abdomen between contractions. review with his wife the breathing pattern needed at each stage of
labor. A entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)

1801 When assessing 12 month old infant with dehydration and metabolic acidosis, the nurse should expect to see which clinical manifestation?
Reduced white blood cell count Reduced platelet count Shallow respirations Tachypnea D The body compensates for
metabolic acidosis through the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations.
Altered blood cell counts are not specific signs of metabolic imbalance.

1802 A 9 month old infant is admitted with diarrhea and dehydration. The nurse plans to assess this client's vital signs frequently. What other action
would provide the most important assessment information? Measuring the infant's body weight Obtaining a stool specimen for analysis
Obtaining a urine specimen for analysis Inspecting the infant's posterior fontanel A Frequent assessment of weight provides
important information about fluid balance and the infant's response to fluid replacement. Results of stool or urine analyses may provide information, but
typically are available for at least 24 hours. The posterior fontanel usually closes between age 6 and 8 weeks and therefore does not reflect fluid balance in a 9
month old infant.

1803 A preschooler has vomiting, diarrhea, and a potassium level of 3.0 mEq/liter. The physician prescribes an I.V. infusion of dextrose 5% in water and .
45 normal saline solution with 10 mEq of potassium chloride. The nurse knows that a child with vomiting and diarrhea needs fluids and potassium chloride to:
Eliminate the cause of diarrhea. Meet physiologic needs. Prevent hyperglycemia. Promote normal stooling. B A
child with vomiting and diarrhea loses excessive fluids and electrolytes, which must be replaced. Fluid and electrolyte replacement cannot eliminate the cause
of diarrhea, which may result from various factors. Administration of I.V. fluids that contain glucose (such as dextrose 5% in water) can induce hyperglycemia
- not prevent it. Fluid and electrolyte replacement has no effect on stooling.

1804 In a 4 year old receiving dextrose 5% in water and .45 normal saline solution at 100 ml/hr, which of the following signs or symptoms suggests
excessive I.V. fluid intake? Worsening dyspnea Gastric distention Nausea and vomiting. temperature of 102o F (38.9o C) A Dyspnea and
other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and
extracellular compartments. Gastric distention may suggest excessive oral fluid intake or infection. Nausea and vomiting or an elevated temperature may
indicate a fluid volume deficit.

1805 For a 9 year old hospitalized with nephrotic syndrome, the physician prescribes methylprednisolone sodium succinate (Solu-Medrol), 80 mg by I.V.
infusion every 8 hours. The pharmacy sends a vial that contains 125 mg/2 ml. To administer 80 mg, the nurse must deliver how many milliliters?0.1
1.0 1.3 1.5 C To determine the amount to deliver, the nurse may use the fraction method, cross-multiplying and
calculating as follows: (125 mg/2 ml = 80 mg/ X ml) (125 x X = 2 x 80) (125 X = 160) (X = 160/125) (X = 1.28 ml) This amount should be rounded off to a
dosage that the nurse can easily administer: 1.3 ml.
1806 When planning preoperative care for a child with Wilms' tumor, the nurse should give which action the highest priority? Restricting oral intake
Monitoring acid-base balance Avoiding abdominal palpation Maintaining strict isolation C Because manipulation of the
abdominal mass may disseminate cancer cells to adjacent and distant sites, avoidance of abdominal palpation takes the highest priority. Restricting oral intake
and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in a client's with Wilms' tumor. Isolation is
not required, because Wilms' tumor is not infectious.

1807 A child, age 15 months, is recovering from surgery to remove Wilms' tumor. Which finding best indicates that the child is free of pain?
Decreased appetite Increased heart rate Decreased urine output Increased interest in play D One of the most valuable
clues to pain is a behavioral change: A child who is pain-free likes to play, but a child in pain is less likely to consume food or fluids. An increased heart rate
indicates increased pain. Decreased urine output may signify dehydration.

1808 A 3 month old infant undergoes surgical repair of a cleft lip. After surgery, the nurse should teach the parents to use which equipment to feed their
infant? Single-hole nipple Plastic spoon Paper straw Rubber dropper D An infant with a surgically repaired cleft lip
needs to be fed with a rubber dropper or Breck feeder to prevent suture line trauma and promote healing. The other feeding equipment does prevent trauma.

1809 Before a routine checkup in the pediatrician's office, an 8 month old infant is sitting contentedly on the mother's lap, chewing on a toy. When
preparing to examine this infant, what should the nurse plan to do first? Measure the head circumference. Ausculate the heart and lungs. Elicit
pupillary reaction. Obtain the body weight. B Heart and lung auscultation should not distress the infant, so it should be done early in the
assessment. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing may cause distress, making the
rest of the examination more difficult.

1810 When teaching a mother who is discontinuing breast-feeding after 5 months, the nurse should advise her to include what in her infant's diet?
Iron-rich formula and baby food Whole milk and baby food Skim milk and baby food Iron-rich formula alone D
The American Academy of Pediatrics recommends that infants at age 5 months should receive iron-rich formula and that infants should not receive
solid food - even baby food - until age 6 months. The Academy does not recommend whole milk until age 12 months or skim milk until after age 2 years.

1811 For an 8 month old infant, the nurse should plan to provide which toy to promote cognitive development? Finger paint Jack-in-the-
box Small rubber ball Play gym strung across the crib B According to Piaget's theory of cognitive development, an 8 month old child will
look for an object once it disappears from sight to develop the cognitive skill of object permanence. Finger paints and small balls are inappropriate because
infants frequently put their fingers or objects in their mouths. Anything strung across a crib is a safety hazard, especially to a child who may use it to pull up to
a standing position.
1812 The mother of a 12 month old infant expresses concern about the effect of frequent thumb sucking on her child's teeth. After the nurse teaches her
about this matter, which response by the mother indicates that the teaching has been effective? Thumb sucking should be discouraged at 12 months. I'll
give the baby a pacifier instead. Sucking is important to the baby. I'll wrap the thumb in a bandage. C Sucking is the infant's chief pleasure.
However, thumb sucking can cause malocclusion if it persists after age 4. Many fetuses begin sucking on their fingers in utero and, as infants, refuse a pacifier
as a substitute. A young child is likely to chew on a bandage, which could lead to airway obstruction.

1813 A 10 month old infant is admitted to the hospital with dehydration and metabolic acidosis. What is the most common cause of dehydration and
acidosis in infants? Early introduction of solid foods Inadequate perianal hygiene Tachypnea Diarrhea D Diarrhea is the most common use of
dehydration and acidosis infants. The early introduction of solid foods may cause loose stools, but not dehydration or acidosis. Poor perianal hygiene may
cause diaper dermatitis. Tachypnea is a sign - not a cause - of acidosis.

1814 A mother tells the nurse that her 22 month old child says "no" to everything. When scolded, the toddler becomes angry and starts crying loudly, but
then immediately wants to be held. What is the best interpretation of this behavior? The toddler is not effectively coping with stress. The toddler's
need for affection is not being met. This is normal behavior for a 2 year old child. This behavior suggests the need for counseling. C
Because toddlers are confronted with the conflict of achieving autonomy, yet relinquishing the much-enjoyed dependence on - and affection of -
others, their negativism is a necessary assertion of self-control. Therefore, this behavior is a normal part of the child's growth and development. Nothing about
this behavior indicates that the child is undevelopment. Nothing about this behavior indicates that the child is under stress, is not receiving sufficient affection,
or requires counseling.

1815 When planning to tell a 4-year-old child about an upcoming procedure, which is the most important nursing consideration? Use simple terms
Speak loudly and clearly Offer a toy to keep the child happy Give the child all the information about the procedure A A
4-year-old child needs the procedure explained in simple terms that he or she can understand. Speaking loudly can provoke anxiety. Distraction with a toy is
more appropriate during the procedure than before it. Because pre-schoolers have a limited attention span, the nurse should provide only the necessary basic
facts to prevent anxiety.

1816 The nurse should expect a 3-year-old child to be able to perform which action? Ride a tricycle Tie shoelaces Roller-skate
Jump rope A At age 3, gross motor development and refinement I eye-hand coordination enable a child to ride a trycycle. The fine motor
skills required to tie shoelaces and the gross motor skills required for roller-skating and jumping rope develop around age 5.

1817 Which of the following poses the most serious safety threat to a hospitalized 2-year-old child and should be removed or changed? Crayons and
paper Teddy bear in the crib Mobile hanging over the crib Side rails in the halfway position D To prevent falls (one of the most frequent
accidents in hospitals), crib rails always should be raised and fastened securely unless an adult is at the bedside. Crayons and paper and a teddy bear are safe
toys for a 2-year-old child. Although a mobile could pose a safety threat to a 2-year-old child, its threat is not as serious as a side rails that is positioned
incorrectly.

1818 What is the best way for the nurse to determine if pain-relief techniques have been effective in an 18-month-old child? Check the child's pupils
Observe for the behavioral changes. Ask the child, "Are you feeling any pain?" Tell the parents to call if the child has pain. B
Behavioral changes are common signs of pain and are especially valuable indicators of pain relief in an 18-month-old child whose verbal skills are
limited. Evaluation of pupillary response is not an appropriate technique for assessing pain relief. Parental report of a child's pain is not a reliable assessment
technique.

1819 A 2-year-old child is brought to the emergency department after ingesting an unknown number of children's aspirin about 30 minutes ago. On
entering the examination room, the child is crying and clinging to the mother. Which assessment data should the nurse obtain first? Heart rate, respiratory
rate and blood pressure Recent exposure to communicable diseases Number of immunizations received. Height and body weight A
The most important assessment data to obtain on a child's arrival in the emergency department are vital sign measurements. The other data should
be gathered later in the assessment

1820 The nurse is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?
Administer ipecac syrup Call an ambulance immediately Call the poison control center Punish the child for being bad C
Before intervening in any way, the parents should call the poison control center for specific directions. Ipecac syrup is not indicated in all types of
poison control center for specific directions. Ipecac syrup is not indicated in all types of poisoning, because some ingested substances cause more damage if
vomiting is induced. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad is not appropriate, because
the parents are responsible for making the environment safe.

1821 When planning to administer medication to a 3 month old infant, which fact should the nurse consider? The metabolic rate is slower in an
infant than in an adult. The liver detoxifies drugs faster in an infant than in an adult. Systemic drug circulation is slower in an infant than in an
adult. The kidneys excrete drugs more slowly in an infant than in an adult. D Because most drugs are excreted by the kidneys and
because an infant's kidneys function immaturely, drug excretion occurs more slowly in an infant and significantly alters the effects of drugs. Compared with an
adult, an infant's metabolic rate is faster, drug detoxification is slower, and systemic circulation is faster.

1822 Which comment by a 7 year old boy to his friend best typifies his developmental stage? "Girls are so yucky." "My mommy and I are always
together." "I can't decide if I like Amy or Heather better." "I can turn into Batman when I come out of my closet." A During the school-age
years, the most important social interactions typically are with peers. These interactions lead to the formation of intimate friendships between same-sex
children. However, friendships with opposite-sex children are uncommon. At this age, children socialize more frequently with friends than with parents.
Interest in peers of the opposite sex does not begin until age 10 to 12. Magical thinking and fantasy play are more characteristic during the preschool years.

1823 What is the most important criterion for the nurse to consider when deciding to report suspected child abuse? Inappropriate parental concern for
the degree of injury Absence of parents for questioning about the injury Inappropriate response of the child to the injury Incompatibility between
the history and injury D Incompatibility between the history and the injury is the most important criterion on which to base the decision to report
suspected abuse. The other criteria also may suggest child abuse, but are less reliable indicators.

1824 The nurse is caring for a 4 year old child who has been hospitalized because of sexual abuse. For this child, what is the best nursing intervention?
Avoid touching the child. Prevent the abuser from visiting the child. Provide play situations that allow disclosure.Discourage the child
from talking about what happened. C Through certain play situations, a sexually abused child can disclose information without actually
talking about himself or herself. An abused child needs to touched and cared for just like any other hospitalized child. The nurse cannot restrict visitation
unless the threat of repeated abuse exists while the child is hospitalized. The nurse should not discourage discussion of the abuse if the child feels able to talk
about it.
1825 For children from infancy through the preschool years, what is the major stressor caused by hospitalization? Separation from family
Fear of bodily injury Loss of control Fear of pain A For infants through preschoolers, separation from family is the major
stressor posed by hospitalization. To minimize the effects of this stressor, the nurse may suggest that a family member stay with the child as much as possible.
By reducing this stressor, a young child may be better able to withstand the others stressors of hospitalization, such as fear of bodily injury, loss of control, and
fear of pain.

1826 The nurse must administer an oral medication to a 3 year old child. What is the best way for the nurse to proceed? "It's time for you to take
your medicine right now." "If you take your medicine now, you'll go home sooner." "Here's your medicine. Would you like apple juice or
grape drink after?" "See how Jimmy took his medicine? He's a good boy. Now it's your turn." C Involving the child helps gain cooperation, and
permitting the child to make choices gives a sense of control. Telling a child to take medicine "right now" commonly provokes a negative response. Promising
that a child will go home sooner can destroy the child's trust in nurses and physicians. Comparing one child to another does not encourage cooperation.

1827 Tepid sponge baths effectively reduce hyperthermia in children. What is the best way to give such bath? Leave the bathroom door open to
increase air movement. Wait until the child has chills to give the bath. Add isopropyl alcohol to the bathwater. Continue the bath for 20
to 30 minutes. D For cooling to be effective, the child must be bathed for 20 to 30 minutes. Leaving the bathroom door open does not help cool
the child. The timing of bath treatments for hyperthermia should be based on the child's temperature - not the presence of chills. Because of its neurotoxic
effects, isopropyl alcohol should never be used for tepid sponge baths.

1828 An 8 month old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.72 kg). The physician orders ceftriaxone sodium (Rocephin)
270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial that contains 500 mg. The nurse adds 2 ml of
preservative-free normal saline to the vial. If the prescribed dose is safe, how many milliliters should the nurse administer? This is not a safe dose.
0.08 ml 1.08 ml 1.8 ml C Because this infant weighs 7.72 kg, the safe dosage range is 386 to 579 mg daily. The dose ordered,
540 mg daily, is a safe dose. To calculate the amount to administer, the nurse may use the fraction method: (500 mg/2 ml = 270 mg/X ml) (500 X = 270 x 2)
(500 X = 540) (X = 540/500) (X = 1.08 ml)

1829 The physician prescribes acetaminophen (Tylenol) elixir 160 mg every 4 hours for a 14-month-old child who weighs 20 lb (9.08 kg). This drug,
which is supplied in a bottle labeled 160 mg/teaspoon, has a safe dosage of 10 mg/kg/dose. If the prescribed dose is safe, how many milliliters should the nurse
administer? This is not safe dose. 2.5 ml 5 ml 7.5 ml A For this client, the drug's safe dose is 90.8 mg (9.08 kg x 10 mg/kg =
90.8 mg). Therefore, the prescribed dose is not safe.

1830 When administering an oral medication to an infant, the nurse should use which method to minimize the risk of aspiration? Administer the oral
medication as quickly as possible. Place the medication in the infant's bottle of formula. Keep the infant upright with the nasal passages blocked.
Use an oral syringe to place the medication beside the tongue. D Use of an oral syringe is best because it allows controlled
administration of a small amount of medication to an infant. Too-rapid administration can cause aspiration. Putting the drug in a bottle of formula is not
preferred because the infant may not take the entire dose of medication and because the contents of the bottle could interfere with the medication's absorption or
action. Blockage of the nasal passages can cause aspiration.
1831 An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During a physical assessment, the nurse notes that the infant has a
pulse rate of 170 beats/minute and respirations of 70 breaths/minute. The nurse should place this infant in which position? Lying on the back Lying on the
abdomen Sitting in an infant seat Sitting in high Fowler's position C Because interpretation of the infant's assessment findings suggests
that respiratory distress is developing, the nurse should position the infant with the head elevated at a 45-degree angle to promote maximum chest expansion.
An infant seat maintains this position. Placing an infant flat on the back or abdomen or in the Fowler's position could increase respiratory distress by
preventing maximum chest expansion.

1832 The physician prescribes digoxin (Lanoxin) elixir for a toddler with congestive heart failure (CHF). Immediately before administering this drug, the
nurse must check the toddler's: Serum sodium level. Urine output. Body weight. Apical pulse. D Because digoxin can
reduce the heart rate and because CHF can cause a pulse deficit, the nurse should check the toddler's apical pulse before administering the drug to prevent
further reduction in the pulse rate. The serum sodium level does not affect digoxin's action. The nurse should check the urine output and body weight regularly
for a child with CHF, but not necessarily immediately before digoxin administration.

1833 When teaching the parents of a toddler with a congenital heart defect, the nurse should explain all medical treatments and should emphasize which
instruction about their child? Reduce the caloric intake to decrease cardiac demand. Relax discipline and limit setting to prevent crying. Avoid contact
with small children to reduce overstimulation. Try to maintain the usual lifestyle to promote normal development. D Parents of a child with a
heart defect should treat the child normally and allow self-limited activity. Reducing the child's caloric intake does not necessarily reduce cardiac demand.
Altering disciplinary patterns and deliberately preventing crying or interactions with other children can foster maladaptive behaviors. Contact with peers
promotes normal growth and development and therefore should be encouraged.

1834 Which assessment finding is an early sign of congestive heart failure in a toddler? Increased respiratory rate Increased urine output
Decreased body weight Decreased heart rate A Increased respiratory and heart rates are the earliest signs of congestive heart
failure. Decreased urine output and increased body weight are later signs.

1835 The nurse is preparing a 4 year old child for cardiac catheterization. Which of these explanations about the procedure is most appropriate?
"Don't worry. It won't hurt." "The test usually takes an hour." "You must sleep the whole time the test is being done." "The special medicine
will feel warm when it's put in the tubing." D To prepare the child without increasing anxiety, the nurse should provide concrete information in small
amounts about nonthreatening aspects of the procedure. Saying the it won't hurt may prevent the child from trusting the nurse in the future. Explaining the
time needed for the procedure does not provide sufficient information. Stating that the child will need to sleep can provoke anxiety and is false statement.

1836 For a child with a congenital, cyanotic heart defect, the complete blood count reveals an elevated hemoglobin level, hematocrit, and red blood cell
(RBC) count. What do these laboratory data indicate? Anemia Dehydration Development of jaundice Compensation for hypoxia D
A congenital, cyanotic heart defect alters the blood flow through the heart and lungs, which produces hypoxia. To compensate for this, the body
increases the RBCs' oxygen-carrying capacity by increasing RBC production, which causes hemoglobin and hematocrit to rise. The hemoglobin level and
hematocrit typically are decreased in anemia. Altered electrolyte levels and other laboratory values provide better evidence of dehydration. An elevated
hemoglobin level and hematocrit are not associated with jaundice.

1837 An 11-year old child with cystic fibrosis is admitted to the pediatric unit for treatment of a respiratory infection. Which mechanism causes the
respiratory problems of cystic fibrosis? Decreased ciliary action that causes mucus stasis in the lungs Edema of the epiglottis that causes airway
obstruction excessive production of thick mucus Laryngeal stricture C The primary factor responsible for the respiratory effects
of cystic fibrosis is increased production of very thick mucus, which mechanically obstructs the airway. Decreased ciliary action is not associated with cystic
fibrosis. Epiglottal edema that leads to airway obstruction is caused by epiglottitis. Laryngeal stricture results from trauma to, or infection of, the larynx.
1838 What is the primary goal of postural drainage for a child with cystic fibrosis? To prevent pneumoniaTo prevent aspiration To help mobilize
secretions To encourage deep breathing C Postural drainage maximizes the effects of gravity, which facilitates the removal of secretions. It does
not prevent pneumonia or aspiration or encourage deep breathing.

1839 A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child check up. To determine whether this child has a long-
term effect associated with cleft palate, a nurse should ask which question? "Was the child recently treated for pneumonia?" "Does the child play
with an imaginary friend?" "Is the child unresponsive when given directions?" "Has the child had any difficulty swallowing food?' C
Unresponsiveness may be an indication that the child has a hearing loss. A child who has history of cleft palate should be routinely checked for
hearing loss. Options A and D are unrelated to cleft palate after repair. Option B is normal behavior for a preschool child. Many preschoolers with vivid
imaginations have imaginary friends.

1840 A child is admitted to the orthopedic unit after insertion of a Harrington rod for the treatment of scoliosis. Which assessment is most important in
the immediate postoperative period? Capillary refill, sensation, and motion in all extremities Pain level Ability to turn using the logroll technique
Ability to flex and extend the lower extremities A When the spinal column is manipulated during surgery, altered neurovascular
status is a possible complication; therefore neurovascular checks, including circulation, sensation, and motion, should be performed every 2 hours. Level of
pain is an important postoperative assessment, but circulatory status is most important. Assessment of flexion and extension of the lower extremities is a
component of option A, which includes checking motion. Logrolling is performed by nurses.

1841 A child has just returned from surgery and has a hip spica cast. A nursing priority at this time is to: Elevate the head of the bed Abduct the
hips using pillows Assess the circulatory status Turn the child on the right side C During the first few hours after a cast is applied, the chief
concern is swelling that may cause the cast to act as tourniquet and obstruct circulation. Therefore circulatory assessment is a high priority. Elevating the
head of the bed of a child in a hip spica cast would cause discomfort. Using pillows to abduct the hips is not necessary, because a hip spica cast immobilizes
the hip and knee. Turning the child side at least every 2 hours is important, because it allows the body cast to dry evenly and prevents complications related to
immobility; however it is not a higher priority than checking circulation.

1842 An emergency department nurse prepares to treat a child with acetaminophen ( Tylenol ) overdose. The nurse reviews the physician's orders
expecting that which of the following will be prescribed? Vitamin K ( Aqua - Mephyton ) Protamine Sulfate Succimer ( Chemet ) N -
Acetylcysteine ( NAC ) D N - Acetylcysteine ( NAC ) is the antidote for Tylenol overdose. It is administered orally with juice or soda or via a
nasogastric tube. Vitamin K is the antidote for warfarin ( Coumadin ). Protamine sulfate is the antidote for heparin. Succimer ( Chemet ) is used in the treatment
of lead poisoning.

1843 A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. On assessment the nurse notes that
the child is now exhibiting decerebrate posturing. The nurse interprets that this change in the child's condition indicate which of the following? An
improvement in condition Decreasing intracranial pressure Deteriorating neurological function An insignificant finding? C
The Progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification.
Options A, B, and D are inaccurate interpretations.
1844 A nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure ( ICP ). The nurse notes that the anterior fontanel
bulges when the infant cries. Based on this assessment finding, which action would the nurse take? Lower the head of the bed Document the findings
Place the infant on NPO status Notify the physician immediatelyB The anterior fontanel is diamond - shaped and located on the top of
the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. A
bulging or tense fontanel may result from crying or increased ICP. Noting a bulging fontanel when the infant cries is a normal finding that should be
documented and monitored. It is not necessary to notify the physician for this finding. Options A and C are inappropriate actions.

1845 A nurse is assessing the vital signs of a 3-year old child hospitalized with a diagnosis of croup. The nurse notes that the respiratory rate is 28
breaths/min. Based on this finding, which nursing action is most appropriate? Reassess the respiratory rate in 15 minutes Notify the physician Document the
findings Administer oxygen C The normal respiratory rate for a 3-year old is 20 to 30 breaths / min. Since the respiratory rate is normal, options
A, B and D are unnecessary action. The nurse would document the findings.

1846 Following tonsillectomy, which of the following fluid or food items is most appropriate to offer to the child? Cool cherry Kool-aid Vanilla
pudding Cold Ginger ale Jell-O D Following tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely
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 ( pudding ) are avoided because they coat the throat and cause the child to clear the throat, increasing the risk of bleeding.

1847 A nurse is checking postoperative orders and planning care for a 110-lb child after spinal fusion. Morphine sulfate, 8 mg subcutaneously ( SC )
every 4 hours PRN for pain, is prescribed. The pediatric drug reference states that the safe dose is 0.1 to 0.2 mg / kg / dose every 2 to 4 hours. From this
information, the nurse determines that: The dose is too low The dose is too high The dose is within the safe dosage range There is not enough
information to determine the safe dose. C Use the following formula to determine to dosage parameters: Convert pounds to kilograms by dividing
by 2.2.110 lb\ 2.2 = 50kg Dosage parameters: 0.1 mg / kg/ dose * 50kg = 5mg 0.2 mg/ kg/ dose * 5kg = 10 mg Dosage is within the safe dosage range

1848 A pediatric nurse specialist provides an educational session to the nursing students about childhood communicable diseases. A nursing student asks
the pediatric nurse specialist to describe the signs and symptoms associated with the most common complication of mumps. The pediatric nurse specialist
responds knowing that which of the following signs or symptoms are indicative of the most common complication of this communicable disease? A red,
swollen testicle Nuchal rigidity Pain Deafness B The most common complication of mumps is aseptic meningitis with the virus
being identified the cerebrospinal fluid. Common signs include nuchal rigidity,lethargy,and vomitting.A red, swollen testicle may be indicative of orchitis.
Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading
causes of unilateral nerve deafness, this does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain is not a sign of a common
complication.

1849 A 5-year old child is hospitalized with Rocky Mountain spotted fever ( RMSF ). The nursing assessment reveals that the child was bitten by a tick 2
weeks ago. The child presents with complains of headache, fever and anorexia. The nurse notes a rash on the palms of the hands and soles of the feet. The nurse
reviews the physician's orders and anticipates that which of the following medications will be prescribed? Tetracycline ( Achromycin ) Amphotericin
B ( Ketoconazole ) Ganciclovir ( Foscarnet ) Amantadine ( Rimantadine ) A The nursing care of a child with RMSF will include the
administration of tetracycline. An alternative medication is chloramphenicol, a fluoroquinolone. Amphotericin B is used for fungal infections. Ganciclovir is
used to treat cytomegalovirus. Amantadine is used to treat influenza A virus

1850 A nursing instructor assigns a student to present a clinical conference to the student group about brain tumors in children. The nursing student
prepares for the conference and includes which of the following information in the presentation? Surgery is not normally performed because of the risk of
functional deficits occurring as a result of the surgery. Head shaving is no longer required before removal of the brain tumor Chemotherapy is the
treatment of choice The most significant symptoms are headache and vomiting D The hallmark symptoms of children with brain tumors are
headache and vomitting.The treatment of choice is total surgical removal of the tumor without residual neurological damage. Before surgery the child's head
will be shaved, although every effort is made to shave only as much as hair as necessary.

1851 A brain tumor is suspected in a 9 -year old child, and a magnetic resonance imaging ( MRI ) and positron emission tomography ( PET ) scan are
ordered. A sedative is prescribed to be administered before these procedures. Which medication does the nurse anticipate will be prescribed for this child?
Ondansetron hydrochloride ( Zofran ) Dexamethasone ( Decadron ) Chloral Hydrate ( Noctec ) Ofloxacin ( Floxin ) C
Noctec is a sedative and the medication used most often to sedate young children. Zofran is an antimetic used during chemotheraphy. Decadron is
administered to reduce some of the brain tissue swelling that occurs from the manipulation of tissue during surgery. Floxin is an antiinfective medication.

1852 A child is hospitalized with a diagnosis of lead poisoning, and chelation therapy is prescribed. The nurse caring for the child would prepare to
administer which of the following medications? Activated charcoal Sodium bicarbonate Ipecac syrup Dimercaprol ( BAL ) D
Dimercaprol (BAL) is a chelating agent that is used to treat lead poisoning. Sodium bicarbonate may be used in salicylate poisoning. Ipecac syrup is
used in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations.

1853 A nurse is teaching the parents of a child with celiac disease about dietary measures. The nurse tells the parents to: Read all label
ingredients carefully to avoid hidden sources of gluten Restrict corn and rice in the diet Restrict fresh starchy vegetables in the diet Substitute grain cereals
with pasta products A Gluten is found primarily in the grains of wheat and rye. Corn and rice become substitute foods. Gluten is added to many
foods as hydrolyzed vegetable protein that is derived from cereal grains, therefore labels need to be read. Corn and rice as well as vegetables are acceptable in a
gluten - free diet. Many pasta products contain gluten. Grains are frequently added to processed food for thickness or filters.

1854 A nurse is planning to give a tepid tub bath to a child who has hyperthemia. The nurse plans to: Obtain isopropyl alcohol to add to the bath
water Warm the water to the same body temperature of the child Have cool water available to add to the bath water Allow 5 minutes for the
child to soak in the tub C Adding cool water to an already warm bath allows the water temperature to drop slowly. The child is able to
adjust to the changing water temperature gradually and will not experience chilling. Alcohol is toxic and contraindicated for tepid sponge or tub baths. To
achieve the best cooling results, the water temperature should be at least 2 degrees F lower than the child's body temperature. The child should be in a tepid
tub bath for 20 to 30 minutes to achieve maximum results.

1855 A nurse is assigned to care for a child on postoperative day 1 following surgical repair of a cleft lip. Which nursing intervention is most appropriate
when caring for this child's surgical incision? Clean the incision only when serous exudate forms Rub the incision gently with a sterile cotton-
tipped swab Rinse the incision with the sterile water after feeding Replace the Logan bar carefully after cleaning the incision C
The incision should be rinsed with sterile water after every feeding. Rubbing alters the integrity of the suture line. Rather, the incision should be
patted or dabbed. The purpose of the Logan bar is to maintain the integrity of the suture line. Removing the Logan bar on the first postoperative day would
increase tension on the surgical incision.

1856 A nurse is caring for an infant with spina bifida (meningomyelocele type) who had the gibbus (sac on the back containing cerebrospinal fluid, the
meninges, and the spinal cord) surgically removed. The nurse plans which of the following in the postoperative period to maintain the infant's safety?
Elevating the head with the infant in the prone position Covering the back dressing with a binder Placing the infant in a head-down position
Strapping the infant in a baby seat sitting up A Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial
cavity. The fluid amount will take several weeks to decrease in volume after the gibbus reservoir is removed. The infant needs to be prone for several days to
decrease the pressure on the surgical site on the back. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site.
1857 A mother arriving at the emergency department with her child states that she just found the child sitting on the floor next to an empty bottle of
aspirin. On assessment, the nurse notes that the child is drowsy but conscious. The nurse prepares to administer: Ipecac syrup Activated charcoal
Magnesium citrate Magnesium sulfate A Ipecac is administered to induce vomiting. In this situation the child is conscious and the
ingested substance (aspirin) will not damage the esophagus or lungs. Therefore the nurse prepares to administer the ipecac syrup. Activated charcoal may be
used as an antidote in some poisoning situations, but its action is to absorb ingested toxic substances. Options C and D are unrelated to treatment for this
occurrence.

1858 A nurse is caring for a child with Reye’s syndrome. The nurse monitors for which major symptom associated with this syndrome? Persistent
vomiting Protein in the urine A history of a staphylococcal infection Symptoms of hyperglycemia A Intracranial pressure and
encephalopathy are major symptoms of Reye’s syndrome. Persistent vomiting is a major symptom associated with intracranial pressure. Protein is not present in
the urine. Reye’s syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.

1859 A child is admitted to the hospital with a suspected diagnosis of pneumococcal pneumonia. The nurse prepares to: Have a chest x-ray film
taken to determine how much consolidation there is in the lungs Allow the child to go to the playroom to play with other children Monitor the child’s
respiratory rate and breath sounds Start antibiotic therapy immediately C A complication of pneumococcal pneumonia is pleural
effusion, so the respiratory status of the child should be monitored. Option A is medical management, not nursing care. Antibiotic therapy is not started until
cultures are obtained. The child should not be allowed in the playroom at this time.

1860 A child is admitted to the hospital with diagnosis of acute rheumatic fever (RF). The nurse reviews the blood laboratory findings knowing that which
of the following will confirm the likelihood of this disorder? Increased leukocyte count Decreased hemoglobin count Increased
antistreptolysin-O (ASO) Decreased erythrocyte sedimentation rate C Children with suspected RF are tested for streptococcal antibodies.
The best and most reliable standardized test to confirm the diagnosis is the ASO titer. An elevated level is indicative of the presence of RF.

1861 A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse reviews the child’s record and notes that the
child has clubbed fingers. The nurse understands that the clubbing is most likely caused by: Peripheral hypoxia Delayed physical growth
Chronic hypertension Destruction of bone marrow A Clubbing, a thickening and flattening of the tips of the fingers and toes, is
thought to occur because of a chronic tissue hypoxia and polycythemia. Options B,C, and D do not cause clubbing.

1862 A nurse is reviewing the result of a sweat test performed on a child with cystic fibrosis (CF). The nurse would expect to note which finding? A
sweat sodium concentration less that 40 mEq/L A sweat potassium concentration less that 40 mEq/L A sweat potassium concentration greater than
40 mEq/L A sweat chloride concentration greater than 60 mEq/L D A consistent finding of an abnormally high sodium and chloride concentrations
in the sweat is unique characteristic of CF. Normally, the sweat chloride concentration is less than 40 mEq/L. A chloride concentration greater than 60 mEq/L is
diagnostic of CF. Potassium concentration is unrelated to the sweat test.
1863 A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will be:
Dark in color Abnormally small in amount Unusually hard Malodorous D The stools of a child with celiac
disease are characteristically malodorous, pale,large(bulky),and soft(loose). Excessive flatus is common, and bouts of diarrhea may occur.

1864 An infant is admitted to the pediatric unit with a diagnosis of tracheoesophageal fistula (TEF). The nurse assesses the infant, knowing that a typical
finding in an infant with TEF is: Continuous drooling Diaphragmatic breathing Slowed reflexes Passage of large amounts of frothy stool A
Esophageal atresia prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from
the mouth and the infant then drools continuously. The inability to swallow amniotic fluid prevents the accumulation of normal meconium, and a lack of stools
results. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of tracheoesphageal
fistula (TEF). Diaphragmatic breathing is not associated with TEF.

1865 The parents of a 6-month-old male report that the infant has been screaming and drawing the knees up to the chest and has passed stools mixed with
blood and mucus that are jellylike. A nurse recognizes these signs and symptoms as indicative of: Hirschsprung’s disease Peritonitis
Intussusception Appendicitis C The classic signs and symptoms of intussusception are acute, colicky abdominal pain with
currant jelly-like stools. Clinical manifestations of Hirschsprung’s disease include constipation, abdominal distention, and ribbonlike, foul-smelling stools.
Peritonitis is a serious complication that may follow intestinal obstructions and perforation. The most common symptom of appendicitis is colicky,
periumbilical or lower abdominal pain in the right quadrant.

1866 A nurse is assigned to give a child a tepid tub bath to treat hyperthermia. Following the bath, the nurse plans to: Place the child in bed and cover the
child with a blanket Leave the child uncovered for 15 minutes Assist the child to put on a cotton sleep shirt Take the child’s axillary temperature in 2 hours.
C Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option A is incorrect because a blanket
is heavy and may increase the child’s body temperature and further increase metabolism. Option B is incorrect because the child should not be left uncovered.
Option D is incorrect because the child’s temperature should be reassessed in ½ hour after the bath.

1867 A nurse is caring for an infant who has diarrhea. The nurse monitors the infant for which early signs of dehydration? Apical pulse rate of 200
beats/min Capillary refill of 4 seconds Gray, mottled skin Cool extremities A Dehydration causes interstitial fluid to shift to the vascular
compartment in an attempt to maintain fluid volume. When the body is unable to compensate for fluid lost, circulatory failure occurs. The blood pressure will
decrease and the pulse rate will increase. This will be followed by peripheral symptoms. Options B, C, and D are incorrect, and these assessment findings
reflect diminished peripheral circulation

1868 A nurse is caring for a newly delivered breastfeeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant?
Encouraging the mother to offer a formula supplement after each breastfeeding session Keeping the infant NPO until the second period of
reactivity Placing the infant under the photo-therapy Encouraging the mother to breastfeed the infant every 2 to 3 hours. D To help prevent jaundice,
the mother should feed the infant frequently in the immediate birth period because colostrum is a natural laxative and helps promote the passage of meconium.
Offering the infant a formula supplement will cause nipple confusion and decreased the amount of milk produce by the mother. Breastfeeding should begin as
soon as possible after birth while the infant is in the first period of reactivity. Delaying breastfeeding decreases the production of prolactin, which decreases the
mother’s milk production. Phototherapy requires a physician’s order and is not implemented until bilirubin levels are 12 mg/dL or higher in the healthy term
infant.

1869 An infant with a dislocated hip is placed in Bryant’s traction. The nurse plans to assess which of the following while the infant is in traction?
Skin integrity over the scapulae Pin sites at the tibia Security of the pelvic belt Pressure over the hip joint A The infant in
Bryant’s traction is supine with both legs elevated at a 90-degree angle. The buttocks should just clear the mattress. The scapulas, fibulas, shoulders, and
Achilles’ tendons are pressure points as a result of positioning and skin traction application. There are no pin sites with Bryant’s traction. Pelvic traction is the
only traction that uses a pelvic belt. No constructive devices are placed over or near the hip joint with Bryant’s traction.
1870 The parent of a male newborn who is not circumcised request information on how to clean the newborn’s penis. The best nursing response is:
Retract the foreskin and cleanse the glans when bathing the newborn. Do not retract the foreskin to cleanse because this may cause
adhesions. Retract the foreskin no farther than it will go and replace it over the glans after cleaning. Retract the foreskin and cleanse it with every diaper
change. B In newborn males, prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to
develop. It is best to allow separation to occur naturally, which will take place between 3 years and puberty. Most foreskins are retractable by 3 years of age and
should be pushed back gently for cleaning once a week.

1871 A nurse is caring for a child following cleft palate repair. To reduce the risks of aspiration after feeding the child, the nurse places the child in which
best position? Right side Left side Supine Prone A The child with left palate repair is placed on the right side after feeding to reduce
the chance of aspirating regurgitated formula. Option B, C, and D are positions that would place the child at risk for aspiration.

1872 A nurse is developing a plan of care for a school-aged child with a knowledge deficit related to use of inhalers and peak flow meters. An appropriate
expected outcome is that the child will: Express feelings of mastery and competence with the breathing devices Have regular respirations at a rate of
18 to 22 breaths/min Deny shortness of breath or difficulty breathing Be encouraged to watch the educational video and read the printed information
provided A School-aged children strive for mastery and competence to achieve the developmental task of industry and accomplishment. Options B
and C do not relate to the knowledge deficit. Option D is an intervention rather than an outcome.

1873 Levothyroxine sodium (Synthroid) is administered to a hospitalized child with congenital hypothyroidism. The child vomits 20 minutes after
administration of the dose. The most appropriate nursing action is to: Repeat the prescribed dose Give two doses of the prescribed medicine on
the next day Contact the physician immediately Hold the dose for today A Levothyroxine sodium (Synthroid) is the
medication of choice for hypothyroidism. The most significant factor adversely affecting the eventual intelligence of children born with congenital
hypothyroidism is inadequate treatment. Therefore compliance with the medication regimen is essential. If the infant or child vomits within 1 hour of taking
medication, the dose should be administered again.

1874 A child is sent to the school nurse by the teacher. As the nurse is assessing the child, the nurse notes that the child has a rash. The nurse suspects that
the child has erythema infectiosum (fifth disease) because the skin assessment revealed a rash that is:A discrete rose-pink maculopapular rash on the trunk A
highly pruritic, profuse macule to papule rash on the trunk A discrete pinkish red maculopapular rash that is spreading to the trunk An erythema
on the face that has a slapped face appearance D The classic rash of erythema infectiosum or fifth disease is the erythma on the face. The
discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule to papule rash is the rash of varicella
(chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles).

1875 A nurse is performing an admission assessment on a newborn infant admitted with the diagnosis of subdural hematoma following a difficult vaginal
delivery. The nurse assesses for major symptoms associated with subdural hematoma when the nurse: Tests for contractures of the extremities
Tests for equality of extremities when stimulating reflexes Monitors the urinary output pattern Monitors the urine for blood B
A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can, especially if the infant is actively bleeding, cause
changes in the stimuli responses in the extremities on the opposite side of the body. Option A is incorrect because contractures would not occur this soon after
delivery. Options C and D are incorrect. An infant , after delivery, would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma
and not be a result of the hematoma.
1876 A nurse employed in a preschool agency is planning a staff education program to prevent the spread of an outbreak of an intestinal parasitic disease.
The nurse includes which priority intervention in the educational session? Staff will practice universal precautions when changing diapers and assisting
children with toileting All toileting areas will be cleansed daily with soap and water Only bottled water will be used for drinking All food will be cooked
before eating A The fecal-oral route is the mode of transmission of an intestinal parasitic disease. Universal precautions prevent the
transmission of infection. Cleaning with soap and water is not as effective as the use of bleach. Water and fresh foods can be vehicles for transmission, but
municipal water sources are usually safe. Some fresh foods do not need to be cooked as long as they are washed well and provided that they weren’t grown in
soil contaminated with human feces.

1877 A home health nurse visits a three-year-old with chickenpox. The child’s mother tells the nurse that the child keeps scratching the skin at night and
ask the nurse what to do. The nurse tells the mother to:Apply generous amounts of cortisone cream to prevent itching Place soft cotton gloves on the
child’s hands at night Keep the child in a warm room at night so the covers will not cause the child to scratch Give the child a glass of warm milk at bed time
to help the child to sleep B Gloves will keep the child from scratching the open lesions from chickenpox. Generous amounts of any topical
cream can lead to drug toxicity. A warm room will increase the child’s skin temperature and make itching worse. Warm milk will have no effect on itching.

1878 A nurse caring for a child with intussusception. While caring for the child, the child passes a normal brown stool. The most appropriate nursing
action is to: Report the passage of a normal brown stool to the physician immediately Prepare the child and the parents for the possibility of
surgery Note the child’s physical symptoms Prepare the child for hydrostatic reduction A Passage of a normal brown stool usually
indicates that the intussusception has reduced itself. This is immediately reported to the physician, who may chose to alter the diagnostic/therapeutic plan of
care. Options B, C and D are incorrect actions.

1879 A community health nurse is providing instructions to a group of mothers regarding the safe use of car seats for toddlers. The nurse determines that
the mother of a toddler understands the instructions if the mother states which of the following? The car seat can be placed in a face-forward position when
the height of the toddler is 27 inches The car seat should never be placed in a face-forward position The car seat can be placed in a face-forward
position at any time The car seat is suitable for a toddler reaches the weight of 40 pounds D The transition point for switching to the
forward-facing position is defined by the manufacturer of the safety seat but is generally at a body weight of 9 kg (20 pounds). The car safety seat should be
used until the child weighs at least 40 pounds, regardless of age. Options A, B, and C are incorrect.

1880 A home health nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury.
Which statement, if made by the mother, indicates a need for further instruction? "I need to remain in the kitchen when I prepare meals" "I need to be
sure to place my cup of coffee on the counter" "I need to use the back burners for cooking" "I need to turn pot handles inward and to the middle of the
stove" B Toddlers, with their increased mobility and developing of motor skills, can reach hot water, or hot objects placed on counters and open
fires or burners on stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal, to use the back burners of the
stove, and to turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended and the toddler should always be
supervised. The mother’s statement in option B does not indicate an adequate understanding of the principles of safety.

1881 A child with brain tumor is admitted to the hospital for removal of the tumor. To ensure a safe environment for this child, the nurse includes which
of the following in the plan of care? Assisting the child with ambulation at all times Avoiding contact with other children on the nursing unit
Initiating seizure precautions Using a wheelchair for out of bed activities C Seizure precautions should be considered for any child
with a brain tumor, both preoperatively and postoperatively. Options A and D are not required unless functional deficits exist. Option B is not necessary.
1882 A home care nurse provides instructions to the mother of a child with croup. The mother express concern regarding the occurrence of an acute
spasmodic episode. The nurse instructs the mother regarding management if an acute episode occurs. Which statement made by the mother indicates a need
for further instructions? "I will place steam vaporizer in the child’s room" "I will place the child in a closed bathroom and allow the child to
inhale steam from warm running water" "I will place a cool mist humidifier in the child’s room" "I will take the child out into the cool, humid night air." A
Steam from warm running water in a closed bathroom and cool mist from bedside humidifier are effective in reducing mucosal edema. Cool mist
humidifiers are recommended over steam vaporizers which present a danger of scald burns. Taking the child out into the cool humid night air may also relieve
mucosal swelling. Remember however, that a cold mist may precipitate bronchospasm and the child needs to be monitored carefully.

1883 A 17-year-old client is about to be discharged with her new born baby. Which statement if made by the client would alert the nurse that further
teaching is required regarding child care? "I have locks on all my cabinets that contain my cleaning supplies." "I have a car seat that I will put in
the front set to keep my baby safe." "I will not use the microwave to heat my baby's formula." "I keep all my pots and pans in my lower
cabinets." B A baby car seat should never be placed in the front seat because of the potential for injury impact. Any cabinets that contain dangerous
items that a baby or a child could swallow be locked. Microwaves should never be used to heat formula because it could burn and even scald the baby’s mouth.
Even though the bottle may feel warm, it could contain hot spots that could severely damage the baby’s mouth. It is perfectly safe to leave the pots and pans in
the lower cabinets for a child to investigate, as long as they are not made of glass, which would warm the baby if broken.

1884 A nurse caring for an adolescent client with conjunctivitis. The nurse provides instructions to the client and tells the adolescent to: Avoid using
all eye makeup to prevent possible reinfection Apply warm compresses to lessen irritation Replace contact lenses for use after the infection clears
Stay home for 3 days after starting antibiotic eye drops to avoid the spread of infection C Eye make up should be replaced, but can still
be worn. Cool compresses decrease pain and irritation. Isolation for 24 hours after antibiotics are initiated is necessary. All contact lenses should be replaced.

1885 A nurse is assigned to care for a hospitalized toddler. The nurse plans care, knowing that the highest priority should be directed toward:
Protecting the toddler from injury Adapting the toddler to the hospital routine Allowing the toddler to participate in play and divisional
activities Providing consistent caregiver A The toddler is at high risk for injury because of developmental abilities and an unfamiliar environment.
While adoption, diversion, and consistency are important, protection from injury is the highest priority.

1886 A nurse in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center
and plans activities that will meet the child’s needs. The priority consideration in planning activities for the child is to ensure: Social interactions with
other children in the same age group Safety with activities Familiarity with all activities and providing orientation throughout the activities
That activities provide verbal stimulation B Safety with all activities is a priority in planning activities with the child. The child with
autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Although social interactions, verbal
communications, and providing familiarity and orientation are also appropriate interventions, the priority is safety.

1887 A nurse is preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which of the following will
not be included in the plan of care for this child? Pad the side rails of the bed with blankets Maintain the bed in a low position Restrain the
child if a seizure occurs Place a child in a side lying lateral position if a seizure occurs C Restraints are not to be applied to a child with a
seizure, because they could cause injury to the child. The side rails of the bed are padded with blankets and bed is maintained in low position to provide safety
in the event that a child has a seizure. Positioning the child on his or her side will prevent aspiration as the saliva drains out of the child’s mouth during the
seizure.
1888 Penicillin V (Pen-Vee K), 250 mg PO every 8 hours, prescribed for a child with a respiratory infection. The medication label reads: Penicillin V, 125
mg per 5 mL. The nurse has determined that the dosage prescribe is safe for the child. The nurse prepares to administer how many milliliters per dose to the
child? 2 mL 4 mL 8 mL 10 mL D Use the following formula for calculating medication dosages: Desired/ Available * volume;
250/125 mg x 5 mL = 10 mL per dose

1889 A cooling blanket is prescribed for a child with a fever. A nurse caring for the child has never used this type of equipment. The charge nurse provides
instructions to the nurse and assists the nurse assigned to the child. Which action by the nurse would indicate the need for further instructions in the use of the
cooling blanket? Placing the cooling blanket on the bed and covering it with a sheet Checking the skin condition of the child before, during, and after the
use of the cooling blanket Keeping the child uncovered to assist in reducing the fever Keeping the child dry while on the cooling blanket to
prevent the risk of frostbite C While on a cooling blanket, the child should be covered lightly to maintain privacy and reduce shivering. Options
A, B, and D are important interventions to prevent shivering, frostbite, and skin breakdown.

1890 A child with respiratory syncytial virus (RSV) who is in an oxygen tent is receiving ribavirin (Virazole). Which precaution will the nurse specifically
take while caring for the child? Wear a mask Wear goggles Wear a gown Wear a gown and mask B Some
caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of contact with ribavirin (Virazole).
Specific to this medication is the use of goggles. A mask may be worn. A gown is not necessary.

1891 A nurse receives a telephone call from the emergency room and is told that a child with a diagnosis of tonic-clonic seizures will be admitted to the
pediatric unit. The nurse prepares the admission of the child and instructs the nursing assistant to place which of the following items at the bedside?
Suction apparatus and an airway A tracheotomy set and oxygen An emergency cart and padded side rails An endotracheal tube and an airway
A Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral secretions are the
major complications during and following a seizure. Suction is helpful to prevent choking and cyanosis. Options B and D are incorrect because inserting
endotracheal tube or a tracheostomy is not done. It is not necessary to have an emergency cart at the bedside but a cart should be available in the treatment room
or on the nursing unit.

1892 The nurse in a well baby clinic is providing safety instructions to a mother of a 1-month-old infant. Which of the following safety instructions is
most appropriate at this age? Covering electrical outlets Remove hazardous objects from low places Lock all poisons Never shake the infant’s
head D The age-appropriate instruction that is most important is to instruct the mother not to shake or vigorously jiggle the baby’s head. Options
A, B, and C are most important instructions to provide to the mother as the child reaches the age of 6 months and begins to explore the environment.

1893 A nurse caring for a 9-month-old child following cleft palate repair. The nurse has applied elbow restraints to the child. The mother visits the child
and asks the nurse to remove the restraints. Which of the following is the most appropriate nursing action? Remove both restraints Tell the
mother that the restraints cannot be removed Remove a restraint from one extremity Loosen the restraints but tell the mother that they cannot be removed
C Elbow restraints are used following cleft palate repair to prevent the child from touching the repair site, which could cause accidental
rupture and tearing of the sutures. The restraints can be removed one at a time only if a parent or nurse is in constant attendance. Options A, B, and D are
inaccurate nursing actions.
1894 A 10-year-old child is admitted to the hospital for surgery. The parents state that the child has been diagnosed as mentally retarded and functions on
the level of a 3-year old. When developing the child's preoperative teaching plan the nurse should: Include explanations aimed at a 3-year-old's cognitive
level Allow the parents to teach the child any needed information Exclude the child from the teaching due to the mental retardation Provide
explanations aimed at a young school-aged child's cognitive level A The child's functioning level is at the level of a 3-year-old; explanations should
be in simple terms, immediately before each procedure.

1895 A 10-year-old is admitted to the hospital in thrombocytic sickle cell crisis. When assigning a room, it is most appropriate for the nurse to place the
child with a roommate who has: Pneumonia Thalassemia Osteomyelitis Acute pharyngitis B Thalassemia is a
hemolytic anemia that is not communicable; roommates with infectious diseases should be avoided because a child with sickle cell anemia is susceptible to
infections.

1896 A 12-year-old child is seen in the health care clinic. During the assessment, which of the following findings would suggest to the nurse that the child
is experiencing a disruption in the development of self-concept? The child has a part-time baby-sitting job The child enjoys playing chess and mastering
new skills with this game The child has many friends The child has an intimate relationship with a significant other D A sense of
industry is appropriate for this age group and may be exhibited by having a part-time job. The increase in self-esteem associate with skill mastery is an
important part of development for the school-aged child. Friends are also important and appropriate in this age group. The formation of an intimate relationship
would not be expected until young adulthood.

1897 A 13-year-old insulin-dependent diabetic with a history of poor adherence to therapy is admitted to the hospital with a blood glucose level of 700
mg/dl. A continuous insulin infusion is begun. When developing a plan of care for this adolescent, the nurse should be alert for possible: Hypovolemia
Hypokalemia Hypernatremia Hypercalcemia B Insulin causes potassium to move into the cells along with glucose,
thus lowering the serum potassium level.

1898 A 14-year-old develops sinusitis and is placed on a broad-spectrum oral antibiotic to be taken 4 times a day. To maintain the blood level, the nurse
should recommend that the medication be taken at: 8 am, 12 pm, 4 pm, and 8 pm 8 am, 4 pm, 12 am, and 4 am 6 am, 12 pm, 6 pm, and 12 am 10
am, 2 pm, 10 pm, and 2 am C Antibiotics should be administered with doses equally spaced over 24 hours so that a constant blood level of the
drug is maintained.

1899 A 15-year-old high school student with hay fever has been taking a prescribed long- acting antihistamine/decongestant q8h for the past 3 days. The
adolescent tells the nurse, "This medication is making me sleepy. Can you change it to something else?" The nurse's best response would be: "Take only
half a tablet before school." "I think you should omit the early morning dose." "The drowsiness will usually diminish after a few days."
"I'll ask the physician to change you to a medication containing ephedrine." C This reply addresses the client's concern; CNS depressant
effects may diminish or spontaneously disappear after several days.

1900 A 15-year-old insulin-dependent diabetic has a history of noncompliance with therapy. The nurse is aware that the noncompliance is
developmentally related to: The need for attention A denial of the diabetes The struggle for identity A regression associated with illness
C Striving to attain identity and independence is a task of the adolescent, and rebellion against established norms may be exhibited.
1901 A 16-year-old client is hospitalized with pneumonia. Which statement by the client would alert the nurse to a potential developmental problem? "Is
it okay if I have a couple of friends in to visit me this evening?" "When my friends get here, I would like to play some computer games with them."
"Please tell my friends not to visit, since I’ll see them back at school next week." "I’d like my hair washed before my friends get here." C
Adolescents who withdraw from peers into isolation struggle with developing identity, so option C should cause the nurse to be concerned. Option A
shows that the client is eager for companionship. Adolescents often develop special interests within their groups that may help to maximize certain skills, such
as with computers. It is appropriate for the client to ask for hygiene measures to be attended to before the client’s peers arrive.

1902 A 16-year-old is admitted to the hospital with hyperglycemia from failure to follow the diet, insulin, and glucose monitoring regimen. The client
states, “I’m fed up with having my life ruled by doctors’ orders and machines! “ A priority nursing diagnosis is: Altered Nutrition, greater than body
requirements, related to a high blood glucose Altered Family Process related to chronic illness Altered Thought Process related to a personal
crisis Ineffective Health Care Management of the therapeutic regimen related to feelings of loss of control D Adolescents strive for identify and
independence and the situation describes a common fear of loss of control. The correct nursing diagnosis relates to the issues of the question, which are not
following the prescribed regimen and the feelings of powerlessness. There is no indication of altered family or altered thought processes in the question. Altered
nutrition is inaccurate and limited.

1903 A 16-year old mother, her 1-month-old baby, and the baby's grandmother come to the emergency room saying that the infant accidentally fell down
the stairs. Legally, consent for the baby's medical care: Should be obtained from the grandmother, who must sign the consent Must be decided by
family court because the baby's mother is a minor Is not necessary because this is an emergency and no consent is needed Is the responsibility of
the baby's mother, and she should sign the consent D In most states, the age of majority is 18 years; however, mothers younger than 18 years are
considered emancipated minors and can sign consents for themselves and their children.

1904 A 1-day-old is born with an imperforate anus and undergoes a pull-through procedure with an anoplasty. The nurse knows that it is most appropriate
postoperatively to place the infant: In Buck's traction In the Trendelenburg's position Prone with the head of the crib elevated Supine with
the legs suspended at a 90-degree angle to the trunk D This is one of the preferred positions to prevent pressure on the perineal sutures following
this surgery, which is done to correct intermediate anorectal malformations.

1905 A 1-month old infant with hydrocephalus is scheduled for surgery for the insertion of a ventriculoperitoneal (VP) shunt. A short-term preoperative
goal for the infant would be to: Keep the infant as comfortable as possible to limit crying Use a thick head bandage to protect the infant's head from
injury Establish and maintain a strict fixed feeding schedule to ensure hydration Provide a wide variety of play objects to maintain age-appropriate
stimulation A This will avoid sudden increases in intracranial pressure.

1906 A 1-year-old is in the pediatric unit for management of AIDS. The child is receiving zidovudine (AZT) every 6 hours. The nurse evaluates that the
child is in life-threatening AZT toxicity when the child manifests: Fatigue and lethargy A progressive weight loss An increased urine output
Multiple bruises on the limbs and trunk D AZT can cause life-threatening blood dyscrasias including thrombocytopenia. "

1907 A 2 1/2-year-old girl whose older sibling has recently died, has started hitting her mother and refusing to go to bed at night. The nurse in the
pediatric well-child clinic tells the mother that the toddler is probably: Fearful of dying in her sleep Trying to get more of her mother's attention
Just going through the terrible twos developmental stage Reacting appropriately to anxiety generated by the family upheavalD
Changes in the daily routines in the home and anxiety expressed by family members lead to anxiety in toddlers.
1908 A 2 1/2-year-old male child who has fallen from a tree tells his parents, "Bad, bad tree." The nurse recognizes that the child is within the cognitive
developmental norm of Piaget's: Concrete operations Concept of reversibility Preconceptual operations Sensorimotor development C
In the toddler, 2- and 3-word phrases are used with an increased vocabulary; attributing lifelike qualities to inanimate objects (animism) is also
associated with preconceptual thought.

1909 A 25-day-old infant is admitted to the hospital after 3 days of vomiting, and pyloric stenosis is diagnosed. The most important nursing assessment at
the time of admission is the: Character, amount, and times when the baby vomited Time of last feeding, type of formula, and amount taken Presence of
an olive-shaped mass in the lower abdomen Amount and color of last voiding, skin turgor, and respiratory status D When a baby has scanty
dark urine, poor skin turgor, and increased depth of respirations, it is likely that dehydration and metabolic alkalosis are present; these occur because of the fluid
and hydrochloric acid loss and the potassium depletion; immediate intervention is necessary.

1910 A 3 1/2-year-old child returns to the room after a cardiac catheterization. Post-procedure nursing care for the child should include: Encouraging
early ambulation Monitoring the insertion site for bleeding Restricting fluids until blood pressure is stabilized Comparing blood pressure in
affected and unaffected extremities B Postprocedure hemorrhage is a major life-threatening complication following cardiac catheterization
because arterial blood is under pressure and an artery has been entered by the catheter.

1911 A 3-month-old infant has a ventriculoperitoneal shunt inserted. The nurse plans to: Keep the infant in the prone position Apply sterile
moist dressings to the incision Observe for signs of leakage of cerebrospinal fluid Teach the parents the signs of increased intracranial pressure D
The parents must be taught to identify increased intracranial pressure, as this can develop if shunt malfunction occurs.

1912 A 3-year-old male has recently been diagnosed with X-linked Duchenne's muscular dystrophy. Neither parent has muscular dystrophy. The statement
by the parents that indicates an understanding of the disease's transmission is: "Our daughters could be carriers. " "Our sons or daughters could have
the disease." "We each contributed a gene that caused our son to have the disease." "By mendelian law, our son's having muscular dystrophy
limits its occurrence in other children. " A Duchenne's muscular dystrophy follows an X-linked recessive inheritance pattern; when the father is
unaffected and the mother is a carrier, there is a 50% chance that a son will be affected and there is a 25% chance that a daughter will be affected.

1913 A 4-month-old baby is being treated for talipes equinovarus. The baby is seen by a pediatric orthopedist every 2 to 3 weeks for cast changes. The
mother brings the baby to the well-baby clinic for a routine visit and immunizations. While assessing the casted foot, the nurse should evaluate: Pedal pulses
and symmetry of both feet The extent of the range of motion of the casted foot Color, warmth, and movement of the toes of the foot in the cast
The ability of the infant to flex and extend the knee of the casted foot C Neurovascular checks of casted extremities allow for
recognition of circulatory impairment caused by the cast.

1914 A 4-month-old is diagnosed with hydrocephalus and treated with the surgical insertion of a ventroperitoneal shunt. In preparation for discharge, the
nurse teaches the parents signs of shunt failure, which include: Fever and irritability Diarrhea and abdominal pain Vomiting and distended fontanels
Dehydration and abdominal distention C Vomiting and bulging fontanels are symptoms of increased intracranial pressure in the
young child; a malfunctioning shunt would produce these symptoms of hydrocephalus.
1915 A 4-year-old child is admitted with the diagnosis of acute lymphocytic leukemia (ALL). Platelets are ordered and an IV is started. The nurse should:
Administer the platelets rapidly Administer the platelets over 2 1/2 hours Check vital signs 3 hours after the transfusion Flush the line
with 5% dextrose and normal saline A Platelets are rapidly administered to avoid destruction after being hung. Platelets should not hang for a
long time because of their fragility.

1916 A 4-year old child who was recently hospitalized is brought to the clinic by the mother for a follow-up visit. The mother tells the nurse that the child
has begun to wet the bed since the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. The most appropriate
nursing response is which of the following? "You need to discipline the child." "This is a normal occurrence following hospitalization.""We will need
to discuss this behavior with the physician.' "The child probably has developed a urinary tract infection." B Regression can occur in a
preschooler and is most often caused by the stress of the hospitalization. It is best to accept the regression if it occurs. Parents may be overly concerned about
the regressive behavior and should be told that regression is normal following hospitalization. It is premature to discuss the situation with the physician.
Options A and D are inappropriate responses to the mother.

1917 A 4-year-old child with nephrotic syndrome has been restricted to 600 ml of fluid for 24 hours. The nursing intervention that would be most
appropriate in assisting the child to cope with such a limitation is: Dividing fluid intake equally among each shift (200 ml each shift) Allowing the child to
drink fluids as desired until the 600 ml limit is reached Withholding fluids from 7 pm to 7 am and giving the entire 600 ml from 7 am to 7 pm Providing the
child a minimum of 1 ounce of fluid in small, 1-ounce cups each waking hour D This allows the child to get a full cup (1 oz medicine cup) without
long waits; a full cup, even if it is a small cup, creates the illusion of receiving more.

1918 A 5 1/2-month-old infant is admitted to the hospital with a fever and a history of vomiting for 48 hours. In view of this infant's responses, the
assessment by the nurse that would initially influence the child's care is: Inspecting the baby's skin for poor turgor Determining the baby's vital signs
and weightChecking the baby's neurologic status and urinary output Asking the mother whether the baby is breastfed or bottle-fed B
The degree of dehydration is correlated with weight loss; continued fever aggravates fluid losses through evaporation.

1919 A 5-year-old child is admitted to the hospital complaining of colicky abdominal pain with guarding, nausea, anorexia, and a low-grade fever.
Palpation of the RLQ elicits pain. The nurse prepares to implement care associated with: Constipation An irritated bowel A parasitic infestation
An inflamed appendixD These are the classic signs and symptoms related to acute appendicitis. They are caused by inflammation and
altered gastrointestinal functioning.

1920 A 7-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most
appropriately selects which of the following play activities for the child? A coloring book with crayons A finger-painting set A large puzzle A
board game D The school-aged child becomes organized with more direction with play activities. Such activities include collection drawing,
construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television. Options A and B are most
appropriate for a pre-schooler. Option C is most appropriate for a toddler.

1921 A 9-year-old child is hospitalized for 2 months after an automobile accident. The best way to promote psychosocial development of this child is to
plan for: Tutoring to keep the child up with school work A phone to call family and friends computer games, TV, and videos at the bedside
Computer games, TV, and videos at the bedside A portable radio and tape player with headphones A The developmental tasks
of the school-aged child is industry vs. inferiority. The child achieves success by mastering skills and knowledge. Maintaining school work provides for
accomplishment and prevents feelings of inferiority from lagging behind the class. The other options provide diversion and care of lesser importance for a child
of this age.

1922 A 9-year-old child with diabetes mellitus is hospitalized for dosage regulation of insulin. The child appears to be very manipulative and has been
observed sneaking food and trying to talk the mother into providing sweets. Based on this behavior, when the child complains of hypoglycemia, the most
appropriate nursing action would be to: Test the urine for glucose Obtain a blood glucose level Administer orange juice with sugar
Ask the child the last time food was eaten B A quick check of the blood glucose level will confirm whether the client is hypoglycemic.

1923 A 9-year-old male child, who has been newly diagnosed with diabetes mellitus, is being discharged. The nurse suspects that there may be a problem
with family dynamics when the child's mother states: "We want to encourage our son to do as much as he can for himself." "We know our child is
special, and we'll have to go easy on the discipline for him." "We know our child and the rest of the family are in for a lot of ups and downs over the
years." "We really hope our son can still be in the Boy Scouts and participate with his Little League baseball team." B Children with diabetes
mellitus need to be treated normally; they need discipline and should have limits set for their behavior.

1924 A 9-year-old with insulin-dependent diabetes mellitus is admitted to the hospital with deep, rapid respirations; flushed, dry cheeks; abdominal pain
with nausea; and increased thirst. Laboratory tests would be expected to show:A blood pH of 7.25 with a blood glucose level of 60 mg/dl A blood pH
of 7.50 with a blood glucose level of 60 mg/dl A blood pH of 7.50 with a blood glucose level of 460 mg/dl A blood pH of 7.25 with a blood
glucose level of 460 mg/dl D The symptoms indicate ketoacidosis so both these values would be expected; the pH indicates acidosis (metabolic
or ketoacidosis) and the blood glucose level, elevated more than the normal range of 70 to 105 mg/dl, indicates severe hyperglycemia.

1925 A child comes to the hospital after exposure to diphtheria and is given antitoxin. This type of immunity is known as: Active natural immunity
Active artificial immunity Passive natural immunity Passive artificial immunity D In passive artificial immunity, an
antibody made in another organism is injected into the infected or presumed infected person to provide immediate immunity to the invading organism.

1926 A child is admitted to a pediatric unit with a diagnosis of acute gastroenteritis. A nurse monitors the child for signs of hypovolemic shock as a result
of fluid and electrolyte losses that have occurred in the child. Which of the following findings would indicate to the nurse the presence of compensated shock?
Bradycardia Hypotension Profuse diarrhea Capillary refill time greater than 2 seconds D Shock may be classified
as compensated or decompensated. In compensated shock, the child becomes tachycardic in an effort to increase the cardiac output. The blood pressure
remains normal. Capillary refill time may be prolonged and greater than 2 seconds, and the child may become irritable because of increasing hypoxia. The
most prevalent cause of hypovolemic shock is fluid and electrolyte losses associated with gastroenteritis. Diarrhea is not a sign of shock; rather it is a cause of
the fluid and electrolyte imbalance.

1927 A child is admitted to the hospital with a diagnosis of meningococcal meningitis. The nurse is aware that isolation: Will be required for 7
days Of any kind is not required Must be maintained during the incubation period Is required for 24 to 72 hours after onset of antibiotic
therapy D The meningococcal organism is rendered inactive after 24 to 72 hours of antibiotic therapy; therefore, isolation is required at least for this
time.
1928 A child is admitted to the hospital with a diagnosis of sickle cell crisis. The nurse contacts the physician to question which order documented in the
child’s record? Intravenous fluids Supplemental oxygen Bed rest Meperidine hydrochloride (Demerol) D Mepedine hydrochloride
is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. Management of severe
pain generally includes the use of strong narcotic analgesics such as morphine sulfate or hydromorphone (Dilaudid). These medications are usually most
effective when given as a continuous infusion or at regular intervals around the clock. Options, A b and C are appropriate prescriptions for treating vaso-
occlusive pain crisis.

1929 A child is admitted to the hospital with a suspected diagnosis of bacterial endocarditis. The child have been experiencing fever, malaise, anorexia,
and a headache, and diagnostic studies are performed. Which of the following studies will primarily confirm the diagnosis? An electrocardiogram
(ECG) A white blood cell count A blood culture A sedimentation rate C The diagnosis is bacterial endocarditis is primarily
established on the basis of a positive blood culture of the organisms and visualization of a vegetation on echocardiographic studies. Other laboratory test results
that may help to confirm the diagnosis are elevated sedimentation rate and C-reactive protein level. An ECF is not usually helpful in the diagnosis of bacterial
endocarditis.

1930 A child is admitted to the hospital with a suspected diagnosis of immune thrombocytopenic purpura (ITP). Diagnostic studies are performed. Which
of the following diagnostic results is indicative of this disorder? Bone marrow examination indicating an increased number of immature white blood cells
Bone marrow examination showing an increased number of megakaryocytes Elevated platelet count Elevated hemoglobin and
hematocrit levels B The laboratory manifestation of ITP include the presence of a low platelet count, usually less than 50,000 cells/mm³.
Thrombocytopenia is the only laboratory abnormality expected with ITP. If there has been significant blood loss, there is evidence of anemia in the blood cell
count (CBC). If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, the precursors of
platelets. Option A indicates the bone marrow result that would be found in leukemia.

1931 A child is admitted to the hospital with a suspected diagnosis of von Willebrand’s disease. On assessment of the child, which of the following
symptoms would most likely be noted? Bleeding from the mucous membranes Presence of hemarthrosis Hematuria Presence of hematomas
A The primary clinical manifestations of von Willebrand’s disease are bruising and mucous membrane bleeding from the nose, mouth, and
gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, with mild disease. In females, menorrhagia may occur.
Bleeding associated with von Willbrand’s disease may be severe and lead to anemia and shock, but unlike the situation in hemophilia, deep characteristic of
those signs found in hemophilia.

1932 A child is given phenytoin (Dilantin) 75 mg orally twice a day. The activities pertinent to long-term Dilantin therapy, which the nurse should teach
the parents, include: Observing for reddish-brown discoloration of urine Administering the drug 2 hours after breakfast and dinner
Supplementing the diet with high-calorie foods and forcing fluids Providing oral hygiene, especially gum massage and flossing of teeth D
This may reduce the risk of gingival hyperplasia, a common side effect of Dilantin.

1933 A child is having a cardiac arrest. The physician orders epinephrine as a cardiac stimulant. The nurse is aware that one factor that would still permit
administration of an epinephrine solution that is on hand would be that the reconstituted solution: Is slightly discolored Has been exposed to light Is
no more than 72 hours old Contains only slight sediment B This would not affect the potency of the solution.
1934 A child is hospitalized with a diagnosis of nephrotic syndrome. Which of the following assessment findings would a nurse expect to note in the
child? Weight loss Hypotension Abdominal pain Constipation C Clinical manifestations associated with
nephrotic syndrome include edema, anorexia, fatigue, and abdominal pain from the presence of extra fluid in the peritoneal cavity. Diarrhea resulting from
edema of the bowel occurs and may case decreased absorption of nutrients. Increased weight and a normal blood pressure are noted.

1935 A child is suspected of having a pinworm infection. To collect a cellophane tape specimen from the anus the nurse should teach the mother to
perform the procedure: At night after the child has a bath In the late morning after the child defecates At night after the child has a bowel movement
Upon awakening before the child has a bath or bowel movement D When the client is asleep, the pinworm emerges from the rectum and
lays its eggs; the eggs can be collected the next morning by using tape on the perianal area.

1936 A child seen in the health care clinic and initial testing for human immunodeficiency virus (HIV) is performed because of the child’s exposure to
HIV infection. Which of the following home care instructions would the nurse provide to the parents of the child? Avoid all immunizations until the
diagnosis is established Avoid sharing toothbrushes Wipe up any blood spills with soap and water and allow to air dry Wash hands with half-
strength bleach if they come in contact with the child’s blood B Immunization must be kept up to date. Blood spills are wiped up with a paper
towel. The area is then washed with soap and water, and allowed to air dry. Hands are washed with soap and water if they come in contact with blood. Parents
are instructed that toothbrushes are not to be shared.

1937 A child survives a near-drowning episode in a cold pond but still has many problems to overcome. The nurse is aware that the ultimate prognosis
will depend mainly on the extent of damage resulting from the: Hypoxia Hyperthermia Emotional trauma Aspiration pneumonia A
The degree of the hypoxia and asphyxia the child had will determine the extent of the neurologic, liver, and renal damage.

1938 A child who has barely survived a near-drowning episode is in critical condition in an intensive care unit. At one point the child opens the eyes and
smiles, prompting the mother to say to the nurse, "Look, I think my child will get better now." The nurse's best response would be: Yes, you are right; this is
a very good sign. See if you can get your child to hold your hand, too. God must have certainly been watching over your child.We are doing everything
we can to help your child to recover. D The nurse must emphasize that everything possible is being done because the outcome cannot be
predicted.

1939 A child with a diagnosis of hepatitis B is being cared for at home. The mother of the child calls the health care clinic and tells a nurse that the
jaundice seems to be worsening. Which of the following responses to the mother would be most appropriate? The hepatitis may be spreading? You need to
bring the child to the health care clinic to see the physician. The jaundice may appear to get worse before it resolves. It is necessary to isolate
the child from others. C The parents should be instructed that jaundice may appear to et worse before it resolves. The parents of a child with hepatitis
should also be taught the danger signs that could indicate a worsening of the child’s condition, specifically changes in neurological status, and fluid retention.

1940 A child with a diagnosis of umbilical hernia has been scheduled for surgical repair in 2 weeks. The clinic nurse instructs the parents about the signs
of possible hernial strangulation. The nurse tells the parents that which sign would require physician notification? Fussiness Diarrhea Constipation
Vomiting D The parents of a child with an umbilical hernia need to be instructed in the signs of strangulation. These signs include
vomiting, pain, and irreducible mass at the umbilicus. The parents should be instructed to contact the physician immediately if strangulation is suspected.
1941 A child with diabetes mellitus who is also learning-disabled has trouble correctly measuring the required insulin dose. The child frequently draws up
42 units of insulin instead of the prescribed 24 units. The most appropriate intervention to ensure dosage safety would be to: Teach the child to use a
magnifying glass to read the numbers on the syringe Exchange the insulin syringe the child has been using for a tuberculin syringe Provide the child with
preset syringe guides that were developed for the blind Allow the child to have the number written down on paper when filling the syringe C
The client's trouble stems from perceptual difficulties; the preset syringe removes the need to differentiate between 24 and 42 units.

1942 A child with leukemia is to be sent home on a protocol that includes several antineoplastics after an intrathecal administration of methotrexate.
Before discharge the nurse instructs the child's parents to: Limit contact with peers because they tend to have communicable diseases Return
weekly for bone marrow aspiration to monitor effectiveness of therapy Schedule routine laboratory screening to evaluate response to the medication
Withhold medications when nausea occurs to prevent additional episodes of vomiting C Blood tests indicate response to therapy; if the
WBC count drops severely, therapy may be temporarily halted.

1943 A child, recently returned from a camping trip, complains of a rash, chills, fever, and a headache and is taken to the clinic by the parents. The nurse
in the clinic recognizes that this child's history and physical assessment should include: A history of allergies and duration of symptoms A
developmental screening and history of exposure to chickenpox Sports played on the trip and when the child has to return to school The date the child
received a flu vaccination and a history of any sunburn A The nurse needs to gather information regarding the symptoms because they can be related
to many factors.

1944 A client with congestive heart failure and secondary hyperaldosteronism is started on spironolactone (Aldactone) to manage this disorder. The nurse
anticipates the need to instruct the client regarding dosage adjustment of which of the following medications, if it is also being taken by the client?
Warfarin sodium (Coumadin) Alprazolam (Xanax) Verapamil hydrochloride (Calan) Potassium chloride D Spironolactone
(Aldactone) is a potassium-sparing diuretic. If the client is taking potassium chloride or another potassium supplement, the risk for hyperkalemia exists.
Potassium doses would need to be adjusted while on this medication. A dosage adjustment would not be necessary if the client is taking either of the
medication identified in options A, B or C.

1945 A clinic nurse an adolescent with iron deficiency anemia about the administration of oral iron preparations. The nurse instructs the adolescent that it
is best to take the iron with: Water Soda Tomato juice Cola C Iron should be administered with vitamin C rich fluids,
because vitamin C enhances the absorption of the iron preparation. Tomato juice contain a high content of ascorbic acid (vitamin C). Water, soda, and cola do
not contain vitamin C.

1946 A clinic nurse has provided information to the mother of a toddler regarding toilet-training. Which statement if made by the mother would indicate a
need for further instructions? I should wait until my child is between 18 and 24 months old. I know that my child will develop bowel control before
bladder control. I should have my child sit on the potty until the child urinates. I know my child is ready to begin toilet training if my child is
walking. C The child should not be forced to sit on the potty for long periods of time. The physical ability to control the anal and urethral sphincters
is achieved sometime after the child is walking, probably between ages 18 and 24 months. Bowel control is usually achieved before bladder control.
1947 A clinic nurse of a well-baby clinic is collecting data regarding the motor development of a 15-month-old child. Which of the following is the
highest level of development that the nurse would expect to observe in this child? The child builds a tower of two blocks The child opens a
doorknob The child unzips a large zipper The child puts on simple clothes independently A At age 15 months, the nurse would expect that
the child could build a tower of two blocks. A 24-month-old would be able to open a doorknob and unzip a large zipper. At age 30 months, a child would be
able to put on simple clothes independently.

1948 A clinic nurse provide instructions to a mother regarding the care of her child who is diagnosed with croup. Which of the following statements, if
made by the mother, indicates a need for further education? I will place a cool mist, humidifier next to my child’s best. Sips of warm fluids
during a croup attack will help. I will give acetaminophen (Tylenol) for the fever. I will give cough syrup every night at bed time. D
The mother needs to be instructed that cough syrup and cold medicines are not to be administered, because they may dry and thicken secretions.
Sips of warm fluid will relax the vocal cords and thin mucus. A cool mist humidifier rather than a steam vaporizer is recommended because of the danger of the
child pulling the machine over and causing a burn. Tylenol will reduce the fever.

1949 A critically ill child develops Cheyne-Stokes respirations, and the nurse suspects an increasing acid-base imbalance related to: Respiratory
alkalosis from overbreathing and excess carbon dioxide output Respiratory acidosis from impeded breathing and the retention of carbon dioxide
Metabolic alkalosis from increased base bicarbonate resulting from the primary health problem Metabolic acidosis from the concentration of
cations in body fluids, which displace bicarbonate D Metabolic acidosis results from an excess concentration of hydrogen cations; potassium
increases; the kidneys cannot convert ammonium (NH3) to ammonia (NH4); there is inadequate base bicarbonate to maintain an appropriate acid-base balance.

1950 A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would
indicate that the child is coping with the illness and bed rest? The child is coloring and drawing pictures in a notebook The mother keeps
providing new activities for the child to do The child insists that the mother stay in the room The child sucks the thumb whenever the child does not get
what is asked for A According to Piaget, for the preschooler, play is the best way to understand and adjust to life’s experiences. Preschoolers are
able to use pencils and crayons. They can draw stick figures and other rudimentary things. A child with scarlet fever needs quiet play, and drawing will provide
that. Options B, C and D do not identify coping behaviors.

1951 A home care nurse visits with a diagnosis of celiac disease. Which of these findings would best maintained and has been effective? The child is
free of diarrhea The child is free of bloody stools The child tolerates dietary wheat and rye A balanced fluid and electrolyte status as noted in the
laboratory result A Watery diarrhea is a frequent clinical manifestation of celiac disease. The absence of diarrhea indicates effective treatment.
The grains of wheat and rye contain gluten and are not allowed. A balance in fluids and electrolytes does not necessarily demonstrate improved status of celiac
disease.

1952 A home health nurse visits a child who is being treated with penicillin for scarlet fever. The mother tells the nurse that the child has only voided a
small amount of tea-colored urine since the previous day. The mother also reports that the child’s appetite has decreased and the child’s face was swollen this
morning. The nurse interprets that these new symptoms are: Signs of the normal progression of scarlet fever Nothing to be concerned about
The symptoms of acute glomerulonephritis Symptoms of an allergic reaction to penicillin C The symptoms identified in the
question indicate glomerulonephritis. Although the child is on penicillin, these are not symptoms of an allergic reaction. These symptoms are not normal and
should not be ignored.

1953 A home health nurse visits a child with Reye’s syndrome and plans to provide instructions to the mother regarding care of the child. The nurse
plans to instruct the mother to: Increase the stimuli in the environment Give the child frequent, small meals if vomiting occurs Avoid daytime naps so
that the child will sleep at night Check the child’s skin and eyes every day for a yellow discoloration D Checking for a jaundice will assist
in identifying the presence of liver complications that are characteristic of Reye’s syndrome. If vomiting occurs in Reye’s syndrome, it is caused by cerebral
edema, is a sign of increased intracranial pressure, and needs to be reported. Decreasing stimuli and providing rest decreases stress on the brain tissue. Options
A and C do not promote a restful environment for the child.

1954 A male adolescent with cystic fibrosis whose

parents are both carriers of the disease asks the nurse, "When I have children could they have cystic fibrosis like me?" The nurse should base a response on the
knowledge that: Men with cystic fibrosis generally have a 50% chance of having children with the disease Only women pass this disease to
their children because it is carried on the sex chromosome This client has a greater chance of passing the disease to his children because his parents
were only carriers Men with cystic fibrosis are usually unable to father a baby, although their sexual functioning is not affected D Because of a
failure of normal development of the vas deferens, epididymis, and seminal vesicles and a blockage of the vas deferens with abnormal secretions, there is
decreased or absent sperm production.

1955 A male client with cystic fibrosis (CF) becomes romantically involved with a female with the same disease. He asks the nurse about the chances of
having an affected child like himself. The most appropriate response by the nurse would be: Use condoms for protection from pregnancy.Young
women with cystic fibrosis are not fertile. All of your children would be carriers of cystic fibrosis. You are probably not able to father children
because of your cystic fibrosis. D With few exceptions males are sterile; failure of normal development of the wolffian duct structures (vas deferens,
epididymis, and seminal vesicles) and blockage of the vas deferens by abnormal secretions result in decreased or absent sperm production.

1956 A mother brings a child to a health care clinic. The child has been complaining of severe headaches and has been vomiting. The child has a high
fever, and a nurse notes the presence of nuchal rigidity in the child. The nurse suspects continues to assess the child for the presence of Kernig’s sign. Which
of the following findings would indicate the presence of this sign? Inability of the child to extend the legs fully when lying supine Flexion of the hips when
the neck is flexed from a lying position Pain when the chin is pulled down to the chest Calf pain when the foot is dorsiflexed A
Kernig’s sign is the inability of the child to extend the legs fully when lying supine. Brudzinski’s sign is flexion of the hips when the neck is flexed
from a supine position. Both of these signs are frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs
when pain prevents the child from touching the chin to the chest. Homans’ sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.
Homans’ sign is present in thrombophlebitis.

1957 A mother brings her child to a health care clinic for a routine examination. The mother tells the nurse that the teacher has reported that the child to
be daydreaming and starring off into space. The teacher tells the mother that this occurs numerous times throughout the day. The remainder of the day the
child is alert and participates in classroom activity. The nurse documents the findings and suspects that which of the following is occurring with this child.
The child has attention deficit hyperactivity syndrome and is in need of medication The child probably has alcohol phobia The child is
experiencing absence seizures The child is showing signs of a behavioral problem C Absence seizures are a type of generalized seizure that was
formerly known as petit mal seizures. They consist of a sudden, brief (no longer than 30 seconds) arrest of the child’s motor activities, accompanied by a blank
state and loss of awareness. The child’s posture is maintained at the end of he seizure. The child returns to activity that was in process as though nothing has
happened. A child with attention deficit hyperactivity syndrome becomes easily distracted., is fidgety, and has difficulty following directions. School phobia
includes physical symptoms that usually occur at home and may prevent the child from attending school. Behavior problems would be characterized by more
over symptoms than described in this question.

1958 A mother comes to the pediatric clinic because her previously continent 6-year-old son has resumed bedwetting. After learning that there is a new
baby in the home, the nurse explains to the mother that the son is most likely using the defense mechanism of: Identification Regression
Rationalization RepressionB The defense mechanism of regression is characterized by returning to an earlier form of expressing an
impulse. Option A occurs when a person models behavior after someone else. Option C occurs when a person unconsciously falsifies an experience by giving a
“rational” explanation. Option D is characterized by blocking a wish or desire from conscious expression.
1959 A mother indicates to the nurse in the pediatric clinic that she is concerned that her 20-month-old baby's bedtime thumbsucking will cause the teeth
to protrude. The nurse's most appropriate response would be: You should seek counseling; the thumbsucking may indicate an emotional problem.
You should switch the baby to a pacifier in the next 2 months to prevent protrusion of the teeth. You need to restrain the baby from sucking the
thumb because it prematurely loosens the first teeth. You need not be concerned about the teeth protruding unless it persists after permanent teeth appear. D
Lips and teeth closed around the finger create suction and can move permanent teeth forward, causing malocclusions.

1960 A mother of a 3-wek-old infant arrives at a well-baby clinic for a rescreening test for phenylketonuria (PKU). A nurse reviews the result and notes
that the serum phenylalanine level is 1.0 mg/dL. The nurse interprets this level as: Normal Elevated, indicating PKU Inconclusive
Requiring a repeat study A The normal PKU level is less than 2 mg/dL. With early postpartum discharge, screening is often
performed at less than 2 days of age because of the concern that the infant will be lost to follow-up. Infants should be prescreened by 15 days of age if the initial
screening was done at 24 to 48 hours of age.

1961 A mother of a 6-month-old child asks about what foods should be introduced first. A likely choice would be to start with: Rice cereal and fruit
Sweets, such as fruits and puddings Meat first, then add fruit and vegetables Cereal and a soft-boiled egg for breakfast A
The first solid foods added to the infant's diet should be easily digestible, such as fruits and cereals, and provide rich sources of iron, such as fortified
cereals.

1962 A mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse of tells the mother that: A gluten-free
diet will need to be followed for life Adequate nutritional status will help prevent celiac crisis Supplemental vitamins, iron, and folate will
prevent complications A lactose-free diet will need to be followed temporarily A The main nursing consideration with celiac disease is helping the
child adhere to dietary management. Treatment of celiac disease consists primarily of dietary management with a gluten-free diet. Options B, C, and D are all
true statements, but do not answer the question the client is asking. Children with untreated celiac disease may have lactose intolerance, which usually improves
with gluten withdrawal. Nutritional deficiencies resulting from malabsorption are treated with appropriate supplements.

1963 A mother of a child with mumps call health care to tell the nurse that the child has been very lethargic and has been vomiting. The nurse most
appropriately tells the mother. To continue to monitor the child That lethargy and vomiting are normal manifestation of mumps To bring the child to the
clinic to be seen by the physician That as long as there is no fever, there is nothing to be concerned about C Mumps generally affects the
salivary glands, but can also affect multiple organs. The most common complication is meningitis, with the virus being identified in the cerebrospinal fluid.
Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the physician.
1964 A mother of three children who was abandoned by her husband shortly after the birth of her youngest daughter brings the child, now 9 months old,
into the hospital with a diagnosis of failure to thrive. As the mother leaves, the nurse is not surprised to see the daughter react by: Clinging to the mother
and expressing fear of the nurse Crying at first but then letting the nurse hold and comfort her Sustaining eye contact with the mother and refusing the
nurse's arms Readily allowing the nurse to take her but remaining stiff while being held D Going to a stranger without protest usually
indicates the lack of a meaningful relationship with the mother.

1965 A mother says to the nurse, “I am afraid that my child might have another febrile seizure.” Which response by the nurse is most therapeutic?
"Why worry about something that you cannot control?" "Most children will never experience a second seizure." "Tell me what frightens you the
most about seizures." "Tylenol can prevent another seizure from occurring." C Option C is the only response that is an open-ended statement and
provides the mother with opportunity to express feelings. Option A is incorrect, because it blocks communication by giving a flippant response to an expressed
fear. Options B and D are incorrect, because the nurse is giving false assurance that a seizure will not recur or can be prevented in this child.

1966 A mother whose child has glomerulonephritis is fearful that her other child may get the disease. To allay the fears of the mother, the nurse should tell
her that: The cause of acute glomerulonephritis is unknown, so it is difficult to know how to prevent it. Acute glomerulonephritis is inherited by an
autosomal recessive trait but usually occurs only in males. Acute glomerulonephritis is caused by clot formation in the small renal tubules secondary to
systemic infection. Acute glomerulonephritis is caused by an antigen-antibody response secondary to group A beta-hemolytic streptococcus. D
The beta-hemolytic streptococcus immune complex becomes trapped in the glomerular capillary loop, causing glomerulonephritis.

1967 A newborn is born with exstrophy of the bladder. The parents of the baby are upset, concerned, and confused when they are told that their infant will
need surgery but it cannot be done until the child is older. At this time the nurse can best help the infant's parents by: Teaching them about preoperative
and postoperative care Caring for the infant in the same manner as caring for other infants Reassuring them that the child can have a normal life after
surgery Keeping the child clean to aid in decreasing the odor of leaking urine B The nurse's acceptance of the infant, even with an altered
appearance, helps the parents adjust.

1968 A newborn with a cardiac defect is fed in the semi-Fowler's position. After the nurse feeds and burps the infant and changes the infant's position, the
infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. These symptoms are most likely caused by the: Burping
Formula Position change Bowel movement D During a bowel movement the Valsalva's maneuver can occasionally initiate a
hypercyanotic spell (tet spell, blue spell); the Valsalva's maneuver causes increased intrathoracic pressure, slowing of the pulse, decreased return of blood to the
heart, and increased venous pressure.
1969 A newborn with a cleft lip is fed with a special nipple. To minimize regurgitation of the feedings the nurse instructs the mother to: Give the baby
the thickened formula as ordered Hold and burp the baby frequently while feeding Lay the baby on the side with the bottle firmly propped Feed the baby
while sitting the baby up in an infant seat B Because of the cleft (opening) in the lip, the infant tends to suck in more air than usual; burping will
prevent frequent regurgitation of formula.

1970 A nonhemophilic woman who had a hemophilic father is married to a man with normal blood clotting. Genetically it can be predicted that:
All children will be hemophiliacs Female children will be unaffected All male children will be hemophiliacs Half the male children
will be hemophiliacs D If the woman had a hemophilic father, she must have had his X chromosome, which carries the recessive gene for hemophilia
(if she had had his Y chromosome, she would have been male); since her blood clots normally, her other X chromosome carries the dominant gene for normal
blood clotting. With one affected chromosome, 50% of the female offspring will be carriers and 50% of the male offspring will have hemophilia.

1971 A nurse demonstrates to a mother how to correctly take an axillary temperature to determine whether the child has a fever. Which action by the
mother would indicate need for further teaching? She selects a mercury thermometer with a slender tip She holds the thermometer in the axilla for 1
minute She records the actual temperature reading and route She places the thermometer in the center of the axilla B Taking an axillary
temperature for at least 5 minutes is most accurate. Options A, C, and D are correct steps for taking an axillary temperature.

1972 A nurse develops a plan of care for a 1-month-old infant hospitalized for intussusception. Which nursing measure would be most effective to provide
psychosocial support for the parent-child relationship? Encourage the parents to go home and get some sleep Encourage the parents to room-in with their
infant Provide educational materials Initiate home nutritional support as early as possible B Rooming-in is effective in reducing separation
anxiety and preserving the parent-child relationship. Parents are under stress when a child is ill and hospitalized. Telling a parent to go home and sleep will not
relieve this stress. Educational materials may be beneficial but will not provide psychosocial support of the parent-child relationship. Home nutritional support
is not usually necessary.

1973 A nurse has completed discharge teaching with the parents of a child with glomerulonephritis. Which statement by the parents indicates that further
teaching is necessary? We’ll check our child’s blood pressure every day. We’ll be sure that our child eats a lot of vegetables and does not add extra salt to
food. It’ll be so good to have my child back in karate next week. We’ll test out child’s urine for albumin every week. C After
discharge, parents should allow the child to return to his or her normal routine and activities, with adequate periods allowed for rest. Karate 1 week after
discharge would be a too rapid increase in activity and unrealistic. Options A, B and D are correct home care measures.
1974 A nurse has reinforced discharge instructions to the parents of a child who has had heart surgery. Which of the following if stated by the parent
would indicate a need for further instructions? I should call the physician if my child develops faster or harder breathing than normal. My child can
return to school for full days in 3 weeks following discharge. I should have my child avoid crowds and people for 1 week after discharge. I should
allow my child to play inside but omit play outside at this time. B The child may return to school 3 weeks after hospital discharge, but the child
should go to school for half-days for the first week. Outside play should be omitted for several weeks; inside play should be allowed as tolerated. The child
should avoid crowds of people for 1 week after discharge, including crowds at day care centers and churches. If any difficulty with breathing occurs, the
parents should notify the physician.

1975 A nurse in the newborn nursery prepares to admit a newborn infant with spina bifida, menigomyelocele type. Which of the following is the priority
nursing action in the immediate plan of care for this infant? Monitor blood pressure Monitor specific gravity of the urine Inspect the
anterior fontanel for bulging Monitor temperature C Intracranial pressure is a complication associated with spina bifida. A sign of intracranial
pressure in the newborn infant with spina bifida is a bulging or tough anterior fontanel. The newborn infant is at risk for infection before the surgical procedure
and closure of the gibbous and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is the immediate
priority. A normal saline dressing is placed over the affected site to maintain moisture of the gibbous and its contents. This prevents tearing or breakdown of
skin integrity at the site. Blood pressure is difficult to asses during the newborn period, and it is not the best indicator of infection or a potential complication.
Urine concentration is not well developed in the newborn stage of development.

1976 A nurse in the well baby clinic has provided instructions regarding dental care to a mother of a 10-mont-old child. Which statement if made by the
mother indicates a need for further instructions? I need to start dental hygiene as soon as the primary teeth erupt. I need to use fluoride supplements if
the water is not fluoridated. I can coat a pacifier with honey during the day as long as I do not give my child a bottle at nap or bedtime. I need to limit
the amount of concentrated sweets. C The practice of coating pacifiers with honey or using commercially availably hard-candy pacifiers is
discouraged. Besides being cardiogenic, honey may also cause botulism, and parts of the candy pacifier may be aspirated. Additionally, a bottle at nap or
bedtime that contains sweet milk or other fluids such as juice, bathes the teeth, producing caries. Fluoride, an essential mineral for building caries-resistant
teeth, is needing beginning at 6 months of age if the infant does not receive adequate fluoride content. A diet that is low in sweets and high in nutritious food
promotes dental health.

1977 A nurse instructs a parent regarding the appropriate actions to take when a toddler has a temper tantrum. Which statement by the parent indicates a
successful outcome of the education? I will send my child to a room alone for 10 minutes after every tantrum. I will reward my child with candy at
the end of each day without a tantrum. I will give frequent reminders that only bad children have tantrums. I will ignore the tantrums as long as
there is no physical danger. D Ignoring a negative attention-seeking behavior in considered the best way to extinguish it, provided the child is
safe from injury. Option A gives attention to the tantrum and also exceeds the recommended time of 1 minute per year of age for time-out. Providing candy for
rewards is unhealthy and unlikely to be effective at the end of a day. Option C is untrue and negative.
1978 A nurse is admitting a child with a diagnosis of irritable bowel syndrome to the hospital. Which of the following data would the nurse expect to
obtain on assessment of the child? Reports of frothy diarrhea Reports of profuse, watery diarrhea and vomiting Reports of foul-smelling
ribbon stools Reports of diffuse abdominal pain unrelated to meals or activity D Irritable bowel syndrome causes diffuse abdominal pain
unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted. Option A
is a clinical manifestation of lactose intolerance. Option B is a clinical manifestation of celiac disease. Option C is a clinical manifestation of Hirschsprung’s
disease.

1979 A nurse is assessing the level of consciousness of a child with a head injury and documents that the child is obtunded. On the basis of this
documentation, which of the following observations did the nurse note? The child is unable to recognize place or person The child is unable to
think clearly and rapidly The child requires considerable stimulation for arousal The child sleeps unless aroused and once aroused has limited
interaction with the environment D If the child is obtunded, the child sleeps unless aroused and once aroused has limited interaction with the
environment. Option A describes disorientation. Option B describes confusion. Option C describes stupor.

1980 A nurse is assigned to care for a child with a basilar skull fracture. The nurse reviews the child’s record and notes that the physician has
documented the presence of Battle sign. Which of the following would the nurse expect to note in the child? Bruising behind the ear Edematous
periorbital area Bruised periorbital area Presence of epistaxis A The most serious type of skull fracture is a basilar skull fracture. Two
classic findings associated with this type of skull fracture are Battle sign and raccoon eyes. Battle sign is the presence of bruising or ecchymosis behind the ear
as a result of leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus, which causes an edematous and
bruised periorbital area.

1981 A nurse is assigned to care for a child with juvenile rheumatoid arthritis (JRA). The nurse reviews the plan of care, knowing that which of the
following is a priority nursing diagnosis? Body Image Disturbance related to activity intolerance Potential for Self-Care Deficit related to immobility
High risk for injury related to impaired physical mobility Pain related to the inflammatory process D All of the nursing
diagnoses are appropriate for the child with JRA; however, pain needs to be managed before other problems can be addressed.

1982 A nurse is caring for a 14-year-old child who is hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length
of the hospital confinement. Which nursing action would be most appropriate to meet the child’s needs? Allow the child to have his or her hair dyed if
the parent agrees Allow the child to play loud music in the hospital room Let the child wear his or her own clothing when friends visit Allow the
child to keep the shades closed and the room darkened at all times C An adolescent needs to identify with peers and has a strong need to belong to a
group. The child should be allowed to wear his or her own clothes to feel a sense of belonging to the group. Adolescents like to dress the group and wear
similar hairstyles. Because Crutchfield traction uses skeletal pins, hair dye is not appropriate. Loud music may disturb others in the hospital. A child’s request
for a darkened room is indicative of a possible problem with depression that may need further evaluation and intervention.

1983 A nurse is caring for a child diagnosed with rubeola (measles). The nurse notes that the physician has documented the presence of Koplik spots. On
the basis of this documentation, which of the following would the nurse, expect to note on assessment of the child? Petechie spots that are reddish and
pinpoint on the soft palate Whitish vesicles located across the chest Small, blue-white spots with a red base, found on the buccal mucosa
Pinpoint petechiae on both legs C Koplik spots appear approximately 2 days before the appearance of the rash. These are small, blue-
white spots with a red base, found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Options A, B and D are
incorrect.

1984 A nurse is caring for a child who is a victim of child abuse. The nurse has determined that the child uses repression to cope with past life
experiences. The nurse implements an appropriate plan of care that includes: Placing the child on medications that will forget the incidents Having the
child talk about the abuse in detail during the first therapy session Encouraging the child to use play therapy to act out past experiences Telling the
child to let the past go and concentrate on the present and future C Play therapy is a nonthreatening avenue through which the child can use artwork,
dolls, or puppets to act out frightening life experiences. Options A and D devalue the child and force the child to further repress harmful past experiences rather
than face them and move on. Option B would be extremely threatening to the child and nontherapeutic.

1985 A nurse is caring for a child with renal disease and is analyzing the laboratory results. The nurse notes a sodium level of 148 mEq/L. On the basis of
this finding which clinical manifestation would the nurse expect to note in the child? Increased heart rate Cold clammy skin Dry sticky mucous
membranes Lethargy C Hypernatremia occurs when the sodium level is greater that 145 mEq/L Clinical manifestations include intense
thirst, oliguria, agitation and restlessness, flushed skin, peripheral and pulmonary edema, dry sticky mucous membranes, and nausea and vomiting. Options A B
and D are not associated with the clinical manifestations of hypernatremia.

1986 A nurse is caring for a hospitalized child with a diagnosis of rheumatic fever (RF), and the child has developed carditis. The mother asks the nurse
to explain the meaning of carditis. The nurse plans to respond, knowing that which of the following most appropriately describes this complication of RF?
Tender, painful joints, especially in the elbows, knees, ankles, and wrists Inflammation of all part of the heart, primarily the mitral vale
Involuntary movements affecting the legs, arms, and face Red skin lesions start as flat or slightly raised macules, usually over the trunk and
spread peripherally B Carditis is the inflammation of all parts of the heart primarily the mitral valve, and is a complication of RF. Option A describes
polyarthritis. Options C Describes chorea. Option D describes erythema marginatum.

1987 A nurse is caring for an 11-year-old child who has been abused. Which of the following is most important to include in the plan of care?
Encourage the child to fear the abuser Provide a care environment that allows for the development of trust Teach the child to make
wise choice when confronted with an abusive situation Have the child point out the abuser if they should visit while the child is hospitalized B
The abused child usually requires long-term therapeutic support. The environment provided during the child’s healing must include one in which
trust and empathy are modeled and provided for the child. Option A reinforces fear, which although it is a legitimate response to abuse, should not be
encouraged. Options C and D ask the child to behave with a maturity beyond that which would be expected for an 11-year-old. Option B is the option that is
most supportive environment in which to begin the healing process.

1988 A nurse is caring for an infant after pyloromyotomy performed to treat hypertrophic pyloric stenosis. The nurse places the infant in which position
following surgery? Flat on the nonoperative side Flat on the operative side Prone with the head of the bed elevated Supine with the head of
the bed elevated C Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration.
Options, A B and D are incorrect position after this type of surgery.

1989 A nurse is caring for an infant who is admitted to the hospital with a diagnosis of hemolytic disease. The nurse reviews the laboratory result,
expecting to note which of the following in this infant? Decreased red blood cell count Decreased bilirubin count Elevated blood glucose level
Decreased white blood cell count A The two primary path physiological alteration associated with hemolytic disease are anemia and
hyperbilirubinemia. The red blood cell count is decreased because the red blood cell production cannot keep pace with red blood cell destruction.
Hyperbilirubinemia results from the red blood cell destruction accompanying this disorder as well as from the normally decreased ability of the neonate’s liver
to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of
insulin. White blood cell count is not related to this disorder.

1990 A nurse is caring for an infant with laryngomalacia (Congenital) laryngeal stridor. In which of the following positions would the nurse place the
infant to decrease the incidence of stridor? Supine Supine with the neck flexed Prone Prone with the neck hyperextended D
The prone position with the neck hyperextended improves the child’s breathing. Options A, B and C are not appropriate positions.

1991 A nurse is developing a plan of care for a child returning from the operating room after a tonsillectomy. The nurse avoids placing which intervention
in the plan of care? Offer clear, cool liquids when the child is awake Eliminate milk or milk products from the diet Monitor for bleeding
from the surgical site Suction whenever necessary D After tonsillectomy, suction equipment should be available, but suctioning is not performed
unless there is an airway obstruction. Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, causing the
child to clear the throat, thus increasing the risk of bleeding. Option C is an important intervention after any type of surgery.

1992 A nurse is developing a plan of care for a newborn infant diagnosed with bilateral club feet. The nurse includes instructions in the plan to tell the
parents that: Genetic testing is wise for future pregnancies, since other children born to this couple may also be affected. If casting is needed, it
will begin at birth and continue for 12 weeks; then the condition will be reevaluated. Surgery performed immediately after birth has been found to be most
effective in achieving a complete recovery. The regimen of manipulation and casing is effective in all cases of bilateral club feet. B Casting
should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to
maintain alignment or surgery can be performed. Surgery is usually delayed until 4 to 12 months of age. Options C and D are inaccurate. Option A does not
address the issue of the question.

1993 A nurse is for a child with a head injury. On review of he record the nurse notes that the physician has documented decorticate posturing. On
assessment of the child, the nurse notes extension of the upper extremities and internal rotation of the upper arm and wrist. The nurse also notes that the lower
extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, which of the following is the appropriate
nursing action? Document the findings Continue to monitor for posturing of the child Attempt to flex the child’s lower extremities
Notify the physician D Decorticate posturing refers to flexion of the upper extremities and extension of the lower extremities. Plantar
flexion of the feet may also be observed. Decerebrate posturing involves extension of the upper extremities with internal rotation of the upper arm and wrist.
The lower extremities will extend, with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually
indicates deteriorating neurological function and warrants physician notification.

1994 A nurse is obtaining a health history for an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and
intervention? I find myself very moody-happy one minute and crying the next. I can’t seem to wake up in the morning. I would sleep until noon if I
could. I don’t eat anything with fat in it, and I’ve lost 8 pounds in 2 weeks. When I get stressed out about school, I just like to be alone. C
During the adolescent period there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme
limitation of omitting all fat in the diet and weight loss during a time of growth suggests inadequate nutrition and a possible eating disorder.

1995 A nurse is performing an admission assessment on a male child and notes the presence of old and new bruises on the child’s back and legs. The
nurse suspects physical abuse. The most appropriate nursing action would be to: File charges against the mother and father of the child Report the
case to legal authorities Ask the mother to identify the individual who is physically abusing the child Tell the child that he will need to go to a foster
home until the situation is straightened out B The primary legal nursing responsibility when child abuse is suspected is to report the case.; All 50
states require health care professionals to report all cases of suspected abuse. It is not appropriate for the nurse to file charges against the father or mother. It is
also inappropriate to ask the mother to identify the abuser, because the abuser may be the mother. If so, the possibility exists that the mother may become
defensive and leave the emergency department with the child. Option D is clearly inappropriate and will produce fear in the child.

1996 A nurse is performing an assessment of a child who is to receive a measles, mumps, and rubella (MMR) vaccine. The nurse notes that the child is
allergic to eggs. Which of the following would be the nurse anticipate to be prescribed for this child? Administration of diphenhydramine (Benadryl)
and acetaminophen (Tylenol) prior to the administration of the MMR vaccine Administration of a killed measles vaccine Eliminating this vaccine from the
immunization schedule Administration of epinephrine (Adrenalin) prior to the administration of the MMR B Live measles vaccine is
produced by chick embryo cell culture, so the possibility of an anaphylactic hypersensitivity in children with egg allergies should be considered. If there is a
question of sensitivity, children should be tested before the administration of MMR vaccine. If a child tests positive for sensitivity, the killed measles vaccine
may be given as an alternative.

1997 A nurse is planning care for a child with an infections and communicable disease. The nurse determines that the primary goals is that the:
Child will experience only minor complications Child will not spread the infection to others Public health department will be notified
Child will experience mild discomfort B The primary goal is to prevent the spread of the disease to others. The child should
experience no complications. Although the health department may need to be notified at some point, it is not the most important primary goal. It is also
important to prevent discomfort as much as possible.

1998 A nurse is planning care for an infant who has pyloric stenosis. In order to most effectively meet the infant’s preoperative needs, the nurse includes
which of the following in the plan of care? Monitor the IV infusion, intake and output, and weight Provide small, frequent feedings of glucose, water, and
electrolytes Administer enemas until returns are clear Provide the mother privacy to breastfeed every 2 hours A Preoperatively, important
nursing responsibilities include monitoring the intravenous infusion, intake and output, and weight, and obtaining urine specific gravity measurements. In
addition, weighing the infant’s diapers provides information regarding output. Preoperatively, the infant is kept NPO unless the physician prescribes a thickened
formula. Enema until clear would further compromise the fluid volume status.

1999 A nurse is planning care for an infant with a diagnosis of encephalocele located in the occipital area. Which of the following items would the nurse
use to assist in positioning the child to avoid pressure on the encephalocele? Sheepskin Foam hal-donut Feather pillow Sandbag B
The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half-donut may be useful in positioning
to prevent this pressure. A sheepskin, feather pillow, or sandbag will not protect the encephalocele from pressure.