Results for Q&A-Random #5

Questions are numbered by the order in which they appeared in the test.
Represents the correct answer.
Question 1
The nurse is caring for a client with a serum potassium Answers Correct C
level of 3.5 mEq/L. The client is placed on a cardiac Student's C
monitor and receives 40 mEq KCL in 1000 ml of 5%
dextrose in water IV. Which of the following EKG patterns
indicates to the nurse that the infusions should be
discontinued?
A) Narrowed QRS complex
B) Shortened "PR" interval
C) Tall peaked T waves
D) Prominent "U" waves
Review Information: The correct answer is C: Tall peaked T waves
A tall peaked T wave is a sign of hyperkalemia. The provider should be notified
regarding discontinuing the medication.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle
River, NJ: Prentice-Hall.

Question 2
A triage nurse has these 4 clients arrive in the emergency Answers Correct B
department within a 15 minute period. Which client should Student's B
the triage nurse send back to be seen first?
A 2 month old infant with a history of rolling off the
A)
bed and has bulging fontanels with crying
B) A teenager who got a singed beard while camping
An elderly client with complaints of frequent liquid
C)
brown colored stools
A middle aged client with intermittent pain behind
D)
the right scapula
Review Information: The correct answer is B: A teenager who got a singed beard
while camping
This client is in the greatest danger with a potential of respiratory distress, Any client
with singed facial hair has been exposed to heat or fire in close range that could have
caused damage to the interior of the lung. Note that the interior lining of the lung has
no nerve fibers so the client will not be aware of swelling.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical,

Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 3
Which individual is at greatest risk for developing Answers Correct A
hypertension? Student's A
A) 45 year-old African American attorney
B) 60 year-old Asian American shop owner
C) 40 year-old Caucasian nurse
D) 55 year-old Hispanic teacher
Review Information: The correct answer is A: 45 year-old African American attorney
The incidence of hypertension is greater among African Americans than other groups
in the US. The incidence among the Hispanic population is rising.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.
(5th edition). St. Louis, Missouri: Mosby.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. (2004). Current medical Diagnosis
and Treatment. (43rd edition). USA:McGraw-Hill.

Question 4
What would the nurse expect to see while assessing the Answers Correct D
growth of children during their school age years? Student's B
A) Decreasing amounts of body fat and muscle mass
B) Little change in body appearance from year to year
C) Progressive height increase of 4 inches each year
D) Yearly weight gain of about 5.5 pounds per year
Review Information: The correct answer is D: Yearly weight gain of about 5.5
pounds per year
School age children gain about 5.5 pounds each year and increase about 2 inches in
height.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.
Question 5
The nurse is caring for a client with a venous stasis ulcer. Answers Correct B
Which nursing intervention would be most effective in Student's C
promoting healing?
A) Apply dressing using sterile technique
B) Improve the client's nutrition status
C) Initiate limb compression therapy
D) Begin proteolytic debridement
Review Information: The correct answer is B: Improve the client''s nutrition status
The goal of clinical management in a client with venous stasis ulcers is to promote
healing. This only can be accomplished with proper nutrition. The other interventions
are appropriate, but without proper nutrition, they would be of little help.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical

Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Question 6
Which complication of cardiac catheterization should the Answers Correct B
nurse monitor for in the initial 24 hours after the Student's D
procedure?
A) Angina at rest
B) Thrombus formation
C) Dizziness
D) Falling blood pressure
Review Information: The correct answer is B: Thrombus formation
Thrombus formation in the coronary arteries is a potential problem in the initial 24
hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the
insertion site which is within the first 12 hours after the procedure.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA:

Thompson Delmar Learning.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 7
In children suspected to have a diagnosis of diabetes, Answers Correct C
which one of the following complaints would be most Student's D
likely to prompt parents to take their school age child for
evaluation?
A) Polyphagia
B) Dehydration
C) Bed wetting
D) Weight loss
Review Information: The correct answer is C: Bed wetting
In children, fatigue and bed wetting are the chief complaints that prompt parents to
take their child for evaluation. Bed wetting in a school age child is readily detected by
the parents.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Question 8
While planning care for a toddler, the nurse teaches the Answers Correct C
parents about the expected developmental changes for this Student's A
age. Which statement by the mother shows that she
understands the child's developmental needs?
A) "I want to protect my child from any falls."
B) "I will set limits on exploring the house."
"I understand our child’s need to use those new
C)
skills."
D) "I intend to keep control over our child’s behavior."
Review Information: The correct answer is C: "I understand our child’s need to use
those new skills."
Erikson describes the stage of the toddler as being the time when there is normally an
increase in autonomy. The child needs to use motor skills to explore the environment.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition).
Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 9
A nurse is to administer meperidine hydrochloride Answers Correct D
(Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and Student's D
promethazine hydrochloride (Phenergan) 50 mg IM to a
pre-operative client. Which action should the nurse take
first?
A) Raise the side rails on the bed
B) Place the call bell within reach
C) Instruct the client to remain in bed
D) Have the client empty bladder
Review Information: The correct answer is D: Have the client empty bladder
The first step in the process is to have the client void prior to administering the pre-
operative medication. The other actions follow this initial step in this sequence: D, C,
B, A. Note: It is much easier to administer IM meds with the side rails down, and then
raising them when the nurse is done. Other activities can then be carried out more
safely.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper
Saddle River, New Jersey: Pearson Prentice Hall.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th
edition). Philadelphia: Saunders.

Question 10
A client with multiple sclerosis plans to begin an exercise Answers Correct B
program. In addition to discussing the benefits of regular Student's D
exercise, the nurse should caution the client to avoid
activities which
A) increase the heart rate
B) lead to dehydration
C) are considered aerobic
D) may be competitive
Review Information: The correct answer is B: lead to dehydration
The client must take in adequate fluids before and during exercise periods.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical

Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 11
A client has been newly diagnosed with hypothyroidism Answers Correct A
and will take levothyroxine (Synthroid) 50 mcg/day by Student's A
mouth. As part of the teaching plan, the nurse emphasizes
that this medication:
A) Should be taken in the morning
B) May decrease the client's energy level
C) Must be stored in a dark container
D) Will decrease the client's heart rate
Review Information: The correct answer is A: Should be taken in the morning
Thyroid supplement should be taken in the morning to minimize the side effect of
insomnia.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition).
Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 12
A nurse enters a client's room to discover that the client has Answers Correct C
no pulse or respirations. After calling for help, the first Student's C
action the nurse should take is
A) start a peripheral IV
B) initiate closed-chest massage
C) establish an airway
D) obtain the crash cart
Review Information: The correct answer is C: establish an airway
Establishing an open airway is always the primary objective in a cardiopulmonary
arrest.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical

Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Question 13
The nurse is speaking at a community meeting about Answers Correct B
personal responsibility for health promotion. A participant Student's B
asks about chiropractic treatment for illnesses. What
should be the focus of the nurse’s response?
A) Electrical energy fields
B) Spinal column manipulation
C) Mind-body balance
D) Exercise of joints
Review Information: The correct answer is B: Spinal column manipulation
The theory underlying chiropractic is that interference with transmission of mental
impulses between the brain and body organs produces diseases. Such interference is
caused by misalignment of the vertebrae. Manipulation reduces the misalignment
(subluxation).

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 14
The home health nurse visits a male client to provide Answers Correct B
wound care and finds the client lethargic and confused. His Student's B
partner states he fell down the stairs 2 hours ago. The nurse
should
A) place a call to the client's provider for instructions
B) send him to the emergency room for evaluation
reassure the client's partner that the symptoms are
C)
transient
instruct the client's partner to call the provider if his
D)
symptoms become worse
Review Information: The correct answer is B: send him to the emergency room for
evaluation
This client requires immediate evaluation. A delay in treatment could result in further
deterioration of his condition and possibly permanent harm. Home care nurses must
prioritize interventions based on assessment findings that are in the client''s best
interest.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis,
Missouri: Mosby.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Question 15
A client comes to the clinic for treatment of recurrent Answers Correct B
pelvic inflammatory disease (PID). The nurse recognizes Student's B
that this condition most frequently follows which type of
infection?
A) Trichomoniasis
B) Chlamydia
C) Staphylococcus
D) Streptococcus
Review Information: The correct answer is B: Chlamydia
Chlamydial infections are one of the most frequent causes of salpingitis or pelvic
inflammatory disease.
Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition).
Prentice Hall: Upper Saddle River, New Jersey.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 16
A client who is pregnant comes to the clinic for a first visit. Answers Correct C
The nurse gathers data about her obstetric history, which Student's D
includes 3 year-old twins at home and a miscarriage 10
years ago at 12 weeks gestation. How would the nurse
accurately document this information?
A) Gravida 4 para 2
B) Gravida 2 para 1
C) Gravida 3 para 1
D) Gravida 3 para 2
Review Information: The correct answer is C: Gravida 3 para 1
Gravida is the number of pregnancies and Parity is the number of pregnancies that
reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant,
had 2 prior pregnancies, and 1 viable birth (twins).

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness.
Upper Saddle River, New Jersey: Prentice Hall.

Question 17
Which of the following should the nurse implement to Answers Correct D
prepare a client for a kidney, ureter, bladder (KUB) Student's B
radiograph test?
A) Client must be NPO before the examination
B) Enema to be administered prior to the examination
Medicate client with Lasix 20 mg IV 30 minutes
C)
prior to the examination
D) No special orders are necessary for this examination
Review Information: The correct answer is D: No special orders are necessary for
this examination
No special preparation is necessary for this examination.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.
Question 18
A child who ingested 15 maximum strength acetaminophen Answers Correct A
tablets 45 minutes ago is seen in the emergency Student's B
department. Which of these orders should the registered
nurse implement first?
A) Gastric lavage PRN
Antidote N-acetylcysteine (NAC) (Mucomyst) for
B)
age per pharmacy
Start a Dextrose 5% with 0.33% normal saline IV to
C)
keep vein open
D) Activated charcoal per pharmacy
Review Information: The correct answer is A: Gastric lavage PRN
Removing as much of the drug as possible is the first step in treatment for this drug
overdose. This is best done by gastric lavage. The next actions to complete would be
to administer activated charcoal, then Mucomyst and lastly the IV fluids.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.

Question 19
The nurse is performing a neurological assessment on a Answers Correct A
client post right cerebral vascular accident (CVA). Which Student's A
finding, if observed by the nurse, would warrant immediate
attention?
A) Decrease in level of consciousness
B) Loss of bladder control
C) Altered sensation of stimuli
D) Emotional lability
Review Information: The correct answer is A: Decrease in level of consciousness
A further decrease in the level of consciousness would be indicative of a further
progression of the CVA.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 20
A client has been taking furosemide (Lasix) for the past Answers Correct D
week. The nurse recognizes which finding may indicate the Student's D
client is experiencing a negative side effect from the
medication?
A) Weight gain of 5 pounds
B) Edema of the ankles
C) Gastric irritability
D) Decreased appetite
Review Information: The correct answer is D: Decreased appetite
Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of
hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle
weakness, and dysrhythmias.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition).
Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th
edition). Philadelphia: Saunders.

Question 21
The nurse anticipates that for a family who practices Answers Correct D
Chinese medicine the priority therapeutic goal would be Student's D
to
A) achieve harmony
B) maintain a balance of energy
C) respect life
D) restore yin and yang
Review Information: The correct answer is D: restore yin and yang
For followers of Chinese medicine, health is maintained through balance between the
forces of yin and yang.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Question 22
An RN who usually works in a spinal rehabilitation unit is Answers Correct C
floated to the emergency department. Which of these Student's C
clients should the charge nurse assign to this RN?
A middle-aged client who says "I took too many diet
A) pills" and "my heart feels like it is racing out of my
chest."
A young adult who says "I hear songs from heaven. I
B) need money for beer. I quit drinking 2 days ago for
my family. Why are my arms and legs jerking?"
An adolescent who has been on pain medications for
C) terminal cancer with an initial assessment finding of
pinpoint pupils and a relaxed respiratory rate of 10
An elderly client who reports having taken a "large
D) crack hit" 10 minutes prior to walking into the
emergency room
Review Information: The correct answer is C: An adolescent who has been on pain
medications for terminal cancer with an initial assessment finding of pinpoint pupils
and a relaxed respiratory rate of 10
Nurses who are floated to other units should be assigned to a client who has minimal
anticipated immediate complications of their problem. The client in option C exhibits
opioid toxicity with the pinpoint pupils and has the least risk of complications
occurring in the near future.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 23
A client is admitted to the emergency room with renal Answers Correct C
calculi and is complaining of moderate to severe flank pain Student's C
and nausea. The client’s temperature is 100.8 degrees
Fahrenheit. The priority nursing goal for this client is
A) Maintain fluid and electrolyte balance
B) Control nausea
C) Manage pain
D) Prevent urinary tract infection
Review Information: The correct answer is C: Manage pain
The immediate goal of therapy is to alleviate the client’s pain, which can be quite
severe with kidney stones.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical

Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.
Question 24
While assessing a 1 month-old infant, which finding Answers Correct C
should the nurse report immediately? Student's C
A) Abdominal respirations
B) Irregular breathing rate
C) Inspiratory grunt
D) Increased heart rate with crying
Review Information: The correct answer is C: Inspiratory grunt
Inspiratory grunting is abnormal and may be a sign of respiratory distress in this
infant.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and
practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and
Children. (7th edition). St. Louis, Missouri: Mosby.

Question 25
When teaching a client with coronary artery disease about Answers Correct C
nutrition, the nurse should emphasize Student's C
A) eating 3 balanced meals a day
B) adding complex carbohydrates
C) avoiding very heavy meals
D) limiting sodium to 7 gms per day
Review Information: The correct answer is C: avoiding very heavy meals
Eating large, heavy meals can pull blood away from the heart for digestion, which is
dangerous for the client with coronary artery disease.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Question 26
The nurse is giving discharge teaching to a client 7 days Answers Correct B
post myocardial infarction. He asks the nurse why he must Student's A
wait 6 weeks before having sexual intercourse. What is the
best response by the nurse to this question?
"You need to regain your strength before attempting
A)
such exertion.
"When you can climb 2 flights of stairs without
B)
problems, it is generally safe."
"Have a glass of wine to relax you, then you can try
C)
to have sex."
"If you can maintain an active walking program, you
D)
will have less risk."
Review Information: The correct answer is B: "When you can climb 2 flights of
stairs without problems, it is generally safe."
There is a risk of cardiac rupture at the point of the myocardial infarction for about 6
weeks. Scar tissue should form about that time. Waiting until the client can tolerate
climbing stairs is the usual advice given by health care providers.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition).
Philadelphia, PA: Lippincott Williams & Wilkins.

Question 27
Which of these statements best describes the characteristic Answers Correct A
of an effective reward-feedback system? Student's C
Specific feedback is given as close to the event as
A)
possible
B) Staff are given feedback in equal amounts over time
C) Positive statements precede a negative statement
Performance goals should be higher than what is
D)
attainable
Review Information: The correct answer is A: Specific feedback is given as close to
the event as possible
Feedback is most useful when given immediately. Positive behavior is strengthened
through immediate feedback, and it is easier to modify problem behaviors if what
constitutes appropriate behavior is clearly understood.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in

Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

Question 28
A child who has recently been diagnosed with cystic Answers Correct C
fibrosis (CF) is being assessed by a pediatric clinic nurse. Student's D
Which finding of this disease would the nurse not expect to
see at this time?
A) Positive sweat test
B) Bulky greasy stools
C) Moist, productive cough
D) Meconium ileus
Review Information: The correct answer is C: Moist, productive cough
Option C is a later sign. Noisy respirations and a dry non-productive cough are
commonly the first of the respiratory signs to appear in a newly diagnosed client with
CF. The other options are the earliest findings. CF is an inherited (genetic) condition
affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally,
these secretions are thin and slippery, but in CF a defective gene causes the secretions
to become thick and sticky. Instead of acting as a lubricant, the secretions plug up
tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure
is the most dangerous consequence of CF.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and
practice (2nd ed.). Philadelphia: Saunders.

Question 29
A nurse prepares to care for a 4 year-old newly admitted Answers Correct A
for rhabdomyosarcoma. The nurse should alert the staff to Student's C
pay more attention to the function of which area of the
body?
A) the muscles
B) the cerebellum
C) the kidneys
D) the leg bones
Review Information: The correct answer is A: the muscles
Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates
in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the
middle of the word -- “myo” --which typically means muscle.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson
Education.

Question 30
Which of these findings indicate that a pump set to deliver Answers Correct C
a basal rate of 10 ml per hour plus PRN morphine drip for Student's B
breakthrough pain is not working?
The client complains of discomfort at the IV insertion
A)
site
B) The client states "I just can't get relief from my pain"
The level of the drug is 100 ml at 8 AM and is 80 ml
C)
at noon
The level of the drug is 100 ml at 8 AM and is 50 ml
D)
at noon
Review Information: The correct answer is C: The level of the drug is 100 ml at 8
AM and is 80 ml at noon
The minimal dose is 10 ml per hour, which would mean 40 mls are given in a 4 hour
period. Only 60 mls should be left at noon. The pump is not functioning when more
than expected medicine is left in the container.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease
processes. (6th edition). Mosby: St. Louis, Missouri.

Question 31
The nurse practicing in a maternity setting recognizes that Answers Correct D
the post mature fetus is at risk due to Student's D
A) Excessive fetal weight
B) Low blood sugar levels
C) Depletion of subcutaneous fat
D) Progressive placental insufficiency
Review Information: The correct answer is D: Progressive placental insufficiency
The placenta functions less efficiently as pregnancy continues beyond 42 weeks.
Immediate and long term effects may be related to hypoxia.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Question 32
A client has a Swan-Ganz catheter in place. The nurse Answers Correct B
understands that this is intended to measure Student's A
A) right heart function
B) left heart function
C) renal tubule function
D) carotid artery function
Review Information: The correct answer is B: left heart function
The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about
the left side of the heart. It can provide hemodynamic information such as intracardiac
pressure readings and oxygen saturation data, and even transvenous pacing.
Information about left ventricular function is important because it directly affects
tissue perfusion. Right-sided heart function is assessed through the evaluation of the
central venous pressure (CVP).

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle
River, NJ: Prentice-Hall.

Question 33
At a community health fair the blood pressure of a 62 year- Answers Correct A
old client is 160/96. The client states “My blood pressure is Student's D
usually much lower.” The nurse should tell the client to
go get a blood pressure check within the next 48 to
A)
72 hours
B) check blood pressure again in 2 months
C) see the health care provider immediately
visit the health care provider within 1 week for a BP
D)
check
Review Information: The correct answer is A: go get a blood pressure check within
the next 48 to 72 hours
The blood pressure reading is moderately high with the need to have it rechecked in a
few days. Although the client states it is ‘usually much lower,’ a concern exists for
complications such as stroke. An immediate check by the provider of care is not
warranted. Waiting 2 months or a week for follow-up is too long.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 34
A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The Answers Correct A
health care provider has written a new order to give Student's A
metoprolol (Lopressor) 25 mg. B.I.D. In assessing the
client prior to administering the medications, which of the
following should the nurse report immediately to the health
care provider?
A) Blood pressure 94/60
B) Heart rate 76 BPM
C) Urine output 50 ml/hour
D) Respiratory rate 16
Review Information: The correct answer is A: Blood pressure 94/60
Both medications decrease the heart rate. Metoprolol affects blood pressure.
Therefore, the heart rate and blood pressure must be within normal range (HR 60-100
BPM; systolic B/P over 100) in order to safely administer both medications.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition).
Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper
Saddle River, New Jersey: Pearson Prentice Hall.

Question 35
The nurse is caring for a client who had a total hip Answers Correct B
replacement 4 days ago. Which assessment requires the Student's B
nurse’s immediate attention?
"I have bad muscle spasms in my lower leg of the
A)
affected extremity."
"I just can't 'catch my breath' over the past few
B)
minutes and I think I am in grave danger."
"I have to use the bedpan to pass my water at least
C)
every 1 to 2 hours."
"It seems that the pain medication is not working as
D)
well today."
Review Information: The correct answer is B: "I just can''t ''catch my breath'' over the
past few minutes and I think I am in grave danger."
The nurse would be concerned about all of these comments, however the most life
threatening is option B. Clients who have had hip or knee surgery are at greatest risk
for development of post operative pulmonary embolism. Sudden dyspnea and
tachycardia are classic findings of pulmonary embolism. Muscle spasms do not
require immediate attention. Option C may indicate a urinary tract infection. Although
option D requires further investigation, it is not life threatening.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 36
The hospital has sounded the call for a disaster drill on the Answers Correct A
evening shift. Which of these clients would the nurse put Student's A
first on the discharge list in order to make room for a new
admission?
A middle aged client with a 7 year history of being
A) ventilator dependent and who was admitted with
bacterial pneumonia five days ago
A young adult with Type 2 diabetes mellitus for over
B) 10 years and who was admitted with antibiotic-
induced diarrhea 24 hours ago
An elderly client with a history of hypertension,
hypercholesterolemia and lupus, and who was
C)
admitted with Stevens-Johnson syndrome that
morning
An adolescent with a positive HIV test and who was
D) admitted for acute cellulitis of the lower leg 48 hours
ago
Review Information: The correct answer is A: A middle aged client with a 7 year
history of being ventilator dependent and who was admitted with bacterial pneumonia
five days ago
The best candidate for discharge is one who has a chronic condition and has an
established plan of care. The client in option A is most likely stable and could continue
medication therapy at home.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical
Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Question 37
A 3 year-old child comes to the pediatric clinic after the Answers Correct D
sudden onset of findings that include irritability, thick Student's D
muffled voice, croaking on inspiration, skin hot to touch,
sits leaning forward, tongue protruding, drooling and
suprasternal retractions. What should the nurse do first?
A) Prepare the child for x-ray of upper airways
B) Examine the child's throat
C) Collect a sputum specimen
D) Notify the healthcare provider of the child's status
Review Information: The correct answer is D: Notify the healthcare provider of the
child''s status
These findings suggest a medical emergency and may be due to epiglottitis. Any child
with an acute onset of an inflammatory response in the mouth and throat should
receive immediate attention in a facility equipped to perform intubation or a
tracheostomy in the event of further or complete obstruction.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and
practice (2nd ed.). Philadelphia: Saunders.
McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and
Children. (7th edition). St. Louis, Missouri: Mosby.

Question 38
During an assessment of a client with cardiomyopathy, the Answers Correct C
nurse finds that the systolic blood pressure has decreased Student's B
from 145 to 110 mm Hg and the heart rate has risen from
72 to 96 beats per minute and the client complains of
periodic dizzy spells. The nurse instructs the client to
A) increase fluids that are high in protein
B) restrict fluids
C) force fluids and reassess blood pressure
D) limit fluids to non-caffeine beverages
Review Information: The correct answer is C: force fluids and reassess blood
pressure
Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg
and an increase in heart rate of more than 15 percent usually accompanied by
dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and
autonomic insufficiency.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle
River, NJ: Prentice-Hall.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 39
The nurse is preparing to administer an enteral feeding to a Answers Correct A
client via a nasogastric feeding tube. The most important Student's A
action of the nurse is to
A) verify correct placement of the tube
check that the feeding solution matches the dietary
B)
order
aspirate abdominal contents to determine the amount
C)
of last feeding remaining in stomach
D) ensure that feeding solution is at room temperature
Review Information: The correct answer is A: verify correct placement of the tube
Proper placement of the tube prevents aspiration.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical

Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.
Question 40
A nurse is evaluating the quality of home care for a client Answers Correct C
with Alzheimer's disease. It would be a priority to Student's C
reinforce which statement by a family member?
A) "At least 2 full meals a day should be eaten."
"We go to a group discussion every week at our
B)
community center."
"We have safety bars installed in the bathroom and
C)
have 24 hour alarms on the doors."
"Taking the medication 3 times a day is not a
D)
problem."
Review Information: The correct answer is C: "We have safety bars installed in the
bathroom and have 24 hour alarms on the doors."
Ensuring safety of the client with increasing memory loss is a priority of home care.
Note all options are positive statements, however safety is most important to reinforce.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia:

Saunders.