NCLEX-RN Q&A Flash Cards by Ray A. Hargrove-Huttel, Kathryn Cadenhead Colgro

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Ray A. Hargrove-Huttel
RN, PhD
Kathryn Cadenhead Colgrove

RN, MS, CNS, OCN
West Coast University

Los Angeles, California
Trinity Valley Community College

Kaufman, Texas
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F. A. Davis Company
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Philadelphia, PA 19103
www.fadavis.com
Copyright 2010 by F. A. Davis Company
All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
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This is our fourth project in writing NCLEX-RN questions for F.A. Davis. We have been in the nursing and teaching
profession for over 30 years, with our goal being to help nursing students successfully pass the nursing program and
become registered nurses. But we also want nurses to care for clients by applying both the art and science of nursing. We
hope you will enjoy your nursing career as much as we have over the last three decades. This book would not be possible
without the unbelievable computer skills of Glada Norris and input from Kathryn McAfee. We would also like to extend
our appreciation to the gang at West Coast University for their invaluable assistance in piloting these questions.
I dedicate this book to the memory of my mother, Mary Cadenhead, and grandmother, Elsie Rogers. They always
said that I could accomplish anything I wanted to accomplish. I also dedicate this book to my husband, Larry; children,
Laurie, Todd, Larry Jr, and Mai; and grandchildren, Chris, Ashley, Justin C., Justin A. Connor, Sawyer, and Carson.
Without their support and patience, the book would not have been possible.
Kathryn Cadenhead Colgrove

I thank my nursing students for always keeping me on my toes and making sure I learn something new every day.
I thank my nursing peers and teaching colleagues for helping me to be the best nurse and teacher I can be. I thank all
my friends for providing me with wonderful experiences and memories. I thank my family for always loving me just the
way I am. I thank my sisters, Gail and Debbie; my nephew, Ben; and Paula for always supporting the choices I make in
life, especially my move to Los Angeles to become the Associate Dean of Nursing at West Coast University. I thank my
children, Teresa and Aaron, being wonderful young people of whom I am so proud and who are always there for me.
I dedicate this book to my parents and to my husband, Bill, who supported me and allowed me to travel a wonderful
journey in my life.
Ray A. Hargrove-Huttel
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REVIEWERS
Tammy Blatnick, RN, MS

Nursing Instructor
Southwestern Oklahoma State University
Weatherford, Oklahoma
Ruth Gladen, MSN

ASN-RN Program Director
North Dakota State College of Science
Wahpeton, North Dakota
Wonda Brown, RN
Nurse Instructor
Connors State College of Nursing
Warner, Oklahoma
Cheri Goit, MSN

Assistant Professor
Northwest University
Kirkland, Washington
Cheryl DeGraw, RN, MSN, CNE, CRNP

Nursing Instructor
Florence Darlington Technical College
Florence, South Carolina
Susan Golden, MSN, RN

Nursing Faculty
ENMU-Roswell
Roswell, New Mexico
Valerie Edwards, RN, MSN

Associate Professor
Passaic County Community College
Paterson, New Jersey
Annie Ruth Grant, BSN, MSN

Medical Surgical Instructor
Florence Darlington Technical College
Florence, South Carolina
Joyce Arlene Ennis, RN, MSN, ANP, BC

Assistant Professor
Carroll University Nursing Program
Waukesha, Wisconsin
Rhonda Renea Hendricks, RN, MSN, BA

Assistant Professor
Nova Southeastern University
Fort Myers, Florida
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Julia Hooley, RN, BSN

Director of the Center for Study and Testing
Malone College
Canton, Ohio
Linda Ann Kucher, MSN, RN, CMSRN

Instructor
St. Joseph School of Nursing
North Providence, Rhode Island
Martha Horst, MSN, RN

Associate Professor of Nursing
Malone College
Canton, Ohio
Christy Madore, FNP-C, MSN

Assistant Professor of Nursing
University of Maine at Fort Kent
Fort Kent, Maine
Cheryl Jackson, RN, BSN

Clinical Specialists
Southeast Kentucky Community and Technical
College
Pineville, Kentucky
Donna Maheady, ARNP, EdD

Adjunct Assistant Professor
Florida Atlantic University and DeVry (Chamberlain
College of Nursing)
Palm Beach Gardens, Florida
Peggy Kelly, RN, BSN

PN Instructor
University of ArkansasFort Smith
Fort Smith, Arkansas
Nadine Mason, CEN, MSN, CRNP

Assistant Professor
Cedar Crest College
Allentown, Pennsylvania
Kim Kocur, MSN, RNC

Assistant Professor
Saint Xavier University
Chicago, Illinois
Susan A. Moore, RN, PhD

Assistant Professor
University of Memphis
Memphis, Tennessee
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Kathy OConnor, MSN, APRN-BC, FNP,

MBA, PLNC
Associate Dean and Assistant Professor
Union University School of Nursing
Jackson, Tennessee
Tricia BrownOHara, RN, MSN
Assistant Professor
Gwynedd-Mercy College
Gwynedd Valley, Pennsylvania
Paula A. Olesen, RN, MSN
Program Director
South Texas College
McAllen, Texas
Martha Olson, RN, BSN, MS
Assistant Professor
Iowa Lakes Community College
Emmetsburg, Iowa
Christine Ouellette, MSN, NP
Adjunct Clinical Faculty
Quincy College
Quincy, Massachusetts
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Diane Peters, RN, MSN

Director, ADN Program
Northwestern Technical College
Rock Spring, Georgia
Kathleen Poindexter, PhD, RN
MSN, Nursing Education Program Coordinator
Michigan State University
East Lansing, Michigan
Pauline Powell, MSN, RN
Nursing Instructor
Northwest Florida State College
Niceville, Florida
Pam Rhodes, MSN
Assistant Professor
University of Arkansas Fort Smith
Fort Smith, Arkansas
Elizabeth Robinson, MSN, RN-BC, CNE
Associate Professor
Northwest Florida State College
Niceville, Florida
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Kowanda O. Robinson, RN, BSN

Program Director
Gwinnett Technical College
Lawrenceville, Georgia
Brigitte Thiele, RN, BSN

Coordinator of Practical Nursing Education
Kennett Career and Technology Center
Kennett, Missouri
Jean Rodgers, RN, MSN

Nursing Faculty
Hesston College
Hesston, Kansas
Kathy Thornton, RN, PhD

Assistant Professor
Georgia Southern University
Statesboro, Georgia
Nancy Rogers, RN, BSN, MA

Associate Professor of Nursing
Carroll Community College
Westminster, Maryland
Joan Ulloth, RN, PhD

Professor of Nursing
Kettering College of Medical Arts
Kettering, Ohio
Patsy M. Spratling, RN, MSN

ADN Faculty
Holmes Community College
Ridgeland, Mississippi
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CONTENTS
Introduction _______________________ X
10. Maternal Child Health ____________ 469
11. Pediatric Disorders _______________ 497
2. Cardiovascular Disorders __________ 55
12. Emergency Nursing ______________ 551
3. Respiratory Disorders _____________ 121
13. Immune Inflammatory

Disorders ________________________ 585
1. Neurological Disorders ____________
4. Gastrointestinal Disorders _________ 177

5. Endocrine Disorders ______________ 235
6. Musculoskeletal Disorders ________ 277
7. Genitourinary Disorders __________ 319
8. Mental Health Disorders __________ 371
9. Womens Health __________________ 429
14. Integumentary ___________________ 637

15. Operative Care ___________________ 671
16. Pharmacology ____________________ 695
Index ____________________________ 759
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Introduction to F.A. Davis Card Questions Features the Latest

Content in the New 2010 Test Plan
These questions are designed to assist nursing students in preparing for various courses across the
curriculum and, of course, that all-important examination, the NCLEX-RN.
This card deck includes 1535 critical thinking questions on flash cards and is organized according
to systems and disease processes. Each card has two to four questions on the front, with answers and
rationales on the back. Approximately half the questions cover medical-surgical content, with the
remaining questions divided equally among pediatric, pharmacology, psychiatric, maternity, womens
health, and management content. All questions are written at the application and analysis leveljust
like the NCLEX.
Users will have access to a unique 265-question final exam on a CD-ROM and included in the
box. The CD also includes all the questions from the card deck, for a total of 1535 questions. All
questions are coded according to the client need category, nursing process step, cognitive level
category of health alteration, and content area, resulting in a diagnostic workup available to the
student for both the final exam and all the questions in the card deck.
The box contains 16 raised tabs to help the user easily find various subjects to review. Included are
key questions on major drug classes, medication administration, plus delegation and management
content integrated within the various tabs. Alternate-format questions are included in the various
systems and diseases/disorders.
For convenience, the box includes a plastic card pouch for easy portability of the flash cards.
The National Council of State Boards of Nursing (NCSBN) provides a blueprint that assists
nursing faculty when developing test questions in preparation for student success on the NCLEX-RN.
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Content included in management of care covers nursing care delivery to protect patients, family/
significant others, and health-care personnel. Related content includes but is not limited to questions
on advance directives, advocacy, case management, patient rights, collaboration with the interdisciplinary
team, delegation, establishing priorities, ethical practice, informed consent, information technology,
and performance improvement. The topics also include legal rights and responsibilities, referrals,
resource management, staff education, supervision, confidentiality/information security, and continuity
of care. The questions in these cards follow this blueprint.
Management, prioritizing, and delegation questions are some of the most difficult questions for the
student and new graduate to answer because there is no reference book in which to find the correct
answer. Answers to these types of questions require a knowledge of basic scientific principles, leadership,
standards of care, pathophysiology, psychosocial behaviors, and the ability to think critically.
Using a Nursing Standard to Make a Decision

The Nursing Process
Nurses base their decisions on many different bodies of information in order to arrive at a course
of action. One of the basic guidelines for nursing practice is to use the nursing process. The nursing
process consists of five steps; the steps are usually completed in a systematic order. The first step
in the nursing process is assessment. Many questions can be answered based on assessment. If a
priority-setting question asks the test taker which step to implement first, then the test taker should
look for an answer that would assess for the problem discussed in the stem.
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For Example:
The nurse is caring for a patient diagnosed with congestive heart failure when the patient complains
of dyspnea. Which intervention should the nurse implement first?
1. Administer furosemide (Lasix), a loop diuretic, IVP.
2. Check the patient for adventitious lung sounds.
3. Ask Respiratory Therapy to administer a treatment.
4. Notify the health-care provider of the problem.
Answer 2, check the patient for adventitious lung sounds, would be assessing the patient to determine
the extent of the breathing difficulties. There are numerous words that can be used to indicate assessment.
The test taker should not discard an option because the word assessment is not used.
The test taker must be aware that the assessment data must match the problem stated in the
stem. Do not jump to a conclusion that an option is correct just because the word assess is used.
The nurse must assess for the correct information. If option 2 in the above example said to assess
the patients urinary output for the last shift, this would be an incorrect option. The exception to
utilizing assessment to guide the test taker is If in stress, DO NOT assess.
Suppose the above question had listed option 3 as:
3. Apply oxygen via nasal cannula at 2 LPM.
Then the nurse would first attempt to intervene to relieve the patients distress before assessing.
These types of questions are designed to determine if the test taker can set priorities in patient care.
To further utilize the nursing process, the test taker must remember the steps of the nursing
process: Assessment, Diagnosis, Planning, Intervention, Evaluation. A question might ask which
the nurse would do next. In this case, the test taker would need to decide which step of the using
process has been completed and then choose an option that matches the next step.
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Maslows Hierarchy of Needs

If the test taker has looked at the question and the nursing process does not assist in determining
the correct answer option, then using a tool such as Maslows Hierarchy of Needs can assist in
choosing the correct answer. Basic physiological needs are the most important in the hierarchy,
followed by safety and security needs, then belongingness and affection, esteem and self respect,
and finally self-actualization. So if a question asks the test taker to determine which is the priority
intervention, and a physiological need is not listed, then a safety-and-security need takes priority.
Prioritizing Questions/Setting Priorities
In a test question that asks for which intervention the nurse would implement first, two or more
of the options will appropriate nursing interventions for the situation. The test taker must decide
which intervention occurs first in a sequence of events or which intervention directly impacts the
situation in order to choose the correct answer.
When the test taker is reading a question that asks which patient the nurse should assess first,
the test taker should look at each option and determine if the signs/symptoms the patient is
exhibiting are normal for the disease process. If they are, the nurse does not need to assess this
patient first. Second, if two or more of the options state signs/symptoms are not normal for the
disease process, then the test taker should select the option that has the greatest potential for a
poor outcome. Each option should be examined carefully to determine the priority by asking these
questions:
1. Is the situation life-threatening or life-altering? If yes, this patient is the highest priority.
2. Is the situation unexpected for the disease process? If yes, then this patient may be priority.
3. Are the lab data abnormal? If yes, then this patient may be priority.
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4. Is the situation expected for the disease process? If yes, then this patient may be but probably is
not priority.
5. Is the situation/presentation normal? If yes, this patient can be seen last because this is the least
priority.
The test taker should try to make a decision pertaining to each option. It is helpful to write out
the decision by the option on pencil-and-paper examinations. This will prevent the test taker from
second guessing. When taking a computerized test, the test taker should make the decision and
move on to the next question.
Delegating and Assigning Care
Although Nursing Practice Acts are individualized by state and province, there are some general
guidelines that apply to all professional nurses.
When delegating to unlicensed assistive personnel (UAP), the nurse may not delegate any activity
that requires nursing judgment. This includes assessing, teaching, evaluating, and medicating and
unstable patients.
When assigning care to a licensed practical nurse, the nurse can assign some medications but
cannot assign assessments, teaching, evaluation, or unstable patients.
Nursing Practice Decisions
The nurse is frequently called upon to make decisions about staffing, movement of patients from
one unit to another, and handling conflicts as they arise. Some general guidelines for answering
questions in this area are:
1. The most experienced nurse gets the most critical patient.
2. A graduate nurse can take care of any patient who is receiving care that a student can give
with supervision.
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3. The most stable patient can move or be discharged. The most unstable patient must move to
or stay in the ICU.
When the nurse must make a decision regarding a conflict in the nursing station, a good rule to
follow is to use the chain of command. The primary nurse should confront a peer (another primary
nurse) or a subordinate, unless the situation is illegal (such as stealing drugs). The primary nurse
should use the chain of command in situations that address superiors (a manager or director of
nursing); then the nurse should discuss the situation with the next in command above the superior.
Nursing Judgment
The nurse is required to acquire information, analyze the data, and make inferences based on
the available information. Sometimes this process is relatively easy; at other times the pieces of
information do not seem to fit. This is when critical thinking and nursing judgment must guide in
making the decision.
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Neurological Disorders
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SECTION ONE
Head Injury
1. The client has sustained a traumatic brain injury
(TBI) secondary to a motor vehicle accident. Which
signs/symptoms would the emergency department (ED)
nurse expect the client to exhibit?
l 1. Blurred vision, nausea, and right-sided hemiparesis.
l 2. Increased urinary output, negative Babinski, and
ptosis.
l 3. Autonomic dysreflexia, positive Brudzinski, and
hyperpyrexia.
l 4. Negative dextrostik, nuchal rigidity, and nystagmus.
2. The intensive care nurse is caring for a client
diagnosed with a closed head injury. Which data would
warrant immediate intervention?
l 1. The client refuses to cough and deep-breathe.
l 2. The clients Glasgow Coma Scale goes from
13 to 7.
l 3. The client complains of a frontal headache.
l 4. The clients Mini-Mental Status Exam
(MMSE) is 30.
3. The rehabilitation nurse is caring for the client with a

closed head injury. Which cognitive goal would be most
appropriate for this client?
l 1. The client will be able to feed himself/herself
independently.
l 2. The client will attend therapy sessions 3 hours a day.
l 3. The client will interact appropriately with staff
members.
l 4. The client will be able to stay on task for 15 minutes.
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ANSWERS
1. Correct answer 1: Signs/symptoms of TBI include

neurological deficits, among them blurred vision,
nausea, and right-sided hemiparesis. A positive
Babinski sign would also occur with head trauma.
Autonomic dysreflexia would be found in a client with
a spinal cord injury; a positive dextrostik for glucose
would be found in someone with a cerebrospinal fluid
leak; and a positive Brudzinski and nuchal rigidity are
signs of meningitis. ContentMedical; Category of
Health AlterationNeurological; Integrated Process
Assessment; Client NeedsPhysiological Integrity,
Physiological Adaptation; Cognitive LevelAnalysis.
2. Correct answer 2: A 15 on the Glasgow Coma Scale

indicates the client is neurologically intact; a decrease
to 7 indicates an increase in the intracranial pressure,
which warrants immediate intervention. A 30 on
the MMSE indicates the client is cognitively intact.
ContentMedical; Category of Health Alteration
Neurological; Integrated ProcessAssessment; Client
NeedsSafe Effective Care Environment, Management
of Care; Cognitive LevelSynthesis.
Copyright 2010 F.A. Davis Company
3. Correct answer 4: Cognitive is mental functioning;

therefore, the ability to stay on task would be the
clients most appropriate cognitive goal. Content
Medical; Category of Health AlterationNeurological;
Integrated ProcessPlanning; Client NeedsPhysiological
Integrity, Physiological Adaptation; Cognitive Level
Synthesis.
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SECTION ONE
4. The intensive care nurse is caring for a client diagnosed

with a TBI who is exhibiting decorticate posturing. Three
hours later the client has flaccid posturing. Which action
should the nurse implement first?
l 1. Notify the clients health-care provider (HCP)
immediately.
l 2. Prepare to administer mannitol (Osmitrol), an
osmotic diuretic.
l 3. Complete a thorough neurological assessment on
the client.
l 4. Reassess the client in 1 hour, including calculating
the Glasgow Coma Scale.
5. The emergency department nurse is entering the room
of a client who was at a baseball game and was hit in the
head with a bat. Which intervention should the nurse
implement first?
l 1. Assess the clients orientation to date, time, and
place.
l 2. Ask the client to squeeze the nurses fingers.
l 3. Determine the clients reaction to the door opening.
l 4. Request the client to move his lower legs.
6. The nurse is preparing the client diagnosed with a
head injury for a magnetic resonance imaging (MRI).
Which interventions should the nurse implement? Select
all that apply.
l 1. Ask the client if he/she is claustrophobic.
l 2. Have the client sign a procedural permit.
l 3. Determine if the client is allergic to shellfish.
l 4. Check if the client has any prosthetic devices.
l 5. Ask the client to empty his/her bladder.
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ANSWERS
4. Correct answer 1: Flaccid posturing is the worst-case

scenario for a client with a TBI; therefore, the nurse
should notify the HCP. Completing a neurological
assessment, administering an osmotic diuretic, and
reassessing the client are all plausible interventions,
but they are not the first to be implemented. Content
Integrated ProcessAssessment; Client NeedsSafe
Effective Care Environment, Management of Care;
Cognitive LevelAnalysis.
5. Correct answer 3: The nurse should first determine

how alert the client is by noticing the reaction when
the door opens. The best reaction is spontaneous
opening of the eyes without verbal or noxious stimuli.
The other three options are appropriate but should
not be the nurses first intervention when entering
the clients room. ContentMedical; Category of
Implementation; Client NeedsPhysiological Integrity,
Physiological Adaptation; Cognitive LevelApplication.
6. Correct answer 1, 4, 5: The client is enclosed in an

MRI tube for an extended period so the client cannot
be claustrophobic or want to stop the procedure. An
MRI cannot be completed on a client with a metal
prosthesis unless it is made with titanium because
the MRI may dislodge the prosthesis. The hospital
admission permit covers the MRI, and because no
contrast dye is now used in most MRIs, an allergy to
shellfish is not pertinent. ContentMedical; Category
of Health AlterationNeurological; Integrated Process
Reduction of Risk Potential; Cognitive LevelApplication.
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SECTION ONE
7. The client with increased intracranial pressure is

receiving mannitol (Osmitrol), an osmotic diuretic.
Which intervention should the nurse implement?
l 1. Monitor the clients complete blood cell (CBC)
count.
l 2. Do not administer the drug if the clients apical
pulse is less than 60.
l 3. Ensure that the clients cardiac status is monitored
by telemetry.
l 4. Use a filter needle when administering the
medication.
8. The male client is being discharged from the ED after
sustaining a minor head injury. Which statement
indicates the wife understands the discharge teaching?
l 1. My husband will be hard to wake up for a couple
of days.
l 2. He doesnt need any pain medication because
I have some at home.
l 3. I should not give my husband anything to eat or
drink for 12 hours.
l 4. I will bring my husband back to the emergency
room if he starts vomiting.
9. The nurse is discussing the TBI Act at a support

group meeting. Which statement best explains the act?
l 1. It is a federal act that provides public policy
regarding community living for clients with a TBI.
l 2. It ensures that all public buildings must have access
for physically challenged clients.
l 3. This act ensures that all clients with a TBI have
access to rehabilitation services.
l 4. It is a national policy that establishes guidelines for
neurological rehabilitation centers.
10. The nurse is caring for a female client who sustained
a closed head injury 8 days ago due to a motor vehicle
accident. Which signs/symptoms would alert the nurse
to a complication of the head injury?
l 1. The client reports having trouble sleeping due to
having nightmares about the wreck.
l 2. The client tells the nurse she has a stuffy nose and
green nasal drainage.
l 3. The client complains of extreme thirst and has an
increased urine output.
l 4. The client informs the nurse that she has started
her menstrual period.
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ANSWERS
7. Correct answer 4: The nurse must use a filter needle

when administering mannitol because crystals may
form in the solution and syringe and be inadvertently
injected into the client. The CBC and apical pulse
are not affected by the medication. Mannitol is
administered cautiously in clients with heart failure,
but telemetry is not required routinely. Content
Integrated ProcessImplementation; Client Needs
Physiological Integrity, Pharmacological and Parenteral
Therapies; Cognitive LevelApplication.
8. Correct answer 4: Vomiting indicates an increase in

intracranial pressure, which is a complication of a
head injury. The client should arouse easily, may eat
and drink (not alcohol), and should not take any type
of pain medication that would mask mental status.
Neurological; Integrated ProcessEvaluation; Client
NeedsHealth Promotion and Maintenance; Cognitive
Level: Evaluation.
9. Correct answer 1: The TBI Act is part of the

Childrens Act of 2000 and is the only federal
legislation designed for clients with a TBI. The Act
provides for a balanced public policy for prevention,
education, research, and community living for clients
with a TBI and their families. ContentMedical;
Category of Health AlterationNeurological; Integrated
ProcessPlanning; Client NeedsPhysiological Integrity,
Physiological Adaptation; Cognitive LevelKnowledge.
10. Correct answer 3: For 710 days post head injury,

the client is at risk for developing diabetes insipidus,
which is a lack of the antidiuretic hormone, resulting
in increased urine output and increased thirst.
NeedsPhysiological Integrity, Physiological Adaptation;
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SECTION ONE
Spinal Cord Injury

11. Which clinical manifestation would the nurse assess
in the client with a T-12 spinal cord injury (SCI) who is
experiencing spinal shock?
l 1. Flaccid paralysis below the waist.
l 2. Lower extremity muscle spasticity.
l 3. Complaints of a pounding headache.
l 4. Hypertension and bradycardia.
12. The nurse is caring for a client who has a C-6 vertebral
fracture and is using Crutchfield tongs with 2-pound
weights. Which data would the nurse expect the client to
exhibit?
l 1. The client is on controlled mechanical ventilation
at 12 respirations a minute.
l 2. The client has no movement of the lower extremities.
l 3. The client has 2+ deep tendon reflexes in the lower
extremities.
l 4. The client has loss of sensation below the C-6
vertebral fracture.
13. The rehabilitation nurse caring for the young client

with a T-12 SCI is developing the nursing care plan.
Which priority intervention should the nurse implement?
l 1. Monitor the clients indwelling urinary catheter.
l 2. Insert a rectal stimulant at the same time every
morning.
l 3. Encourage active lower extremity range of motion
(ROM) exercises.
l 4. Refer the client to a vocational training assistance
program.
14. The nurse is caring for a client with a C-6 SCI in the
neurological intensive care unit. Which nursing intervention
should be implemented?
l 1. Monitor the clients heparin drip.
l 2. Assess the neurological status every shift.
l 3. Maintain the clients ice saline infusion.
l 4. Administer corticosteroids intrathecally.
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ANSWERS
11. Correct answer 1: Spinal shock is associated with an

SCI. It is a sudden depression of reflex activity, a loss
of sensation, and flaccid paralysis below the level of
the injury. T-12 is just above the waist. Content
Integrated ProcessAssessment; Client Needs
Physiological Integrity, Physiological Adaptation;
12. Correct answer 3: The spinal cord has not been

injured; therefore, normal body movement,
responses, and reflexes should be intact. The
Crutchfield tongs ensure that the cervical spine
remains in alignment. ContentMedical; Category of
10
13. Correct answer 2: The clients bowel and bladder

functions must be addressed; therefore, administering
a daily rectal stimulant will ensure a daily bowel
movement. Indwelling urinary catheters are
discouraged due to the increased risk of infection
associated with their use. ContentMedical; Category
Basic Care and Comfort; Cognitive LevelApplication.
14. Correct answer 3: Current treatment options that

have proven efficacy in treating SCI is to decrease
inflammation and edema by lowering the body
temperature with ice saline solutions. Intravenous
corticosteroid therapy is a standard of care but not
intrathecal, into the spinal cord. ContentMedical;
ProcessImplementation; Client NeedsPhysiological
Integrity, Pharmacological and Parenteral Therapies;
Cognitive LevelApplication
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SECTION ONE
15. The male client with a C-6 SCI tells the home health
nurse he has had a severe pounding headache for the last
2 hours. Which intervention should the clinic nurse
implement?
l 1. Determine when and how much the client last
urinated.
l 2. Ask the client if he has taken any medication for
the headache.
l 3. Inquire when the client had his last bowel
movement.
l 4. Check the clients respiratory rate reading
immediately.
16. The client with a T-1 SCI complains of
lightheadedness and dizziness when the head of the
bed is elevated. The clients B/P is 84/40. Which
action should the nurse implement first?
l 1. Increase the clients intravenous (IV) rate by
50 mL/hr.
l 2. Administer dopamine, a vasopressor, via an IV pump.
l 3. Notify the HCP immediately.
l 4. Lower the clients head of bed immediately.
11
17. The nurse caring for a client with a C-6 SCI

determines the client has no plantar reflexes. Which area
on the stick figure should the nurse document this
finding?
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ANSWERS
15. Correct answer 1: The cause of the pounding

headache is most likely autonomic dysreflexia, a
result of exaggerated autonomic responses to stimuli.
An elevated blood pressure would confirm this.
The most common cause of autonomic dysreflexia
is a full bladder. All the other options could be
implemented, but confirming the autonomic
dysreflexia is priority. ContentMedical; Category
of Health AlterationNeurological; Integrated
ProcessImplementation; Client NeedsSafe Effective
Care Environment, Management of Care; Cognitive
LevelAnalysis.
16. Correct answer 4: The blood pressure tends to be

very unstable and low for clients with an SCI of T-6
or above, and slight elevations of the head of the bed
can cause profound drops in the clients vital signs.
Neurological; Integrated ProcessImplementation;
Client NeedsSafe Effective Care Environment,
Management of Care; Cognitive LevelApplication.
12
17. Correct answer: ContentMedical; Category of Health

AlterationNeurological; Integrated ProcessAssessment;
Client NeedsSafe Effective Care, Management of Care;
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SECTION ONE
18. The nurse on the rehabilitation unit is caring for the

following clients with SCIs. Which client should the
nurse assess first after receiving the change-of-shift report?
l 1. The client with a C-6 SCI who has a warm,
reddened edematous gastrocnemius muscle.
l 2. The client with an L-4 SCI who is concerned
about being able to live independently.
l 3. The client with an L-2 SCI who is complaining of
a headache and nausea.
l 4. The client with a T-4 SCI who is unable to move
the lower extremities.
19. The nurse is caring for clients on a rehabilitation
unit. Which nursing task would be most appropriate
for the nurse to delegate to the unlicensed assistive
personnel (UAP)?
l 1. Ask the UAP to hold the urinal while the client
performs the Cred maneuver.
l 2. Discuss the proper method of administering tube
feedings to the family member.
13
3. Assist with bowel training by inserting a suppository
4. Observe the client demonstrating self-catheterization
into the clients rectum.

technique.
20. The 25-year-old client with an SCI is sharing with

the nurse that he is worried about how his family will be
able to survive financially until he can go back to work.
l 1. Refer the client to the American Spinal Injury
Association.
l 2. Refer the client to the state rehabilitation
commission.
l 3. Refer the client to the social worker about applying
for disability.
l 4. Refer the client to an occupational therapist for life
skills training.
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ANSWERS
18. Correct answer 1: The gastrocnemius muscle is the

calf muscle, and warmth, redness, and swelling in
the muscles indicate the client has a deep vein
thrombosis (DVT), which requires immediate
intervention. A client with an L-2 SCI (option 3)
would not experience autonomic dysreflexia. A client
with a T-4 SCI (option 4) would not be expected to
be able to move the lower extremities. Content
19. Correct answer 1: The UAP can hold a urinal for

the client. The UAP cannot assess, teach, evaluate,
administer medications, or care for an unstable client.
Neurological: Integrated ProcessPlanning; Client
NeedsEffective Care Management, Management of
Care; Cognitive LevelSynthesis.
14
20. Correct answer 3: The social worker is responsible

for assisting the client with financial concerns. The
ASIA assists clients to live with their SCI, and the
rehabilitation commission can assist with employment.
Client NeedsPsychosocial Integrity; Cognitive
LevelApplication.
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SECTION ONE
15
Seizures
21. The nurse walks into the room and notes the male
client is lying supine, and the entire body is rigid with his
arms and legs contracting and relaxing. The client is not
aware of what is going on and is making guttural sounds.
Which action should the nurse implement first?
l 1. Loosen constrictive clothing.
l 2. Place padding on the side rails.
l 3. Assess the clients vital signs.
l 4. Turn the client on his side.
22. The client newly diagnosed with epilepsy who works in
an office asks the nurse, What can I do to prevent having
seizures? Which statement is the nurses best response?
l 1. I recommend getting about 4 hours of sleep a
night.
l 2. Ask your supervisor to have someone else make
copies.
l 3. Request your employer to provide a work area
with dim lighting.
l 4. You should get your serum blood level checked
every month.
23. The nurse observes a client having a tonic-clonic

seizure. Which information should the nurse document
in the clients chart? Select all that apply.
l 1. Determine if the client is incontinent of urine or
stool.
l 2. Document the client had privacy during the
seizure.
l 3. Note the time and where the movement or stiffness
began.
l 4. Note the circumstances before the clients seizure
activity began.
l 5. Note the results of a complete neurological
assessment.
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ANSWERS
21. Correct answer 4: Placing the client on his side

helps keep the airway patent; therefore, it is the first
intervention. All the other interventions may be
done, but airway is priority. ContentMedical;
LevelAnalysis.
22. Correct answer 2: Flashing lights, such as occur

with a copying machine, can evoke a seizure and
should be avoided; other causes of seizures include
stress, fatigue, and alcohol intake. Serum blood levels
will not help prevent seizures, but they do indicate
the serum drug level. ContentMedical; Category of
Planning; Client NeedsPhysiological Integrity,
Reduction of Risk Potential; Cognitive LevelSynthesis.
16
23. Correct answer 1, 3, 4: The nurse should assess

the client before, during, and after seizure activity.
Providing privacy is expected and would not be
documented in the chart. The client in the postictal
state needs rest; therefore, a complete neurological
assessment would not be appropriate. ContentMedical;
LevelApplication.
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SECTION ONE
24. The UAP is holding the arms of a client who is having

a tonic-clonic seizure. Which action should the nurse
implement?
l 1. Help the UAP restrain the clients upper extremities.
l 2. Instruct the UAP to release the clients arms
immediately.
l 3. Take no action because the assistant is handling the
situation.
l 4. Notify the charge nurse of the situation
immediately.
25. The client diagnosed with a seizure disorder is
prescribed phenytoin (Dilantin), an anticonvulsant.
Which statement indicates the client needs more
teaching concerning this medication?
l 1. I will brush my teeth after every meal.
l 2. I will get my Dilantin level checked regularly.
l 3. My urine will turn orange while on Dilantin.
l 4. This medication will help prevent my seizures.
17
26. The client is admitted to the intensive care unit

(ICU) experiencing status epilepiticus. Which intervention
should the nurse anticipate implementing first?
l 1. Assess the clients neurological status frequently.
l 2. Monitor the clients heart rhythm via telemetry.
l 3. Administer diazepam (Valium), a benzodiazepine.
l 4. Prepare to administer anticonvulsant medication.
27. The client is admitted to the ED after experiencing a
partial seizure. Which question would be most appropriate
for the nurse to ask the client?
l 1. Do you know if you lost consciousness during the
seizure?
l 2. Are you feeling sleepy or very tired at this time?
l 3. When did you last take your seizure medication?
l 4. Were you feeling jittery or irritable prior to the
seizure?
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ANSWERS
24. Correct answer 2: The client should be protected

from injury but be allowed to move freely. Restraining
the clients extremities could result in orthopedic
injury to the client. ContentMedical; Category of
Implementation; Client NeedsSafe Effective Care
Environment, Management of Care; Cognitive
LevelApplication.
25. Correct answer 3: Dilantin does not turn the urine

orange; therefore this statement indicates the client
needs more teaching. ContentMedical; Category of
Health AlterationDrug Administration; Integrated
ProcessEvaluation; Client NeedsPhysiological
Cognitive LevelSynthesis.
18
26. Correct answer 3: The client is in distress; therefore,

assessment is not priority. The nurse should first
administer Valium to halt the seizure immediately
to ensure adequate oxygen supply to the brain.
Anticonvulsant medications are administered later
to maintain a seizure-free state. ContentMedical;
ProcessPlanning; Client NeedsSafe Effective Care,
Management of Care; Cognitive LevelAnalysis.
27. Correct answer 3: The nurse must determine if the

client has been compliant with medication; therefore,
this question is appropriate. The client does not
lose consciousness in a partial seizure and does not
experience a postictal state. Hypoglycemia (feeling
jittery or irritable) causes tonic-clonic seizures, not
partial seizures. ContentMedical; Category of Health
Client NeedsPhysiological Integrity, Physiological
Adaptation; Cognitive LevelAnalysis.
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SECTION ONE
28. Which statement by the female client indicates that

the client understands factors that may precipitate seizure
activity?
l 1. I should not take birth control pills to prevent
pregnancy.
l 2. I need to limit my intake of dairy products.
l 3. I should not participate in any contact sports.
l 4. My menstrual cycle may affect my seizure
disorder.
29. The clinic nurse is checking diagnostic test results.
Which diagnostic test result would warrant notifying the
client immediately?
l 1. The female client who is taking an anticonvulsant
who has a low bone density scan.
l 2. The client who is diagnosed with epilepsy who has
a phenytoin (Dilantin) level of 28 mcg/dL.
l 3. The client with a seizure disorder who has a
carbamazepine (Tegretol) of 10 mcg/mL.
l 4. The client who has partial seizures who has a
serum sodium level of 143 mEq/L.
19
30. The mother of a child who had a febrile seizure tells

the pediatric clinic nurse, I am so upset because now my
child has epilepsy. Which statement is the clinic nurses
best response?
l 1. Your child had a seizure due to a high fever, not
due to epilepsy.
l 2. You are upset about your child having epilepsy.
Lets talk.
l 3. The Epilepsy Foundation of America provides
good information.
l 4. I would recommend you attend the local epilepsy
support group.
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ANSWERS
28. Correct answer 4: Because of the fluctuations in

hormones that alter the excitability of neurons in
the cerebral cortex, an increase in seizure frequency
may occur during menses. ContentMedical; Category
Evaluation; Client NeedsPhysiological Integrity,
Physiological Adaptation; Cognitive LevelEvaluation.
29. Correct answer 2: The therapeutic Dilantin level is

1020 mcg/dL; a level of 28 mcg/dL requires
notifying the client. ContentMedical; Category of
Health AlterationNeurological; Integrated
ProcessAssessment; Client NeedsPhysiological Integrity,
Physiological Adaptation; Cognitive LevelSynthesis.
20
30. Correct answer 1: A high fever in a child can cause

a seizure, but it does not indicate the child has a
seizure disorder. The nurse should provide
information if at all possible instead of a therapeutic
response that encourages the client to ventilate
feelings. ContentMedical; Category of Health
AlterationNeurological; Integrated ProcessEvaluation;
Client NeedsHealth Promotion and Maintenance;
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SECTION ONE
21
Cerebrovascular Accident
(Stroke, Brain Attack)
31. The 88-year-old client is admitted to the ED with
numbness and weakness of the left arm and slurred
speech. The computed tomography (CT) scan was negative
for bleeding. Which nursing intervention is priority?
l 1. Prepare to administer tissue plasminogen activator
(TPA).
l 2. Discuss the precipitating factors that caused the
symptoms.
l 3. Determine the exact time the symptoms occurred.
l 4. Notify the speech pathologist for an emergency
consult.
32. The nurse is assessing the client experiencing a
left-sided cerebrovascular accident (CVA). Which clinical
manifestations would the nurse expect the client to
exhibit?
l 1. Hemiparesis of the left arm and apraxia.
l 2. Paralysis of the right side of the body and aphasia.
l 3. Inability to recognize and use familiar objects.
l 4. Impulsive behavior and hostility toward family.
33. The HCP has discussed a carotid endarterectomy

with the client who has experienced two transient ischemic
attacks (TIAs). The client tells the nurse, I really dont
understand why I need this procedure, and I dont want
to have it. Which scientific rationale would support the
nurses response?
l 1. This surgery is indicated for clients with symptoms
of a TIA due to carotid artery stenosis.
l 2. This surgical procedure will ensure the client does
not have a cerebrovascular accident.
l 3. This surgery will remove all atherosclerotic plaque
from the carotid arteries.
l 4. This surgical procedure will increase the elasticity
of the carotid arterial wall.
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ANSWERS
31. Correct answer 3: The nurse must first determine

when the symptoms started before administering
TPA, a standard of care. TPA must be initiated
within 3 hours of the start of symptoms because,
after that time, revascularization of necrotic tissue,
which occurs with the administration of TPA,
increases the risk for cerebral edema and hemorrhage.
NeedsReduction of Risk Potential; Cognitive
LevelAnalysis.
32. Correct answer 2: A left-sided CVA results in rightsided paralysis, right visual field deficit, aphasia
(inability to speak), and altered intellectual ability.
All other options are results of right-sided CVA.
22
33. Correct answer 1: This is the rationale the nurse

would utilize to encourage the client to have this
surgical procedure. An endartectomy does not ensure
the client will not have a CVA nor does it ensure
that all atherosclerotic plaque will be removed or
that the carotid artery wall will become more elastic.
Neurological; Integrated ProcessPlanning; Client
NeedsPhysiological Adaptation, Reduction of Risk
Potential; Cognitive LevelSynthesis.
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SECTION ONE
34. Which client would the nurse identify as being least

at risk for experiencing a CVA?
l 1. A 55-year-old African-American male who is obese.
l 2. A 73-year-old Japanese female who has essential
hypertension.
l 3. A 67-year-old Caucasian male whose cholesterol
level is below 200 mg/dL.
l 4. A 39-year-old female who is taking oral
contraceptives.
35. The client diagnosed with a right-sided CVA is
admitted to the rehabilitation unit. Which intervention
should be included in the nursing care plan?
l 1. Turn and reposition the client every shift.
l 2. Place a small pillow under the clients left shoulder.
l 3. Have the client perform quadriceps exercises three
times a day.
l 4. Instruct the client to hold fingers in a fist.
23
36. The nurse is planning care for the client experiencing

dysphagia secondary to a CVA. Which intervention
should be included in the plan of care?
l 1. Evaluate the client during mealtime.
l 2. Position the client in a semi-Fowler position.
l 3. Administer oxygen during meals.
l 4. Refer the client to a physical therapist.
37. The nurse and a UAP are caring for a client with
right-sided paralysis. Which action by the UAP requires
the nurse to intervene?
l 1. The UAP places the gait belt under the clients
axilla prior to ambulating.
l 2. The UAP places the client on the abdomen with
the clients head to the side.
l 3. The UAP uses a lift sheet when moving the client
up in the bed.
l 4. The UAP praises the client for attempting to
perform activities of daily life (ADLs) independently.
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ANSWERS
34. Correct answer 3: Caucasians have a lower risk of

CVA than African Americans, Hispanics, and Native
Pacific Islanders. A high cholesterol level, being African
American, hypertension, and oral contraceptive use are
risk factors for developing a CVA. ContentMedical;
ProcessDiagnosis; Client NeedsHealth Promotion and
Maintenance; Cognitive LevelAnalysis.
35. Correct answer 2: Placing a small pillow under the

left shoulder will prevent the shoulder from adducting
toward the chest and developing a contracture. The
client should be repositioned at least every 2 hours;
quadricep exercises should be done for 10 minutes at
least five times a day; and the fingers are positioned so
that they are barely flexed. ContentMedical; Category
Planning; Client NeedsPhysiological Integrity, Basic
Care and Comfort; Cognitive LevelSynthesis.
24
36. Correct answer 1: Dysphagia (swallowing difficulty)

puts the client at risk for aspiration, pneumonia,
dehydration, and malnutrition; therefore, the nurse
should evaluate the client during mealtime. The client
should be in a high Fowler position or, preferably, in a
chair. ContentMedical; Category of Health Alteration
Neurological; Integrated ProcessPlanning; Client Needs
37. Correct answer 1: The gait belt should be around

the waist because this is the clients center of gravity.
All other options are appropriate interventions for
the UAP and would not require intervention.
Immobility; Cognitive LevelSynthesis.
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SECTION ONE
38. The client diagnosed with chronic atrial fibrillation has

experienced a transient TIA. Which discharge instruction
should the nurse implement?
l 1. Keep nitroglycerin tablets in a dark-colored bottle.
l 2. Check the radial pulse prior to all medications.
l 3. Obtain International Normalized Ratio (INR)
routinely.
l 4. Take over-the-counter vitamin K tablets daily.
39. The client diagnosed with a CVA has hemiparesis.
Which problem would be priority for the client?
l 1. Impaired skin integrity.
l 2. Fluid volume overload.
l 3. High risk for aspiration.
l 4. High risk for injury.
25
40. The nurse has received the morning shift report.

Which client should the nurse assess first?
l 1. The client who is complaining of a headache at
a 3 on a scale of 110.
l 2. The client who has an apical pulse of 56 and a
blood pressure of 210/116.
l 3. The client who is reporting not having a bowel
movement in 3 days.
l 4. The client who is angry because the call light was
not answered for 1 hour.
Brain Tumors
41. The client is being admitted with rule-out (R/O)
brain tumor. Which signs/symptoms support the
diagnosis of a brain tumor?
l 1. Widening pulse pressure, hypertension, and
bradycardia.
l 2. Headache, vomiting, and diplopia.
l 3. Hypotension, tachycardia, and tachypnea.
l 4. Abrupt loss of motor function, diarrhea, and
changes in taste.
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ANSWERS
38. Correct answer 3: An oral anticoagulant, warfarin

(Coumadin), will be prescribed to help prevent the
formation of thrombi in the atrium secondary to atrial
fibrillation. The thrombi can become embolic, which
may cause a TIA. The INR is the laboratory value
used to determine therapeutic oral anticoagulant
levels. ContentMedical; Category of Health Alteration
LevelSynthesis
39. Correct answer 4: Hemiparesis is a weakness on one

side of the body that may lead to falls; this makes
high risk for injury the priority problem for this
client. ContentMedical; Category of Health Alteration
Neurological; Integrated ProcessDiagnosis; Client Needs
Physiological Integrity, Reduction of Risk Potential;
26
40. Correct answer 2: This blood pressure is extremely

high, and the pulse rate is decreased; therefore, this
client should be assessed first. A 3 headache, no
bowel movement, and an upset client would not be
priority over a client who may be having a CVA.
of Care; Cognitive LevelAnalysis.
41. Correct answer 2: The classic triad of symptoms of

a brain tumor includes a headache that is dull and
unrelenting and worse in the morning, vomiting
unrelated to food intake, and edema of the optic
nerve (papilledema) causing diplopia. Option 1 is the
Cushing triad, which indicates increased intracranial
pressure that would not be seen initially on diagnosis;
option 3 is signs/symptoms of hypovolemic shock.
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SECTION ONE
Page 27
27
42. The client is diagnosed with a frontal lobe brain

tumor. Which sign/symptom would the nurse expect
the client to exhibit?
l 1. Ataxia.
l 2. Decreased visual acuity.
l 3. Scanning speech.
l 4. Personality changes.
44. The client diagnosed with lung cancer has developed

metastasis to the brain. Which problem would be priority
for this client?
l 1. Anticipatory grieving.
l 2. Impaired gas exchange.
l 3. Altered nutritional status.
l 4. Alteration in comfort.
43. The male client diagnosed with a brain tumor is

having a closed magnetic resonance imaging (MRI) scan
in 1 hour. The client tells the radiology nurse, I dont
like small enclosed spaces. Which action should the
nurse implement?
l 1. Allow the client to express his feelings.
l 2. Discuss the procedure with the client.
l 3. Obtain an order for an anti-anxiety medication.
l 4. Reschedule the procedure for another day.
45. The client diagnosed with a brain tumor was

admitted to the ICU with decorticate posturing. Which
indicates that the clients condition is improving?
l 1. The client has purposeful movement with painful
stimuli.
l 2. The client assumes adduction of the upper
extremities.
l 3. The client assumes the decerebrate posture upon
painful stimuli.
l 4. The client has become flaccid and does not respond
to stimuli.
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ANSWERS
42. Correct answer 4: Personality changes occur in a

client with a frontal lobe tumor. Ataxia or gait
problems indicate a temporal lobe tumor. Decreased
visual acuity is a symptom indicating papilledema, a
general symptom of the majority of all brain tumors,
not specifically a frontal lobe tumor. Scanning
speech is symptomatic of multiple sclerosis. Content
Medical; Category of Health AlterationNeurologic;
Integrated ProcessAssessment; Client NeedsPhysiological
Analysis.
43. Correct answer 3: The client is claustrophobic and

will need medications to help decrease the anxiety
associated with small enclosed spaces. Ventilating
feelings and discussing the procedure will not help
claustrophobia. Reschedule for an open MRI, not
another closed MRI. ContentMedical; Category of
28
44. Correct answer 1: Anticipatory grieving is priority

because brain metastasis is a terminal diagnosis,
indicating death within 6 months or less. With the
development of brain metastasis, the nurse must
address death and dying issues, which is why this is
priority over all the other client problems. Content
Integrated ProcessDiagnosis; Client NeedsSafe
45. Correct answer 1: Purposeful movement following

painful stimuli would indicate an improvement in the
clients condition. Adducting the upper extremities
while internally rotating the lower extremities is
decorticate positioning; this would indicate the
clients condition had not changed. Decerebrate
posturing and flaccid movement indicate a worsening
of the condition. ContentMedical; Category of Health
AlterationNeurological; Integrated ProcessEvaluation;
Adaptation; Cognitive LevelEvaluation.
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SECTION ONE
46. The intensive care nurse is caring for a client following

an infratentorial craniotomy. Which interventions should
the nurse implement? Select all that apply.
l 1. Keep the head of the bed elevated at 30 degrees.
l 2. Keep a humidifier in the clients room.
l 3. Do not put anything in the clients mouth.
l 4. Provide the client with a clear liquid diet.
l 5. Assess the clients respiratory status every hour.
47. The client is diagnosed with a pituitary tumor and is
scheduled for a transsphenoidal hypophysectomy. Which
postoperative instruction is important to discuss with the
client?
l 1. Demonstrate to a family member how to change a
turban dressing.
l 2. Explain to the client how to monitor urine output
at home.
l 3. Tell the client not to blow his nose for 2 weeks
after surgery.
l 4. Tell the client he will have to lie flat for 24 hours
following the surgery.
29
48. The client has undergone a craniotomy for a brain

tumor. Which data indicate a complication of this surgery?
l 1. The client complains of a headache at a 34 on a
110 scale.
l 2. The client has a urinary output of 250 mL over the
last 24 hours.
l 3. The client has a serum sodium level of 137 mEq/L.
l 4. The client experiences dizziness when trying to get
up too quickly.
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ANSWERS
46. Correct answer 2, 4, 5: Humidified air would be

provided; the clients diet is started slowly; and the
respiratory status is assessed because the centers that
control respiration and vomiting are in the area of
the brain affected by the surgery. The head of the
bed would be flat, and caution with oral care is
appropriate for a client with a transsphenoidal
hypophysectomy, not with an infratentorial
craniotomy. ContentSurgical; Category of Health
AlterationNeurological; Integrated Process
Reduction of Risk Potential; Cognitive LevelAnalysis.
47. Correct answer 3: Blowing the nose creates

increased intracranial pressure and could result in a
leak of cerebral spinal fluid. A transsphenoidal
hypophysectomy is done by an incision above the
gum line, and there is no turban dressing. The head
of the bed is elevated to 30 degrees to allow for
gravity to assist in draining the cerebrospinal fluid.
ContentSurgical; Category of Health Alteration
30

48. Correct answer 2: The decreased urinary output

may indicate syndrome of inappropriate antidiuretic
hormone (SIADH), which is a complication of a
craniotomy. A headache after this surgery would be
an expected occurrence. The sodium level is normal
(135145 mEq/L). Dizziness upon arising quickly
would not be a complication of this surgery. Content
Surgical; Category of Health AlterationNeurological;
Adaptation, Reduction of Risk Potential; Cognitive
LevelAnalysis.
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SECTION ONE
31
Meningitis
49. The client diagnosed with a brain tumor is prescribed
intravenous dexamethasone (Decadron), a steroid.
Which intervention should the nurse implement when
administering this medication?
l 1. Administer medication with normal saline only.
l 2. Check the clients white blood cell (WBC) count.
l 3. Determine if the client has oral candidiasis.
l 4. Monitor the clients glucose level.
50. The male client is scheduled for gamma knife
stereotactic surgery for a brain tumor. Which preoperative
instruction should the nurse discuss with the client?
l 1. Instruct the client to avoid bright lights and wear
sunscreen.
l 2. Tell the client he must sleep with the head of the
bed elevated.
l 3. Explain there are no activity limitations after this
procedure.
l 4. Encourage the client to take off at least 2 weeks
from work.
51. The nurse is assessing the client diagnosed with

bacterial meningitis. In addition to nuchal rigidity, which
clinical manifestations would the nurse assess?
l 1. Positive Cushing sign and ascending paralysis.
l 2. Negative Kernig sign and facial tingling.
l 3. Positive Brudzinski sign and photophobia.
l 4. Negative Trousseau sign and descending paralysis.
52. The nurse is admitting a client diagnosed with
meningococcal meningitis and notes lesions over the face
and extremities. Which priority intervention should the
nurse implement?
l 1. Initiate the intravenous antibiotics stat.
l 2. Obtain a skin biopsy for culture and sensitivity.
l 3. Perform a complete neurological assessment.
l 4. Close all the curtains in the room and turn off
lights.
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ANSWERS
49. Correct answer 4: Decadron, a glucocorticosteroid,

will increase insulin resistance, which increases
glucose levels; therefore, glucose levels should be
monitored. Decadron is compatible with dextrose,
so normal saline does not need to be used, and the
WBC count and oral candidiasis would not be
interventions pertinent to administering this
medication. ContentMedical; Category of Health
AlterationDrug Administration; Integrated Process
Pharmacological and Parenteral Therapies; Cognitive
LevelApplication.
50. Correct answer 3: This is a day-surgery procedure,

and the client is usually discharged home 34 hours
after the surgery and can resume normal activities.
Surgical; Integrated ProcessPlanning; Client Needs
Safe Effective Care Environment, Management of Care;
32
51. Correct answer 3: A positive Brudzinski sign (raise

the clients head, and the knees will come up) and
photophobia due to meningeal irritation are key
signs of meningitis. A positive Kernig sign (client is
unable to extend leg when lying flat) would also be
expected. ContentMedical; Category of Health
AlterationNeurological; Integrated ProcessDiagnosis;
52. Correct answer 1: Purpuric lesions over the face and

extremities are the signs of a fulminating infection in
clients with meningococcal meningitis. The infection
can lead to death within a few hours. The nurse
should start the antibiotics immediately. Content
Integrated ProcessImplementation; Client NeedsSafe
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SECTION ONE
53. Which type of precautions should the nurse implement

for the client diagnosed with aseptic meningitis?
l 1. Standard precautions.
l 2. Airborne precautions.
l 3. Contact precautions.
l 4. Droplet precautions.
54. A college student came to the university health clinic
and was diagnosed with bacterial meningitis and admitted
to a local hospital. Which intervention should the university
health clinic nurse implement?
l 1. Place the clients dormitory under strict respiratory
isolation.
l 2. Notify the parents of all students about the
meningitis outbreak.
l 3. Arrange for students to receive the meningococcal
vaccination.
l 4. Ensure dormitory roommates receive
chemoprophylaxis using rifampin.
33
55. The nurse is preparing for a lumbar puncture for the

client diagnosed with R/O meningitis. Which interventions
should the nurse implement? Select all that apply.
l 1. Determine if the client has any allergies to iodine.
l 2. Do not let the client urinate 2 hours before the
procedure.
l 3. Place the client in a prone position with the face
turned to the side.
l 4. Instruct the client to take slow deep breaths during
the procedure.
l 5. Label the specimen and send to the laboratory for
cultures.
56. The client diagnosed with septic meningitis is admitted
to the medical floor at 1200. Which HCPs order would
the nurse implement first?
l 1. Administer intravenous antibiotic.
l 2. Start the clients intravenous line.
l 3. Provide a quiet, calm dark room.
l 4. Initiate seizure precautions.
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ANSWERS
34
53. Correct answer 1: Aseptic meningitis is caused by a
55. Correct answer 1, 4, 5: The lumbar area is cleansed
noninfectious agent or a virus and is not likely to be

transmitted to other people; therefore, standard
precautions would be expected. Septic meningitis
would require droplet precautions for 24-48 hours
after initiation of antibiotics. ContentMedical;
with Betadine; therefore, iodine allergies should be

noted. The clients bladder should be empty for
comfort during the procedure, and the client should
be in a side-lying position with back arched for
access to intravertebral space. Taking slow deep
breaths will help calm the client, and specimens are
sent to the laboratory. ContentMedical; Category of

LevelApplication.
54. Correct answer 4: People in close contact with

clients diagnosed with meningococcal meningitis,
the most common type of infectious agent in group
settings, should receive chemoprophylaxis for
prevention of meningitis. The public health nurse or
college administration would notify parents. It is too
late for the vaccine. ContentMedical; Category of
Health AlterationInfectious Disease; Integrated
ProcessPlanning; Client NeedsSafe Effective Care
Environment, Safety and Infection Control; Cognitive
LevelSynthesis.

56. Correct answer 2: Intravenous antibiotics are of

paramount importance, so the nurse must start an
intravenous line first. ContentMedical; Category of
Health AlterationInfectious Diseases; Integrated
LevelSynthesis.
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SECTION ONE
57. The nurse asks the UAP to help admit the client
diagnosed with bacterial meningitis. Which nursing task
is priority?
l 1. Take the clients vital signs.
l 2. Obtain the clients height and weight.
l 3. Prepare the room for respiratory isolation.
l 4. Pull the drapes and make sure the room is dim.
58. The 18-year-old client is admitted to the medical
floor with a diagnosis of meningitis. Which priority
intervention should the nurse assess?
l 1. Assess the clients neurovascular status.
l 2. Assess the clients cranial nerve IX function.
l 3. Assess the clients brachioradialis reflex.
l 4. Assess the clients neurological status.
Page 35
35
59. The nurse is developing a plan of care for a client

diagnosed with septic meningitis. Which client goal
would be most appropriate for the client problem of
altered thermoregulation?
l 1. The client will have no injury from using the
hypothermia blanket.
l 2. The client will be protected from injury if seizure
activity occurs.
l 3. The client will be afebrile for 48 hours prior to
discharge.
l 4. The client will have serum electrolytes within
normal limits.
meningitis who has AIDS. Which signs/symptoms would
the nurse expect the client to exhibit?
l 1. A positive Babinski sign.
l 2. Diplopia and blurred vision.
l 3. Auditory deficits.
l 4. The client may be asymptomatic.
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ANSWERS
57. Correct answer 3: Equipment needed for the staff

to enter the clients room safely is the priority
nursing task that can be delegated. All other tasks
could be safely delegated to the UAP, but they are
not priority. ContentMedical; CategoryInfectious
Diseases; Integrated ProcessPlanning; Client Needs
58. Correct answer 4: Meningitis directly affects

the clients brain; therefore, assessing the
neurological status would have priority for this
client. Neurovascular assessment involves peripheral
nerves and changes such as paralysis and skin
temperature. ContentMedical; Category of Health
AlterationInfectious Diseases; Integrated Process
Assessment; Client NeedsSafe Effective Care
LevelAnalysis.
36
59. Correct answer 3: The client with septic meningitis

has a high fever; therefore, being afebrile for 48 hours
would be an appropriate goal. ContentMedical; Category of Health AlterationInfectious Diseases; Integrated
60. Correct answer 4: The client with AIDS may be

asymptomatic or may exhibit atypical symptoms
because of blunted inflammatory responses. Content
Medical; Category of Health AlterationInfectious
Diseases; Integrated ProcessAssessment; Client Needs
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SECTION ONE
37
Parkinson Disease
61. Which clinical manifestations would the nurse
expect to assess in the client diagnosed with Parkinson
disease (PD)?
l 1. Nausea, vomiting, and diarrhea.
l 2. Polyuria, polydipsia, and polyphagia.
l 3. Dysphonia, dysphagia, and scanning speech.
l 4. Tremors, rigidity, and bradykinesia.
62. The nurse caring for a client diagnosed with Parkinson
disease writes a problem of Impaired Nutrition. Which
nursing intervention would be included in the plan of care?
l 1. Give the client a pureed diet.
l 2. Request a low-residue heart-healthy diet.
l 3. Provide an 1800-calorie American Diabetic
Association diet.
l 4. Offer bite-sized foods on a plate warmer.
63. The nurse and the UAP are caring for clients on
a medical surgical unit. Which task would be most
appropriate to assign to the UAP?
l 1. Feed the client with Parkinson disease who has
intention tremors of the hand.
l 2. Change the sterile pressure ulcer dressing for a
client who is on bedrest.
l 3. Give the client who is having heartburn 30 mL of
the antacid Maalox.
l 4. Obtain vital signs on a client with Parkinson
disease who is hallucinating.
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ANSWERS
61. Correct answer 4: Tremors, rigidity, and bradykinesia

are the classic manifestations of PD. They are known
as the triad of PD. ContentMedical; Category of
62. Correct answer 4: Bite-sized foods require less

energy from the client for chewing, and a plate
warmer preserves the appeal of the food. Nothing in
the stem of the question indicates that the client has
diabetes, so the ADA diet would not be necessary.
The client should have a high-residue (fiber) diet to
prevent constipation. A pureed diet has baby-food
consistency and should not be given to a client
who can chew. ContentMedical; Category of Health
AlterationNeurological; Integrated ProcessPlanning;
Management of Care; Cognitive LevelSynthesis.
38
63. Correct answer 1: The client with intention tremors

is stable but cannot keep the food on the eating
utensil to get it to the mouth; this task could be
safely delegated to the UAP. UAP cannot assess,
teach, evaluate, administer medications, or care for
an unstable client. The client hallucinating is having
a reaction to the Parkinson disease medications and
is unstable. ContentMedical; Category of Health
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SECTION ONE
39
64. The charge nurse is making assignments on a medical

surgical unit. Which client should be assigned to the
licensed practical nurse (LPN)?
l 1. The client with Parkinson disease who became
disoriented throughout the night.
l 2. The client with aseptic meningitis who is
complaining the light is bothersome.
l 3. The client newly diagnosed with Parkinson disease
who is being discharged.
l 4. The client diagnosed with a brain tumor who had
a seizure at the change of shift.
66. The client diagnosed with Parkinson disease is

being discharged. Which statement made by the clients
significant other indicates a need for more teaching?
l 1. I know that my husband may have some
emotional mood swings.
l 2. My spouse may experience hallucinations until the
medication starts working.
l 3. I will schedule appointments late in the morning
after his morning bath.
l 4. My spouse must take his medication at the same
time every day.
65. The nurse is planning the care for a client diagnosed

with Parkinson disease. Which goal would be appropriate
for the client problem of impaired mobility?
l 1. The client will experience periods of akinesia
throughout the day.
l 2. The client will be able to turn from side to
side in bed.
l 3. The client will be able to ambulate in the hall three
times a day.
l 4. The client will be able to carry out ADLs.
67. The client with Parkinson disease is admitted to the

medical unit diagnosed with pneumonia. The nurse needs
to administer ceftriaxone (Rocephin) 100 mg in 100 mL
of normal saline to infuse over 30 minutes. Which rate
should the nurse set the intravenous pump?
Answer: ____________________
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ANSWERS
64. Correct answer 2: Photophobia is an expected clinical

manifestation of aseptic meningitis, so the LPN could
be assigned to this client. New-onset disorientation
indicates the client is unstable and would require the
registered nurse (RN) to assess the client. The newly
diagnosed client with PD requires extensive teaching.
Seizure activity may indicate increasing intracranial
pressure. ContentMedical; Category of Health
65. Correct answer 3: The goal of a client with impaired

mobility would be to be mobile; walking in the hall
would be an appropriate goal. Akinesia is lack of
movement, and the client should not be allowed to
stay in bed due to immobility complications. Ability
to do ADLs would be appropriate for self-care deficit
problem. ContentMedical; Category of Health
Client NeedsPhysiological Integrity, Basic Care and
Comfort; Cognitive LevelSynthesis.
40
66. Correct answer 2: Hallucinations are a sign that the

client is experiencing drug toxicity; therefore, this
statement indicates that the significant other needs
more teaching. The other statements indicate the
clients significant other understands the discharge
teaching. ContentMedical; Category of Health
Adaptation; Cognitive LevelSynthesis.
67. Correct answer 200 mL/hour: Intravenous pumps

are set at an hourly rate; if 100 mL is infused in
1 hour, the nurse should double the rate so that
100 mL would infuse in 30 minutes. ContentMedical;
Category of Health AlterationDrug Administration;
Cognitive LevelApplication.
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SECTION ONE
68. The home health nurse is caring for a client diagnosed

with Parkinson disease. Which comment by the clients
significant other would suggest a common cognitive
problem associated with Parkinson disease?
l 1. My wife is never happy about anything
I do for her.
l 2. All my wife does is sit on the porch and look at
her garden.
l 3. My wife is becoming more forgetful about routine
things.
l 4. My wife thinks the medication I give her is poison.
41
69. The nurse is conducting a support group for clients

diagnosed with PD and their significant others. Which
information regarding physiological needs should be
included in the discussion?
l 1. Remove all throw rugs and tack down all loose
carpet.
l 2. Recommend the client completes an advance
directive.
l 3. Explain the reason why the client has pill rolling
tremors.
l 4. Give simple, short, concise directions to their
loved one.
70. The client has been diagnosed with Parkinson disease
for 12 years and has been taking levodopa (L-dopa) for
the last 8 years. Which symptom would alert the nurse to
a possible medication complication?
l 1. The client is unable to initiate voluntary movement.
l 2. The client has recently developed dyskinesia.
l 3. The client has masklike facies and cogwheel
movements.
l 4. The client has excessive saliva production.
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ANSWERS
68. Correct answer 3: Memory deficits are cognitive
42
70. Correct answer 2: Dyskinesia is abnormal involun-
impairments; the client may also develop a dementia.

Emotional liability, depression, and paranoia are
psychosocial problems, not cognitive ones. Content
tary movement, including facial grimacing, rhythmic

jerking movements, and head-bobbing. These movements indicate a complication of the L-dopa.

Integrated ProcessEvaluation; Client NeedsPsychosocial
Integrity; Cognitive LevelEvaluation.

NeedsPhysiological Integrity, Pharmacological and
Parenteral Therapies; Cognitive LevelAnalysis.
69. Correct answer 1: The clients safety is priority due to

the physiological shuffling gait that makes the client
high risk for injuries due to falls. ContentMedical;
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SECTION ONE
43
Sensory Deficits
71. The client is diagnosed with acute otitis media.
Which statement would cause the nurse to suspect the
client had a ruptured tympanic membrane?
l 1. I always have a lot of earwax buildup.
l 2. I have been running a fever with my ear pain.
l 3. I had ear pain but then it went away on its own.
l 4. I had a sinus infection prior to getting the ear pain.
72. The client is diagnosed with Mnire disease. Which
statement by the client supports that the client needs
more teaching concerning the management for this
disease?
l 1. Surgery is the only cure for Mnire, but I may
be deaf.
l 2. I will have to use a hearing aid for the rest of
my life.
l 3. I must adhere to a low-sodium diet, 2000 mg/day.
l 4. When I get dizzy I need to lie down on my bed.
73. The nurse is preparing to administer otic drops into

the adult clients right ear. Which action should the nurse
implement?
l 1. Grasp the ear lobe and pull up and out when
putting drops in the ear.
l 2. Insert the eardrops without touching the outside of
the ear.
l 3. Place the applicator 14 inch into the outer ear canal.
l 4. Pull the auricle down and back prior to instilling
drops.
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ANSWERS
71. Correct answer 3: The pain associated with otitis

media is relieved after spontaneous perforation or
therapeutic incision of the tympanic membrane.
Ear pain and fever are expected with otitis media.
Neurosensory; Integrated ProcessAssessment; Client
NeedsPhysiological Integrity, Reduction of Risk
Potential; Cognitive LevelAnalysis.
72. Correct answer 2: Mnire disease does not lead to

deafness unless surgery is done, which may result in
permanent deafness in the affected ear. Sodium regulates the balance of fluid within the body; therefore, a
low-sodium diet is prescribed to help control the
symptoms of Mnire disease. ContentMedical;
Category of Health AlterationNeurosensory; Integrated
ProcessEvaluation; Client NeedsPhysiological Integrity,
44
73. Correct answer 4: Pulling the auricle down and back

prior to instilling drops will straighten the ear canal
so that the ear drops will enter the ear canal and
drain toward the tympanic membrane (eardrum).
Nothing should be placed in the outer ear canal.
ContentMedical; Category of Health AlterationDrug
Administration; Integrated ProcessImplementation;
Client NeedsPhysiological Integrity, Pharmacological
and Parenteral Therapies; Cognitive LevelApplication.
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SECTION ONE
74. The client is scheduled for right tympanoplasty.

Which statement indicates the client understands the
preoperative teaching concerning the surgery?
l 1. If I have to sneeze or blow my nose, I will do it
with my mouth open.
l 2. If I have any dizzy spells, I will contact my doctor
immediately.
l 3. I will probably have permanent hearing loss in my
right ear.
l 4. I can shampoo my hair the day after surgery as
long as I am careful.
75. The client diagnosed with osteoarthritis has been
self-medicating with high doses of aspirin for the pain.
Which comment by the client would warrant further
evaluation by the nurse?
l 1. I always take my medication with food.
l 2. I have noticed a buzzing sound in my ears.
l 3. I soak in a hot tub bath in the morning.
l 4. I will call my doctor if my gums bleed.
45
76. The client is diagnosed with cataracts. Which

symptom would the nurse expect the client to report?
l 1. Halos around lights.
l 2. Floating spots in the eye.
l 3. Everything has a yellow haze.
l 4. Painless, blurry vision.
77. The 65-year-old client is diagnosed with macular
degeneration. Which statement indicates the client
understands the discharge teaching concerning this
diagnosis?
l 1. I should use artificial tears three times a day.
l 2. I will look at my Amsler grid at least twice a week.
l 3. I am going to use low-watt lightbulbs in my house.
l 4. I will wear dark sunglasses when I go outside.
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ANSWERS
74. Correct answer 1: Leaving the mouth open when

coughing or sneezing will minimize the pressure
changes in the middle ear. Dizziness is expected after
ear surgery. Tympanoplasty is a repair of the inner ear
structure and will not cause permanent hearing loss.
Shampooing is avoided to prevent contamination of
the ear canal. ContentSurgical: Category of Health
AlterationNeurosensory; Integrated ProcessEvaluation;
Client NeedsPhysiological Integrity, Reduction of Risk
Potential: Cognitive LevelEvaluation.
75. Correct answer 2: The buzzing should alert the

nurse to possible tinnitus, which is a sign of aspirin
toxicity and warrants further evaluation by the nurse.
46
76. Correct answer 4: A cataract is a lens opacity or

cloudiness resulting in painless, blurry vision. The
symptom in option 1 is characteristic of glaucoma;
that in option 2 of retinal detachment; and that in
option 3 of digoxin toxicity. ContentMedical;
Category of Health AlterationNeurosensory; Integrated
77. Correct answer 2: Amsler grids provide the earliest

sign of worsening of the clients macular degeneration.
If the lines of the grid become distorted or faded,
the client should call the ophthalmologist. Content
Medical; Category of Health AlterationNeurosensory;
Integrated ProcessEvaluation; Client NeedsPhysiological
Integrity, Physiological Adaptation; Cognitive
LevelEvaluation.
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SECTION ONE
78. The nurse is preparing to administer eyedrops to a

client. To which area should the nurse apply pressure to
prevent systemic absorption of the medication?
l 1. A
l 2. B
l 3. C
l 4. D
47
79. A male client is brought to the employee health

clinic reporting some type of chemical was splashed in his
eyes. Which action should the nurse implement first?
l 1. Arrange for transportation to the ophthalmologist.
l 2. Perform a vision screening test on the client.
l 3. Flush the eye continuously with water.
l 4. Complete an occurrence report for the situation.
80. The client with glaucoma is prescribed a miotic
cholinergic medication. Which data support the teaching
for this medication has been effective?
l 1. The client reports taking the medication on
vacations.
l 2. The client reports taking a stool softener every day.
l 3. The client places the medication in the inner
canthus.
l 4. The client wears gloves when instilling the
medication.
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ANSWERS
78. Correct answer 4: The area marked A is known as

the inner canthus; gentle pressure to this area will
prevent systemic absorption of the medication.
Client NeedsPhysiological Adaptation, Pharmacological
and Parenteral Therapies; Cognitive LevelSynthesis.
79. Correct answer 3: The first and most important

intervention is to flush the agent out of the eye.
Then the nurse should refer the client to an
ophthalmologist, maybe check vision, and then
complete an occurrence report because the client was
not wearing goggles. ContentMedical; Category of
Health AlterationNeurosensory; Integrated Process
LevelSynthesis.
48
80. Correct answer 1: The client realizes that medication

compliance is priority for glaucoma and consequently
takes the medication while on vacation. The client
should prevent constipation, but it has nothing to do
with miotic medications. Medication should be placed
in the conjunctiva. The client needs to wash the hands
but not wear gloves. ContentMedical; Category of
ProcessEvaluation; Client NeedsHealth Promotion and
Maintenance; Cognitive LevelEvaluation.
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SECTION ONE
49
Management Issues
81. The nurse is caring for clients on a medical surgical
floor. Which client should be assessed first?
l 1. The client diagnosed with epilepsy who reports
over the intercom having an aura.
l 2. The client with an L-1 SCI who is complaining of
shortness of breath while exercising.
l 3. The client diagnosed with Parkinson disease who is
being discharged today.
l 4. The client diagnosed with a CVA who has
resolving left hemiparesis.
82. The charge nurse in the medical/surgical department

is making rounds at 0700. Which client should the nurse
see first?
l 1. The client diagnosed with a brain tumor who is
complaining of a headache.
l 2. The client diagnosed with meningitis who is
complaining of a stiff neck.
l 3. The client diagnosed with diabetes who is
reporting seeing spots in the eyes.
l 4. The client diagnosed with low back pain who has
radiating pain down the left leg.
83. The registered nurse (RN), an LPN, and a UAP are
caring for clients on a neurological unit. Which task would
be most appropriate for the nurse to assign/delegate?
l 1. Instruct the LPN to complete the clients admission
assessment.
l 2. Request the UAP to change the central line
dressing.
l 3. Assign the LPN to administer routine medications.
l 4. Tell the UAP to complete the Glasgow Coma Scale.
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ANSWERS
81. Correct answer 1: The client with an aura is getting

ready to have a seizure. This client should be seen
first. ContentMedical; Category of Health Alteration
82. Correct answer 3: Seeing spots could indicate a

retinal detachment, and this requires the nurse to
assess this client first. If the signs/symptoms are
expected for the disease processsuch as headache
with a brain tumor, a stiff neck with meningitis, and
pain radiating down the leg in a client with low back
painthen the nurse should not assess that client
first unless the symptom is life-threatening. Content
50
83. Correct answer 3: The LPN can administer routine

medications. The RN should not delegate/assign
assessment to an LPN or a UAP (options 1 and 4).
The central line dressing change is a sterile dressing
that should not be delegated to a UAP. Content
Medical; Category of Health AlterationDrug
Administration; Integrated ProcessPlanning; Client
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SECTION ONE
51
84. The nurse is caring for a client diagnosed with septic

meningitis. The UAP reports T 101.6F, P 128, R 32,
B/P 96/46. Which action should the nurse implement
first?
l 1. Notify the HCP.
l 2. Assess the client immediately.
l 3. Prepare to administer acetaminophen (Tylenol).
l 4. Check the chart for the culture and sensitivity
report.
86. The 22-year-old client with a severe head injury is

admitted to the critical care unit. Some of the clients
friends come to the nurses station requesting information.
Which action would be most appropriate by the nurse?
l 1. Tell the friends to talk to the parents.
l 2. Discuss the clients situation with the friends.
l 3. Allow the friends to visit the client for 10 minutes.
l 4. Explain that no information can be shared with the
friends.
85. The nurse is preparing to administer dexamethasone

(Decadron) intravenous push (IVP) to a client with an
acute spinal cord injury. Which interventions should the
nurse implement? Rank in order.
l 1. Administer the medication over 2 minutes.
l 2. Dilute the medication with normal saline.
l 3. Check the clients medication administration
record (MAR).
l 4. Check the clients identification band.
l 5. Clamp the primary tubing distal to the port.
87. The male client diagnosed with a brain tumor who is

receiving hospice care is admitted to the hospital and
provides the nurse with a copy of his living will, stating
he does not want any heroic measures. Which action
l 1. Check the chart to make sure there is a do not
resuscitate (DNR) order.
l 2. Inform the HCP that the client has a living will.
l 3. Place a copy of the living will in the front of the
clients chart.
l 4. Request the hospital chaplain to come and talk to
the client.
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ANSWERS
84. Correct answer 2: Whenever another health-care team

member reports information to the nurse, assessment
should be completed to confirm the data. Then the
nurse should notify the HCP, administer Tylenol to
decrease the fever, and check the chart, but the nurse
must first realize this is potential septic shock, and the
client should be assessed. ContentMedical; Category of
Health AlterationInfectious Diseases; Integrated Process
LevelApplication.
85. Correct answer 3, 2, 4, 5, 1: First check the MAR

to ensure the right medication, the right dose, at the
right time. Diluting the medication saves the vein
and decreases the clients pain during administration.
Check for the right client by checking the clients
identification band. Clamping the tubing will ensure
the medication goes into the vein, and 2 minutes is
the recommended administration time. Content
52
Cognitive LevelSafe Effective Care Environment,

86. Correct answer 4: The nurse cannot violate the

clients confidentiality according to the Health
Information Privacy and Portability Act (HIPPA).
ContentFundamentals; Category of Health Alteration
of Care; Cognitive LevelApplication.
87. Correct answer 1: This action should be implemented

first to ensure the clients wishes will be honored in
case the client codes. All other actions could be taken,
but the clients wishes are priority. ContentMedical;
LevelApplication.
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SECTION ONE
88. The charge nurse has received laboratory data for

clients. Which situation requires the charge nurses
intervention first?
l 1. The client with a brain tumor who has ABGs:
ph 7.36, PaO2 95, PaCO2 38, HCO3 24.
l 2. The postoperative craniotomy client who has a
serum sodium level of 153 mEq/L.
l 3. The client with septic meningitis who has a white
blood cell count of 12,000 mm.
l 4. The client with epilepsy who has a serum
phenytoin (Dilantin) level 15 mcg/mL.
89. The primary nurse in the neurological critical
care unit is very busy. Which nursing task must be
implemented first?
l 1. Assist the HCP with a sterile dressing change for a
client who has a turban dressing.
l 2. Obtain a tracheostomy tray for a client with a
C-4 SCI who is exhibiting air hunger.
l 3. Transcribe orders for a client who was transferred
from the emergency department.
l 4. Administer the antibiotic therapy to the client
diagnosed with meningitis.
53
90. The nurse and a UAP are caring for a client with
right-sided paralysis secondary to a CVA. Which action
by the UAP requires the nurse to intervene?
l 1. The UAP encourages the client to perform ROM
exercises.
l 2. The UAP places the client on a side with a pillow
between the legs.
l 3. The UAP leaves a urinal full of urine at the clients
bedside.
l 4. The UAP praises the client for attempting to get
dressed alone.
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ANSWERS
88. Correct answer 2: An elevated serum sodium level

(normal is 135145 mEq/L) indicates possible
diabetes insipidus, which is a complication of brain
surgery. The ABGs are within normal limits, the
WBC count would be elevated in a client with
meningitis, and the therapeutic Dilantin level is
1020 mcg/mL. ContentMedical; Category of Health
AlterationSurgical; Integrated ProcessImplementation;
89. Correct answer 2: The client with a C-4 SCI may

have ascending edema that could cause respiratory
compromise; therefore, the nurse should have a
tracheostomy tray at the bedside. ContentMedical;
LevelEvaluation.
54
90. Correct answer 3: The UAP should be instructed to

keep all urinals and bedpans clean when at the bedside.
Neurological; Integrated ProcessImplementation; Client
NeedsSafe Effective Care Environment, Management of
Care; Cognitive LevelApplication.
SECTION TWO
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Cardiovascular Disorders
55
11/11/09
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Page 56
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SECTION TWO
57
Angina/Myocardial Infarction
1. The nurse is caring for a client who was diagnosed
with a myocardial infarction 24 hours ago. The client has
developed an audible S3 heart sound. Which action
l 1. Notify the health-care provider (HCP)
immediately.
l 2. Document the finding in the client's chart.
l 3. Assess the client's blood pressure.
l 4. Check the client's telemetry reading.
2. While the nurse is ambulating the client diagnosed
with angina to the bathroom, the client begins to
complain of chest pain radiating to the left arm. Which
intervention should the nurse implement first?
l 1. Administer a nitroglycerin tablet sublingually.
l 2. Return the client to bed and tell client to lie in
the bed.
l 3. Place oxygen on the client via nasal cannula.
l 4. Request a stat electrocardiogram (ECG).
3. Which statement indicates the client diagnosed with

angina needs more discharge teaching?
l 1. I will keep my nitroglycerin in a dark bottle at all
times.
l 2. I should stay on a low-fat, low-cholesterol diet.
l 3. I will not walk outside if it is colder than 40F.
l 4. I should perform isometric exercises three times
a week.
4. The client comes to the emergency department
complaining of chest pain. Which comment by the client
would indicate to the nurse the client is experiencing
angina instead of a myocardial infarction?
l 1. I was resting in my recliner when my chest started
hurting.
l 2. I was mowing my lawn when I started having
chest pain.
l 3. I started having chest pain when I took a deep
breath.
l 4. My heart started pounding in my chest and then
I felt pain.
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ANSWERS
1. Correct answer 1: An audible S3 heart sound indicates

heart failure, which is a complication of a myocardial
infarction. Therefore, the nurse should notify the
HCP first. Assessing the blood pressure, checking
the telemetry, and documenting findings in the
patient's chart are interventions that should be implemented, but the nurse should notify the HCP first.
Content AreaMedical; Category of Health Alteration
Cardiovascular; Integrated ProcessImplementation;
2. Correct answer 2: The nurse should first have the

client lie down to help decrease the need for oxygen to
the myocardium. Then the nurse should administer
sublingual nitroglycerin and place oxygen on the
client. After these interventions, the nurse should
request a stat ECG. Content AreaMedical; Category
of Health AlterationCardiovascular; Integrated
LevelApplication.
58
3. Correct answer 4: Isometric exercises are musclebuilding exercises such as weightlifting. The client
should perform isotonic exercises such as walking
and swimming. This indicates the client needs more
discharge teaching. All other statements indicate the
client understands the teaching.Content AreaMedical;
Category of Health AlterationCardiovascular; Integrated
ProcessEvaluation; Client NeedsHealth Promotion and
Maintenance; Cognitive LevelEvaluation
4. Correct answer 2: Angina is usually brought on by

activity such as exercising, cold weather (constriction),
stress, or sexual intercourse. Content AreaMedical;
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SECTION TWO
5. The nurse is discussing modifiable risk factors with the

client diagnosed with angina. Which instructions should
be included in the instructions? Select all that apply.
l 1. Discuss the importance of eating a diet low in fiber.
l 2. Explain the need to keep the cholesterol level under
200 mg/dL.
l 3. Instruct the client to walk for 30 minutes three
times a week.
l 4. Tell the client to decrease the amount of cigarettes
smoked daily.
l 5. Inform the client the blood glucose level should be
70120 mg/dL.
6. The nurse is caring for a client diagnosed with a
myocardial infarction. Which assessment data would
warrant immediate attention by the nurse?
l 1. The client has a urinary output of 120 mL in
2 hours.
l 2. The client's telemetry shows multifocal premature
ventricular contractions (PVCs).
59
3. The client's bilateral anterior and posterior breath
4. The client's cardiac enzymes and white blood cells
sounds are clear.

are elevated.
7. The HCP has prescribed thrombolytic therapy for the

client diagnosed with a myocardial infarction. Which data
indicate the medication is effective?
l 1. The client's cardiac enzymes decrease.
l 2. The client's chest pain is relieved.
l 3. The client exhibits reperfusion dysrhythmias.
l 4. The client's blood pressure is within normal limits.
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ANSWERS
5. Correct answer 2, 3, 5: Risk factors include a high

cholesterol level, sedentary lifestyle, cigarette smoking,
and diabetes. The client must quit smoking, not just
decrease smoking. The client should eat a low-fat, lowcholesterol, and high-fiber diet. Content AreaMedical;
ProcessImplementation; Client NeedsHealth Promotion
and Maintenance; Cognitive LevelApplication.
6. Correct answer 2: Cardiac dysrhythmias occur in

about 90% of clients experiencing a myocardial
infarction. Multifocal PVCs are life-threatening
and require immediate intervention by the nurse.
Cardiovascular; Integrated ProcessAssessment; Client
Potential; Cognitive LevelEvaluation.
60
7. Correct answer 3: Reperfusion dysrhythmias

(premature ventricular contractions) indicate the
tissue is viable, which indicates the medication is
effective. Content AreaMedical; Category of Health
AlterationCardiovascular; Integrated Process
LevelEvaluation.
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SECTION TWO
61
8. The charge nurse is making assignments for clients on

a medical unit. Which client should the charge nurse
assign to the recent graduate nurse?
l 1. The client diagnosed with angina whose pain is
unrelieved with nitroglycerin.
l 2. The client who is scheduled for a left-sided cardiac
catheterization.
l 3. The client with a myocardial infarction whose
pulse oximeter reading is 90%.
l 4. The client diagnosed with heart disease who needs
discharge teaching.
10. The charge nurse is observing a licensed practical

nurse (LPN) applying a nitroglycerin patch to the client
diagnosed with angina. Which action warrants immediate
intervention from the charge nurse?
l 1. The LPN places the nitroglycerin patch on a
non-hairy area.
l 2. The LPN dates and times the nitroglycerin patch.
l 3. The LPN wears gloves when applying the
nitroglycerin patch.
l 4. The LPN applies the new patch while leaving the
old patch in place.
9. The intensive care nurse is caring for a client

diagnosed with a myocardial infarction. Which
intervention should the nurse implement?
l 1. Monitor the client's urine output every shift.
l 2. Keep the head of the client's bed flat.
l 3. Assess the client's breath sounds every 2 hours.
l 4. Discourage the client from deep breathing.
Atherosclerosis
11. Which statement indicates to the nurse the client
understands a modifiable risk factor for atherosclerosis?
l 1. As I get older my chance of having a heart attack
increases.
l 2. My father and grandfather both died of heart disease.
l 3. I listen to relaxation tapes to help decrease my
high stress level.
l 4. I will take saw palmetto every day to help decrease
my blood pressure.
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ANSWERS
8. Correct answer 2: A newly graduated nurse would be

able to care for a stable client scheduled for a cardiac
catheterization. The client with angina not relieved
by nitroglycerin is not stable, and a client with
hypoxemia (a pulse oximeter reading less than 93%)
should be assigned to a more experienced nurse, as
should discharge teaching. Content AreaMedical;
LevelAnalysis.
9. Correct answer 3: The client is at risk for cardiac

failure; therefore, the nurse should assess the breath
sounds for crackles. The urine output should be
checked more frequently than every shift, the head of
the bed should be in semi-Fowler position, and deep
breathing should be encouraged to decrease the chance
of pneumonia. Content AreaMedical; Category of
Health AlterationCardiovascular; Integrated Process
62
10. Correct answer 4: The LPN should remove

the old patch prior to administering the new
patch. Content AreaMedical; Category of Health
LevelApplication.
11. Correct answer 3: A modifiable risk factor is a risk

factor that can possibly be altered by modifying or
changing behavior, such as developing new ways to
deal with stress. Age and family history are nonmodifiable risk factors. Saw palmetto helps treat benign
prostatic hypertrophy, not high blood pressure.
Cardiovascular; Integrated ProcessEvaluation; Client
LevelEvaluation.
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SECTION TWO
12. The client asks the nurse, My doctor just told me

that atherosclerosis is why my chest hurts when I walk
real fast. What does that mean? Which statement is the
nurse's best response?
l 1. The muscle fibers and endothelial lining of your
arteries have become thickened.
l 2. You sound concerned because your chest hurts
when you walk real fast.
l 3. The valves in your heart are incompetent, which
is why your chest hurts with activity.
l 4. You have a hardening of your arteries with fatty
buildup that decreases the oxygen to your heart.
13. The client diagnosed with peripheral vascular disease
is overweight, has smoked two packs of cigarettes a day
for 20 years, and sits behind a desk all day. Which
statement by the client refers to the strongest factor in
the development of atherosclerotic lesions?
l 1. I am going to try and lose at least 20 pounds.
l 2. I have to get out from behind the desk more often.
l 3. I am going to eat foods that are high in fiber.
l 4. I have to quit smoking cigarettes but it will be hard.
63
14. The female client tells the nurse that her cholesterol
level was 189 mg/dL. Which action should the nurse
implement?
l 1. Praise the client for having an acceptable cholesterol
level.
l 2. Explain that the client needs to lower the cholesterol
level.
l 3. Discuss dietary changes that could help increase the
level.
l 4. Allow the client to ventilate feelings about the
blood result.
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ANSWERS
12. Correct answer 4: This response explains in plain

terms why the client has chest pain with increased
activity. The client needs information, not a therapeutic response (option 2). The nurse should assume
the client is a layperson and should not explain
disease processes using medical terminology such as
in option 1. Content AreaMedical; Category of
Implementation; Client NeedsPhysiological, Physiological Adaptation; Cognitive LevelApplication.
13. Correct answer 4: Tobacco use is the strongest factor in the development of atherosclerosis. Nicotine
decreases blood flow to the extremities and increases
heart rate and blood pressure. In addition it increases
the risk of clot formation by increasing the aggregation of platelets. Content AreaMedical; Category of
Evaluation; Client NeedsHealth Promotion and
64
14. Correct answer 1: The American Heart Association

recommends the cholesterol level should be less than
200 mg/dL; therefore the nurse should praise the
client. Content AreaMedical; Category of Health
Implementation; Client NeedsHealth Promotion and
Maintenance; Cognitive LevelApplication.
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SECTION TWO
15. The nurse is discussing the pathophysiology of

atherosclerosis with a client who has a high low-density
lipoprotein (LDL) level. Which information should
the nurse discuss with the clients concerning the
pathophysiology of LDL?
l 1. A high LDL is good because it has a protective
action in the body.
l 2. This test result measures the free fatty acids and
glycerol in the blood.
l 3. LDLs are the primary transporters of cholesterol
into the cell.
l 4. The client needs to decrease the amount of
cholesterol and fat in the diet.
16. Which assessment data would cause the nurse to
suspect the client has atherosclerosis?
l 1. The client complains of her legs swelling when she
stands for long periods.
l 2. The client has episodes of jitteriness and headache
when feeling hungry.
65
3. The client has bilateral calf pain when walking for
4. The client complains of mid-epigastric pain after
short periods.
eating spicy foods.
17. The HCP prescribed atorvastatin, (Lipitor), an

HMG-CoA reductase inhibitor. Which teaching
intervention should the nurse include when discussing
this medication?
l 1. Tell the client to take the medication with
food only.
l 2. Instruct the client to take the medication in the
evening.
l 3. Explain that muscle pain is a common side effect
of this medication.
l 4. Demonstrate how to use the machine to check the
cholesterol level daily.
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ANSWERS
15. Correct answer 3: LDLs have the harmful effect of
66
17. Correct answer 2: These medications should be taken
depositing cholesterol into the walls of the arterial

vessels, which is the pathophysiology of LDL. Highdensity lipoprotein transports cholesterol away from
the tissue and cells of the arterial wall to the liver for
excretion, which helps decrease the development
of atherosclerosis. Content AreaMedical; Category
in the evening for best results, because the enzyme

that destroys cholesterol works best in the evening,
and the medication enhances this process. Muscle
pain is an adverse effect and should be reported to
the HCP immediately. Cholesterol levels cannot be
checked daily. Content AreaMedical; Category of

Application.

Intervention; Client NeedsPhysiological Integrity,
LevelApplication.
16. Correct answer 3: The client is describing intermittent claudication, which should make the nurse
suspect the client has generalized atherosclerosis, a
marker of coronary artery disease. Option 1 could be
heart failure, option 2 hypoglycemia, and option 4
peptic ulcer disease. Content AreaMedical; Category
ProcessAssessment; Client NeedsPhysiological
Integrity, Reduction of Risk Potential; Cognitive
LevelApplication.
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SECTION TWO
18. Which menu selection indicates to the nurse the

client diagnosed with atherosclerosis understands the
teaching concerning a low-fat, low-cholesterol diet?
l 1. Fried chicken, garlic mashed potatoes, and
skim milk.
l 2. Ham and cheese on white bread and whole milk.
l 3. Baked fish, brown rice, lettuce salad, and iced tea.
l 4. A hamburger, potato chips, and carbonated
beverage.
19. Which interventions should the nurse implement
when teaching the 54-year-old client diagnosed with
atherosclerosis? Select all that apply.
l 1. Include significant other when teaching the client.
l 2. Provide the client with written handouts and
pamphlets.
l 3. Refer the client to the American Heart Association
(AHA).
l 4. Help the client to identify ways to deal with
stressful situations.
l 5. Discuss the importance of isometric exercises daily.
67
20. The nurse is caring for clients on a telemetry floor.

Which nursing task would be most appropriate to
delegate to unlicensed assistive personnel (UAP)?
l 1. Teach the client how to take their radial pulse for
1 minute.
l 2. Escort the discharged client in a wheelchair to the
client's car.
l 3. Check the triglyceride level for the client diagnosed
with atherosclerosis.
l 4. Assist the client who just returned from a cardiac
catheterization to ambulate.
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ANSWERS
18. Correct answer 3: Baked, broiled, or grilled meats
68
20. Correct answer 2: The UAP can escort a stable
or fish, high-fiber brown rice, and ice tea would be

an appropriate meal. Fried foods are high in fat and
cholesterol; white bread is low in fiber; and whole
milk is high in fat. Hamburger meat is high in fat,
and carbonated beverages are high in calories.
client to the car. The nurse cannot delegate assessment (option 3), teaching (option 1), evaluation,
administering medications, or care of an unstable
client. A client returning from cardiac catheterization
cannot ambulate for 6 hours. Content AreaMedical;

LevelEvaluation.
Category of Health AlterationCardiovascular;

Integrated ProcessIntervention; Client NeedsSafe
19. Correct answer 1, 2, 3, 4: Including the significant

other increases adherence to lifestyle modifications;
written information helps the client review information after the teaching session; the AHA is an appropriate referral; and decreasing stress is appropriate for
teaching about atherosclerosis. Isotonic exercises,
not isometric exercises, should be recommended.
Cardiovascular; Integrated ProcessIntervention; Client
LevelApplication.
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SECTION TWO
69
Valve Disorders
21. The nurse is discharging a 65-year-old client diagnosed
with aortic stenosis who had undergone mechanical valve
replacement surgery. Which information should the nurse
teach the client?
l 1. Splint the incision when turning, coughing, and
deep breathing.
l 2. Sleep in a recliner or with the head on two pillows
at night.
l 3. Avoid being around children or people who have
had an immunization.
l 4. Take antibiotics prior to any dental or other
invasive procedures.
22. The nurse caring for clients on a medical unit thinks
she hears a murmur while assessing the client. After
determining that no other HCP have documented a
murmur, which action should the nurse implement next?
l 1. Do nothing because the nurse was probably mistaken.
l 4. Ask the client if there is a history of a murmur.
23. The nurse is admitting a client diagnosed with a

mitral valve murmur. Which information supports this
finding?
l 1. The client has a history of rheumatic fever as a
child.
l 2. The client takes an oral anticoagulant daily.
l 3. The client has elevated troponin levels.
l 4. The client recently took a vacation to Central
America.
24. The nurse is preparing the 52-year-old male client diagnosed with mitral valve regurgitation for surgery. Which
statement by the client warrants immediate intervention?
l 1. I have been told that I will be on medication for
the rest of my life.
l 2. I get short of breath walking to the bathroom to
bathe myself.
l 3. I made out an advance directive to make sure my
wishes are known.
l 4. I will be in the intensive care unit for a day or two
after surgery.
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ANSWERS
21. Correct answer 4: Clients with a mechanical valve

are at risk for developing bacterial endocarditis after
dental cleaning or other invasive procedures, such as
genitourinary or gastrointestinal procedures. Prophylactic antibiotics prevent this. Content AreaSurgical;
ProcessIntervention; Client NeedsHealth Promotion
22. Correct answer 4: Part of assessing the client is to

conduct a client interview about abnormal data.
The nurse can reassess the client to gather more data
before notifying the HCP and documenting the
finding in the chart. The nurse should never ignore
abnormal data. Content AreaMedical; Category of
Intervention; Client NeedsSafe Effective Care
LevelApplication.
70
23. Correct answer 1: Rheumatic fever is caused by a

streptococcal infection that can result in vegetative
growth on the cardiac valves, resulting in valvular
disease later in life. Oral anticoagulants are prescribed after mechanical valve surgery, and troponin
levels are elevated after a myocardial infarction.
Potential; Cognitive LevelApplication.
24. Correct answer 2: This statement indicates heart

failure, and the nurse should investigate this further
and notify the HCP. The other statements convey
correct information or indicate appropriate preparation. Content AreaSurgical; Category of Health
Intervention; Client NeedsPhysiological Integrity,
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SECTION TWO
25. The 24-year-old female client has had surgery to

replace a diseased mitral graft. Which information should
the nurse teach the client prior to discharge?
l 1. Take your temperature four times a day and notify
the HCP of the results.
l 2. Have routine International Normalized Ratio
(INR) lab tests performed.
l 3. Limit lifting to less than 5 pounds until you are
seen by the surgeon.
l 4. Your menses will be heavier because of the
anticoagulant medications.
26. The nurse is assisting the client diagnosed with
cardiac valve disease to choose a menu for the next day.
Which menu is most appropriate for this client?
l 1. A ham and cheese sandwich, potato chips, and
2% milk.
l 2. Roast beef, lettuce salad with low-fat dressing, and
water.
l 3. Eggs, bacon, whole wheat toast, jelly, and black
coffee.
l 4. Chicken-fried steak, mashed potatoes and gravy,
and iced tea.
71
27. The client diagnosed with aortic stenosis scheduled

for an echocardiogram tells the nurse, I am scared. What
will they do during the test? Which statement is the
l 1. You're scared? We should discuss how you are
feeling.
l 2. The doctor will insert a catheter into the artery in
your groin.
l 3. I think you should talk with the doctor about you
fears.
l 4. Sound waves will be used to determine how your
heart is working.
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ANSWERS
25. Correct answer 3: Postoperative instructions for

any surgery that involves the abdomen or trunk area
require a lifting restriction to prevent pulling on the
surgical site. Female clients of childbearing age are
given living-tissue valves so that anticoagulant therapy is not needed during a pregnancy, if one should
occur, and therefore routine INR lab tests are not
necessary. Content AreaSurgical; Category of
Intervention; Client NeedsHealth Promotion and
26. Correct answer 2: The client should be on a hearthealthy diet, limiting caffeine (black coffee) and
alcohol, salt, and fat- and cholesterol-containing
foods (ham, cheese, potato chips, eggs, bacon,
fried steak, etc.). Content AreaMedical; Category
ProcessIntervention; Client NeedsHealth Promotion
72
27. Correct answer 4: An echocardiogram uses sound

waves to determine the functioning of the heart.
It is not invasive. The nurse should provide factual
answers, not refer the client to a health-care provider.
Nor should the nurse in a situation in which the
client is asking for information provide a therapeutic
response (option 1). Content AreaMedical; Category
ProcessIntervention; Client NeedsPhysiological
LevelApplication.
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SECTION TWO
28. The client diagnosed with mitral valve stenosis

complains of shortness of breath and chest pain while
ambulating in the hall with a UAP. Which action should
l 1. Tell the UAP to take the client's vital signs.
l 2. Determine if this has happened to the client before.
l 3. Get a wheelchair for the client to sit down.
l 4. Have a stat electrocardiogram (ECG) done.
29. The client is admitted to the intensive care unit post
aortic valve replacement. Which interventions should the
nurse implement? Select all that apply.
l 1. Monitor the client's telemetry readings.
l 2. Monitor vital signs every 4 hours.
l 3. Assess for S3 or S4 heart sounds.
l 4. Auscultate for a heart click.
l 5. Maintain intravenous lines.
30. The client diagnosed with a grade II aortic murmur
is admitted to the telemetry unit. Which symptoms
should the nurse expect to assess?
l 1. Peripheral edema, jugular vein distention, and a
productive cough.
2. A murmur heard with a stethoscope at the right
l
l
3. Shortness of breath on exertion and weakness.

4. Palpitations, fatigue, and pink frothy sputum.
sternal notch.
Dysrhythmia
31. Which medication should the nurse prepare to
administer for the client exhibiting the following
telemetry strip?
1. The miscellaneous antidysrhythmic adenosine
l
l
l
2. The antidysrhythmic lidocaine (Xylocaine).

3. The cardiac glycoside digoxin (Lanoxin).
4. The inotropic medication dopamine (Intropin).
(Adenocard).
73
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ANSWERS
28. Correct answer 3: The nurse should first stop the

activity that is causing the client's distress by providing a place for the client to sit. Assessment can be
made after interventions for the client's comfort or
safety. Content AreaMedical; Category of Health
Intervention; Client NeedsSafe Effective Care
LevelApplication.
29. Correct answer 1, 3, 5: The nurse should monitor

the client's telemetry for dysrhythmias, assess for
symptoms of heart failure such as S3 or S4 heart
sounds, and maintain IV lines. Vital signs should be
monitored every 515 minutes initially and then
every 12 hours when the patient is stable. A heart
click is a symptom of a mitral valve problem.
Content AreaSurgical; Category of Health Alteration
Cardiovascular; Integrated ProcessIntervention; Client
74
30. Correct answer 2: A stage 2 murmur can be heard

over the area of the chest closest to the diseased
valve. Many valve disorders are present long before
any other symptoms occur. Answers 1, 3, and 4 are
symptoms of heart failure and would not be present
with a stage 2 aortic murmur. Content AreaMedical;
Category of Health AlterationCardiovascular; Integrated ProcessAssessment; Client NeedsPhysiological
LevelApplication.
31. Correct answer 2: Lidocaine is an antidysrhythmic

medication that suppresses ventricular ectopy and is
the drug of choice for multifocal premature ventricular contractions, which is a potentially life-threatening
dysrhythmia. Content AreaMedical; Category of
LevelApplication.
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SECTION TWO
32. The client is exhibiting the following telemetry strip.

Which interventions should the nurse implement? Rank
in order of performance.
l
l
l
l
l
1. Administer the antidysrhythmic atropine.

2. Determine if the telemetry strip is artifact.
3. Administer epinephrine, a sympathomimetic.
4. Perform 30 hard and fast cardiac compressions.
5. Administer two breaths with the nose pinched.
33. The client is exhibiting sinus bradycardia on the

telemetry monitor. Which intervention should the nurse
implement first?
l 1. Administer the antidysrhythmic atropine.
l 2. Determine if the client is symptomatic.
l 3. Prepare for an insertion of a pacemaker.
l 4. Notify the client's HCP.
75
34. The telemetry nurse is unable to read the telemetry

monitor at the nurse's station. Which intervention should
the telemetry nurse implement?
l 1. Go to the client's room to check the client.
l 2. Instruct the primary nurse to assess the client.
l 3. Notify the charge nurse of the emergency situation.
l 4. Request the UAP to take the crash cart to the
client's room.
35. Which intervention should the nurse implement
first when defibrillating a client who is in ventricular
fibrillation?
l 1. Defibrillate the client at 360 joules.
l 2. Remove the client's oxygen source.
l 3. Energize the defibrillator source.
l 4. Shout all clear prior to defibrillation.
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ANSWERS
32. Correct answer in order 2, 5, 4, 3, 1: The nurse

should first determine if the client is in asystole
(it could be an artifact). Then the nurse should
start cardiopulmonary resuscitation by giving two
breaths and cardiac compressions. This is followed
by administering intravenous epinephrine to vasoconstrict the peripheral circulation and shunt the
blood to the central circulation (brain, heart, lungs)
in clients who do not have a heartbeat. Atropine is
then administered; it decreases vagal stimulation and
increases the heart rate and is the drug of choice for
a client exhibiting asystole. Content AreaMedical;
33. Correct answer 2: The nurse must first determine if

the client is weak, lightheaded, or experiencing other
symptoms of syncope and hypotension. If the client is
symptomatic, atropine is the drug of choice, along
with insertion of a pacemaker, which must be done by
76
the HCP. Content AreaMedical; Category of Health

Assessment; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelApplication.
34. Correct answer 2: The telemetry nurse cannot leave

the monitors; therefore, the primary nurse should be
instructed to go and assess the client immediately. The
primary nurse must assess the client before contacting
the charge nurse and taking the crash cart to the room.
35. Correct answer 2: The oxygen source should be

removed to prevent any type of spark during defibrillation. Then the nurse should shout all clear,
energize the source, and defibrillate at 360 joules.
Adaptation; Cognitive LevelApplication.
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SECTION TWO
36. The client who has been exhibiting the following

telemetry reading for the last 6 months is being
discharged from the hospital. Which statement indicates
the discharge teaching by the nurse has been effective?
1. I will take my blood pressure prior to taking my
2. I need to eat a low-fat, low-cholesterol, and
3. I must have an INR frequently while I am taking
4. I should use a straight razor instead of an electric
77
37. The client is in complete heart block. Which

l 1. Prepare to insert a pacemaker.
l 2. Administer atropine, an antidysrhythmic.
l 3. Obtain a stat ECG.
l 4. Assess the client's peripheral pulses.
38. The client is 1 day postoperative open heart surgery
and has a temperature (T) of 99F, a pulse (P) of 96,
a respiration rate (R) of 22, and B/P 128/92 and is
complaining of incisional pain of 8 on a 110 pain scale.
medication.
low-salt diet.
warfarin (Coumadin).
razor.
l
l
l
l
1. Continue to monitor the client and take no action.

2. Administer the antipyretic acetaminophen (Tylenol).
3. Administer a narcotic analgesic to the client.
4. Assess the client's pulse oximeter reading.
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ANSWERS
36. Correct answer 3: Atrial fibrillation could cause a

blood clot; therefore, the client is placed on the anticoagulant warfarin (Coumadin), which is monitored
for effectiveness by the INR (23). Atrial fibrillation
does not cause hypertension; therefore, the client
does not need to monitor the blood pressure or be
on a low-salt diet. An electric razor is appropriate
to prevent cuts, which lead to bleeding. Content
AreaMedical; Category of Health Alteration
Parenteral Therapies; Cognitive LevelEvaluation.
37. Correct answer 2: Atropine decreases vagal stimulation and increases the heart rate; therefore, it is the
first intervention. Remember, the client is in distress;
therefore, do not assess the peripheral pulses first.
78
38. Correct answer 3: Pain, elevated temperature, exercise, anxiety, hypoxemia, hypovolemia, and cardiac
failure may all cause sinus tachycardia. The nurse
should administer pain medication to the client. The
pulse oximeter reading will not help the client's pain.
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SECTION TWO
79
Cardiac Inflammatory Diseases

39. The client is exhibiting the following telemetry
reading. Which intervention should the nurse implement?
l
l
l
1. Document this as normal sinus rhythm.

2. Request a 12-lead electrocardiogram.
3. Prepare to administer the cardiotonic digoxin by
4. Assess the client's cardiac enzymes.
mouth (PO).
40. Which client problem is priority for the client with a

cardiac dysrhythmia?
l 1. Knowledge deficit.
l 2. Altered cardiac output.
l 4. Activity intolerance.
41. The client is diagnosed with pericarditis. Which

signs/symptoms should the nurse expect in this client?
l 1. The client has pulsus paradoxus and night sweats.
l 2. Complaints of fatigue and arthralgias.
l 3. Constant chest pain and friction rub.
l 4. Increased chest pain when ambulating but not
at rest.
42. The client is diagnosed with acute pericarditis.
During the shift assessment, the nurse notes muffled
heart sounds. Which intervention should the nurse
implement?
l 2. Continue to monitor the client.
l 3. Get an order to place the client on telemetry.
l 4. Recheck the client in 4 hours.
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ANSWERS
39. Correct answer 1: The P-wave represents atrial

contraction, and the QRS complex represents
ventricular contraction. This electrocardiogram strip
indicates a normal telemetry reading. In addition, a
rate 60100 indicates normal sinus rhythm. The
nurse should document these findings and not take
any action. Content AreaMedical; Category of
80
41. Correct answer 3: In pericarditis, chest pain is

usually constant but can be aggravated by respiratory
movements (deep inspiration, coughing), changes in
body position, or swallowing. The most characteristic symptom is a friction rub. Pulsus paradoxus is
associated with cardiac tamponade, not pericarditis.


40. Correct answer 2: Any abnormal electrical activity of
42. Correct answer 1: Muffled heart sounds require the
the heart causes an altered or decreased cardiac output.

Cardiovascular; Integrated ProcessDiagnosis; Client
nurse to notify the HCP. Acute pericardial effusion

interferes with normal cardiac filling and pumping,
causing venous congestion and decreased cardiac
output, resulting in muffled heart sounds. Content
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SECTION TWO
81
43. The nurse is assessing the client diagnosed with

subacute bacterial endocarditis. Which question should
the nurse ask the client during the admission interview to
support this diagnosis?
l 1. Have you had a sore throat in the last month?
l 2. Did you have frequent strep throats as a child or
young adult?
l 3. Do you have a family history of heart disease?
l 4. What prescription medications do you take?
45. The client diagnosed with endocarditis is complaining

of increased dyspnea and nausea. Which intervention
l 1. Ask Respiratory Therapy to evaluate the client's
dyspnea.
l 2. Obtain an order for an indwelling urinary catheter.
l 3. Auscultate the client's lung sounds and assess the
periphery.
l 4. Give the client a specimen cup to collect sputum.
44. The client with pericarditis is prescribed a

nonsteroidal anti-inflammatory drug (NSAID). Which
teaching instruction should the nurse discuss with the
client?
l 1. Explain the importance of keeping a pain diary to
show the HCP.
l 2. Discuss not driving or operating machinery while
taking the medication.
l 3. Instruct the client not to take the medication on an
empty stomach.
l 4. Alternate the medication with acetaminophen
(Tylenol) every 8 hours.
46. The client diagnosed with pericarditis complains

of pressure in the chest and shortness of breath. The
intensive care nurse assesses a decreasing systolic blood
pressure and jugular vein distention. Which collaborative
intervention should the nurse anticipate for this client?
l 1. Prepare for a pericardiocentesis.
l 2. Send the client for a cardiac catheterization.
l 3. Have Respiratory Therapy draw arterial blood
gases.
l 4. Refer the client to the chaplain for anticipatory
grief counseling.
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ANSWERS
43. Correct answer 2: Rheumatic fever, a systemic

inflammatory disease caused by an abnormal immune
response to pharyngeal infection by group A betahemolytic streptococci, causes carditis in about 50%
of the people. Frequent strep throats can lead to rheumatic fever; therefore, this would be the most appropriate question. Content AreaMedical; Category of
44. Correct answer 3: The medication must be taken

with food, milk, or antacids to help decrease gastric
distress. NSAIDs reduce fever, inflammation, and
pericardial pain. Steroids are tapered; NSAIDs do
not make the client drowsy; and NSAIDs should be
taken routinely to decrease inflammation, not alternated with Tylenol. Content AreaMedical; Category
82
45. Correct answer 3: The nurse should assess the client

for heart failure and then plan interventions based on
the data collected. Some clients develop intractable
heart failure as a result of endocarditis. Content
46. Correct answer 1: These are symptoms of cardiac

tamponade, and the treatment is an emergency pericardiocentesis. A pericardiocentesis removes fluid
from the pericardial sac, which requires collaboration
with the health-care provider. The other options are
collaborative but not appropriate for the client's
condition. Content AreaMedical; Category of
Health AlterationCardiovascular; Integrated
LevelApplication.
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SECTION TWO
47. The female client is diagnosed with rheumatic fever

and prescribed penicillin, an antibiotic. Which statement
indicates the client understands the discharge teaching?
l 1. I must take the prescribed antibiotics for 7 days
only.
l 2. I may get a vaginal yeast infection with penicillin.
l 3. I will have no problems as long as I take my
medication.
l 4. My throat culture was positive for a staph
infection.
48. The nurse is planning the care of a client diagnosed
with acute bacterial endocarditis who has been admitted
for intravenous therapy. Which intervention should the
nurse include in the plan of care?
l 1. Limit interruptions to allow for uninterrupted rest
and sleep.
l 2. Refer the client to inpatient cardiac rehabilitation.
l 3. Maintain oxygen via nasal cannula at 2 L/min.
l 4. Discuss the need for valve replacement surgery.
83
49. The client has just had a pericardiocentesis. Which

interventions should the nurse implement? Select all that
apply.
l 1. Monitor vital signs every 2 hours for 24 hours.
l 2. Assess the client for a fluid wave.
l 3. Record the amount of fluid removed as output.
l 4. Evaluate the client's cardiac rhythm.
l 5. Keep the client in a semi-Fowler position.
50. The client with infective endocarditis is admitted to
the medical department. Which HCP's order should be
implemented first?
l 1. Administer the intravenous antibiotic.
l 2. Schedule an echocardiogram.
l 3. Insert a 20-gauge intravenous catheter.
l 4. Bedrest with bathroom privileges.
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ANSWERS
47. Correct answer 2: Female clients may experience

vaginal yeast infections when taking antibiotics
because the antibiotics kill the good bacteria and
well as the bad. The client should take all the antibiotics, not for just 7 days. Rheumatic fever is caused
by a group A beta-hemolytic streptococcus infection.
48. Correct answer 1: This helps decrease the workload

of the heart and helps ensure the restoration of physical and emotional health. The client is placed on
bedrest to decrease the workload of the heart.
Endocarditis may lead to valve damage and the need
for valve replacement, but not in the acute phase.
Cardiovascular; Integrated ProcessPlanning; Client
Parenteral Therapies; Cognitive LevelApplication.
84
49. Correct answer 3, 4, 5: This fluid is output and

should be documented on the client's daily intake
and output record. The nurse must assess for cardiac
failure. The client should be in the semi-Fowler
position, not flat, which increases the workload
of the heart. Vital signs should be assessed more
frequently initially, and a fluid wave is for assessing
the abdomen. Content AreaMedical; Category of
50. Correct answer 3: Initiation of antibiotics is priority, so the nurse must start the intravenous line for
the antibiotics. Obtaining cultures would be done
before starting the antibiotics.Content AreaMedical;
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SECTION TWO
85
Essential Hypertension
51. The male client diagnosed with hypertension has
epistaxis and a flushed face. Which action should the
nurse implement first?
l 2. Assess the client's blood pressure lying, standing,
and sitting.
l 3. Elevate the client's head of the bed.
l 4. Prepare to administer an intravenous
antihypertensive medication.
52. The nurse is completing discharge teaching for a
client diagnosed with essential hypertension. Which
statement indicates the client understands the discharge
teaching?
l 1. I can eat bacon, eggs, and wheat toast for breakfast.
l 2. I will walk for 30 minutes a day at least once
a week.
l 3. I am going to lose 23 pounds a week until I lose
30 pounds.
l 4. When I feel all right I do not need to take my
medication.
53. The nurse is caring for the client diagnosed with

essential hypertension who is prescribed hydrochlorothiazide
(HTCZ), a thiazide diuretic. Which intervention should
the nurse implement when administering this medication?
l 1. Check the client's apical pulse for 1 minute.
l 2. Question administering if the client's potassium
level is less than 5.5 mEq/L.
l 3. Instruct the client to rise slowly from a lying to a
sitting position.
l 4. Tell the client to drink 1000 mL of fluid daily.
54. The charge nurse is checking laboratory results for
clients on a medical unit. Which laboratory data would
warrant notifying the HCP?
l 1. The client who has an arterial blood gases (ABGs)
of pH 7.38, PaO2 90, PaCO2 38, and HCO3 34.
l 2. The client who has a serum potassium level of
3.8 mEq/L.
l 3. The client who has a serum sodium level of
138 mEq/L.
l 4. The client who has an INR of 4.2.
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ANSWERS
51. Correct answer 2: The client is exhibiting signs of

a hypertensive crisis; therefore; the nurse should
check the client's blood pressure. Epistaxis is a
nosebleed. Elevating the head of the bed (option 3),
administering antihypertensive medication
(option 4), and notifying the HCP (option 1)
should be done in this order. Content AreaMedical;
Category of Health AlterationCardiovascular; Integrated ProcessImplementation; Client NeedsSafe
52. Correct answer 3: Being overweight is a risk factor

for essential hypertension; therefore; losing weight
indicates the client understands the discharge
teaching. Bacon is high in salt, and eggs are high
in cholesterol. The client should walk at least
three times a week, and medication should be
taken every day, no matter how the client feels.
86
NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelEvaluation.
53. Correct answer 3: The nurse must teach the client

about orthostatic hypotension. The blood pressure,
not the apical pulse, should be checked. The normal
potassium level is 3.55.5 mEq/L, and the client
should not be on fluid restriction. Content Area
Medical; Category of Health AlterationCardiovascular;
54. Correct answer 4: The therapeutic INR is 23;

therefore, this laboratory information should be
reported to the HCP. All other laboratory data are
within normal limits. Content AreaMedical; Category
LevelApplication.
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SECTION TWO
55. The client newly diagnosed with essential hypertension

tells the nurse, I don't feel bad, so why do I have to take
medication every day? Which statement is the nurse's
best response?
l 1. Even if you feel all right, your blood pressure
could still be high.
l 2. Your doctor would not have prescribed them if
you didn't need them.
l 3. People have strokes and heart attacks with high
blood pressure.
l 4. If you don't feel bad, then you don't have to take
your medication.
56. The nurse is caring for clients on a medical unit.
Which task would be appropriate for the nurse to
delegate to a UAP?
l 1. Vital signs of a client who is having chest pain.
l 2. Take the client downstairs to smoke a cigarette.
l 3. Remove the telemetry leads from the client who is
being discharged.
l 4. Help the client who is scheduled for a cardiac
catheterization to eat.
87
57. The nurse is preparing to administer a calcium

channel blocker to a client diagnosed with arterial
hypertension. Which data would cause the nurse to
question administering this medication?
l 1. The client's blood pressure is 110/70.
l 2. The client has a calcium level of 10.5 mg/dL.
l 3. The client reports having a dry mouth.
l 4. The client complains of being dizzy.
58. The nurse is discussing essential hypertension with a
group of clients. Which interventions should be included
in the discussion? Select all that apply.
l 1. Discuss the importance of a low-cholesterol,
low-fat, low-salt diet.
l 2. Encourage isotonic exercises at least three times a
week.
l 3. Explain that uncontrolled diabetes increases blood
pressure.
l 4. Recommend relaxation classes to help decrease
stress.
l 5. Tell them to elevate the head of the bed to sleep.
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ANSWERS
55. Correct answer 1: Essential hypertension is the

silent killer, and the blood pressure could be elevated when the client is asymptomatic. Clients with
hypertension may have stokes and heart attacks, but
the nurse should address the client's comment.
56. Correct answer 3: The UAP can remove the

telemetry leads from a client's chest. A client with
chest pains is unstable so cannot be assigned to the
UAP. The UAP also needs to be on the unit, not
downstairs with a client smoking, and the client
scheduled for a cardiac catheterization should have
nothing by mouth. Content AreaMedical; Category
LevelApplication.
88
57. Correct answer 4: Dizziness may indicate the client is

experiencing hypotension; therefore, the nurse should
question administering an antihypertensive medication. The blood pressure is within normal limits,
but if the client had elevated blood pressure, then the
client could be experiencing hypotension; the calcium
level is not monitored when administering this medication, and dry mouth will not affect the medication
administration. Content AreaMedical; Category of
LevelApplication.
58. Correct answer 1, 2, 3, 4: Diet, isotonic exercises,

diabetes, and stress are modifiable risk factors for
essential hypertension. Elevating the head of the bed
will not help clients with essential hypertension.
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SECTION TWO
89
Congestive Heart Failure

59. The nurse is taking blood pressure readings at a community health fair. The 68-year-old client's blood pressure is
168/98. Which action should the nurse implement?
l 1. Recommend the client see a HCP within 2 days.
l 2. Tell the client to go to the nearest emergency
department.
l 3. Explain the blood pressure is all right for an elderly
person.
l 4. Instruct the client to go home and rest for the
remainder of the day.
60. The UAP tells the nurse the client whose T is 98.9F,
P 92, R 18, and B/P 164/92 is complaining of a
headache. Which action should the nurse implement?
l 1. Assess the client as soon as possible.
l 2. Administer acetaminophen (Tylenol), a non-narcotic
analgesic.
l 3. Tell the UAP to check on the client in 1 hour.
l 4. Request the charge nurse to check on the client.
61. The nurse is caring for a client diagnosed with

congestive heart failure (CHF) who is complaining of
shortness of breath and dyspnea. Which intervention
l 1. Assess the client's lung sounds.
l 2. Elevate the client's head of the bed.
l 3. Administer oxygen via nasal cannula.
l 4. Check the client's pulse oximeter reading.
62. The client is preparing to administer the initial dose
of digoxin (Lanoxin), a cardiac glycoside, to the client
diagnosed with CHF. Which intervention should the
nurse implement?
l 1. Check the client's serum potassium level.
l 2. Assess the client's blood pressure.
l 3. Monitor the client's digoxin level.
l 4. Take the client's apical pulse.
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ANSWERS
59. Correct answer 1: The client should be seen by an
90
61. Correct answer 2: The nurse should first elevate
HCP because the diastolic blood pressure is greater

than 85, but the client does not need to go to the
emergency department. Content AreaMedical;
the head of the bed to help the client breathe more

easily, then apply oxygen, and then the nurse can
assess the client. Content AreaMedical; Category of


LevelApplication.
60. Correct answer 1: The nurse should assess the client
62. Correct answer 4: The nurse should check the
because the blood pressure is elevated along with

the complaint of a headache. The nurse should not
administer medication without assessing the client;
the UAP cannot assess the client; and this client is
not in a life-threatening situation so the charge
nurse does not need to check the client. Content
client's apical pulse, and if it is less than 60, the

nurse should question administering the digoxin.
The client's potassium level and digoxin level would
not be affected by the first dose of the medication.
The blood pressure does not have to be assessed
prior to administering digoxin. Content AreaMedical;
AreaMedical: Category of Health Alteration


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SECTION TWO
63. The home health-care nurse is visiting a client

diagnosed with CHF. Which comment by the client
would warrant intervention by the nurse?
l 1. I take my water pill every morning.
l 2. I have to sleep on two pillows at night
l 3. I have some leg cramps every now and then.
l 4. I must rest after I walk around the block.
64. The clinic nurse is checking laboratory data for
clients seen yesterday. Which laboratory data would
warrant contacting the client at home?
l 1. The client whose serum digoxin level is 2.4 mg/dL.
l 2. The client whose serum potassium level is
4.2 mEq/L.
l 3. The client whose serum brain or beta natriuretic
peptide (BNP) level is 92 mg/mL.
l 4. The client whose glycosylated hemoglobin is 5.3%.
91
65. The nurse, along with a UAP, is caring for a client

diagnosed with an acute exacerbation of congestive heart
failure. Which task could the nurse delegate to the UAP?
l 1. Request the UAP to evaluate client's intake and
output.
l 2. Ask the UAP to assist the client to ambulate in
the hall.
l 3. Tell the UAP to increase the oxygen rate from
4 to 6 L.
l 4. Instruct the UAP to assist the client with taking a
bed bath.
66. The nurse is preparing to administer digoxin (Lanoxin),
a cardiac glycoside intravenous push (IVP). The digoxin vial
has 5 mg/2 mL. The HCP has ordered 0.25 mg. How
much medication would the nurse administer?
Answer: ______________________
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ANSWERS
63. Correct answer 3: Leg cramps could indicate
92
65. Correct answer 4: The UAP could assist the client
hypokalemia, which would warrant intervention by

the nurse. Taking the diuretic every morning, sleeping with two pillows, and resting after extended
walks would not warrant intervention by the nurse.
to take a bath. The UAP cannot assess, teach, evaluate, administer medications, or care for a client who
is unstable. The client in an acute exacerbation of
congestive heart failure is unstable. Content Area


64. Correct answer 1: The therapeutic level for digoxin
66. Correct answer 0.1 mL: 5 is to 2 = 0.25 mg is
is 0.82.0 mg/dL; therefore, the nurse should notify

this client concerning the potential for digoxin
toxicity. All other data are within normal limits.
to x. Cross-multiply to get 5x = 0.50. Divide both

sides of the equation by 5 to solve for x and get the
answer = 0.1 mL. Content AreaMedical; Category of


LevelApplication.
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SECTION TWO
67. The nurse is caring for a client diagnosed with CHF

who is receiving 40 mg furosemide (Lasix) intravenous
push (IVP) daily. Which data indicate the medication is
effective?
l 1. The client's urine output for the last 8 hours is
300 mL.
l 2. The client's lungs are clear bilaterally anterior and
posterior.
l 3. The client has lost 1 kg of weight in 2 days.
l 4. The client's arterial blood pressure is
138/90 mm Hg.
68. The nurse is preparing to administer an ACE-inhibitor
to a client diagnosed with congestive heart failure. Which
statement best describes the scientific rationale for
l 1. The medication will help increase the urine output,
thereby decreasing the volume of blood in the
intravascular system.
l 2. The medication will decrease the sympathetic
stimulation to the beta cells in the heart muscle.
93
3. The medication will help prevent vasoconstriction of
4. The medication blocks calcium from entering the cell
the periphery and prevents the release of aldosterone.

membrane, resulting in vasodilation of the vessels.
69. The nurse is admitting a client diagnosed with CHF.

Which HCP's admission order would the nurse question?
l 1. Oxygen 2 L via nasal cannula.
l 2. Fursosemide (Lasix) 40 mg IVP daily.
l 3. Low-cholesterol, low-fat, low-salt diet.
l 4. Activity as tolerated.
70. The nurse is completing discharge teaching for a
client diagnosed with end-stage congestive heart failure.
discharge teaching?
l 1. I will notify my HCP if I lose more than 2 lb in
a week.
l 2. I will check my digoxin level daily and write down
the results.
l 3. I will increase my intake of foods that are high in
potassium.
l 4. I will drink at least 3000 mL of fluid every day.
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ANSWERS
67. Correct answer 2: Clear lung sounds indicate that the

client's CHF is responding to diuretic therapy. The
output should be much greater than 30 mL/hr for a
diuretic to be effective, and a 2.2-lb weight loss does
not indicate effective therapy. The blood pressure does
indicate the effectiveness of a diuretic for the client
with CHF. Content AreaMedical; Category of Health
AlterationCardiovascular; Integrated ProcessEvaluation;
Client NeedsPhysiological Integrity, Pharmacological and
68. Correct answer 3: ACE inhibitors prevent

angiotensin-1 from converting to angiotensin-2,
which is a potent vasoconstrictor and prevents the
release of aldosterone, which, in turn, prevents
the reabsorption of sodium. The medication that
increases urine output (option 1) is a diuretic. The
medication that decreases sympathetic stimulation to
the beta cells in the heart muscle (option 2) is a
beta blocker. The medication that blocks calcium
from entering the cell membrane (option 4) is a
calcium-channel blocker. Content AreaMedical;
94

LevelEvaluation.
69. Correct answer 1: The client does not have chronic

obstructive pulmonary disease; therefore; the client
does not need a low oxygen rate. This order should
be questioned. Content AreaMedical; Category of
70. Correct answer 3: The client with congestive heart

failure will be on digoxin and a diuretic; therefore,
the client should increase foods high in potassium.
Weight loss would not warrant notifying the HCP;
the digoxin level is not done daily; and the client
should drink about 2000 mL a day unless on a fluid
restriction. Content AreaMedical; Category of Health
AlterationCardiovascular; Integrated ProcessEvaluation;
Client NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelEvaluation.
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SECTION TWO
95
Peripheral Vascular Disease

71. The client is diagnosed with arterial occlusive disease.
Which data would the nurse expect the client to exhibit?
l 1. Intermittent claudication and cool extremities.
l 2. Capillary refill <3 seconds and 4+ pedal pulses.
l 3. Dry scaly skin and 3+ pitting edema.
l 4. Piloerection and alligator skin.
72. The client is diagnosed with peripheral vascular
disease. Which statement indicates the client understands
the discharge teaching?
l 1. I will buy my new shoes first thing in the
morning.
l 2. I use a heating pad when my feet are really cold.
l 3. I need to wear knee-high socks when wearing
shoes.
l 4. I should not cross my legs when I am sitting down.
73. The clinic nurse is caring for the female client

diagnosed with venous insufficiency. Which intervention
l 1. Instruct the client to elevate her feet frequently.
l 2. Encourage the client to eat a low-sodium diet.
l 3. Tell the client to wear open-toed shoes.
l 4. Recommend going to the podiatrist for nail cutting.
74. The client diagnosed with arterial occlusive disease is
1 day postoperative right femoral popliteal bypass. Which
l 1. Keep the right leg in the dependent position.
l 2. Maintain the leg in alignment with abductor pillow.
l 3. Monitor the client's continuous passive motion
(CPM) machine.
l 4. Assess the client's right leg for paralysis and
paresthesia.
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ANSWERS
96
71. Correct answer 1: Intermittent claudication, calf
73. Correct answer 1: The client should elevate her feet to
pain with walking, and cool extremities would be

expected because the client has decreased arterial
blood flow to the lower extremities. Content Area
help decrease edema. A low-sodium diet will not help

decrease the lower extremity edema; wearing open-toed
shoes will not help; and as the client does not have
decreased vision, the client can cut her own toenails.

Application.
72. Correct answer 4: The client should not perform

activity that will impede blood flow to the lower
extremities; therefore, the client should not cross
the legs. New shoes should be bought in the afternoon when the feet are swollen. The legs may have
decreased feeling; therefore, a heating pad should
not be applied to the lower extremities. Content
Cardiovascular; Integrated ProcessEvaluation;

Client NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelApplication.
74. Correct answer 4: The nurse should assess the 6 Ps:

paralysis, paresthesia, poikilothermia (temperature),
pain, pulses, and pallor. The leg should be elevated to
decrease postoperative edema; the abductor pillow is
used for total hip replacement, not for femoral popliteal
bypass; and the CPM machine is used with total
knee replacement. Content AreaSurgical; Category of
Reduction for Risk Potential; Cognitive LevelApplication.
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SECTION TWO
75. The UAP and a nurse are caring for clients in a

long-term facility. Which action by the UAP would
require intervention by the nurse?
l 1. The UAP elevated the legs of a client diagnosed
with arterial occlusive disease.
l 2. The UAP is ambulating the client using a gait belt
around the waist.
l 3. The UAP placed the client in the chair while
assisting the client to eat.
l 4. The UAP assisted the client with venous
insufficiency to put on antiembolic hose.
76. Which data would require the nurse to notify the HCP
for the client diagnosed with arterial occlusive disease?
l 1. The client has 1+ bilateral dorsalis pedis pulses.
l 2. The client has bilateral leg pain while resting.
l 3. The client has numbness and tingling of the legs.
l 4. The client has cool, pale extremities.
97
77. The client is diagnosed with arterial occlusive disease.

Which information should the nurse discuss with the
client?
l 1. Encourage the client to walk three times a day.
l 2. Discuss the need to increase fluid intake.
l 3. Explain how to prevent orthostatic hypotension.
l 4. Tell the client to take acetaminophen four times
a day.
78. The client is diagnosed with venous insufficiency.
Which discharge teaching should the nurse discuss with
the client?
l 1. Take one baby aspirin every day with food.
l 2. Check the feet daily for cuts and blisters.
l 3. Monitor the popliteal and pedal pulses daily.
l 4. Perform passive range-of-motion exercise daily.
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ANSWERS
75. Correct answer 1: The client with arterial occlusive
98
77. Correct answer 1: Walking will help increase collat-
disease should have the legs in the dependent, not

elevated, position, because elevating the feet further
impedes the arterial blood supply to the legs. The
nurse would need to intervene. Using a gait belt, sitting the client up to eat, and putting on antiembolic
hose are all appropriate interventions. Content Area
eral circulation, which will, in turn, increase the blood

supply to the lower extremities. Increasing fluid intake
will not help; the client does not experience orthostatic hypotension or take medications that would cause
it; and acetaminophen is not prescribed to treat arterial occlusive disease. Content AreaMedical; Category

of Health AlterationCardiovascular; Integrated Process

76. Correct answer 2: Resting pain indicates the client

is not receiving any blood supply to the calf muscles,
and this would require notifying the HCP. Weak
pedal pulses, paresthesia, and cool extremities are
expected in the client diagnosed with arterial
occlusive disease. Content AreaMedical; Category of
78. Correct answer 2: In a client with venous insufficiency, the feet are edematous; the skin is fragile;
and the sensation is decreased. Cuts will not heal
effectively; therefore, the client should check the feet
daily. Baby aspirin is for arterial insufficiency, not
venous insufficiency. The client does not check
pulses. The client should perform active range-ofmotion exercises. Content AreaMedical; Category of
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SECTION TWO
99
Abdominal Aortic Aneurysm

79. The nurse is unable to palpate the dorsalis pedis
pulse for the client diagnosed with arterial occlusive
disease. Which action should the nurse implement first?
l 2. Place the feet in the dependent position.
l 3. Use a Doppler to assess for pedal pulse.
l 4. Assess for proximal pulses bilaterally.
81. The nurse is assessing the client's abdomen. Which

assessment data would support the diagnosis of abdominal
aortic aneurysm (AAA)?
l 1. Visible peristalsis and hyper bowel sounds.
l 2. A palpable mass and an abdominal bruit.
l 3. Rebound tenderness and protruding umbilicus.
l 4. Hard rigid abdomen and low-grade fever.
80. The client diagnosed with arterial occlusive disease

asks the nurse, What caused me to have this problem?
Which statement is the nurse's best response?
l 1. Being overweight can lead to incompetent valves,
which caused your problem.
l 2. Sometimes people who stand all the time can have
arterial occlusive disease.
l 3. There is not a definite cause for developing
arterial occlusive disease.
l 4. Increased plaque in your arteries is the cause of
peripheral vascular disease.
82. The client diagnosed with a 3-cm AAA asks the

nurse, What will the doctors do for my abdominal aortic
aneurysm? Which statement is the nurse's best response?
l 1. You will probably have an ultrasound every
6 months to check on the size.
l 2. Usually an endoscopy is done once a year to make
sure it doesn't get too big.
l 3. You will have to check your abdominal girth once
a week and keep a record.
l 4. You will need to have an abdominal aortic
aneurysm repair within 2 weeks.
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ANSWERS
79. Correct answer 3: The nurse should first attempt to

assess the pedal pulse with a Doppler and place an X
when the pulse is heard. Placing the feet in dependent position will increase blood supply, which is not
desirable. The nurse can assess proximal pulses and
notify the HCP if total occlusion is determined.
Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelApplication.
80. Correct answer 4: Arterial occlusive disease is due to

atherosclerosis, which is a buildup of plaque in the arteries. Incompetent valves cause venous insufficiency.
Occupations where clients stand all the time lead to
varicose veins. Content AreaMedical; Category of
100
81. Correct answer 2: A systolic bruit over the abdomen

and a palpable mass are indicative of an AAA. The
nurse should palpate the area very lightly to prevent
rupture of the AAA. Content AreaMedical; Category
of Health AlterationCardiovascular; Integrated Process
Assessment; Client NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelApplication.
82. Correct answer 1: When the aneurysm is small

(<56 cm), an abdominal sonogram will be done
every 6 months until the aneurysm reaches a size
at which surgery to prevent rupture is of more
benefit than possible complications of the surgery.
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SECTION TWO
83. Which client would be most likely to develop an AAA?

l 1. A 45-year-old African-American female with type 1
diabetes mellitus.
l
l
2. A 75-year-old Oriental female with COPD.

3. A 54-year-old Caucasian male diagnosed with
4. A 30-year-old Hispanic male with a genetic
essential hypertension.
predisposition to AAA.
84. The nurse is caring for a client diagnosed with an

AAA who is scheduled for surgery in the morning. Which
statement would require immediate intervention by the
nurse?
l 1. I just started having pain in my lower back.
l 2. When I urinate I can't quit dribbling.
l 3. I am having loose runny stools.
l 4. I feel my heart beating when I lie down.
101
85. The client is 2 days postoperative AAA repair. Which

assessment data would require immediate intervention
from the nurse?
l 1. The client refuses to perform range-of-motion
exercises.
l 2. The client urinary output is 300 mL in 8 hours.
l 3. The client's dorsalis pedis pulse is not palpable.
l 4. The client's vital signs are T 98F, P 90, R 18,
B/P 130/70.
86. The nurse is assessing the client who had an AAA
repair 2 days ago. Which intervention should the nurse
implement first?
l 1. Assess the client's bowel sounds.
l 2. Administer an IV prophylactic antibiotic.
l 3. Encourage the client to splint the incision.
l 4. Ambulate the client in the room with assistance.
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ANSWERS
83. Correct answer 3: The most common cause of AAA

is atherosclerosis (which is the cause of essential hypertension and peripheral vascular disease). AAA occurs
in men four times more often than in women, and
primarily in Caucasians. Content AreaMedical; Category of Health AlterationCardiovascular; Integrated
84. Correct answer 1: Low back pain is present because

of the pressure of the aneurysm on the lumbar
nerves; this is a serious symptom usually indicating
that the aneurysm is expanding rapidly and about to
rupture. A sign/symptom of AAA is heart beating in
the abdomen. Content AreaSurgical; Category of
85. Correct answer 3: Any neurovascular abnormality,

such as nonpalpable dorsalis pedis pulse in the
client's lower extremities, indicates the graft is
102
occluded or there is possibly internal bleeding and

requires immediate intervention by the nurse. The
client should be ambulating on the second postoperative day; urine output should be greater than
30 mL/hrwhich it is; and the vital signs are stable.
86. Correct answer 1: Assessment is the first part of the

nursing process and is the first intervention the nurse
should implement. Antibiotic therapy, splinting the
incision when coughing, and ambulating are appropriate interventions but not prior to assessment.
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SECTION TWO
87. The client is being admitted for repair of an AAA.

Which HCP's order should the nurse question?
l 1. Complete blood cell count.
l 2. Tap water enema until clear fecal return.
l 4. Start intravenous line with normal saline.
88. The client is diagnosed with a 2-cm AAA. Which

interventions should be included in the client's teaching?
Select all that apply.
l 1. Perform isometric exercises for 30 minutes three
times a week.
l 2. Encourage a low-fat, low-cholesterol, low-salt diet.
l 3. Use an abdominal binder when amputating.
l 4. Discuss with the client the importance of losing
weight.
l 5. Demonstrate the correct way to apply a truss.
103
89. Which assessment data would require immediate

intervention by the nurse for the client who is 6 hours
postoperative AAA repair?
l 1. A blood pressure of 92/68 and apical pulse 114.
l 2. Complaints of incisional pain of 7 on a scale of
110.
l 3. A soft nondistended, tender abdominal area.
l 4. Green bile draining from the nasogastric tube.
90. The nurse is discussing discharge teaching with the
client who is 3 days postoperative AAA repair. Which
statement indicates the client needs more discharge
teaching?
l 1. I will notify my doctor if there is any redness or
irritation of my incision.
l 2. I will not lift any objects that weigh more than
5 pounds for 46 weeks.
l 3. I will have abdominal pain that will not be
relieved by my pain medication.
l 4. I should increase my fluid intake and make sure
I do not get constipated."
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ANSWERS
87. Correct answer 2: Increasing pressure in the
104
89. Correct answer 1: These vital signs indicate hypo-
abdomen secondary to a tap water enema could

cause the AAA to rupture. Blood work, bathroom
privileges, and intravenous line would be expected
HCP orders. Content AreaSurgical; Category of
volemia, which is a medical emergency and requires

immediate intervention. Incisional pain, a soft nondistended abdomen, and green bile would be expected
assessment data. Content AreaSurgical; Category of


88. Correct answer: 2, 4: The most common cause of
90. Correct answer 3: Pain medication should keep the
AAA is atherosclerosis and essential hypertension;

therefore, a low-fat, low-cholesterol diet will help
decrease development of atherosclerosis. Losing
weight will help decrease the pressure on the AAA
and will help address decreasing cholesterol level.
A truss is worn for a client with a hernia, not an
AAA, and an abdominal binder should not be
worn because it will increase abdominal pressure.
client comfortable, and if it does not help, the client

should call the HCP; this statement indicates the
client needs more teaching. Redness or irritation of
the incision indicates infection; lifting more than
5 pounds may cause dehiscence; and constipation
will increase pressure on the incision. Content Area

Surgical; Category of Health AlterationCardiovascular;

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SECTION TWO
105
Deep Vein Thrombosis

91. The nurse is discharging a client diagnosed with deep
vein thrombosis (DVT). Which discharge instructions
should be provided to the client?
l 1. Have the PTT levels checked routinely to maintain
a therapeutic level.
l 2. When traveling, the client should plan rest stops to
exercise the legs.
l 3. Eat a diet high in green leafy vegetables and expect
the urine to be red-tinted.
l 4. Wear knee stockings with an elastic band around
the top.
92. The nurse is caring for clients on a surgical floor.
Which client should be assessed first?
l 1. The postoperative abdominal surgery client who
has a red swollen left calf.
l 2. The postoperative hernia client who just voided
350 mL of clear amber urine.
l 3. The postoperative cholecystectomy client who is
refusing to turn and cough.
l 4. The postabdominal hysterectomy client who is
complaining of gas pains.
93. The male client is diagnosed with Guillain-Barr

(GB) syndrome and is in the intensive care unit on a
ventilator. Which intervention should the nurse
implement to prevent complications?
l 1. Percutaneous tube feedings once a day.
l 2. Encouraging the client to verbalize feelings.
l 3. Administer a narcotic pain medication PRN.
l 4. Frequent passive range-of-motion to the legs.
94. The nurse and a UAP are bathing an immobile
client. Which instruction should the nurse provide
the UAP?
l 1. Place a clean gown on the client before beginning
the bath.
l 2. Wash the calves, but do not massage the muscles.
l 3. Use lots of soap and water to get the client clean.
l 4. Dispose of the linens in a red container in the room.
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ANSWERS
91. Correct answer 2: The client should perform frequent active and passive leg exercises. In an airplane
the client should be instructed to drink plenty of
fluids and move the legs up and down and flex the
muscles. In an automobile the client should take
frequent breaks to walk around. PT/INR should
be monitored. Content AreaMedical; Category of
106
93. Correct answer 4: Passive range of motion will help

prevent deep vein thrombosis as well as contractures
of the limbs. Venous blood returns to the heart in
part because of the action of the muscles against the
walls of the veins. Content AreaMedical; Category of
94. Correct answer 2: Massaging the calves can dislodge
after surgery is developing a deep vein thrombosis

(DVT). This client should be assessed for a DVT.
The other clients are exhibiting expected findings
that are not life-threatening. Content AreaMedical;
a thrombus and create an embolus. The calves can

be washed and lotion applied gently, but they should
not be massaged. Clean gowns are put on the client
after the bath. Minimal soap and water are used to
prevent drying of the client's skin. Linens are not
thrown away in the biohazard trash. Content Area
Category of Health AlterationCardiovascular; Integrated ProcessImplementation; Client NeedsSafe


92. Correct answer 1: A complication of immobility
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SECTION TWO
95. The client diagnosed with a DVT in the right leg is

admitted to the medical unit. Which nursing interventions
should be implemented? Select all that apply.
l 1. Place an antiembolism hose on the unaffected calf.
l 2. Instruct the client to ambulate in the hallway
frequently.
l 3. Encourage fluids and a diet high in roughage.
l 4. Monitor the intravenous site every 24 hours
l 5. Assess for calf tenderness in the left leg.
96. The nurse is caring for a client receiving heparin
sodium via constant infusion. The heparin protocol reads
to decrease the IV rate by 50 units/hour if the PTT is
greater than 85 seconds. The current PTT level is
92 seconds. The heparin comes in 500 mL of D5W with
25,000 units of heparin added. The current rate on the
IV pump is 24 mL/hr. At what rate should the pump
be set?
Answer: ____________________
107
97. Which client should the nurse assess first after

receiving the shift report?
l 1. The client diagnosed with DVT who complains of
chest pain on inspiration.
l 2. The immobile client who has not been turned
from the left side for 3 hours.
l 3. The client who had a partial pancreatectomy and
who is refusing a blood glucose test.
l 4. The client who has had an inguinal hernia repair
and must void before discharge.
98. The client diagnosed with a DVT is on a heparin
(anticoagulant) drip at 1200 units per hour, and the HCP
has ordered Coumadin (warfarin sodium), an anticoagulant,
5 mg daily. Which should be the nurse's first action?
l 1. Check the client's laboratory values for PTT and
PT/INR.
l 2. Call the HCP to see which drug should be
discontinued.
l 3. Administer both medications as prescribed.
l 4. Discontinue the heparin when the client receives
the first dose of Coumadin.
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ANSWERS
95. Correct answer 1, 3, 5: An antiembolism hose

should be put on to prevent a thrombosis from
forming in the other calf. The client is on bedrest for
57 days. Drinking lots of fluids and a diet high in
roughage will help prevent constipation and provide
adequate fluid volume. The intravenous site should
be monitored more frequently than every 24 hours,
and the nurse should assess for signs of DVT in the
unaffected calf. Content AreaMedical; Category of
96. Correct answer 23 mL/hr: The nurse must first

determine the number of units of heparin in each mL
of solution. Divide 25,000 by 500 to equal 50 units
per mL of solution. If the current rate is 24 mL/hr,
then decreasing by 50 units results in 23 mL an hour.
24 mL1 mL = 23 mL/hr. Content AreaMedical;
Integrated ProcessImplementation; Client
108

97. Correct answer 1: A potentially life-threatening

complication of DVT is pulmonary embolus, which
causes chest pain. The nurse should determine if
the client has thrown a pulmonary embolus.
98. Correct answer 3: It will take several days for the

client to reach a therapeutic level of anticoagulation
with the Coumadin. The client should not be
removed from the heparin until appropriate levels of
oral anticoagulant can be achieved. Content Area
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109
Anemia
99. The client is being admitted with Coumadin
(anticoagulant) toxicity. Which medication should the
nurse prepare to administer?
l 1. Protamine sulfate intravenously.
l 2. Warfarin sodium orally.
l 3. Aquamephyton (vitamin K) intravenously.
l 4. Sodium heparin subcutaneously.
100. The charge nurse observes the primary nurse
assessing the client diagnosed with DVT. Which action
by the nurse warrants immediate intervention by the
charge nurse?
l 1. The nurse assesses for the Homan sign in the
affected leg.
l 2. The nurse instructs the client to stay in bed as
much as possible.
l 3. The nurse tells the client to notify the nurse if
developing chest discomfort.
l 4. The nurse reminds the client not to pull on the
intravenous tubing.
101. The nurse is admitting a client with a diagnosis of

rule out (R/O) anemia. The client has a history of gastric
bypass surgery for obesity 3 years ago. Current assessment
findings include height 5'9", weight 75 kg, P 120, R 27,
BP 100/70, pale mucous membranes, and dyspnea on
exertion. Which type of anemia would the nurse suspect
the client has developed?
l 1. Sickle cell anemia.
l 2. Folic acid deficiency.
l 3. Iron deficiency.
l 4. Vitamin B12 deficiency.
102. The client who has menorrhagia complains to
the nurse of feeling listless and tired all the time. Which
laboratory data should the nurse monitor?
l 1. Blood urea nitrogen (BUN).
l 2. White blood cell (WBC) count.
l 3. Hemoglobin and hematocrit (H&H).
l 4. Urinalysis (UA).
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ANSWERS
99. Correct answer 3: AquaMephyton (vitamin K), is

the antidote for Coumadin. Warfarin is the generic
form of Coumadin. Protamine sulfate is the antidote for heparin. Content AreaMedical; Category of
LevelApplication.
100. Correct answer 1: Assessing for the Homan sign

used to be standard practice, but current research
indicates that there is a possibility of dislodging
the clot from the vein wall. The charge nurse
should intervene to prevent this from occurring.
101. Correct answer 4: Gastric bypass surgery drastically reduces the amount of rugae in the stomach.
Rugae produce intrinsic factor, which allows the
110
body to utilize vitamin B12 from the foods eaten.

With a reduced number of rugae, clients who have
had gastric bypass surgery often develop pernicious
anemia (vitamin B12 deficiency). Other symptoms
of anemia include dizziness, tachycardia, and
dyspnea. Content AreaMedical; Category of Health
102. Correct answer 3: Menorrhagia means excessive

blood loss during menses. The nurse should
monitor the client's H & H. The symptoms are
the direct result of the excessive blood loss. Content
Client NeedsPhysiological Integrity, Reduction of
Risk Potential; Cognitive LevelApplication.
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SECTION TWO
103. The nurse writes a diagnosis of altered tissue

perfusion for a client diagnosed with folic acid deficiency
anemia. Which interventions should be included in the
plan of care? Select all that apply.
l 1. Administer iron supplements.
l 2. Move to room near the nurse's desk.
l 3. Encourage the client to eat green vegetables.
l 4. Assess for history of alcohol consumption.
l 5. Allow for rest periods during the day.
104. The client diagnosed with iron deficiency anemia is
prescribed iron dextran intravenously. Which intervention
should the nurse implement when administering this
medication?
l 1. Administer epinephrine intravenously prior to
beginning the infusion.
l 2. Start the infusion with a test dose, and monitor the
client for 15 minutes.
l 3. Place the client on bedrest with bathroom
privileges.
l 4. Teach the client the stools may be very dark, and
this can mask blood.
111
105. The nurse and UAP are caring for clients on a

medical unit. Which task is inappropriate for the nurse to
delegate to the UAP?
l 1. Checking on the bowel movements of a client
diagnosed with melena.
l 2. Taking the vital signs of a client who received
blood the day before.
l 3. Documenting the amount of food a client
consumed from the lunch tray.
l 4. Setting up the food tray for a client with an
intravenous line in the hand.
106. The client is diagnosed with anemia. The HCP
ordered a transfusion of 2 units of packed red blood cells.
The unit has 250 mL of red blood cells plus 45 mL of
additive. The blood transfusion set delivers 10 gtt/mL.
At what rate should the nurse set the IV tubing to infuse
each unit of packed red blood cells in 4 hours?
Answer: ____________________
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ANSWERS
103. Correct answer 2, 3, 4, 5: A room near the nurse's

desk is important because decreased oxygenation
levels to the brain, resulting from the anemia, can
cause the client to become confused, and a history
of alcohol consumption can require observation for
delirium tremens. The client should include leafy
green vegetables in the diet. These are high in folate.
Folic acid deficiency is common among heavy
drinkers. Fatigue is the primary presenting symptom
of anemia. Content AreaMedical; Category of Health
104. Correct answer 2: Because iron dextran can cause

anaphylactic reactions in the client to the dextran,
the nurse should start with a test dose and monitor
the client for 15 minutes before initiating the full
dose. Epinephrine is administered if the client has
an allergic reaction to the medication, but not
before. Activity is not restricted, and the stools
become dark with oral iron. Content AreaMedical;
112

Physiological Integrity, Pharmacological and
105. Correct answer 1: The nurse must assess the stools

for blood (melena); the nurse should not delegate
this task. The UAP can take vital signs on a stable
client, document the amount of food consumed
from a tray, and set up the tray for a client. Content
106. Correct answer 12 gtt/min: 250 + 45 = 295 mL
to infuse in 4 hours. 295 divided by 4 = 73.75 mL to

infuse in 1 hour, divided by 60 minutes = 12.2 mL
per minute to infuse. Multiplied by 10 gtt per mL =
12 gtt per minute. Content AreaMedical; Category of

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SECTION TWO
107. The charge nurse is making assignments on a

medical floor. Which client should be assigned to the
new graduate nurse?
l 1. The client diagnosed with iron-deficiency anemia
who is prescribed iron tablets.
l 2. The client diagnosed with pernicious anemia who
is receiving intravenous iron.
l 3. The client diagnosed with aplastic anemia who has
developed pancytopenia.
l 4. The client diagnosed with renal disease on an
experimental medication protocol.
108. The client diagnosed with folic acid anemia is
admitted to the medical unit. Which HCP order would
the nurse question?
l 1. Chlordiazepoxide (Librium), a benzodiazepine,
every 8 hours.
l 2. Serum vitamin B12 laboratory studies.
l 3. Administer 3 units of packed red blood cells over
2 hours each.
l 4. Assist the client with activities of daily living
(ADLs).
113
109. The nurse is discharging a client prescribed oral

iron supplements. Which instructions should the nurse
teach?
l 1. Sit upright after taking the medication for
3060 minutes.
l 2. Perform a daily stool test for occult blood.
l 3. Eat a full meal and then take the iron supplement.
l 4. Take the iron about 2 hours after you eat breakfast
each day.
anemia. Which nursing intervention should the nurse
implement first?
l 1. Teach the client to pace activities.
l 2. Refer the client to the dietitian.
l 3. Assess the client's activity tolerance.
l 4. Obtain an order for daily hemoglobin.
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ANSWERS
107. Correct answer 1: The new graduate can administer and teach about oral medications. Clients
receiving parenteral iron are at risk for anaphylactic
reactions. Pancytopenia requires an experienced
nurse as does administering an experimental
medication protocol. Content AreaMedical; Category of Health AlterationCardiovascular; Integrated
LevelApplication.
108. Correct answer 3: Blood transfusions are given

cautiously for clients diagnosed with anemia because the client's body has compensated for the
anemia. If given, the blood is administered slowly
to prevent pulmonary edema. Vitamin B12 studies
are done to help differentiate between B12 anemia
and folic acid deficiency. Antianxiety medications
would not be questioned because folic acid anemia
is usually secondary to alcoholism. Content Area
Integrated ProcessImplementation; Client
114
NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelApplication.
109. Correct answer 4: Approximately 2 hours after

breakfast is the correct dosing time for iron to
achieve the best effects. Iron preparations should be
administered 1 hour before a meal or 2 hours after
the meal. Iron can cause gastrointestinal upset if
administered with a meal, and absorption can be
diminished by as much as 50%. Content Area
110. Correct answer 3: The nurse should assess for the

symptoms associated with anemia first and then plan
other interventions based on the assessment data.
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SECTION TWO
115
Management Issues
111. The nurse is discharging a client diagnosed with
coronary artery disease. Which discharge instructions
should the nurse teach the client?
l 1. Instruct the client to decrease the amount of
cigarettes smoked.
l 2. Encourage to perform weight-lifting exercises
3 days a week.
l 3. Teach the client how to take coronary vasodilators.
l 4. Explain the need to prepare an advance directive
and living will.
congestive heart failure. Which diagnostic test indicates
the client's condition is getting better?
l 1. The client's chest x-ray (CXR) shows a large
cardiac silhouette.
l 2. The client's LDH and SGOT levels have decreased.
l 3. The client's blood urea nitrogen (BUN) is 10 points
higher.
l 4. The client's B-type natriuretic peptide (BNP) has
decreased.
113. The nurse is preparing to administer digoxin

to a client diagnosed with heart failure. Which nursing
l 1. Check the client's potassium level.
l 2. Assess the client's radial pulse.
l 3. Monitor the client's respirations.
l 4. Ask if the client has eaten today.
114. Which client should the nurse on a cardiac unit
assess first after receiving the shift report?
l 1. The client diagnosed with a myocardial infarction
with four unifocal PVCs in a minute.
l 2. The client diagnosed with mitral valve prolapse
(MVP) who has an audible S3 and dyspnea.
l 3. The client diagnosed with coronary artery disease
who wants to ambulate in the hallway.
l 4. The client diagnosed with pericarditis whose third
dose of intravenous antibiotic is late.
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ANSWERS
111. Correct answer 3: The client diagnosed with

coronary artery disease will have angina at times.
The nurse should discuss how to use the medication, storage, and when to know the medication is
still potent. The nurse should also discuss when to
call the emergency medical response system. Content AreaMedical; Category of Health Alteration
112. Correct answer 4: BNP is secreted from the

ventricles and directly relates to the amount of fluid
volume overload. A decreased BNP indicates the
therapy is effective. LDH and SGOT measure liver
function; BUN measures kidney function; and a
large cardiac silhouette indicates heart failure and
does not indicate the client is getting better.
116
113. Correct answer 1: Digoxin can potentiate dysrhythmias if the potassium level is low. The nurse
should check the apical pulse and the digoxin level.
The medication does not have to be given with
food. Content AreaMedical; Category of Health
LevelApplication.
114. Correct answer 2: The development of an S3

heart sound indicates heart failure, a complication
of MVP. The nurse should assess this client first.
The client may have up to 6 unifocal PVCs in a
minute and be considered within normal limits.
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SECTION TWO
115. The nurse is told in report that the client has mitral
valve regurgitation. Which anatomical position should the
nurse auscultate to assess the murmur?
l 1. Second intercostal space, right sternal notch.
l 2. Erb point.
l 3. Fourth intercostal space, left axillary line.
l 4. Fifth intercostal space, midclavicular line.
116. The nurse is assisting with a synchronized

cardioversion on a client in atrial fibrillation. Which
statement by the client indicates the client understands
the pre-procedure teaching?
l 1. This procedure will cure my atrial fibrillation
problems for good.
l 2. I should be able to eat breakfast before the
procedure.
l 3. I will be given some medication to relax me before
the procedure.
l 4. I won't need to be hooked up to telemetry after
the procedure.
117
117. The nurse is reviewing HCP orders on a client

diagnosed with an AAA who is scheduled for surgery in
the morning. Which orders should the nurse question?
l 1. Administer biscodyl (Dulcolax), a cathartic laxative,
on admission to the unit.
l 2. Send an intravenous piggyback (IVPB) antibiotic
to surgery with the client.
l 3. Have the client bathe using an iodine preparation
at night and in the morning.
l 4. Elevate the head of the bed at 45.
118. The nurse is admitting a client with a suspected
myocardial infarction who was brought in by ambulance.
Which nursing intervention has priority?
l 1. Ask if the client is allergic to aspirin.
l 2. Place the client on the telemetry monitor.
l 3. Notify the cardiac catheterization lab.
l 4. Have the client sign for permission to treat.
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ANSWERS
115. Correct answer 4: The fifth intercostal space, midclavicular line is directly over the mitral valve and is
the best place to hear a mitral murmur. Option 1 is
the aortic area; option 2 is the pulmonic area; and
option 3 is in between areas. Content AreaMedical;
Integrated ProcessAssessment; Client NeedsHealth
Promotion and Maintenance; Cognitive Level
Application.
116. Correct answer 3: The client is given sedating

medications prior to the procedure. The other
options are false statements. Content AreaMedical;
117. Correct answer 1: Administering a stimulant

laxative will increase intra-abdominal pressure and
could cause the aneurysm to rupture. Sending an
IVPB antibiotic to surgery for administration is
118
appropriate. Research indicates that administering

antibiotics within an hour of the first incision is
the best practice for prophylaxis of infection.
118. Correct answer 1: The nurse must immediately

begin morphine, oxygen, nitroglycerin, and
aspirin (MONA is an acronym to help the
students remember the initial treatment ). Aspirin
decreases platelet aggregation and may prevent
worsening of the damage to the cardiac muscle.
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SECTION TWO
119. The nurse is preparing to administer daily

medications. Which medication would the nurse
question?
l 1. The ACE inhibitor to the client who tells the nurse
his cough has gone away.
l 2. The calcium channel blocker to the client who
states an allergy to calcium.
l 3. The beta blocker to the client who has a BP of
156/94 and a pulse of 58.
l 4. The antidysrhythmic medication to the client in
normal sinus rhythm.
119
120. The client admitted with deep vein thrombosis is

prescribed heparin by constant infusion after an initial
dose of 5000 units intravenous push. The heparin comes
prepared 20,000 units in 500 mL of D5W. The bolus
heparin was administered at 0800 and the infusion
initiated per protocol at 25 mL/hr. At the 1900 shift
change, how much heparin had been administered?
Answer: ____________
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ANSWERS
119. Correct answer 3: Beta blockers decrease the blood
120
120. Correct answer 5440: The nurse must determine
pressure and the pulse. The nurse should question

administering this medication because of the pulse.
Calcium channel blockers do not contain calcium.
The body must have calcium in order to live. Con-
the number of units in each mL; 20,000 divided by

500 = 40 units per mL; 40 units times 11 hours
= 440 units administered via constant infusion +
5000 = 5440 units administered this shift. Content
tent AreaMedical; Category of Health Alteration


SECTION THREE
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Respiratory Disorders
121
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Page 122
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SECTION THREE
123
Chronic Obstructive Pulmonary

Disease (COPD)
1. The nurse is teaching a class at a local community
center. Which information is the most important fact
to discuss with the clients regarding the prevention of
chronic obstructive pulmonary disease (COPD)?
l 1. Explain the importance of quitting smoking
cigarettes, which will help repair lungs.
l 2. Inform the participants that people who have never
smoked can get COPD.
l 3. Tell the participants there is no reason to quit
smoking if they have smoked for years.
l 4. Discuss that secondhand smoke is not as harmful
as actually smoking the cigarette.
2. The nurse is admitting the client diagnosed with an

acute exacerbation of end-stage COPD. The client has a
dusky color, is dyspneic, and has a respiration rate of 36.
Which intervention should the nurse implement first?
l 1. Apply O2 at 10 liters per minute (LPM) via nasal
cannula.
l 2. Assist the client into the high Fowler position.
l 3. Monitor the clients telemetry reading.
3. The nurse is caring for a client diagnosed with COPD.
Which assessment data requires the nurse to intervene?
l 1. Use of accessory muscles during inspiration.
l 2. Oxygen flow meter set on 3 L while the client is
ambulating.
l 3. Presence of a barrel chest and dyspnea.
l 4. Rust-colored sputum in the sputum collection
container.
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ANSWERS
1. Correct answer 1: When the client stops smoking,

the lungs will begin to repair themselves. Some clients
who do not smoke but have familial asthma or occupational exposure to irritants can still have forms of
COPD. Many medications will be more effective
without the presence of the chemicals in cigarette
smoke. ContentMedical; Category of Health Alteration
Respiratory; Integrated ProcessPlanning; Client Needs
Health Promotion and Maintenance; Cognitive
LevelSynthesis.
2. Correct answer 2: The client should be assisted into a

high sitting position, which helps increase lung expansion. Some clients find it easier sitting on the side of
the bed leaning over the bed table in a three-point
stance. Oxygen will be applied as soon as possible but
at 2 LPM, not 10 LPM, because of the clients
hypoxic drive. Because the client with COPD has
become adapted to a low oxygen level, the client will
be supplied oxygen at a lower level2 LPMthan
what would be expected based on the amount of
124
carbon dioxide in the blood. ContentMedical; Category

of Health AlterationRespiratory; Integrated Process
LevelAnalysis.
3. Correct answer 4: Rusty-colored sputum indicates the

presence of an infection and the nurse should intervene by notifying the HCP and obtaining cultures.
Oxygen at 3 LPM during ambulation is appropriate; it
is decreased when the client is at rest. Use of accessory
muscles and barrel chest and dyspnea are characteristic
of COPD. ContentMedical; Category of Health AlterationRespiratory; Integrated ProcessAssessment; Client
Care; Cognitive LevelAnalysis.
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SECTION THREE
4. The nurse is evaluating the care provided to a client

diagnosed with COPD. Which client outcome indicates
the plan of care is effective?
l 1. The clients sputum culture indicates Klebsiella.
l 2. The clients circumoral mucosa is pale gray.
l 3. The client ambulates in the hallway without
dyspnea.
l 4. The client participates in establishing goals.
5. The nurse and an unlicensed assistant personnel
(UAP) are caring for clients on a medical unit. Which
nursing task should the nurse delegate to the UAP?
l 1. Instruct the UAP to increase the oxygen level for a
client who is dyspneic.
l 2. Document the amount, color, and consistency of a
sputum collection specimen.
l 3. Bag the sputum specimen in a plastic bag and take
it to the laboratory.
l 4. Refer the client to the respiratory therapist to
collect a sputum specimen.
125
6. The home health-care nurse is providing care for a

client diagnosed with COPD. Which instruction should
the nurse teach the client?
l 1. Instruct the client to call the HCP if the sputum is
white in the mornings.
l 2. Tell the client to practice blowing into the
incentive spirometer every 2 hours.
l 3. Encourage the client to sleep on one pillow with
the head of the bed (HOB) flat.
l 4. Recommend the client maintain a fluid intake of
1500 mL per 24 hours.
7. Which statement made by the client diagnosed with
COPD indicates to the clinic nurse that teaching has
been effective?
l 1. I should take the pneumonia vaccine annually.
l 2. I need to get the flu shot every year in the fall.
l 3. I must reduce how many cigarettes I smoke a day.
l 4. I will make an appointment to see an
endocrinologist.
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ANSWERS
4. Correct answer 3: Ambulating without dyspnea

indicates the plan of care is effective. Klebsiella is a
bacterium that causes some types of pneumonia.
Cyanosis (option 2) does not indicate effective
care. Establishing goals does not indicate the care
is effective. ContentMedical; Category of Health
AlterationRespiratory; Integrated ProcessEvaluation;
126
6. Correct answer 2: An incentive spirometer will assist

the client to expand the lungs and improve breathing.
White sputum is normal for a client with COPD. The
client should elevate the HOB or may need to use two
or more pillows. Fluid intake is not limited. Content
Medical; Category of Health AlterationRespiration;
Integrated ProcessPlanning; Client NeedsSafe Effective
LevelSynthesis.
5. Correct answer 3: The UAP can obtain the specimen
7. Correct answer 2: The client should receive the flu vac-
and take it to the lab for analysis. The UAP cannot

care for a client who is unstable. The UAP cannot
teach or evaluate the specimen. Referrals are made by
the nurse. ContentMedical; Category of Health Alter-
cine annually prior to the winter flu season. Pneumonia

vaccines are recommended every 56 years. The client
should stop smoking. A pulmonologist, not an
endocrinologist, cares for a client with COPD. Content
ationRespiratory; Integrated ProcessPlanning; Client

Medical; Category of Health AlterationRespiratory;

LevelEvaluation.
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SECTION THREE
8. The nurse is assessing the client diagnosed with black

lung. Which intervention should the nurse delegate to
the UAP?
l 1. Ask the UAP to take all liquids off the clients meal
trays.
l 2. Tell the UAP to give the client a sputum cup for a
sputum culture.
l 3. Have the UAP measure the clients chest expansion
with each breath.
l 4. Instruct the UAP to suction the client for a sputum
specimen.
9. The elderly client with COPD is admitted to the
medical unit. The clients level of consciousness is altered
and the vital signs are P 118, R 28, BP 176/96. Which
arterial blood gases (ABGs) results would the nurse
expect?
l 1. pH 7.28, PaCO2 56, HCO3 29, PaO2 76.
l 2. pH 7.48, PaCO2 33, HCO3 25, PaO2 98.
l 3. pH 7.35, PaCO2 56, HCO3 18, PaO2 100.
l 4. pH 7.40, PaCO2 38, HCO3 24, PaO2 80.
127
10. The client diagnosed with end-stage COPD has a

pulse oximeter reading of 91%. Which intervention
l 1. Document the findings in the clients chart.
l 2. Request a stat arterial blood gas reading.
l 3. Notify the respiratory therapist immediately.
l 4. Encourage the client to cough and deep-breathe.
Reactive Airway Disease (Asthma)

reactive airway disease who is prescribed montelukast
(Singulair), a leukotriene modifier. Which information
l 1. Instruct the client to take the Singulair when there
is a tightening in the chest.
l 2. Tell the client it will take up to 2 weeks for the
medication to become effective.
l 3. Explain that a fast-acting medication is needed for
an asthma attack, not Singulair.
l 4. Recommend the client take the breathing
medication three times a day with meals.
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ANSWERS
8. Correct answer 2: Black-streaked sputum is a classic

sign of coal workers pneumoconiosis (black lung). All
clients sputum should be assessed for color and
amount. The UAP can deliver a specimen cup to the
client; the nurse must instruct the client and evaluate
the specimen. ContentMedical; Category of Health
AlterationManagement; Integrated ProcessPlanning;
Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
9. Correct answer 1: The client would be in respiratory

acidosis with a low oxygen level. Normal pH is
7.357.45; a pH of 7.28 indicates acidosis. A PaCO2
of 56 (normal is 3545) indicates a respiratory problem,
and a low oxygen levelPaO2 of 76 (normal is
80100)is associated with confusion. The HCO3 of
29 (normal is 2226) indicates the bodys attempt to
compensate. ContentMedical; Category of Health
AlterationRespiratory; Integrated ProcessAssessment;
128
10. Correct answer 1: The client with end-stage COPD

would be expected to have a low oxygen levelless
than 93% indicates a low oxygen leveleven as low as
80%. The nurse should document the oxygen level in
the clients chart. ContentMedical; Category of Health
AlterationRespiratory; Integrated Process Implementation; Client NeedsSafe Effective Care Environment,
11. Correct answer 3: Singulair prevents the

excitability of leukotrienes and maintains medication
blood levels, but it is not useful in an acute attack.
The medication will begin to work in 24 hours and
is taken once a day. ContentMedical; Category of
Health AlterationRespiratory; Integrated Process
Physiological Adaptation: Cognitive LevelSynthesis.
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SECTION THREE
129
12. The client presents to the emergency department (ED)

diagnosed with status asthmaticus. Which intervention
l 1. Administer Solu-Medrol, a glucocorticoid,
intravenously.
l 2. Give the client a short-acting beta adrenergic agonist.
l 3. Hang an intravenous infusion of the
bronchodilator theophylline.
l 4. Assess the clients breath sounds every 5 minutes.
14. The nurse on the medical unit is caring for a client

experiencing an asthma attack. Which nursing intervention
should be implemented first?
l 1. Obtain the clients short-acting beta agonist
medication.
l 3. Have Respiratory Therapy administer a breathing
treatment.
l 4. Elevate the head of the bed.
13. The nurse is completing the admission assessment on

a client diagnosed with reactive airway disease. Which
signs and symptoms would indicate an acute exacerbation
of reactive airway disease?
l 1. The client complains of tightness in the chest and
difficulty breathing.
l 2. The client has a temperature of 100F and nausea.
l 3. The nurse hears crackles in all lung fields and
notices red raised areas on the chest.
l 4. The client is able to expand the thoracic cavity
symmetrically during inhalation.
15. The nurse is planning the care of a 65-year-old client

diagnosed with adult onset of reactive airway disease.
Which interventions should the nurse include? Select all
that apply.
l 1. Assess the client for gastroesophageal reflux symptoms.
l 2. Teach the client about rescue and maintenance
medications.
l 3. Ambulate the client with a gait belt when short of
breath.
l 4. Do not allow the client to perform activities of
daily living.
l 5. Encourage the client to drink 68 glasses of
water a day.
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ANSWERS
12. Correct answer 2: The client should first be given a
130
14. Correct answer 4: The nurse should elevate the
short-acting beta-adrenergic medication to treat the

symptoms. The nurse can then administer the steroid
Solu-Medrol and the bronchodilator theophylline.
Remember, If in stress, do not assess.
head of the clients bed to assist in lung expansion.

The nurse can send another nurse to obtain the
clients medication; the nurse should not leave
the client. ContentMedical; Category of Health

Respiratory; Integrated ProcessImplementation;
AlterationRespiratory; Integrated Process

LevelSynthesis.
13. Correct answer 1: During an asthma attack, the
15. Correct answer: 1, 2, 5: Up to 85% of the time,
muscles surrounding the bronchioles constrict, causing a narrowing of the bronchioles. The lungs then
respond with production of secretions that further
narrow the lumen. The resulting symptoms include
wheezing from air passing through narrow clogged
spaces and dyspnea. ContentMedical; Category of
adult-onset asthma is caused by gastric reflux. The

client should be knowledgeable of the medication
regimen and drink the recommended amount of
water daily. The client should not be ambulated when
having difficulty breathing, and the nurse should
encourage the clients independence. Content

Assessment; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelAnalysis.

Integrated ProcessPlanning; Client NeedsSafe
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SECTION THREE
16. The client is diagnosed with reactive airway disease.

Which information should the nurse teach when discussing
zone classifications?
l 1. The green zone means the client has mild symptoms.
l 2. The yellow zone means the client is at 50%80%
of peak inspiratory effort.
l 3. The red zone means the client has improved since
the last HCP visit.
l 4. The black zone means the client should go to the
emergency department.
17. Which statement by the client indicates to the
nurse the client understands the teaching regarding the
inhaled steroid medication fluticasone (Flovent) by
metered dose inhaler (MDI)?
l 1. I should take two puffs of the medications within
30 seconds of one another.
l 2. I should eat before I use the inhaler to prevent
stomach upset.
l 3. I should rinse my mouth before using the inhaler.
l 4. I should not take these drugs when I am having
an asthma attack.
131
18. The client diagnosed with reactive airway disease is

admitted to the ED with difficulty breathing and a bluish
tint around the mouth. Which intervention should the
ED nurse implement first?
l 1. Draw blood for a complete blood count.
l 2. Apply oxygen via nasal cannula.
l 3. Request arterial blood gases (ABGs).
l 4. Take the clients vital signs.
19. The clinic nurse is discussing the clients frequent
asthma attacks. Which intervention should the nurse
implement?
l 1. Discuss the client moving to a different climate.
l 2. Ask the client when and where the attacks occur.
l 3. Tell the client to buy cotton linens for the home.
l 4. Teach the client to attempt to avoid all stress.
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ANSWERS
16. Correct answer 2: Health-care providers rank asthma

symptoms by zones. Green means everything is going
well, and yellow indicates the client is not at top performance and is beginning to show distress. The
client with 50%80% of normal lung capacity is in
the yellow zone. The red zone indicates more severe
distress and the need for immediate medical intervention. There is no black zone. ContentMedical; Category of Health AlterationRespiratory; Integrated
17. Correct answer 4: Inhaled steroids are used for prophylaxis and are not effective during an acute asthma
attack. The puffs should be spaced apart to allow for
increased absorption of the medication. The mouth is
rinsed after the medication to prevent oral candidiasis;
the client does not need to eat before using the medication. ContentMedical; Category of Health Alteration
Drug Administration: Integrated ProcessEvaluation;
132
18. Correct answer 2: The nurse should first take care

of the client by applying oxygen, which is the only
option that will directly affect the clients cyanosis.
Drawing blood, requesting ABGs, and taking vital
signs are appropriate interventions, but they will not
help the clients cyanosis. ContentMedical; Category
of Health AlterationRespiratory; Integrated
LevelAnalysis.
19. Correct answer 2: The nurse should assess for possible causes of the frequent asthma attacks by asking
when and where they occur. Moving to a different
climate may not help and could even be worse for
the client. The client may not be reacting to the bed
linens. Avoiding all stress is not realistic. Content
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Page 133
133
20. The charge nurse on a medical unit is making

rounds. Which client should the charge nurse see first?
l 1. The client diagnosed with reactive airway disease
whose pulse oximeter reading is 90%.
l 2. The client diagnosed with heart failure who
has 2+ edema of the lower extremities.
l 3. The client diagnosed with type 2 diabetes whose
blood glucose reading is 243 mg/dL.
l 4. The client diagnosed with COPD who states he
cannot breathe without his oxygen.
22. The nurse planning the care of a client diagnosed

with pneumonia writes a problem of impaired gas
exchange. Which nursing interventions should be
included in the plan of care? Select all that apply.
l 1. Respiratory therapy to perform chest physiotherapy.
l 2. Complete activities of daily living at the same time.
l 3. Ambulate in the hall and back several times each
shift.
l 4. Assess the client neurological status frequently.
l 5. Keep the clients HOB elevated at all times.
Lower Respiratory Infections
23. The nurse is planning the care for a client with

continuous percutaneous gastrostomy (PEG) feedings.
Which intervention should the nurse include in the plan
of care?
l 1. Inspect the insertion line at the nares daily.
l 2. Elevate the HOB only after feeding the client.
l 3. Auscultate the lungs each shift and as needed.
l 4. Change the dressing on the feeding tube every
72 hours.
21. The nurse is assessing an 89-year-old client

diagnosed with pneumonia. Which signs and symptoms
would the nurse expect the client to exhibit?
l 1. Pink frothy sputum and edema.
l 2. Confusion and lethargy.
l 3. High fever and chills.
l 4. Bradypnea and jugular vein distention.
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ANSWERS
20. Correct answer 1: A pulse oximeter reading of 90%

is the equivalent of an arterial blood gas oxygen level
of 60. This client should be evaluated first. The other
clients have expected clinical manifestations of their
conditions and are not in life-threatening situations.
Respiratory; Integrated ProcessAssessment; Client
21. Correct answer 2: The elderly client diagnosed with

pneumonia may present with weakness, fatigue,
lethargy, confusion, and poor appetite but may not
have any of the classic signs and symptoms of
pneumonia. Fever and chills are classic symptoms of
pneumonia but are usually absent in the elderly
client. ContentMedical; Category of Health Alteration
134
22. Correct answers: 1, 4, 5: Respiratory therapy

should perform chest physiotherapy. A decrease in
oxygenation will cause the client to become confused
and disoriented; therefore, the nurse should assess
the clients neurological status. Keeping the HOB
elevated will increase lung expansion. Activities
should be spaced out, and the client should not
ambulate. ContentMedical; Category of Health
AlterationRespiratory; Integrated ProcessDiagnosis;
23. Correct answer 3: PEG tube feedings are placed

directly into the stomach, resulting in a risk of regurgitation into the lungs; therefore, the nurse should
assess for aspiration pneumonia. The insertion site is
through the abdominal wall, not the nares; the
feedings are continuous, not bolus; and the dressing
should be changed daily. ContentMedical; Category
Diagnosis; Client NeedsSafe Effective Care Environment,
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SECTION THREE
24. The client diagnosed with community-acquired

pneumonia is being admitted to a medical unit. Which
nursing intervention should the nurse implement first?
l 1. Administer the intravenous antibiotic stat.
l 2. Order the meal tray to be delivered as soon as
possible.
l 3. Obtain a sputum specimen for culture and
sensitivity.
l 4. Notify the pharmacy to prepare the antibiotic.
25. The client diagnosed with tuberculosis (TB) is being
discharged on rifampin, an antitubercular antibiotic.
Which statement made by the client indicates an
understanding of the discharge instructions?
l 1. I will take my medication for the full 3 weeks
prescribed.
l 2. My urine may turn a red-orange but I still should
take my medication.
l 3. I can be around my friends since I have started
taking antibiotics.
l 4. I should get a tuberculin skin test every 3 months
to determine if I still have TB.
135
26. The employee health nurse is administering tuberculin

skin testing to the employees who have possibly been
exposed to a client with active tuberculosis. Which finding
indicates the need for radiological evaluation?
l 1. The employees skin test indicates a purple flat area
at the site of injection.
l 2. The employees skin test indicates a red area
measuring 6 mm.
l 3. The employee whose previous skin test was read as
12 mm.
l 4. The employee who has never been outside the
country.
27. The nurse is feeding the client diagnosed with
aspiration pneumonia, and the client begins to cough and
is having difficulty breathing. Which intervention should
l 1. Suction the clients mouth.
l 2. Change the client to tube feedings.
l 3. Apply oxygen via nasal cannula.
l 4. Turn the client to the side.
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24. Correct answer 3: In order to determine which

antibiotic will effectively treat an infection, a sputum
culture must be obtained prior to initiating antibiotic therapy. Administering antibiotics prior to
cultures may make it impossible to determine the
actual agent causing the disease. ContentMedical;
Category of Health AlterationRespiratory; Integrated
Process Implementation; Client NeedsSafe Effective
LevelSynthesis.
25. Correct answer 2: Rifampin may turn body fluids a

red-orange, but it will not cause permanent damage,
and the client must take the medication. Clients will
need to take the medications for 912 months, not
3 weeks. Clients are contagious until three morning
sputum specimens are cultured negative; and the
client should have chest x-rays, not TB skin tests.
Administration; Integrated ProcessEvaluation; Client
Cognitive LevelEvaluation.
136
26. Correct answer 3: Induration of 10 mm or greater

is considered a positive skin test. Once the skin test
result is positive, it will always be positive. This
employee requires a chest x-ray to determine if
tuberculosis is present. ContentMedical; Category of
27. Correct answer 4: Turning the client to the side will

allow for the food to be coughed up and come out
of the mouth. The nurse could suction the clients
mouth next, but the nurse should first assist the
client to cough the food up and out of the mouth.
Respiratory; Integrated ProcessImplementation; Client
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SECTION THREE

rounds after report. Which client should be seen first?
l 1. The client diagnosed with tuberculosis who has a
sputum specimen to send to the lab.
l 2. The client diagnosed with aspiration pneumonia
who has a clogged feeding tube.
l 3. The client diagnosed with pneumonia who has a
pulse oximeter reading of 98%.
l 4. The client diagnosed with bronchitis who has an
arterial oxygenation level of 78 mm Hg.
29. The client is admitted with a diagnosis of rule-out
(R/O) tuberculosis. Which type of isolation precautions
l 1. Standard.
l 2. Contact.
l 3. Droplet.
l 4. Airborne.
Page 137
137
30. The female client is admitted to a medical unit with

a diagnosis of pneumonia. Which nursing task should the
nurse delegate to the UAP?
l 1. Ask the client if he/she is having chest discomfort
and anxiety.
l 2. Draw a blood specimen for admitting lab work.
l 3. Assist the radiology technician to take a stat
portable x-ray.
l 4. Show the client the call light and bathroom.
Upper Respiratory Infections

31. The male client calls the clinic nurse to ask, Which
over-the-counter (OTC) remedy should I take for my
cold and runny nose? Which question is the most
important for the nurse to ask the client?
l 1. Which medications do you have in your house?
l 2. What chronic conditions do you have?
l 3. Do you have any allergies to decongestants?
l 4. Did you take the flu shot this year?
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ANSWERS
28. Correct answer 4: The normal arterial oxygenation
138
30. Correct answer 4: The UAP can orient the client to
level is 80100 mm Hg; therefore, this client should

be seen first. A sputum culture, a clogged feeding
tube, and a normal pulse oximeter reading would
not be priority over a client who is in respiratory
distress. ContentMedical; Category of Health
the room. The UAP cannot assess for chest discomfort,

and the lab is responsible for drawing blood for lab
work. The nurse must make sure a female UAP is
not pregnant before asking her to assist with radiological procedures.ContentMedical; Category of


Planning; Client NeedsSafe Effective Care Environment,
29. Correct answer 4: Tuberculosis bacteria are capable

of disseminating over distances on air currents.
Airborne precautions are needed. The client should
be placed in a negative air pressure room where the
air is not allowed to cross-contaminate the air in
the hallway. ContentMedical; Category of Health
AlterationRespiratory; Integrated Process
LevelApplication.
31. Correct answer 2: The nurse should determine

what, if any, medical conditions the client has
because many OTC cold and flu medications work
by vasoconstriction and are contraindicated in clients
diagnosed with hypertension and diabetes. Content
Integrity, Physiological Adaptation: Cognitive Level
Analysis.
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SECTION THREE
32. The school nurse is preparing a class to present to

staff members who teach the primary grades. Which
information is most important to teach regarding the
prevention of the transmission of the common cold?
l 1. The teacher should keep tissues available for the
students to use.
l 2. The teacher should encourage the children to share
their food at lunch.
l 3. The teacher should remind the children to cough
into their sleeve.
l 4. The teacher should disinfect the classroom at the
end of the day.
33. Which statement made by the female client indicates
to the nurse that the client understands the teaching
about the new diagnosis of acute sinusitis?
l 1. I will get a bulb syringe to irrigate my sinuses
twice each day.
l 2. If I need to blow my nose, I will use a disposable
Kleenex.
139
3. I should eat a container of yogurt every day while
4. I must take all the prescribed medication before
I am on the antibiotic.
I feel better.
34. The client diagnosed with chronic sinusitis calls the

clinic nurse and reports a severe headache and a stiff
neck. Which intervention should the nurse implement?
l 1. Have the HCP call in a different antibiotic
prescription.
l 2. Make an appointment for the client to see the
HCP next week.
l 3. Instruct the client to sleep with the head elevated
on several pillows.
l 4. Tell the client to go to the hospitals ED.
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ANSWERS
32. Correct answer 3: Current recommendations are to

encourage good hand washing and teach children to
cough into their sleeves. These activities prevent
bacteria and viruses from reaching the childs hands.
Tissues are not always disposed correctly; children
should not share their foods; and disinfectant will
not kill the cold virus. ContentMedical; Category of
Planning; Client NeedsHealth Promotion and
Maintenance; Cognitive LevelSynthesis.
33. Correct answer 3: Female clients on antibiotics

frequently get vaginal yeast infections. Eating yogurt
will replace the good bacteria in the vagina that are
destroyed by the antibiotic. The client may feel
better before the prescription is completed, but she
still needs to take all of the medication to prevent
resistant strains of bacteria from developing. A bulb
syringe will not help client. ContentMedical;
140
ProcessEvaluatiol; Client NeedsPhysiological Integrity,

LevelEvaluation.
34. Correct answer 4: Neck stiffness (nuchal rigidity)

and headache are symptoms of meningitis, a potential fatal complication of sinusitis. Survival depends
on the appropriate antibiotic being administered in a
timely manner. The client should go to the hospitals
ED. ContentMedical; Category of Health Alteration
Respiratory; Integrated ProcessImplementation; Safe
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SECTION THREE
35. The client diagnosed with tonsillitis is scheduled to

have a tonsillectomy in the morning. Which statement
made by the client would warrant immediate intervention
by the nurse?
l 1. I have been told that I will not feel anything during
the operation.
l 2. My tonsils have been giving me problems for over
a year now.
l 3. The doctor said that I will hear better once I have
the tube put in my ears.
l 4. My spouse bought gelatin and ice cream for me to
eat when I go home.
36. The client diagnosed with sinusitis who has undergone
a Caldwell-Luc procedure is complaining of pain. Which
l 1. Assess the clients pain level on a 110 scale.
l 2. Administer the narcotic analgesic by intravenous
push (IVP).
l 3. Perform gentle oral hygiene with an antiseptic
mouthwash.
l 4. Place the client in a semi-Fowler position.
141
37. The charge nurse on a surgical floor is making shift

assignments. Which client should be assigned to the least
experienced registered nurse (RN)?
l 1. The client who has undergone an antral irrigation
for sinusitis who has a severe headache.
l 2. The pediatric client scheduled for a tonsillectomy
who will not swallow medication.
l 3. The client who had a Caldwell-Luc procedure and
has purulent drainage on the drip pad.
l 4. The elderly client with a peritonsillar abscess who
has a feeling of tightness in the throat.
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ANSWERS
35. Correct answer 3: This statement indicates that

another procedure may be done. The nurse should
investigate to determine if a myringotomy (placing a
tube in the tympanic membrane) is also planned to
be done so the appropriate permits can be obtained.
All the other statements indicate the client understands the surgical procedure. ContentSurgical;
ProcessEvaluation; Client NeedsSafe Effective Care
LevelSynthesis.
36. Correct answer 1: The nurse should assess the level

of pain first to determine if the client is experiencing
a postoperative complication or having routine
postoperative pain. If it is routine postoperative pain,
then the nurse should administer the pain medication. A semi-Fowler position may help to reduce
edema, but oral hygiene will not help the pain.
142

37. Correct answer 2: An inexperienced nurse can care

for a child who is not cooperative and is NPO for
surgery. A severe headache after an antral irrigation
procedure could indicate meningitis. Purulent
drainage and feelings of tightness in the throat
indicate possible complications and should be
assigned to a more experienced nurse. Content
Surgical; Category of Health AlterationManagement;
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SECTION THREE
38. The clinic nurse is discharging a client diagnosed

with influenza type A. Which statement best describes the
scientific rationale for the HCP prescribing antibiotics?
l 1. The antibiotics will vasoconstrict the sinuses.
l 2. The antibiotics will kill the influenza bacteria.
l 3. The medication may help the client get better
faster.
l 4. The medication may prevent pneumonia from
developing.
39. The nurse is delegating tasks to the UAP. Which
nursing task should not be delegated to the UAP?
l 1. Feed a postoperative tonsillectomy client the third
meal of clear liquids.
l 2. Encourage the client diagnosed with a cold to
drink an 8-ounce glass of juice.
l 3. Obtain a throat swab on a client diagnosed with
bacterial pharyngitis.
l 4. Take the client diagnosed with laryngitis to the
radiology department for a chest x-ray.
143
40. The female client tells the clinic nurse that she prefers
to treat her cold symptoms with natural medications.
Which complimentary alternative medicine (CAM) is an
example of this type of therapy?
l 1. Echinacea.
l 2. A sulfa antibiotic.
l 3. Over-the-counter (OTC) antihistamines.
l 4. Amantadine, an anti-Parkinson preparation.
Lung Cancer
41. The nurse is taking the social history from a client
diagnosed with small-cell carcinoma of the lung. Which
information is significant for this disease?
l 1. The client worked with asbestos for a short time
many years ago.
l 2. The client has no family history for this type of
lung cancer.
l 3. The client has numerous tattoos covering upper
and lower arms.
l 4. The client has smoked two packs of cigarettes a day
for 20 years.
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ANSWERS
38. Correct answer 4: Antibiotics are prescribed as prophylaxis to prevent a secondary bacterial pneumonia.
Antibiotics will not vasoconstrict sinuses, will not
kill a virus, and will not help the client feel better
because influenza is a viral, not a bacterial, infection.
Respiratory; Integrated ProcessDiagnosis; Client
39. Correct answer 3: Throat swabs for culture must be

done correctly, or false negatives can result; the nurse
should obtain the throat culture. The UAP can feed
a stable client, can encourage the client to drink juice,
and can escort clients to the radiology department.
Management; Integrated ProcessPlanning; Client
144
40. Correct answer 1: Echinacea is an herb used to

stimulate the immune system. Research on echinacea
has not shown efficacy against cold viruses. All other
options are medications. ContentMedical; Category
of Health AlterationComplimentary Alternative
Medicine; Integrated ProcessEvaluation; Client
41. Correct answer 4: Smoking is the primary risk

factor for developing cancer of the lung, with risk
increasing with the amount of use and length of
time the client smoked. Asbestos is significant for
mesothelioma, not small-cell carcinoma. Family
history and tattoos are not risk factors for lung
cancer. ContentMedical; Category of Health
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SECTION THREE
42. The nurse writes a problem of anticipatory grieving

for a client diagnosed with metastatic cancer of the lung.
Which interventions should be included in the plan of
care for this problem? Select all that apply.
l 1. Apply O2 via nasal cannula.
l 2. Spend time with the client and family.
l 3. Place the client in respiratory isolation.
l 4. Assist the client to prepare an advance directive.
l 5. Listen to lung sounds every shift.
43. The nurse is discussing lung cancer with a group of
individuals in the community. Which information should
the nurse teach the group?
l 1. Explain lung cancer is the second leading cause of
cancer deaths in women.
l 2. Tell the individuals most cases of lung cancer can
be prevented.
l 3. Explain that young people are not at risk for
developing lung cancer.
l 4. Tell the individuals lung cancer deaths have begun
to decline.
145
44. The nurse and a UAP are caring for a group of

clients on a medical unit. Which information provided by
the UAP warrants immediate intervention by the nurse?
l 1. The client diagnosed with cancer of the lung has a
small amount of blood in a tissue.
l 2. The client diagnosed with emphysema is sitting on
the side of the bed, leaning on a table.
l 3. The client receiving intravenous (IV)
chemotherapy for lung cancer has a T 100.2F and
BP of 148/92.
l 4. The client receiving prednisone, a steroid, is
requesting an antacid for indigestion.
45. The client diagnosed with lung cancer has been
placed on experimental IV antineoplastic medication.
Which priority intervention should the nurse implement
when administering the medication?
l 1. Discuss the need to implement the advance directive.
l 2. Make sure the client understands the possible
reactions.
l 3. Obtain an IV pump to infuse the medication.
l 4. Include the significant other in the discussion
about the treatment.
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ANSWERS
42. Correct answer 2, 4: The nurse should take time

with the client and family to help them cope with
the grieving process. Preparing an advance directive
helps the family and HCP know the clients wishes.
Oxygen administration and assessing lung sounds
are not appropriate for grieving. The client is not in
respiratory isolation. ContentMedical; Category of
Diagnosis; Client NeedsPsychosocial Integrity;
43. Correct answer 2: Most lung cancers are directly

related to the incidence of cigarette smoking. The
longer the time and the greater the number of
cigarette smoked, the greater the risk for developing
lung cancer. Young people are at risk if they choose
to smoke. Lung cancer is the primary cause of cancer
deaths of both sexes in the United States. Content
Integrated ProcessPlanning; Client NeedsHealth
Promotion and Maintenance; Cognitive LevelSynthesis.
146
44. Correct answer 3: This client is receiving medications that can decrease the ability to fight infection;
therefore, the low-grade fever should be investigated
by the nurse. A small amount of blood on the tissue
of a client with lung cancer, the orthopneic position
in a client with emphysema, and indigestion in a
client receiving steroids would not warrant immediate
intervention by the nurse. ContentMedical; Category
45. Correct answer 2: In order to receive experimental

medication, the client must sign an informed consent
document stating an understanding of the possible
reactions to the medication. Discussing an advance
directive, obtaining an IV pump, and including
significant others are plausible interventions, but not
priority interventions. ContentMedical; Category of
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SECTION THREE
147
46. The client diagnosed with lung cancer is being

discharged. Which statement made by the client
indicates that discharge teaching is effective?
l 1. I should quit smoking even though I have cancer.
l 2. My primary care provider can answer all my
questions.
l 3. A low-grade fever is expected after chemotherapy.
l 4. I should plan to visit my children before it is
too late.
48. The client is 4 hours post right pneumonectomy

for cancer of the lung. Which assessment data warrant
immediate intervention by the nurse?
l 1. The client has an intake of 1500 mL IV and an
output of 1000 mL.
l 2. The client has absent lung sounds on the right side.
l 3. The client is complaining of pain of 10 on a
110 scale.
l 4. The client has turned onto the right side.
47. The nurse in a clinic is completing a client admission

interview. Which statement by the client warrants further
investigation?
l 1. I have been using the nicotine patch for 2 weeks.
l 2. I know I should stop dipping snuff, but I really
like the taste.
l 3. I have two siblings who have smoked for
30 years.
l 4. I coughed up blood the past several mornings.
49. The client is admitted to the outpatient surgery

center for a bronchoscopy to rule out cancer of the lung.
Which information should the nurse provide to the
client?
l 1. Instruct the client to eat breakfast before the
0900 procedure.
l 2. Explain that a catheter will be inserted in the groin
and dye instilled.
l 3. Inform the client there is discomfort associated
with this procedure.
l 4. Tell the client the HCP can do a biopsy of the
tumor through the scope.
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ANSWERS
46. Correct answer 1: Research indicates the smoking

will interfere with the clients response to treatment.
The oncologist should be asked questions regarding
cancer treatment and prognosis. The client should
report any fever, not expect it. There is no indication
that death is imminent. ContentMedical; Category of
47. Correct answer 4: Coughing up blood, especially in

the mornings, should be investigated because it is a
sign of lung cancer. Using the nicotine patch, liking
the taste of tobacco, and having siblings who smoke
would not warrant further investigation. Content
Synthesis.
148
48. Correct answer 3: This is a very high pain level;

therefore, the nurse should rule out complications
and then administer pain medication. Option 1 is an
adequate output because of the fluid shift occurring
as a result of trauma to the body. The nurse should
encourage the client to turn, and the right side has
no lung to have lung sounds. ContentSurgical;
ProcessAssessment; Client NeedsSafe Effective Care
LevelSynthesis.
49. Correct answer 4: The HCP will insert a fiber-optic

tube through the mouth (not the groin) into the clients
lungs to obtain a biopsy of suspicious tissue. Clients
have nothing by mouth prior to the procedure and
are sedated throughout the procedure so there is no
discomfort. ContentSurgical; Category of Health
AlterationRespiratory; Integrated ProcessPlanning;
Client NeedsSafe Effective Care Environment, Reduction
of Risk Potential; Cognitive LevelSynthesis.
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SECTION THREE
50. The client diagnosed with oat cell carcinoma of the

lung tells the nurse, I am so tired of all this. I might as
well just end it all. Which therapeutic response would be
most appropriate by the nurse?
l 1. This must be hard for you. Would you like to talk
about your feelings?
l 2. Are you planning to do something that will end
your life?
l 3. Have you discussed your feelings with your
significant other?
l 4. I think you should tell your HCP how you are
feeling.
Cancer of the Larynx

cancer of the larynx. Which intervention should the nurse
implement first?
l 1. Allow the client to verbalize feelings of having
cancer.
l 2. Request a diet with a mechanical soft consistency.
l 3. Assess the clients ability to swallow.
l 4. Elevate the head of the bed during meals.
149
52. The male client diagnosed with cancer of the larynx

is scheduled to have radiation therapy to the area. Which
information should the nurse teach the client?
l 1. Explain to the client that his teeth will be extracted
and he will be fitted for dentures.
l 2. Tell the client the therapy will be administered for
4 days and then again in 4 weeks.
l 3. Instruct the client to scrub his throat area with an
antibacterial soap nightly.
l 4. Inform the client to expect mild throat irritation
that will resolve quickly.
53. The client is 3 days post partial laryngectomy. Which
action is the nurses best method to communicate with
the client?
l 1. The nurse provides the client with a tablet for
writing.
l 2. The nurse and client have a verbal conversation.
l 3. The nurse attempts to use sign language to talk to
the client.
l 4. The nurse requests the speech therapist to provide
an electric larynx.
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ANSWERS
50. Correct answer 1: A therapeutic response encourages

the client to verbalize feelings. Option 2 and 3 requires
yes/no answers, which do not encourage verbalizations.
Option 4 is advising the client. ContentMedical;
ProcessImplementation; Client NeedsPsychosocial
Integrity; Cognitive LevelApplication.
51. Correct answer 3: The nurse should assess the clients

ability to swallow before implementing a change in
the consistency of the food served. All other interventions are appropriate but not before assessment,
which is the first step of the nursing process.
150
52. Correct answer 1: The teeth will be in the area of

radiation; the roots of teeth are highly sensitive to
radiation. Exposure to radiation results in abscesses of
the teeth roots; therefore, the teeth are removed, and
the client is fitted for dentures. Radiation therapy is
administered daily for 46 weeks; no soap is used in
the area; and the client can develop esophagitis, which
is extremely painful. ContentMedical; Category of
53. Correct answer 2: A partial laryngectomy leaves the

client with some vocal cords. The voice quality may
change, but the ability to speak does not. Content
Surgical; Category of Health AlterationRespiratory;
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SECTION THREE
54. The nurse is preparing the client diagnosed with

laryngeal cancer for a total laryngectomy in the morning.
all that apply.
l 1. Take the client to the intensive care unit (ICU) for
a visit.
l 2. Explain that the client will need to request pain
medication.
l 3. Demonstrate how to apply anti-embolism hose.
l 4. Determine if the client has the ability to read and
write.
l 5. Refer the client to the occupational therapist.
55. The nurse is discharging a client who had a total
laryngectomy. Which referral should the nurse make for
this client?
l 1. CanSurmount.
l 2. Dialogue.
l 3. Lost Chords.
l 4. The hospital chaplain.
151
56. The nurse and a UAP are caring for a group of

clients on a surgery floor. Which information provided by
the UAP requires immediate intervention by the nurse?
l 1. The client who had a radical neck dissection who
has a small amount of dark dried blood on the
dressing.
l 2. The client who had a right upper lobectomy and is
complaining that the patient-controlled anesthesia
(PCA) pump is not giving any relief.
l 3. The client diagnosed with cancer of the lung who
is complaining of being tired and short of breath.
l 4. The client admitted with COPD who whistles with
every breath.
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ANSWERS
54. Correct answer 1, 2, 4: A visit to the ICU will
152
56. Correct answer 2: The client is in pain, and the
familiarize the client with the machines and rules; the

client needs to know pain control methods; and the
nurse needs to know if the client can read and write.
The client will not have antiembolism hose, and a
referral to a speech therapist, not an occupational
therapist, would be appropriate. ContentSurgical;
nurse should assess the situation. Dark dried blood

on the dressing of a client who had a radical neck
dissection and dyspnea and fatigue in a client with
cancer of the lung are expected findings. Whistling
with every breath in a client with COPD indicates
the client is purse-lip breathing. ContentSurgical;

LevelApplication.

LevelSynthesis.
55. Correct answer 3: The Lost Chords Club is an

American Cancer Societysponsored group for
survivors of laryngeal cancer. These clients are able
to discuss their feelings and needs concerning the
laryngectomies because the volunteers have also had
this surgery. ContentSurgical; Category of Health
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SECTION THREE
57. The charge nurse is assigning clients for the shift. Which
client should be assigned to the most experienced nurse?
l 1. The client diagnosed with cancer of the lung who
has chest tubes.
l 2. The client diagnosed with laryngeal spasms who
has a respiratory rate of 16.
l 3. The client diagnosed with laryngeal cancer who has
multiple fistulas.
l 4. The client who is 1 week post partial laryngectomy.
58. The nurse is developing a care plan for a client
diagnosed with cancer of the larynx who has had a radical
neck dissection. Which problem would have the highest
priority?
l 1. Risk for wound infection.
l 2. Risk for hemorrhage.
l 3. Altered nutrition.
153
59. The male client has had a radial neck dissection for
cancer of the larynx. Which action by the client could
indicate a disturbance in body image?
l 1. The client refuses to allow visitors in the room.
l 2. The client asks for a hand-held mirror.
l 3. The client is trying to learn esophageal speech.
l 4. The client practices neck and shoulder exercises.
60. The HCP has recommended a total laryngectomy for
a male client diagnosed with cancer of the larynx, but the
client refuses. Which intervention by the nurse illustrates
the ethical principle of beneficence?
l 1. The nurse listens to the client explain why he is
refusing surgery.
l 2. The nurse and clients wife insist the client have the
surgical procedure.
l 3. The nurse tells the client he may die if he does not
have the surgery.
l 4. The nurse asks a cancer visitor to come and discuss
the surgery with the client.
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ANSWERS
57. Correct answer 3: A client with multiple fistulas in
154
59. Correct answer 1: Refusing to allow friends and
the neck area is at high risk for airway compromise

and should be assigned to a more experienced nurse.
Clients with chest tubes, a respiratory rate of 16, or
being 1 week postoperative could be cared for by a
less experienced nurse. ContentMedical; Category of
family to visit could indicate that the client has a

disturbance in body image. Looking at the incision
in a mirror, attempting to speak, and performing
postoperative exercises indicate the client is accepting
the surgery. ContentSurgical; Category of Health
Health AlterationManagement; Integrated Process

Planning; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.

LevelEvaluation.
58. Correct answer 2: The client who has had a radical

neck dissection is at risk for carotid hemorrhage.
Prophylactic antibiotics can be prescribed to prevent
wound infections. ContentSurgical; Category of
Diagnosis; Client NeedsPhysiological Integrity,
60. Correct answer 4: The nurse is attempting to do

good for the client. This is beneficence. Listening is
non-malfeasance, insisting the client have the surgery
is paternalism, and telling the client what may
happen is veracity. ContentFundamentals; Category
LevelSynthesis.
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155
Adult Respiratory Distress

Syndrome (ARDS)
61. The UAP is bathing the client diagnosed with adult
respiratory distress syndrome (ARDS). The bed is in a
high position with the opposite side rail in the up
position. Which action should the nurse implement?
l 1. Demonstrate the correct technique when giving a
bed bath.
l 2. Encourage the UAP to put the bed in the lowest
position.
l 3. Instruct the UAP to get another person to help
with the bath.
l 4. Provide praise for performing the bath safely for
the client and the UAP.
62. The client diagnosed with ARDS is transferred to the
intensive care department and placed on a ventilator.
Which intervention should the intensive care unit nurse
implement first?
l 1. Confirm that the ventilator settings are correct.
l 2. Verify that ventilator alarms are functioning
properly.
l
l
3. Assess the clients upper extremity restraints.

4. Monitor the clients ABG results.
63. The nurse suspects the client may be developing

ARDS. Which assessment data confirm the diagnosis
of ARDS?
l 1. The client has dyspnea and tachycardia and is feeling
anxious.
l 2. The client respiratory rate is 26, and he has cyanotic
buccal mucosa.
l 3. The clients arterial blood gases are pH 7.38,
PaO2 90, PaCO2 44, HCO3 24.
l 4. The clients pulse oximeter is 90% after 15 minutes
of 10 L of oxygen.
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ANSWERS
61. Correct answer 4: The opposite side rail should be

elevated so the client will not fall out of the bed.
Because the UAP is ensuring the clients safety, the
nurse should acknowledge the UAPs performance
with praise. ContentMedical; Category of Health
AlterationRespiratory; Integrated ProcessImplementation;
62. Correct answer 1: Maintaining ventilator settings

and checking to ensure they are specifically set as
prescribed is the nurses first intervention; this
machine is now functioning as the clients lungs.
Verifying alarms, assessing the clients hands, and
monitoring ABGs are appropriate but not before
confirming the ventilator settings. ContentMedical;
LevelSynthesis.
156
63. Correct answer 4: The classic sign of ARDS is

decreased arterial oxygen level (PaO2) while high
levels of oxygen are being administered; the oxygen
is unable to cross the alveolar membrane. Dyspnea,
tachycardia, anxiety, tachypnea, and cyanosis are also
signs of ARDS. The ABGs are within normal limits.
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SECTION THREE
64. The client whose husband has ARDS asks the nurse,
What is happening to my husband? Why did he get
this? Which statement by the nurse is most appropriate?
l 1. No one really knows why your husband developed
ARDS.
l 2. Platelets and fluid enter the alveoli due to
permeability instability.
l 3. Your husbands lungs are filling up with fluid,
causing breathing problems.
l 4. You are concerned about what is happening to
your husband.
65. Which assessment data would indicate the client
diagnosed with ARDS is experiencing a complication
secondary to the ventilator?
l 1. The clients urine output is 210 mL in 8 hours.
l 2. The pulse oximeter reading is greater than 95%.
l 3. The client has asymmetrical chest expansion.
l 4. The telemetry reading shows sinus tachycardia.
157
66. The HCP ordered stat ABGs for the client suspected
of having ARDS. The ABG results are pH 7.42, PaO2 84,
PaCO2 41, HCO3 23. Which action should
the nurse implement?
l 1. Administer oxygen via nasal cannula to the client.
l 2. Encourage the client to take deep breaths and
cough.
l 3. Administer 1 amp of intravenous sodium
bicarbonate.
l 4. Notify the respiratory therapist of the ABG results.
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ANSWERS
64. Correct answer 3: This is a very basic explanation of

ARDS and explains why the client is having trouble
breathing. It is the nurses best response. The nurse
should provide information in simple terms. The
layperson may not know terms such as platelets,
alveoli, and permeability. The cause of ARDS is
unknown, but the wife does not need to know this.
The spouse is asking for information, so a therapeutic
response (option 4) is not appropriate. Content
Psychosocial Integrity; Cognitive LevelApplication.
65. Correct answer 3: Asymmetrical chest expansion

indicates the client has had a pneumothorax, which
is a complication of ventilation. A urine output less
than 30 mL/hr indicates renal failure, but it is not
secondary to the ventilator. Sinus tachycardia is not
secondary to the ventilator. ContentMedical;
158

Environment, Management of Care; Cognitive Level
Analysis.
66. Correct answer 1: These ABGs are within normal

limits, but the oxygen level is low, possibly secondary
to ARDS. Because the client is suspected of having
ARDS, administering oxygen will either increase the
oxygen level or help confirm ARDS. If the oxygen
level continues to decrease even with supplemental
oxygen, the client is developing ARDS. Content
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SECTION THREE
67. The client with ARDS is on a mechanical ventilator.

Which intervention addressing endotracheal tube (ET)
care should be included in the nursing care plan?
l 1. Alternate the ET from side to side in the mouth.
l 2. Replace the ET daily.
l 3. Ensure the ET is deflated.
l 4. Check the lip line of the ET daily.
68. Which medication should the nurse anticipate the
HCP prescribing for the client diagnosed with ARDS?
l 1. An intravenous Tridil (nitroglycerin) drip.
l 2. A synthetic surfactant.
l 3. An intravenous loop-diuretic.
l 4. A nonsteroidal anti-inflammatory drug (NSAID).
159
69. The client diagnosed with ARDS is on a ventilator,

and the high alarm is going off. The client is having
respiratory difficulty, and the nurse cannot determine the
cause of the problem. Which intervention should the
l 1. Notify the respiratory therapist immediately.
l 2. Auscultate the clients lung sounds.
l 3. Ventilate with a manual resuscitation bag.
l 4. Check the clients pulse oximeter reading.
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ANSWERS
160
67. Correct answer 1: Alternating the ET tube will help
69. Correct answer 3: If the ventilator system malfunc-
prevent a pressure ulcer on the clients tongue and

mouth. The ET tube is not replaced daily; the cuff
should be inflated no more than 25 cm H2O to ensure
there is no air leakage; and the lip line should be
checked more often than daily. ContentMedical;
tions, the nurse must ventilate the client with a

manual resuscitation bag (Ambu) until the problem
is resolved. Remember when in distress, do not
assess. Assessing the lungs and pulse oximeter
reading will not help the clients respiratory distress.

ProcessDiagnosis; Client NeedsPhysiological Integrity,
Basic Care and Comfort; Cognitive LevelAnalysis.

68. Correct answer 2: Surfactant therapy may be prescribed to reduce the surface tension of the alveoli.
This medication helps maintain open alveoli,
decreases the work of breathing, improves compliance,
and helps prevent atelectasis. Tridil is a coronary
vasodilator. Diuretics and NSAIDs are not routine
medications for ARDS. ContentMedical; Category of
LevelSynthesis.
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SECTION THREE

ARDS who is on a ventilator. Which interventions should
l 1. Assess the clients level of consciousness.
l 2. Monitor the clients urine output.
l 3. Perform passive range-of-motion (ROM) exercises.
l 4. Maintain intravenous fluids as ordered.
l 5. Place the client with the HOB flat.
Pulmonary Embolus
71. The client is diagnosed with a pulmonary embolus
(PE) and is on a heparin drip. The bag hanging is
20,000 units/500 D5W infusing at 20 mL/hr.
How many units of heparin is the client receiving
an hour?
Answer: ___________________
161
72. The client is suspected of having a PE. Which

diagnostic laboratory test confirms the diagnosis?
l 1. Plasma D-dimer test.
l 2. Arterial blood gases (ABGs).
l 3. Chest x-ray (CXR).
l 4. Pulmonary/ventilation perfusion scan.
73. Which statement by the client would make the nurse
suspect the client has experienced a PE?
l 1. I have pain in my calf muscle when I move
my foot.
l 2. My chest hurts and I feel like something bad is
going to happen.
l 3. I have chest pain that is radiating down my left arm.
l 4. I hear myself wheezing and I have a low-grade
fever.
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ANSWERS
70. Correct answer 1, 2, 3, 4: Altered level of conscious-
162
72. Correct answer 1: The plasma D-dimer test is highly
ness is the earliest sign of hypoxemia; urine output less

than 30 mL/hr indicates decreased cardiac output; the
client is at risk for complications of immobility and
fluid volume overload. The semi-Fowler position, not
the supine position, facilitates lung expansion and
reduces the workload of breathing. ContentMedical;
specific to the presence of a thrombus; an elevated

D dimer indicates a thrombus formation and lysis.
ABGs evaluate oxygenation level; a CXR shows
pulmonary infiltration; and a pulmonary/ventilation
scan is a radiological diagnostic test, not a laboratory
test. ContentMedical; Category of Health Alteration

LevelApplication.

71. Correct answer 800 units:

20,000 units
L
500 mL 20 mL
400,000
Cross multiply and divide =
= 800
500
73. Correct answer 2: The most common signs of a PE

are sudden onset of chest pain when taking a deep
breath, shortness of breath, and a feeling of impending
doom. Calf pain is a sign of a deep vein thrombosis,
which is a precursor to a PE, not a sign of one. Chest
pain radiating down the left arm is a sign of a
myocardial infarction, and wheezing and low-grade
fever may indicate pneumonia. ContentMedical;
Physiological Adaptation; Cognitive Level Analysis.
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163
74. The client diagnosed with a PE is in the intensive

care department. Which assessment data would warrant
immediate intervention from the nurse?
l 1. The clients ABGs are pH 7.36, PaO2 95, PaCO2 38,
HCO3 24.
l 2. The clients telemetry exhibits multifocal premature
ventricular contractions (PVCs).
l 3. The clients pulse oximeter reading is 96%.
l 4. The clients urinary output for the 12-hour shift is
800 mL.
76. The nurse is preparing to administer the oral

anticoagulant warfarin (Coumadin) to a client who has a
prothrombin time/partial thromboplastin time (PT/PTT)
of 32/39 and an International Normalized Ratio (INR)
of 3.8. What action should the nurse implement first?
l 1. Assess the client for abnormal bleeding.
l 2. Prepare to administer vitamin K (AquaMephyton).
l 3. Administer the medication as ordered.
l 4. Notify the HCP to obtain an order to decrease
the dose.
75. The client has just been diagnosed with a PE. Which
l 1. Administer parenteral anticoagulants.
l 2. Assess the clients bilateral popliteal pulses.
l 3. Prepare the client for a thoracentesis.
77. The nurse is completing the discharge teaching for a

client diagnosed with a PE. Which statement indicates
the client needs more teaching?
l 1. I am going to use a soft-bristle toothbrush.
l 2. I will not go barefooted while taking my
medication.
l 3. I can take enteric-coated aspirin for my
headache.
l 4. I will wear a medic alert band at all times.
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ANSWERS
74. Correct answer 2: Multifocal PVCs are a potentially

life-threatening dysrhythmia; therefore, the nurse
should assess this client immediately. The ABGs and
pulse oximater reading are within normal limits,
and urine output more than 30 mL/hr would not
warrant immediate intervention by the nurse.
75. Correct answer 1: The intravenous anticoagulant

heparin should be administered immediately after
diagnosis of a PE. The pulses behind the knees
(popliteal pulses) would not need to be assessed by
the nurse. A thoracentesis is used to aspirate fluid
from the pleural space and is not a treatment of
choice for a PE. Strict bedrest reduces metabolic
demands and tissue needs for oxygen; therefore,
bathroom privileges would be denied. Content
164

76. Correct answer 1: The normal INR is 23; the

clients level is too high. The nurse should first assess
for abnormal bleeding and then obtain an order
from an HCP to either decrease the dose of warfarin
or to administer vitamin K, which is the antidote for
warfarin overdose. ContentMedical; Category of
77. Correct answer 3: Aspirin, enteric-coated or not, is

an antiplatelet, which may increase bleeding tendencies and should be avoided. The client needs more
teaching. Using a soft-bristle toothbrush, preventing
possible cuts or injuries, and wearing a medic alert
band indicate the client understands the discharge
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SECTION THREE
78. The client diagnosed with a PE is being discharged.

Which intervention should the nurse discuss with the
client?
l 1. Decrease fluid intake to 1 L a day.
l 2. Do not eat foods high in vitamin K.
l 3. Avoid being around large crowds.
l 4. Take pneumonia and flu vaccines.
79. The nurse is preparing to administer medications to
the following clients. Which medication would the nurse
question administering?
l 1. The oral coagulant warfarin (Coumadin) to the
client with an INR of 1.9.
l 2. A coronary vasodilator to the client with a digoxin
level of 1.3.
l 3. Hanging the heparin bag of a client with a
PT/PTT of 12.9/98.
l 4. The anticonvulsant medication to a client with a
dilantin level of 22.
165
80. The client is getting out of bed and becomes very

anxious and has a feeling of impending doom. The nurse
thinks the client may be experiencing a PE. Which action
l 1. Administer oxygen 10 L via nasal cannula.
l 2. Place the client in high Fowler position.
l 3. Notify the clients HCP.
l 4. Assess the client for a positive Homan sign.
Chest Trauma
81. The client is admitted to the ED with chest trauma.
Which signs/symptoms would the nurse expect to assess
that supports the diagnosis of pneumothorax?
l 1. Bronchovesicular lung sounds and friction rub.
l 2. Absent breath sounds and tachypnea.
l 3. Nasal flaring and lung consolidation.
l 4. Symmetrical chest expansion and bradypnea.
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ANSWERS
78. Correct answer 2: The client will be discharged on

warfarin (Coumadin); the antidote for Coumadin is
vitamin K; therefore, the client should not eat foods
high in vitamin K. Increasing fluids will help prevent
the development of a deep vein thrombosis (DVT),
which is the most common cause of PE. The client
can have another DVT. ContentMedical; Category of
Health AlterationRespiratory; Integrated ProcessPlanning; Client NeedsPhysiological Integrity, Physiological
79. Correct answer 3: A PTT of 98 is greater than

1.52 times the normal value, which puts the client at
risk for abnormal bleeding; therefore, the medication
should be questioned. Therapeutic PTT is 6888, so
a value of 98 means the client is not clotting, and the
medication should be held. An INR of 23 is therapeutic; digoxin therapeutic level is 0.820, and therapeutic
dilantin level is 1020. ContentMedical; Category of
Health AdministrationDrug Administration; Integrated
166
80. Correct answer 2: Placing the client in high Fowler

position facilitates maximal lung expansion and
reduces venous return to the right side of the heart,
thus lowering pressures in the pulmonary vascular
system. Administering oxygen and notifying the
HCP would be appropriate but not prior to placing
the client in a high Fowler position. The client is
in distress; therefore do not assess for a positive
Homan sign first. ContentMedical; Category of
Health AlterationRespiratory; Integrated ProcessImplementation; Client NeedsSafe Effective Care Environment,
81. Correct answer 2: Absent breath sounds, tachypnea,

and asymmetrical chest expansion would indicate a
pneumothorax. Lung consolidation occurs when
there is no air moving through the alveoli and occurs
in pneumonia; friction rub occurs with pericarditis.
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SECTION THREE
167
82. The client had a right-sided chest tube inserted for a

pneumothorax 3 days ago. Which action should the nurse
take first if there is no fluctuation (tidaling) in the water-seal
compartment?
l 1. Obtain an order for a chest x-ray.
l 2. Prepare for the removal of the chest tube.
l 3. Pre-medicate the client with an analgesic.
l 4. Assess the clients right-sided lung sounds.
84. The client has a right-sided chest tube. As the client

is getting out of the bed, the tube is accidentally pulled
out of the pleural space. Which action should the nurse
implement first?
l 2. Request a new chest tube.
l 3. Place a vaseline gauze over the insertion site.
l 4. Tell the client to exhale forcefully.
83. The male client who has right-sided chest tubes asks
the UAP to help him go to the bathroom. Which situation
warrants immediate intervention from the nurse?
l 1. The UAP keeps the chest tube below the level of
the chest.
l 2. The UAP removes the Pleuravac from the wall
suction.
l 3. The UAP stands to the side and behind the client
when the client is ambulating.
l 4. The UAP clamps the chest tube closest to the
clients chest.
85. The client with a flail chest asks the nurse, What is a
tension pneumothorax? My doctor is worried about my
getting one. Which statement is the nurses best response?
l 1. It is an air-filled bleb on the lung that ruptures
spontaneously.
l 2. Air moves freely between your lungs and the
atmosphere.
l 3. There is air between your lung and chest lining
that cant escape.
l 4. The air in your pleural space causes the trachea to
shift.
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ANSWERS
82. Correct answer 4: No fluctuation in the water seal

3 days after tube insertion may indicate the clients
pneumothorax has resolved. Breath sounds over the
area would indicate re-expansion of the lung. Then
the nurse should contact the health-care provider for
a chest x-ray, medicate the client prior to removal of
the tube, and prepare for the removal of the tube.
83. Correct answer 4: The chest tubes should never be

clamped because it may lead to a tension pneumothorax. Ambulating the client safely facilitates lung
ventilation. Drainage systems are portable and
should be kept lower than the chest to promote
drainage and prevent reflux. The chest tube system
can function due to gravity; it does not have to be
attached to suction. ContentMedical; Category of
168

Evaluation; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
84. Correct answer 4: The client should first exhale

forcefully to push air out of the pleural space. Then
the nurse can apply a Vaseline gauze, request a new
chest tube, and notify the HCP. ContentMedical;
LevelApplication.
85. Correct answer 3: This describes a tension pneumothorax; this is a medical emergency requiring
immediate intervention to preserve life. Option 4 is
called a mediastinal shift. ContentMedical; Category
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SECTION THREE
86. Which action should the nurse implement for the

client with a hemothorax and a right-sided chest tube who
has excessive bubbling in the water seal compartment?
l 1. Pinch the chest tubing nearest the client.
l 2. Assess the tubing for any blood clots.
l 3. Milk the tubing proximal to distal.
l 4. Encourage the client to cough forcefully.
87. The nurse is caring for a client with a right-sided
chest tube secondary to a hemothorax. Which interventions
should the nurse implement when caring for this client?
l 1. Place the client in a high Fowler position.
l 2. Document the amount of bloody drainage.
l 3. Empty the blood from the drainage compartment.
l 4. Secure a loop of drainage tubing to the sheet.
l 5. Observe the site for subcutaneous emphysema.
169
88. The charge nurse is making client assignments on a

medical floor. Which client should the charge nurse assign
to the LPN?
l 1. The client with a pneumothorax who has a pulse
oximeter reading of 91%.
l 2. The client with a hemothorax who has hemoglobin
of 12 and hematocrit of 40%.
l 3. The client with chest tubes who has jugular vein
distention and B/P of 96/60.
l 4. The client with a flail chest who is having chest
tubes inserted.
89. The alert and oriented client is diagnosed with a
spontaneous pneumothorax, and the HCP is scheduled to
insert a left-sided chest tube. Which intervention should
l 1. Teach the client how to deep-breathe.
l 2. Obtain a signed informed consent form.
l 3. Assist the client into a side-lying position.
l 4. Open the chest tube insertion equipment.
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ANSWERS
86. Correct answer 1: The nurse should pinch the chest

tube nearest the client to determine if the bubbling
stops. If the bubbling stops, the air leak is within the
client, which is an emergency. If the bubbling continues, the air leak is in the system, which is not an
emergency. ContentMedical; Category of Health
AlterationRespiratory; Integrated ProcessImplementation;
87. Correct answer 1, 2, 4, 5: The client should be in

a high-Fowler position to facilitate lung expansion.
The nurse should document the amount of drainage
every shift and loop the draining tubing to prevent
direct pressure on the chest tube. The nurse should
also observe the site for subcutaneous emphysema,
which is air under the skin, a common occurrence
after chest tube insertion. The PLEURAvac is a
closed system, and the blood should not be emptied
from the drainage compartment. ContentMedical;
170

88. Correct answer 2: This client is the most stable

because the hemoglobin and hematocrit levels are
within normal limits. A client with a low pulse
oximeter reading (91%), a jugular vein distention, or
a flail chest is unstable and should not be assigned to
an LPN. ContentMedical; Category of Health
89. Correct answer 2: Inserting a chest tube is an invasive procedure and requires informed consent; without a consent form this procedure cannot be done
on an alert and oriented client. Then the nurse could
also teach the client how to deep-breathe, assist the
client into the side-lying position, and open up the
equipment. ContentMedical; Category of Health
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SECTION THREE
90. The client who is 2 days postoperative left

pneumonectomy has an apical pulse (AP) of 128 and
B/P 92/60. Which intervention should the nurse implement?
l 1. Elevate the clients head of the bed (HOB).
l 2. Assess the clients incisional wound.
l 3. Administer a narcotic analgesic.
l 4. Decrease the clients intravenous rate.
Management
91. The charge nurse is reviewing the morning laboratory
results. Which data should the charge nurse report to the
HCP via telephone?
l 1. The client who is 4 hours postoperative
pneumonectomy who has a white blood cell
(WBC) count of 9000 mm.
l 2. The client who has chest tubes secondary to a
hemothorax who has H&H of 9/20.
l 3. The client diagnosed with fractured ribs who has a
l 4. The client with a flail chest who has ABGs of
pH 7.43, PaO2 90, PaCO2 43, HCO3 24.
171
92. The nurse is administering medications to clients

on a surgical unit. Which medication should the nurse
administer first?
l 1. The narcotic analgesic morphine IV to the client
with a hemothorax and pain of 8.
l 2. The aminoglycoside antibiotic vancomycin
intravenous piggyback (IVPB) to the client with a
gunshot wound to the chest.
l 3. The proton pump inhibitor pantoprazole
(Protonix) IVPB to the client who is NPO after
chest surgery.
l 4. The loop diuretic furosemide (Lasix) PO to the
client who is diagnosed with congestive heart
failure.
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ANSWERS

hypovolemia, and the nurse should determine the
cause and assess the incisional wound. Elevating the
HOB, administering narcotic analgesics, and
decreasing the intravenous rate would not help
identify the source or stop the bleeding. Content
91. Correct answer 2: The client has a low H&H, and

the nurse should notify the HCP of this clients
situation. All the other data are within normal
limits and would not require notifying the HCP.
Management: Integrated ProcessAssessment; Client
of Care; Cognitive Level: Analysis.
172
92. Correct answer 1: The client who is in pain is priority

because pain is considered the fifth vital sign; none
of the other clients have life-threatening conditions
nor are their medications priority medications.
Parenteral Therapies; Cognitive LevelSynthesis.
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SECTION THREE
93. The charge nurse is making shift assignments to the

surgical staff, which consists of 2 RNs, 2 LPNs, and
2 UAPs. Which assignment would be most appropriate
by the charge nurse?
l 1. Instruct the RN to transcribe all the new HCP orders.
l 2. Delegate the UAP to assist the client who has been
discharged.
l 3. Assign the LPN to administer a unit of packed red
blood cells.
l 4. Request the LPN to complete the admission for a
new client.
94. The charge nurse is making assignments for the
surgical unit. Which client should be assigned to the new
graduate nurse?
l 1. The client who has a chest tube for a hemothorax
that is draining bright red blood.
l 2. The client who is 1 day postoperative
pneumonectomy with a temperature of 102.2F.
l 3. The client with pneumonia who has bilateral
crackles and a productive cough.
l 4. The client who has a deep vein thrombosis and is
complaining of chest pain.
173
95. The client is diagnosed with laryngeal cancer and is

scheduled for a laryngectomy. Which intervention would
be priority for the clinic nurse?
l 1. Recommend contacting the American Cancer
Society.
l 2. Refer the client to a speech therapist.
l 3. Order the clients preoperative lab work.
l 4. Determine if the client has an advance directive
(AD).
96. The HCP is angry and yelling in the nurses station
because the client diagnosed with reactive airway disease
has not had the stat chest x-ray ordered yesterday. Which
action should the female charge nurse implement first?
l 1. Contact the radiology department immediately.
l 2. Tell the HCP she will find out what has happened.
l 3. Tell the HCP to discuss the issue with x-ray
department.
l 4. Report the HCPs behavior to the chief nursing
officer.
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ANSWERS
93. Correct answer 2: The UAP can discharge a client

home. A unit secretary/ward clerk and an LPN can
transcribe orders; the RN should be assessing and caring for clients. An LPN cannot initiate a blood transfusion or assess the client. ContentMedical; Category of
Health AlterationManagement; Integrated ProcessPlanning; Client NeedsSafe Effective Care Environment,
94. Correct answer 3: The client diagnosed with pneumonia would be expected to have bilateral crackles
and a productive cough; therefore this client should
be assigned to the new graduate nurse. Bleeding may
lead to hypovolemia; elevated temperature indicates
infection; and chest pain may be pulmonary embolus;
clients with these problems should be assigned to a
more experienced nurse. ContentMedical; Category
of Health AlterationManagement; Integrated Process
174
95. Correct answer 2: The client will not be able to

speak after the removal of the larynx; therefore,
discussing an alternate communication technique
and eventual communication ability are the priorities. Referral to the American Cancer Society and
discussion about an AD may be appropriate, but
they are not priority over communication. Content
Surgical; Category of Health AlterationRespiratory;
LevelSynthesis.
96. Correct answer 2: The charge nurse should immediately investigate why the chest x-ray was not done.
This may include contacting the radiology department
or having the HCP contact the radiology department.
If the HCPs behavior continues to be inappropriate,
the chief nursing officer could be notified. Content
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SECTION THREE
175
97. The client diagnosed with terminal lung cancer who

is upset and crying tells the nurse, I think they are
keeping something from me. I just want to know the
truth. Which response by the nurse is an example of
the ethical principle of veracity?
l 1. You are concerned because you think they are not
telling you the truth.
l 2. I know this is hard, but the truth is you have lung
cancer.
l 3. You should ask your doctor for the truth. You
have a right to know.
l 4. Who do you think is keeping something from you?
99. The female nurse tells the male nurse, I really think
you look sexy when you wear that white scrub suit. The
male nurse thinks this comment is sexual harassment.
Which action should the male nurse implement first?
l 1. Document the comment in writing and file a
formal grievance.
l 2. Tell the female nurse this makes him feel very
uncomfortable.
l 3. Notify the clinical manager of the sexual
harassment.
l 4. Discuss the female nurses behavior with the
hospital lawyer.
98. Which client should the nurse on the medical unit

assess first after receiving the morning shift report?
l 1. The client diagnosed with reactive airway disease
who is short of breath and wheezing.
l 2. The client diagnosed with COPD who is in the
orthopneic position.
l 3. The client diagnosed with pneumonia whose pulse
oximeter reading is 95%.
l 4. The client diagnosed with DVT whose calf is
edematous and reddened.
100. The nurse is caring for a male client diagnosed with

lung cancer who has a Do Not Resuscitate (DNR) order
and has Cheyne-Stokes respirations. The clients wife is
at the bedside. Which intervention should the nurse
implement first?
l 1. Notify the nurses desk of the impending death.
l 2. Remain quietly at the clients bedside.
l 3. Make the client as comfortable as possible.
l 4. Ask the wife if she would like to stay at the
bedside.
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ANSWERS
97. Correct answer 2: The ethical principle of veracity is

the duty to tell the truth; telling the client about the
diagnosis of cancer is telling the truth. A therapeutic
response (option 1), passing the buck (option 3),
and attempting to obtain more information about
the situation (option 4) is not telling the truth.
NeedsPsychosocial Integrity; Cognitive LevelApplication.
98. Correct answer 1: The client with reactive airway

disease is having an acute exacerbation and requires
immediate attention; therefore, this client should be
seen first. The orthopneic position is expected in a
client with COPD; a pulse oximeter reading greater
than 93% is normal; and a client with a DVT would
be expected to have an edematous and reddened calf.
Management; Integrated ProcessAssessment; Client
176
99. Correct answer 2: The first action when an employee thinks he/she is being sexually harassed is
to directly confront the harasser with the allegation
of sexual harassment. If it happens again, the male
nurse should notify the clinical manager and then
file a formal grievance. Then, if necessary, it may
need to be reported to an attorney. Content
Fundamentals; Category of Health Alteration
Management; Integrated ProcessImplementation;

if the wife wants to be at her husbands bedside
when he dies. Then the nurse should make the
client comfortable, remain at the bedside, and
notify the nurses desk so that another nurse can
care for the nurses clients until the client dies.
Respiratory; Integrated ProcessImplementation;
SECTION FOUR
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12:09 PM
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Gastrointestinal Disorders
177
11/11/09
12:09 PM
Page 178
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179
Inflammatory Bowel Disease

1. The nurse is admitting a client diagnosed with regional
enteritis (Crohn disease). Which data would the nurse
expect the client to exhibit?
l 1. The client has 1020 loose stools a day.
l 2. The client has left lower quadrant pain and
low-grade fever.
l 3. The client complains of abdominal pain when
eating.
l 4. The client has an increased abdominal girth.
3. The client diagnosed with ulcerative colitis is 3 days

postoperative creation of an ileostomy. Which information
should the nurse discuss with the client?
l 1. Demonstrate how to perform colostomy irrigations.
l 2. Explain that the stoma site should be pink and moist.
l 3. Refer the client to the dietitian to discuss foods on
a high-fiber diet.
l 4. Tell the client that with time an ostomy appliance
may not be needed.
2. The client diagnosed with an acute exacerbation of

regional enteritis (Crohn disease) is prescribed total
parenteral nutrition (TPN). Which intervention should
l 1. Insert an 18-gauge needle in the clients forearm.
l 2. Monitor the clients urine for ketones.
l 3. Check the TPN bag with the prescription.
l 4. Encourage the client to eat a low-residue diet.
4. The client is diagnosed with an acute exacerbation of

inflammatory bowel disease (IBD). Which statement
indicates the client needs more discharge teaching?
l 1. When I quit taking my prednisone I will taper it
off slowly.
l 2. I will not drink any caffeinated or alcoholic
beverages.
l 3. I am going to call the Ileitis and Colitis
Foundation.
l 4. I am so glad I can eat anything I want because
I am not NPO.
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ANSWERS
1. Correct answer 3: Peristalsis causes the ulcerated,

inflamed area to contract, causing pain. If the client
does not eat, then there is no pain. The abdomen does
not increase in size with Crohn disease. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessAssessment; Client NeedsPhysiological
Adaptation, Physiological Integrity; Cognitive Level
Analysis.
2. Correct answer 3: The TPN bag should be checked

to make sure the prescribed nutrients are included.
The TPN must be administered via a central line, and
glucometer checks are necessary because of the high
glucose level of the TPN. The client on TPN is nothing by mouth (NPO). ContentMedical; Category of
Health AlterationGastrointestinal; Integrated Process
Synthesis.
180
3. Correct answer 2: The stoma site should be pink and

moist. A purple stoma site indicates necrosis and the
health-care provider should be notified. An ileostomy
will have continuous drainage and will need an ostomy
appliance at all times. An ileostomy is not irrigated.
A high-fiber diet is not prescribed for a client with
an ileostomy. ContentMedical; Category of Health
AlterationGastrointestinal; Integrated ProcessPlanning;
4. Correct answer 4: The client should eat a lowresidue, low-fat, high-protein, and high-calorie diet
and avoid foods that cause diarrhea. The client should
avoid caffeinated beverages, pepper, alcohol, and
milk products. ContentMedical; Category of Health
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SECTION FOUR

acute exacerbation of ulcerative colitis. Which priority
l 1. Ensure privacy when the client is having a bowel
movement.
l 2. Provide perianal care to help excoriation of the
clients buttocks.
l 3. Allow the client to ventilate feelings of powerless
over disease process.
l 4. Instruct the unlicensed assistive personnel (UAP)
to obtain the clients weight daily.
acute exacerbation of ulcerative colitis. Which data would
warrant immediate intervention by the nurse?
l 1. The clients serum potassium level is 4.2 mEq/L.
l 2. The clients serum sodium level is 138 mEq/L.
l 3. The clients arterial blood gases (ABGs) are
pH 7.33, PaO2 95, PaCO2 38, HCO3 20.
l 4. The clients hemoglobin/hematocrit is 12/40%.
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181
7. The male client diagnosed with regional enteritis

(Crohn disease) calls the clinic nurse and tells the nurse,
I have been having abdominal pain and some diarrhea.
l 1. Make an appointment for the client to be seen in
the clinic today.
l 2. Tell the client to rest the bowel by not eating or
drinking anything.
l 3. Encourage the client to write down all the foods he
ate during the last 24 hours.
l 4. Ask the client if he has experienced any type of leg
cramps in the last 8 hours.
8. The nurse and the UAP are caring for clients on a
medical/surgical unit. Which task would be most
appropriate for the nurse to delegate to the UAP?
l 1. Transfer the client to the intensive care unit via the
stretcher.
l 2. Assist the client who is receiving TPN to eat.
l 3. Empty the bedside commode of the client who has
loose runny stools.
l 4. Check the client who is complaining of abdominal
cramping.
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ANSWERS
5. Correct answer 2: The client may have up to

1020 stools a day; therefore, impaired skin integrity
of the perianal care is priority for the client. Daily
weights, privacy, and ventilating feelings are not
priority over a physiological problem. Content
Medical; Category of Health AlterationGastrointestinal;
6. Correct answer 3: These ABGs indicate metabolic
182
7. Correct answer 2: The nurse should first instruct the

client to rest the bowel. Making an appointment and a
24-hour food diary should be implemented but not
prior to resting the bowel. Leg cramps may indicate
hypokalemia, but some diarrhea would not cause
hypokalemia. ContentMedical; Category of Health
AlterationGastrointestinal; Integrated ProcessEvaluation;
Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelEvaluation.
8. Correct answer 3: The UAP can empty the clients
acidosis, which is caused by excessive diarrhea; this

client requires immediate intervention. The potassium,
sodium, hemoglobin, and hematocrit levels are within
normal limits (WNLs). ContentMedical; Category of
bedside commode. A client being transferred to the

intensive care unit is not stable; the client on TPN
should have nothing by mouth; and the UAP cannot
assess a client who has abdominal cramping. Content


LevelSynthesis.
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SECTION FOUR
183
Gastroesophageal Reflux
Disease (GERD)
9. The nurse is preparing to hang the third bag of TPN
for the client diagnosed with an acute exacerbation of
regional enteritis (Crohn disease). The third bag is not
ready, and the second bag is empty. Which action should
l 1. Hang dextrose 10% at the same rate as the TPN.
l 2. Administer normal saline at keep open vein rate.
l 3. Stop the TPN and wait for the third bag to come
to the unit.
l 4. Notify the HCP of the situation.
ulcerative colitis is admitted to the medical unit. Which
HCPs order would the nurse question?
l 1. Prepare the client for a colonoscopy in the morning.
l 2. Administer Lomotil, an antidiarrheal, once after
each loose stool up to 8 in 24 hours.
l 3. Total parenteral nutrition (TPN) at 83 mL/hr via a
subclavian line.
l 4. Administer the steroid SoluCortef intravenous
piggyback (IVPB) every 12 hours.
11. The client in the clinic tells the nurse that he has
been experiencing heartburn. Which intervention
l 1. Measure the clients abdominal girth.
l 2. Schedule the client for gastrointestinal x-rays.
l 3. Determine alleviating and aggravating factors.
l 4. Perform an electrocardiogram.
12. The nurse caring for a client diagnosed with GERD
writes the client problem of behavior modification.
Which intervention should be included for this problem?
l 1. Instruct the client to bend with knees and not to
stoop over.
l 2. Encourage the client to decrease the amount of
smoking.
l 3. Instruct the client to take OTC medication,
specifically proton pump inhibitors.
l 4. Discuss the need to attend Al-Anon to learn to quit
drinking.
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ANSWERS
9. Correct answer 1: The nurse should hang dextrose

10% (D10) at the same rate to prevent the client
from developing hypoglycemia. ContentMedical;
Category of Health Alteration DrugAdministration;
10. Correct answer 1: The client should not have invasive

procedures in the colon during an acute exacerbation.
Antidiarrheals, steroids, and resting the bowel are
orders the nurse would expect for the client with an
acute exacerbation of ulcerative colitis. Content
LevelApplication.
11. Correct answer 3: Determining alleviating and

aggravating factors is part of assessing the client.
Most clients with heartburn have gastroesophageal
184
reflux disease and have been self-medicating with

over-the-counter medications prior to seeking advice
from health-care provider. It is important to know
what the client has been using to treat the problem.
Gastrointestinal; Integrated ProcessImplementation;
12. Correct answer 1: The client should bend with the

knee to prevent intra-abdominal pressure. Behavior
modification is changing ones behavior. The client
should be encouraged to quit smoking completely.
Drinking alcohol is not a cause of GERD. Content
Integrated ProcessPlanning; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive
LevelSynthesis.
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SECTION FOUR
13. The nurse is preparing a client diagnosed with GERD

for discharge following an esophagogastroduodenoscopy.
Which statement indicates the client needs further teaching
concerning the discharge instructions?
l 1. I should not eat until I can swallow water without
gagging.
l 2. After I eat, I should sit up for several hours before
I go to bed.
l 3. Stomach contents can cause my esophagus to have
an ulcer.
l 4. I can drink orange juice and tomatoes whenever
I feel like it.
14. The nurse is discussing dietary modifications with
a client diagnosed with lower esophageal sphincter
dysfunction. Which menu indicates the client understands
the nurses instructions?
l 1. Tortillas with hot sauce, three-bean-and-cheese
enchiladas, and tea.
l 2. Four pieces of fried chicken, mashed potatoes with
gravy, and water.
l
l
185
3. A large pepperoni pizza, green salad, and coffee.

4. One piece of baked fish, buttered carrots, and a
cup of pudding for a snack.
15. The nurse is caring for a client diagnosed with GERD.

Which interventions should the nurse implement?
l 1. Have the client lie prone in bed when sleeping.
l 2. Administer nonsteroidal anti-inflammatory drugs
(NSAIDs) for pain.
l 3. Encourage the client to drink 810 glasses of water
each day.
l 4. Place the head of the bed (HOB) on 6-inch blocks.
16. The nurse is administering morning medications at
0730. Which medication should the nurse administer first?
l 1. The mucosal barrier agent to a client who is going
home this morning.
l 2. The proton pump inhibitor to a client diagnosed
with peptic ulcer disease.
l 3. The non-narcotic analgesic to a client complaining
of a mild headache.
l 4. The histamine receptor antagonist to a client
scheduled for an endoscopy.
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ANSWERS
13. Correct answer 4: Orange and tomato juices are

acidic; the client diagnosed with GERD should avoid
acidic foods until the esophagus has had a chance to
heal. ContentSurgical; Category of Health Alteration
Gastrointestinal; Integrated ProcessEvaluation; Client
NeedsPhysiological Integrity, Reduction of Risk Potential;
14. Correct answer 4: Clients with lower esophageal

sphincter dysfunction should eat small frequent
meals and limit fluids with the meals to prevent
reflux from a distended stomach. The client should
avoid spicy or acidic or fried foods and foods or
drinks that contain caffeine. ContentMedical; Category of Health AlterationGastrointestinal; Integrated
Evaluation.
186
15. Correct answer 4: Elevating the HOB allows

gravity to work to prevent reflux. NSAIDs inhibit
prostaglandin synthesis in the stomach, and this, in
turn, puts the client at increased risk for developing
gastric ulcers. The client is already experiencing
gastric acid difficulty. Water increases the amount
of substances in the stomach and increases GERD.
16. Correct answer 1: Mucosal barrier agents (Carafate)

must be administered on an empty stomach if the
medication is going to coat the mucosa and not the
food the client has eaten. ContentMedical; Category
of Health AlterationDrug Administration; Integrated
Evaluation.
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SECTION FOUR
17. The nurse in the operating suite is preparing a male

client diagnosed with GERD for surgery. Which data
would require the nurse to call a time out?
l 1. The client marked the right upper quadrant as the
operative site.
l 2. The clients abdominal x-ray indicates the client has
a hiatal hernia.
l 3. The clients WBC count is 7000 mg/dL.
l 4. The clients hemoglobin is 13.8 mg/dL.
18. The charge nurse is making assignments. Staffing
includes a registered nurse (RN) with 5 years of
medical-surgical experience, a newly graduated RN,
and two UAPs. Which client should be assigned to the
new graduate nurse?
l 1. The client diagnosed with lower esophageal
dysfunction who has changes noted on an
electrocardiogram (ECG).
l 2. The client diagnosed with Barrett esophagitis
who is scheduled to have an endoscopy this
morning.
187
3. The client diagnosed with GERD who has wheezes
4. The client who is 3-days postoperative hiatal hernia
in all lobes.
who has a temperature of 101.2F.
19. The home health nurse is caring for an obese adult

client. Which statement made by the client would indicate
to the nurse that the client may be experiencing GERD?
l 1. My abdomen hurts if I bend over too much.
l 2. My spouse wont sleep with me because I snore.
l 3. I take Prilosec over-the-counter every day.
l 4. I drink several soft drinks every day.
20. The nurse is performing an admission assessment
on a client diagnosed with GERD. Which signs and
symptoms would indicate GERD?
l 1. Pyrosis, water brash, and flatulence.
l 2. Weight loss, dysrthymias, hernia, and diarrhea.
l 3. Decreased abdominal fat, proteinuria, and
constipation.
l 4. Midepigastric positive H. pylori test and melena.
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ANSWERS
17. Correct answer 1: A hiatal hernia is a problem

between the esophagus and the stomach in the left
upper quadrant of the abdomen, not the right upper
quadrant. Time out procedures are called when what
the client understands he/she consented to and what
the health-care team understands are not the same.
Gastrointestinal; Integrated ProcessAssessment; Client
18. Correct answer 2: Barrett esophagitis is a complication of GERD. A new graduate should be capable of
preparing a client for an endoscopy procedure. The
signs/symptoms in the other clients could indicate
an undiagnosed problem. ContentMedical; Category
of Health AlterationGastrointestinal; Integrated
Synthesis.
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188
19. Correct answer 3: Clients self-medicate for problems such as GERD. If the Prilosec relieves the
clients symptoms, then the client probably does have
some amount of reflux occurring. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessAssessment; Client NeedsPhysiological
LevelAnalysis.
20. Correct answer 1: Pyrosis is heartburn; water brash

is the feeling of saliva secretion as a result of reflux;
and flatulence is gas. All are symptoms of GERD.
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SECTION FOUR
189
Peptic Ulcer Disease

21. The nurse is admitting a client diagnosed with rule
out (R/O) peptic ulcer disease. Which statement by the
client supports the diagnosis of a gastric ulcer?
l 1. I have bright red rectal bleeding after a bowel
movement.
l 2. If I lie down after eating a meal, I get a burning in
my chest.
l 3. After I eat a big meal, I get pain in my right side
so bad I double over.
l 4. I get pain in my stomach about 30 minutes after
I eat, so I dont eat much.
22. The client has been seen by an HCP in an outpatient
clinic, and a presumptive diagnosis of peptic ulcer disease
was made. Which diagnostic test confirms this diagnosis?
l 1. Esophagogastroduodenoscopy (EGD).
l 2. Magnetic resonance imaging (MRI).
l 3. Fecal occult blood test.
l 4. Gastric acid stimulation.
23. The nurse in the intensive care unit (ICU) is preparing

to hang a daily continuous infusion of the histamine-2
blocker ranitidine (Zantac) for a client on a ventilator. The
medication is mixed in 100 mL of normal saline. At which
rate should the nurse set the pump?
Answer: ____________________
24. The charge nurse observes the primary nurse assessing

a client diagnosed with peptic ulcer disease. Which action
by the primary nurse warrants immediate intervention by
the charge nurse?
l 1. The nurse auscultates the clients bowel sounds in
all four quadrants.
l 2. The nurse begins by palpating the abdominal area
for tenderness.
l 3. The nurse percusses the abdominal borders to
identify organs.
l 4. The nurse assesses the non-tender area progressing
to the tender area.
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ANSWERS
21. Correct answer 4: The pain associated with a gastric

ulcer usually occurs 3060 minutes after eating, and
the client experiences no pain at night. A duodenal
ulcer has pain during the night that is often relieved
by eating food. Bright red blood would indicate
hemorrhoids; burning in the chest would indicate
GERD; and right-sided pain would indicate gallbladder problems. ContentMedical; Category of
Evaluation; Client NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelEvaluation.
22. Correct answer 1: The EGD is an invasive diagnostic test that visualizes the esophagus and stomach.
This test accurately diagnoses an ulcer and evaluates
the effectiveness of the clients treatment. Cultures
and biopsies of suspicious tissue can be made at the
time of the procedure. ContentMedical; Category of
Planning; Client NeedsPhysiological Integrity, Reduction of Risk Potential; Cognitive LevelSynthesis.
190
23. Correct answer 4 mL/hr: The medication cannot be

allowed to hang for more than 24 hours. 100 mL
divided by 24 = 4.16 mL/hr, rounded to 4 mL/hr.
24. Correct answer 2: Auscultation should be used

prior to palpation or percussion when assessing the
abdomen. If the nurse manipulates the abdomen,
the bowel sounds can be altered, giving false information. Palpation gives good information that the
nurse needs to collect but if done prior to auscultation, the sounds will be altered. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessAssessment; Client NeedsSafe Effective
LevelAnalysis.
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SECTION FOUR

with peptic ulcer disease admitted into the hospital. The
client is complaining of midepigastric pain and has a
hemoglobin of 9.2 mg/dL. Which client problem is
priority?
l 1. Alteration in bowel elimination.
l 3. Inability to cope.
26. The client has been admitted to the emergency
department vomiting coffee-ground emesis. The client is
pale and clammy. Which intervention should the nurse
implement first?
l 1. Perform a complete head-to-toe assessment.
l 2. Take the clients pulse and blood pressure.
l 3. Start an intravenous (IV) line with an 18-gauge
catheter.
l 4. Request a stat type-and-crossmatch.
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191
27. The clinic nurse is planning the care of a client

diagnosed with peptic ulcer disease. Which is an expected
short-term outcome for the client?
l 1. The clients pain decreases by 34 points 30 minutes
after the NSAID is given.
l 2. The client will maintain lifestyle changes of
decreasing stress for 1 month.
l 3. The client will not have signs and symptoms of
hemoptysis within 1 week.
l 4. The client will take antacids before each meal and
at bedtime.
28. The nurse has been assigned to care for a client
diagnosed with peptic ulcer disease. Which assessment
data require further intervention?
l 1. Bowel sounds auscultated 15 times in 1 minute.
l 2. A positive H. pylori laboratory report.
l 3. Pulse 96, respirations 22, and blood pressure 104/79.
l 4. The nurse notes red drainage on a tissue at the
bedside.
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ANSWERS
25. Correct answer 4: Physiological problems are priority, and hemorrhage is a greater priority than bowel
elimination. ContentMedical; Category of Health
AlterationGastrointestinal; Integrated Process
26. Correct answer 3: This client is in hypovolemic

shock, and the nurse must intervene to support the
clients cardiovascular status by starting an IV line.
Vital signs, assessment, and ordering lab work can
be done after starting an IV line. Remember, If in
distress, do not assess. ContentMedical; Category
LevelEvaluation.
192
27. Correct answer 2: Maintaining lifestyle changes

such as diet and stress reduction indicate that the
client is complying with the medical modalities.
Many clients with bleeding ulcers have recurrence of
the bleeding. The goal of treatment is to prevent this
and other complications. The client is taught not
to take NSAIDs. ContentMedical; Category of Health
Diagnosis; Client NeedsHealth Promotion and
Maintenance; Cognitive LevelAnalysis.
28. Correct answer 4: The most common red drainage

is blood. The nurse should assess the client for bleeding. Normal bowel sounds are 535 in a minute. The
clients pulse and blood pressure are still within normal
range. ContentMedical; Category of Health Alteration
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Page 193
193
Colorectal Disease
29. Which medication should the nurse question
administering to the 28-year-old female client diagnosed
with peptic ulcer disease?
l 1. Misoprostol, (Cytotec), a prostaglandin E analog.
l 2. Prilosec, a proton pump inhibitor.
l 3. Flagyl, an antimicrobial.
l 4. Bismuth (Pepto Bismol), an antibiotic.
30. The nurse is assessing a client diagnosed with peptic
ulcer disease and notes a painful hard rigid abdomen.
l 1. Administer a narcotic analgesic intravenously.
l 2. Rule out complications and check the clients
armband.
l 4. Reassess the client in 12 hours.
31. The nurse is discussing information about colon

cancer to a 23-year-old client with a family history of
colorectal cancer. Which statement indicates the client
needs more teaching concerning the colorectal cancer?
l 1. I should drink at least 3 L of water a day.
l 2. I need to eat a diet that is high in fiber and
low in fat.
l 3. I will take a multiple vitamin with iron every day.
l 4. I should try and have a least one bowel
movement a day.
32. The nurse is caring for a client who is 1 day
postoperative abdominal perineal resection for cancer
of the colon. Which intervention(s) should the nurse
implement? Select all that apply.
l 1. Irrigate the sigmoid colostomy in the morning.
l 2. Assess the clients rectal dressing.
l 3. Maintain the suprapubic catheter.
l 4. Check the clients vital signs every 4 hours.
l 5. Place the client in semi-Fowler position.
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ANSWERS
29. Correct answer 1: Cytotec is listed as category X.

This client is of childbearing age. The nurse must
determine if the client is or could become pregnant.
30. Correct answer 3: A hard, rigid abdomen indicates

an inflammation of the peritoneum, a complication
of a perforated ulcer. The nurse must notify the HCP
and not mask symptoms by medicating the client.
Client NeedsPhysiological Integrity, Reduction for Risk
31. Correct answer 3: Taking a multivitamin with iron

will not affect the chances of developing colon
cancer. The longer the transit time (the time from
ingestion of the food to the elimination of the waste
Page 194
194
products), the greater the chance of developing

cancer of the colon. Therefore, the client should
prevent constipation by increasing fluids, by eating a
high-fiber diet, and by having a daily bowel movement.
32. Correct answer 2, 4, 5: Assessing the rectal dressing,

checking vital signs, and placing the client in a semiFowler position (upright position causes pressure on
the perineum) are all interventions the nurse should
implement. The client would have an indwelling
catheter, not a suprapubic catheter, and the
colostomy would not be irrigated for several days
after the surgery. ContentSurgical; Category of Health
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SECTION FOUR
33. The client who has had an abdominal perineal

resection with a creation of a sigmoid colostomy is being
discharged. Which discharge information should the
nurse discuss with the client?
l 1. Instruct the client to notify the HCP if the stoma
is pink.
l 2. Tell the client to irrigate the colostomy with a Fleet
enema.
l 3. Encourage the client to look at the stoma site in a
mirror.
l 4. Recommend the client empty the pouch when it is
75% full.
34. The client with a new colostomy is being discharged.
Which statement made by the client indicates the client
understands the teaching?
l 1. I should use spirit of peppermint to help with the
fecal odor.
l 2. I should drink only liquids until the colostomy
starts to work.
l 3. I should take a tub bath for at least 46 weeks.
l 4. I should eat a low-residue diet because I have a
colostomy.
Page 195
195
35. The nurse is preparing to hang a new bag of total

parental nutrition for a client who has had an abdominal
perineal resection. The bag has 1000 mL of 50% dextrose,
500 mL of amino acids, 200 mL of lipids, 10 mL of
trace elements, 20 mL of multivitamins, and 20 mL of
potassium chloride. The bag is to infuse at a 24 hour rate.
At what rate should the nurse set the pump?
Answer ____________________
36. The nurse is caring for clients in an outpatient clinic.

Which information should the nurse teach regarding the
American Cancer Societys recommendations for the early
detection of colon cancer?
l 1. A carcinoembryonic antigen (CEA) serum level
every 2 years.
l 2. A rectal digital examination every year after age 40.
l 3. A colonoscopy every year after age 50.
l 4. A stool blood test every year at physical examinations
after age 21.
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ANSWERS
33. Correct answer 3: Looking in the mirror allows the

client to be sure there is no irritation or redness
around the site and that the stoma is pink. The
colostomy should be irrigated with 500750 mL tap
water, not with a Fleet enema, and the pouch should
be emptied when it is 1312 full to prevent the contents from becoming too heavy for the seal to hold
and leakage occurring. ContentSurgical; Category
34. Correct answer 1: The client can use spirit of peppermint or commercially prepared deodorants to
help with the odor, which can be very embarrassing
to the client. The client should be on a regular diet,
and until the incision is completely healed the client
should not sit in bath water because of the potential
contamination of the wound by the bath water.
Gastrointestinal; Integrated ProcessPlanning; Client
196

35. Correct answer 73 mL/hr: 1000 + 500 + 200 +
10 + 20 + 20 = 1750 mL per 24 hours; 1750

divided by 24 = 72.9 = 73 mL/hr. This should be
rounded to the nearest whole number to set the
pump. ContentMedical; Category of Health Alter-
ationDrug Administration; Integrated ProcessImplementation; Client NeedsPhysiological Integrity, Pharmacological and Parenteral Therapies; Cognitive
LevelApplication.
36. Correct answer 2: The American Cancer Society

recommends a rectal digital exam every year after
age 40, a colonoscopy every 5 years after age 50, and
a stool blood test every year after age 50. A CEA is a
tumor marker used to evaluate the effectiveness of
chemotherapy, not diagnosis. ContentMedical;
Category of Health AlterationOncology; Integrated
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SECTION FOUR
37. The nurse writes a psychosocial problem of risk for

ineffective coping related to a new colostomy. Which
l 1. Recommend the client complete a durable power
of attorney for health care.
l 2. Ensure that the client and significant other are able
to change the ostomy pouch.
l 3. Discuss the importance of eating a high-fiber diet
to prevent constipation.
l 4. Refer the client to the American Cancer Society
ostomate support group.
38. Which sign/symptom would make the nurse suspect
the client may have colon cancer?
l 1. The client has one soft brown stool every morning.
l 2. The client reports having clay-colored stools.
l 3. The client saw blood in the commode after a bowel
movement.
l 4. The client reported the stool was fatty-looking.
197
39. The nurse is preparing the client for a colonoscopy.

nurses teaching?
l 1. I do not have to sign a permit for this procedure.
l 2. I cannot eat or drink anything after midnight.
l 3. I need to eat a low-residue diet 24 hours before
the test.
l 4. I should drink a clear liquid diet the morning of
the test.
40. The nurse is demonstrating how to irrigate a sigmoid
colostomy to the client who was diagnosed with colon
cancer. Which interventions should the nurse implement?
Rank in order of performance.
l 1. Cleanse the stomal site with mild soap and water.
l 2. Wait 3045 minutes for the stool to evacuate the
bowel.
l 3. Remove the ostomy drainage bag from the abdomen.
l 4. Insert the enema cone into the stoma site.
l 5. Allow 500750 mL tap water to enter stoma.
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ANSWERS
37. Correct answer 4: A support group provides the

client with help after discharge from the hospital.
The group can support the client emotionally and
provide information on how to live with an ostomy.
A durable power of attorney, changing the pouch,
and high-fiber diet do not address psychosocial issues.
LevelApplication.
38. Correct answer 3: Rectal bleeding and change of

bowel habits are signs of colon cancer. One brown
soft stool is normal for most individuals; clay-colored
stool indicates liver failure; and fatty-looking stool
is steatorrhea. ContentMedical; Category of Health
198
39. Correct answer 2: Along with a bowel preparation,

the client must have nothing by mouth prior to the
procedure to ensure the colon is empty of stool. A
permit must be signed for an invasive procedure, and
the client is on a liquid diet 24 hours prior to test.
Gastrointestinal; Integrated ProcessEvaluation;
40. Correct answer 3, 4, 5, 2, 1: The client should first

remove the drainage bag, insert the enema cone, and
allow water to enter the stoma; there will be an
initial gush of water because the stoma does not
have a sphincter. Then the client should wait for
3045 minutes for all stool to be evacuated. Then,
the stoma site should be cleansed and a new ostomy
bag placed in position. ContentMedical; Category of
Health AlterationGastrointestinal; Integrated
LevelApplication.
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199
Diverticulosis/Diverticulitis
diverticulosis. Which instruction should the nurse discuss
with the client?
l 1. Discuss the need to eat a low-residue diet.
l 2. Tell the client to drink at least 3000 mL water a day.
l 3. Encourage the client to walk at least once a week.
l 4. Explain the importance of sitting up after meals.
43. The client is diagnosed with acute diverticulitis.

Which data would warrant immediate intervention by
the nurse?
l 1. The client is having left lower quadrant pain.
l 2. The client has an elevated temperature.
l 3. The client has hypoactive bowel sounds.
l 4. The clients abdomen is soft and tender.
42. The client diagnosed with acute diverticulitis is

admitted to the medical unit. Which intervention should
l 1. Administer an intravenous narcotic analgesic.
l 2. Insert a 20-gauge angiocath in the distal forearm.
l 3. Ensure the client is maintained on NPO status.
l 4. Administer intravenous antibiotic therapy.
44. The client diagnosed with acute diverticulitis has

green bile draining from the nasogastric (N/G) tube.
l 1. Document the finding in the clients chart.
l 2. Irrigate the N/G tube with sterile normal saline.
l 4. Increase the clients intravenous rate.
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ANSWERS
41. Correct answer 2: The priority for the client with

diverticulosis is to prevent constipation; therefore,
increasing fluids, eating a high-fiber diet, and daily
exercise would be appropriate teaching for this
client. ContentMedical; Category of Health
42. Correct answer 3: The first intervention for an acute

exacerbation of a gastrointestinal problem is to put the
bowel on rest, which is to keep the client NPO. All
other interventions are implemented after placing
client on NPO status. ContentMedical; Category of
200
43. Correct answer 3: Hypoactive bowel sounds indicate

a possible obstruction, which would warrant further
intervention by the nurse. All the other data would be
expected for a client diagnosed with acute diverticulitis.
44. Correct answer 1: Green bile is the normal color

output for the nasogastric output; therefore, the
nurse should document the finding in the clients
chart. ContentMedical; Category of Health Alteration
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SECTION FOUR
45. The client diagnosed with acute diverticulitis is

scheduled for a gastric resection. Which intervention
l 1. Provide written instructions on how to perform
colostomy irrigations.
l 2. Demonstrate how to splint the abdomen when
coughing and deep-breathing.
l 3. Explain that the client will be receiving TPN
postoperatively.
l 4. Discuss the importance of maintaining bedrest for
72 hours after surgery.
46. Which statement indicates the client with diverticulosis
needs more teaching concerning how to prevent
diverticulitis?
l 1. I shoFuld not eat any foods that have seeds such
as tomatoes.
l 2. I will do low-impact weightlifting exercises every
day for 30 minutes.
l 3. I must cook all my vegetables and not eat any
foods that have peels.
l 4. I need to have at least one soft bowel
movement a day.
201
47. The nurse is caring for a client diagnosed with acute

diverticulitis who is receiving antibiotic therapy. Which
data would warrant intervention by the nurse?
l 1. The client has thrush in the mouth.
l 2. The client has a temperature of 100.2F.
l 3. The client had a soft brown stool.
l 4. The client has moist buccal mucosa.
48. The client diagnosed with diverticulosis asks the
nurse, What did I do to make myself get this disease?
Which statement is the nurses best response?
l 1. There is no exact cause for developing
diverticulosis.
l 2. Chronic constipation over time caused the
diverticulosis.
l 3. Eating a high-fiber diet over time causes
diverticulosis.
l 4. You are wondering why you have diverticulitis?
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ANSWERS
45. Correct answer 2: The nurse should discuss the

importance of coughing and deep-breathing to help
prevent postoperative pneumonia, and splinting the
incision will help decrease pain. ContentSurgical;
Category of Health AlterationGastrointestinal;
46. Correct answer 3: The client should be on a highfiber diet, which includes raw vegetables and leaving
the peels on foods such as apples and potatoes. This
statement indicates the client needs more teaching.
202
47. Correct answer 1: Thrush indicates the client has a

suprainfection secondary to the antibiotic therapy
and warrants notifying health-care provider to
obtain an order for an oral Nystatin swish and
swallow. A moist buccal mucosa, soft brown stool,
and a low-grade fever do not require the nurses
immediate intervention. ContentMedical; Category
48. Correct answer 2: Chronic constipation causes

increased gastrointestinal intraluminal pressure,
which is the precipitating factor for diverticulosis.
Gastrointestinal; Integrated ProcessDiagnosis; Client
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203
Gallbladder Disease
49. The client diagnosed with diverticulosis has just had
a colonoscopy. Which discharge teaching should the
l 1. Notify the HCP if any rectal bleeding.
l 2. Do not eat or drink anything for at least 8 hours.
l 3. Expect the stool to be clay-colored for a few days.
l 4. Drink 30 mL of an antacid every 4 hours for 2 days
50. Which client should the nurse assess first after
receiving the change-of-shift report?
l 1. The client who is scheduled for a colonoscopy.
l 2. The client who has a hard, rigid abdomen.
l 3. The client who has abdominal pain of 4 on a
110 scale.
l 4. The client who is complaining of jitteriness and
headache.
51. The client is 8 hours postoperative open

cholecystectomy. Which data would warrant
l 1. The client has hypoactive bowel sounds in all four
quadrants.
l 2. The clients T-tube has 40 mL of green drainage.
l 3. The clients surgical dressing is dry and intact.
l 4. The client refuses to use the incentive spirometer.
52. The client who is 2 hours postoperative laparoscopic
cholecystectomy is complaining of pain in the right
shoulder. Which nursing intervention should the nurse
implement?
l 1. Perform active range-of-motion (ROM) exercises to
the right arm.
l 2. Administer Tylenol #3 by mouth (PO) to the client
for the shoulder pain.
l 3. Request an order to have an x-ray of the clients
right shoulder.
l 4. Apply a heating pad to the abdomen for
1520 minutes.
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ANSWERS
49. Correct answer 1: The client should notify the

HCP if any rectal bleeding occurs because this
could indicate a possible perforation of the intestines, which is a potential complication. Clay-colored
stools occur with a barium enema or barium swallow.
50. Correct answer 2: The client with a hard, rigid

abdomen may have peritonitis, which is a medical
emergency; therefore, this client should be seen first.
The client in pain and the client who is jittery need
to be seen, but peritonitis is life-threatening and
takes priority. ContentMedical; Category of Health
204
51. Correct answer 4: Refusal to use the incentive

spirometer may result in the client developing pneumonia, which is a complication, especially due to the
location of the cholecystectomy incision. Hypoactive
bowel sounds, green drainage, and a dry dressing
would be expected. ContentSurgical; Category of
Health AlterationGastrointestinal; Integrated
ProcessAssessment; Client NeedsSafe Effective
LevelSynthesis.
52. Correct answer 4: A heating pad should be applied

for 1520 minutes to assist the migration of the carbon dioxide that was used to insufflate the abdomen
for surgery. Pain medication, ROM exercises, and
an x-ray will not help alleviate the pain, due to the
reason for the pain. ContentSurgical; Category
LevelApplication.
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SECTION FOUR
53. The nurse is teaching a client recovering from a

laparoscopic cholecystectomy. Which statement indicates
the client needs more discharge teaching?
l 1. I will take my lipid-lowering medicine at the
same time each night.
l 2. I may experience some discomfort when I eat
a high-fat meal.
l 3. I will be able to go back to work in a couple
of days.
l 4. I should splint my incision when I take deep
breaths and cough.
54. When assessing the client recovering from an open
cholecystectomy, which signs and symptoms should the
nurse report to the HCP? Select all that apply.
l 1. Clay-colored stools.
l 2. Yellow-tinted sclera.
l 3. Dark yellow urine.
l 4. T 99F, P 90, R 20, B/P 112/80.
l 5. Hypoactive bowel sounds.
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205
55. The nurse is caring for the immediate postoperative

client who had a laparoscopic cholecystectomy. Which
task would be most appropriate for the nurse to delegate
to the UAP?
l 1. Assist the client to take a bed bath.
l 2. Empty the clients indwelling catheter.
l 3. Bring a pitcher of ice water to the client.
l 4. Discuss care of the band-aid incisions.
56. Which statement by the client scheduled for an
upper gastrointestinal series (UGI) indicates the client
teaching has been effective?
l 1. I will have soft brown stools after this procedure.
l 2. I need to check my stool for any bright red
bleeding.
l 3. I should increase my fluid intake for at least
1 week.
l 4. If I am allergic to shellfish, I cannot have this
procedure.
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ANSWERS
53. Correct answer 1: This surgery does not require lipid-
206
55. Correct answer 3: Laparoscopic surgery is per-
lowering medications, but high fatty meals may cause

discomfort. Laparoscopic surgeries are performed in
day surgery, and the client can return to work within a
few days of surgery. Using a pillow to splint the
abdomen provides support for the incision and should
be continued after discharge. ContentSurgical;
formed in ambulatory care centers, and clients take

fluids/food and ambulate immediately after surgery.
A bed bath and an indwelling catheter would not be
nursing interventions for a client with a laparoscopic
cholecystectomy. The nurse cannot delegate teaching
to the UAP. ContentSurgical; Category of Health
Category of Health AlterationGastrointestinal; Integrated ProcessEvaluation; Client NeedsPhysiological

Evaluation.

54. Correct answer 1, 2, 3: Clay-colored stools,

jaundice, and dark yellow urine are signs of postcholecystectomy syndrome, which should be
reported to the surgeon. The vital signs and hypoactive bowel sounds would be expected. Content
Surgical; Category of Health AlterationGastrointestinal;
Integrated ProcessAssessment; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive
LevelAnalysis.
56. Correct answer 3: The barium used in the UGI

can cause constipation; therefore, the client should
increase fluid intake to help prevent constipation. The
client stools will be chalky, not brown. This procedure
does not cause bright red bleeding, and iodine is not
used for this procedure. ContentSurgical; Category of
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SECTION FOUR
57. The client is immediate post-procedure endoscopic

retrograde cholangiopancreatography (ERCP). Which
l 1. Monitor the clients stool for bleeding.
l 2. Provide the client with a regular diet.
l 3. Assess for return of the clients gag reflex.
l 4. Administer the clients held medications.
58. The nurse is preparing the female client for an open
cholecystectomy. Which information would alert the
nurse that the client may be at risk for a postoperative
complication?
l 1. The client is 20 lb over the desired weight.
l 2. The client has delivered two children by
cesarean-section.
l 3. The client has a 10-year history of essential
hypertension.
l 4. The client has smoked two packs of cigarettes for
the last 20 years.
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207
59. The client in the ambulatory care unit scheduled for

a laparoscopic cholecystectomy tells the nurse, I think
I may be allergic to latex. Which intervention should
l 1. Notify the operating room personnel.
l 2. Label the clients chart with the allergy.
l 3. Place a red allergy band on the client.
l 4. Check the chart to see if the allergy is documented.
60. Which signs/symptoms would the nurse expect the
client diagnosed with cholelithiasis to exhibit?
l 1. Fever and elevated white blood cell count.
l 2. Jaundice and clay-colored stools.
l 3. Rigid, board-like abdomen.
l 4. Elevated amylase and lipase.
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ANSWERS
57. Correct answer 3: The ERCP requires that an anes-
208
59. Correct answer 4: The nurse must first see if this
thetic spray be used prior to insertion of the endoscope. If medication, food, or fluid is given orally
prior to the return of the gag reflex, the client may
aspirate, causing pneumonia that could be fatal. If
there is any blood in the stool, it will not occur until
after the gag reflex returns. ContentSurgical; Cate-
information is documented in the clients chart prior to

taking any other action. If it is documented, then the
nurse should check the allergy band. If it is not in the
chart, the nurse should label the chart and notify the
operating room so that no latex glove or equipment
comes into contact with the client. ContentSurgical;
gory of Health AlterationGastrointestinal; Integrated

LevelApplication.
Category of Health AlterationGastrointestinal; Integrated

ProcessImplementation; Client NeedsSafe Effective Care
Environment, Management of Care; Cognitive LevelSynthesis.
58. Correct answer 4: The location of the incision, the

general anesthesia, and smoking makes this client
high risk for pulmonary complications. Obesity,
hypertension, or history of cesarean section would
not put this client at risk for any postoperative
complication more than any other type of surgery.
ContentSurgery; CategoryGastrointestinal; Integrated
LevelAnalysis.
60. Correct answer 2: Cholelithiasis (gallstones) may

block the gallbladder duct, leading to signs of liver
dysfunction such as jaundice and clay-colored stools.
Fever and elevated white blood cell count may indicate cholecystitis (inflammation of the gall bladder).
A board-like abdomen would indicate peritonitis,
and elevated amylase/lipase levels would indicate
pancreatitis. ContentMedical; Category of Health
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209
Liver Failure
end-stage liver failure. Which data indicates the laxative
lactulose (Chronulac) is effective?
l 1. The client no longer complains of pruritus.
l 2. The clients skin is no longer jaundiced.
l 3. The client is alert and oriented times three.
l 4. The clients abdominal girth has decreased in size.
63. The client diagnosed with end-stage liver disease has

bleeding esophageal varices. Which HCP order would the
nurse question?
l 1. Insert a Sengstaken-Blakemore tube.
l 2. Administer salt-poor albumin intravenously.
l 3. Type and cross for 4 units of blood.
l 4. Administer AquaMephyton subcutaneously.
62. The HCP schedules a paracentesis for the client

diagnosed with end-stage liver failure who has ascites.
Which priority intervention should the nurse implement
post procedure?
l 1. Assess the clients abdominal girth.
l 2. Monitor the clients blood pressure and pulse.
l 3. Label the specimen and send to the laboratory.
l 4. Place the client on the right side.

end-stage liver failure. Which data would warrant
l 1. The client is complaining of clay-colored stools.
l 2. The clients abdominal girth increased 1 inch.
l 3. The clients urine output is 180 mL in 8 hours.
l 4. The clients ammonia level is elevated.
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ANSWERS
61. Correct answer 3: Lactulose is administered to help

decrease the ammonia level in a client with end-stage
liver failure. Increased ammonia level causes neurological deficits. The fact that the client is alert and
oriented indicates a lessening of any neurological
deficits and that the medication lactulose is effective.
62. Correct answer 2: The client is at risk for hypovolemic

shock; therefore, the priority intervention is assessing
the clients vital signs. The client should be placed on
the right side for a liver biopsy. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessPlanning; Client NeedsPhysiological
LevelSynthesis.
210
63. Correct answer 2: Salt-poor albumin is administered to help treat ascites, not bleeding esophageal
varices. All the other orders would be expected for a
client who is bleeding. ContentMedical; Category of
64. Correct answer 3: The client may be going into renal

failure as the urine output is less than 30 mL/hr. All
the other data would be expected in a client with
end-stage liver failure. ContentMedical; Category of
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SECTION FOUR
65. The home health nurse is caring for a client

diagnosed with end-stage liver failure who has ascites.
l 1. Instruct the client to decrease drinking alcohol.
l 2. Tell the client to increase the intake of protein.
l 3. Encourage the client to eat canned soup daily.
l 4. Explain the need to limit fluid intake.
66. The client diagnosed with end-stage liver failure is
being discharged home. Which statement indicates the
client needs more teaching?
l 1. If I gain 2 pounds in 1 day, I will notify my HCP.
l 2. If my handwriting gets worse, it means my
ammonia level is increasing.
l 3. If I start itching, it is all right to scratch as long as
I do it very carefully.
l 4. I will not use any sharp utensils or go barefoot in
my house or yard.
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211
67. The client diagnosed with end-stage liver failure who

has ascites is complaining of trouble breathing. Which
l 1. Elevate the clients head of the bed.
l 2. Administer the loop-diuretic furosemide (Lasix)
intravenous push (IVP).
l 3. Encourage the client to take slow, deep breaths.
l 4. Measure the clients abdominal girth.
68. The nurse and a UAP are caring for clients on a
medical unit. Which task could the nurse delegate to
the UAP?
l 1. Take the clients urine specimen to the laboratory.
l 2. Evaluate the clients intake and output for the shift.
l 3. Give an antacid to the client complaining of
heartburn.
l 4. Clean the room of a client who has been discharged.
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ANSWERS
65. Correct answer 4: The client with ascites should

limit fluid intake. Alcohol will further damage the
liver; therefore, the client should not decrease alcohol
intake but rather should stop alcohol intake completely. The client should decrease protein intake and
maintain a low-salt (canned soup usually has a large
amount of salt) diet. ContentMedical; Category
Application.
66. Correct answer 3: Even if the client starts itching

secondary to pruritus, the client should not scratch
because it could cause a break in the skin with
bleeding and possible infection. The client needs
more teaching. ContentMedical; Category of Health
212
67. Correct answer 1: Elevating the head of the bed

will help the client breathe easier. A loop-diuretic
will not work for at least 1530 minutes. Content
68. Correct answer 1: The UAP can take specimens to

the laboratory. The UAP cannot assess, teach, evaluate, administer medications, or care for a client who
is unstable. The housekeeping department cleans the
room, not the UAP. ContentMedical; Category of
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SECTION FOUR
213
Hepatitis
clients on a medical unit. Which medication should the
nurse question administering?
l 1. Acetaminophen (Tylenol), an analgesic, to a client
diagnosed with liver failure.
l 2. The potassium supplement to the client who has a
potassium level of 4.2 mEq/L.
l 3. The laxative lactulose to the client whose ammonia
level is WNL.
l 4. The antihistamine Benadryl to the client who is
complaining of pruritus.
70. Which client should the nurse assess first after receiving
the shift report?
l 1. The client diagnosed with liver failure whose liver
enzymes are elevated.
l 2. The client diagnosed with pancreatitis whose
amylase is elevated.
l 3. The client diagnosed with type 2 diabetes whose
glucose level is 160 mg/dL.
l 4. The client diagnosed with end-stage liver failure
whose platelet count is 25,000.
71. The clinic nurse is teaching the client just diagnosed

with hepatitis C. Which intervention should the nurse
discuss with the client?
l 1. Explain the need to decrease alcohol intake.
l 2. Discuss the importance of resting the liver.
l 3. Recommend getting the hepatitis C vaccine.
l 4. Tell the client to wash the hands for 20 seconds.
72. Which signs/symptoms would the nurse expect the
client diagnosed in the pre-icteric stage of hepatitis to
exhibit?
l 1. Mild, flu-like symptoms and anorexia.
l 2. Jaundiced sclera and skin pigmentation.
l 3. Dark-colored urine and clay-colored stool.
l 4. Right epigastric pain and flatulence.
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ANSWERS
69. Correct answer 1: Tylenol is detoxified by the liver

and should not be administered to clients in liver failure.
70. Correct answer 4: The normal platelet level is

greater than 150,000; this client is at risk for bleeding and should be seen first. All other laboratory
data would not warrant the nurse seeing those clients
214
71. Correct answer 2: The liver will regenerate and

recover from the acute inflammation if the client does
not drink alcohol at all (not decrease intake), takes
medications, and rests the body. Hepatitis C is transmitted via blood and body fluid so washing hands will
not help prevent transfer. There is no hepatitis C vaccine.
72. Correct answer 1: Most clients are asymptomatic,

are anicteric (without jaundice) at first, and anorexic
due to the release of a toxin by the damaged liver.
The other signs/symptoms will appear as the hepatitis advances to the icteric (yellow) phase. Content
Analysis.
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SECTION FOUR
73. The nurse is discussing how to prevent hepatitis with

a group of clients. Which intervention is important in
preventing hepatitis B?
l 1. Wash hands after having bowel movements.
l 2. Do not share any type of eating utensils.
l 3. Obtain three doses of the hepatitis B vaccine.
l 4. Use caution when eating fresh fish.
74. The home health nurse is caring for a client with
viral hepatitis. Which intervention should the nurse
l 1. Do not drink more than 1000 mL of water a day.
l 2. Eat a diet low in protein and high in fat.
l 3. Take acetaminophen (Tylenol) for fever.
l 4. Recommend small, frequent meals.
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215
75. Which intervention is most important when preventing

the transmission of hepatitis A?
l 1. Careful hand washing before eating.
l 2. Environmental sanitation of food.
l 3. Effective sewage disposal.
l 4. Good personal hygiene.
76. The client scheduled to receive a unit of blood tells
the nurse, I am afraid to get the blood because I dont
want to get hepatitis. Which statement is the nurses best
response?
l 1. I can see you are frightened about receiving a
blood transfusion.
l 2. Would you like me to have your doctor talk to
you about the transfusion?
l 3. The blood is screened, and there is very little
chance of you getting hepatitis.
l 4. Hepatitis is a possibility with a transfusion, but
you must have the blood.
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ANSWERS
73. Correct answer 3: The hepatitis B vaccine will prevent

the client from getting hepatitis B. The virus is transmitted via blood and body fluids. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessImplementation; Client NeedsHealth
74. Correct answer 4: Small, frequent meals will help

decrease the nausea/vomiting associated with viral
hepatitis. The client should increase fluid intake
20003000 mL a day and eat a high-protein, highcalorie, low-fat diet. The client should refrain from
taking medications, especially Tylenol, which is
hepatotoxic. ContentMedical; Category of Health
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216
75. Correct answer 1: Careful hand washing after bowel

movements and before meals is the most important
intervention to prevent transmission of hepatitis A.
Good personal hygiene, sanitation of foods, and
proper sewage disposal are appropriate but not more
important than good hand washing. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessImplementation; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive
LevelApplication.
76. Correct answer 3: Screening of blood has reduced

the incidence of hepatitis associated with blood
transfusions; therefore, this is the best response. The
nurse cannot tell the client to take blood; it is the
clients decision. The client is expressing a concern
and needs information so a therapeutic response
(option 1) is not the best answer. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessPlanning; Client NeedsPhysiological
LevelSynthesis.
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SECTION FOUR
77. The clinic nurse is caring for a client with hepatitis C.

Which statement by the client requires teaching by the
nurse?
l 1. I enjoy having one glass of wine with my evening
meal.
l 2. I check with my pharmacist before I take any
medication.
l 3. I was asked to donate blood but I knew that
I could not.
l 4. I get at least 68 hours of sleep a night.
78. The nurse and UAP are caring for a client with an
acute exacerbation of hepatitis C. Which action by the
UAP warrants immediate intervention by the nurse?
l 1. The UAP assists the client to the semi-private
bathroom.
l 2. The UAP takes a food tray to the client without
wearing gloves.
l 3. The UAP wears gloves when helping the client
with a bath.
l 4. The UAP does not wash the hands after caring for
the client.
217

hepatitis A who asks, What about my family? Can
anything be done to help them from getting this? Which
statement is the nurses best response?
l 1. No; once someone is exposed to the hepatitis A
virus, they will get it.
l 2. Yes; globulin can be given within 2 weeks of
exposure to prevent hepatitis A.
l 3. Doses of interferon and ribavirin will help prevent
the spread of hepatitis A.
l 4. You should not have sexual intercourse with your
wife or kiss your children.
Which client should the nurse see first?
l 1. The client with hepatitis C who has dark-colored
urine.
l 2. The client with hepatitis B who has jaundiced sclera.
l 3. The client with hepatitis A who is nauseated and
vomiting.
l 4. The client with hepatitis B who needs to have
blood drawn.
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ANSWERS
77. Correct answer 1: The client should abstain from

drinking any type of alcohol, including wine, beer,
or foods or medications that contain alcohol.
78. Correct answer 4: The UAP must wash the hands

thoroughly after caring for the client and prior to
caring for the next client. This is a part of standard
precautions. ContentMedical; Category of Health
LevelSynthesis.
218
79. Correct answer 2: Globulin bolsters the persons

antibody production and provides 68 weeks of
passive immunity. Hepatitis A is transmitted via
fecal/oral route. Interferon and ribavirin are used in
clients with hepatitis C. ContentMedical; Category
80. Correct answer 3: The client who is nauseated and

vomiting needs an antiemetic; therefore, this client
should be seen first. Dark-colored urine and jaundice
are expected with a client who has hepatitis. The
laboratory technician is responsible for adhering to
standard precautions when drawing blood. Content
Integrated ProcessEvaluation; Client NeedsSafe Effective
LevelEvaluation.
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SECTION FOUR
219
Gastroenteritis
81. The female client called the clinic complaining of
abdominal cramping and has had several episodes of
diarrhea for 2 days. The client reported that she had
been in Mexico on a trip and just returned. Which
l 1. Instruct the client to take an over-the-counter antacid.
l 2. Encourage the client to drink sports drinks, such as
Gatorade, frequently.
l 3. Discuss the need to decrease the amount of protein
in the diet.
l 4. Explain to the client that she should watch for
fluid buildup in the extremities.
82. The public health nurse is discussing with a group
of peers some ways to help prevent potential episodes
of gastroenteritis due to Clostridium botulism. Which
information should the nurse teach?
l 1. Make sure that all hamburger meat is well cooked.
l 2. Ensure that all dairy products are refrigerated.
l 3. Teach that campers should drink only bottled water.
l 4. Discard all canned goods that are damaged.
83. The emergency department nurse is assessing the

client diagnosed with salmonellosis. Which question is
the most appropriate for the nurse to ask the client?
l 1. Did the food you ate have an unusual odor or
taste?
l 2. Do you eat rare or medium-rare hamburgers?
l 3. Do you have insurance to cover the cost of the
visit?
l 4. What made you decide to come to the emergency
department?
84. The client is diagnosed with gastroenteritis. Which
laboratory data would warrant immediate intervention by
the nurse?
l 1. ABGs of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
l 2. A serum potassium level of 3.5 mEq/L.
l 3. A stool sample that is positive for fecal leukocytes.
l 4. A serum sodium level of 154 mEq/L.
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ANSWERS
81. Correct answer 2: The client probably has travelers

diarrhea, and oral rehydration is the preferred choice
for replacing fluids lost due to diarrhea. Oral glucose
electrolyte solutions, such as Gatorade, All-Sport,
and Pedialyte, are recommended. ContentMedical;
82. Correct answer 4: Any food that is discolored or

comes from a can or jar that has been damaged or
does not have a tight seal should be destroyed without
tasting or touching. Cooking beef well prevents
Salmonella and avoiding unrefrigerated dairy products
prevents Staphylococcus food poisoning. Avoiding
contaminated water prevents E. coli infections.
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220
83. Correct answer 2: Salmonella is frequently transmitted through undercooked beef. This is the most
appropriate question. Most foods causing bacterial
poisoning do not have an unusual odor or taste.
84. Correct answer 4: The normal serum sodium level

is 135145 mEq/L; this elevated sodium level indicates dehydration, and the nurse should intervene.
The potassium level and ABGs are within normal
limits, and the stool sample would be expected to
have leukocytes. ContentMedical; Category of
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SECTION FOUR
85. The client diagnosed with gastroenteritis is being

discharged from the emergency department. Which
statement by the client indicates an understanding of the
discharge teaching?
l 1. I should wash my hands before I eat or cook
any food.
l 2. I will call the doctor if I have diarrhea for more
than 4 days.
l 3. I will have to taper off the steroids and not just
quit taking them.
l 4. I will bring all my stools into the laboratory for
analysis in 24 hours.
86. The nurse is caring for an elderly client diagnosed
with staphylococcal food poisoning. Which client
problem has the highest priority?
l 1. Altered comfort.
l 2. Risk for aspiration.
l 3. Risk for spread of the bacteria.
l 4. Fluid volume deficit.
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221
87. Which data would the nurse assess in the client

diagnosed with acute gastroenteritis?
l 1. Bowel assessment reveals loud, rushing bowel
sounds.
l 2. Decreased gurgling sounds upon auscultation of
abdominal wall.
l 3. A soft, firm edematous abdomen upon palpation.
l 4. Frequent, small melena-type liquid bowel
movements.
88. The elderly client diagnosed with acute gastroenteritis
is admitted to the medical unit. Which nursing task
would be most appropriate for the registered nurse (RN)
to delegate to the UAP?
l 1. Record the clients intake and output.
l 2. Discuss the purpose of collecting a stool sample.
l 3. Insert an indwelling urinary catheter.
l 4. Assess the clients skin turgor.
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ANSWERS
85. Correct answer 1: This should be done by a client

at all times but especially one with gastroenteritis. If
hands are not washed properly, the bacteria in feces
that cause the illness may be transferred to other
people via food. The client should contact healthcare provider if diarrhea persists for 48 hours. A onetime stool specimen may be required but not a 24hour specimen. ContentMedical; Category of Health
86. Correct answer 4: Fluid volume deficit secondary

to the diarrhea associated with staphylococcal food
poisoning is priority due to the potential for metabolic acidosis and hypokalemia, which are both
life-threatening, especially in the elderly. Content
222
87. Correct answer 1: Borborygmi, loud, rushing bowel

sounds, indicate increased peristalsis, which occurs in
clients with diarrhea. Diarrhea is the primary clinical
manifestation in a client diagnosed with acute gastroenteritis. ContentMedical; Category of Health
88. Correct answer 1: The UAP can record the clients

intake and output. The nurse must evaluate the
findings. The UAP cannot teach (discuss the purpose
of a stool sample), assess a clients condition, or
perform a sterile procedure (inserting an indwelling
urinary catheter). ContentMedical; Category of Health
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223
Constipation and Diarrhea

gastritis on a medical unit. Which action by the client
warrants immediate intervention?
l 1. The client tells the nurse that his legs have stopped
cramping.
l 2. The client writes down his intake and output on
the record by the bed.
l 3. The client chooses a large meal of fried foods from
the hospital menu.
l 4. The client takes frequent drinks from the bedside
water container.
90. Which nursing intervention(s) should the nurse
include in the care plan of an elderly client diagnosed
with acute gastroenteritis? Select all that apply.
l 1. Assess the skin turgor on the upper abdomen.
l 2. Monitor the client for hypertension.
l 3. Record the frequency and characteristic of stools.
l 4. Use contact precautions when caring for the client.
l 5. Assist the client when getting out of bed.
91. The client in the long-term care facility has a

fecal impaction. Which intervention should the nurse
implement first?
l 1. Administer a stool softener.
l 2. Remove the fecal impaction manually.
l 3. Administer an oil retention enema.
l 4. Increase the clients fluid intake.
92. The clinic nurse is caring for a 78-year-old client
who takes cathartics daily to have a bowel improvement.
Which statement indicates the client needs more teaching
concerning cathartic abuse?
l 1. I will take a bulk laxative every morning with my
breakfast meal.
l 2. I do not have to have a bowel movement every day.
l 3. I should try and walk about 30 minutes every day
to help prevent constipation.
l 4. If I feel sluggish and not had a BM, I will eat a lot
of cheese and dairy products.
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ANSWERS
89. Correct answer 3: Solid foods are reintroduced

slowly in small amounts, and fried foods are limited.
This allows the bowel to rest and the mucosa to
return normal. ContentMedical; Category of Health
Assessment; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
90. Correct answer 1, 3, 5: The abdomen is an approved place for assessing tissue turgor. The frequency and characteristics of the stools should be
documented. The elderly client is at risk for orthostatic hypotension; therefore, safety precautions
should be instituted to ensure that the client does
not fall due to drop in a blood pressure. Content
Integrated ProcessDiagnosis; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive
LevelAnalysis.
224
91. Correct answer 3: Oil retention enemas help to

soften the feces and evacuate the stool, but if necessary the nurse could remove the fecal impaction
manually. A stool softener would help soften the
stool, and increasing fluid may prevent constipation
but would not help evacuate the fecal impaction.
92. Correct answer 4: Cheese and dairy products are

low in residue and are constipating; therefore, the
client needs more teaching. A BM is not needed
daily, and exercising helps decrease constipation.
A bulk laxative does not cause the client to become
cathartic- (laxative- ) dependent. ContentMedical;
Integrated ProcessEvaluation; Client Needs
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SECTION FOUR
93. The client has been experiencing difficulty and

straining when expelling feces. Which statement indicates
the client understands the teaching?
l 1. I should expect to have some bright red blood
when I have a bowel movement (BM).
l 2. I will perform the Crede maneuver whenever
I need to have a BM.
l 3. I will sit in a sitz bath at night to help me
have a BM.
l 4. I will eat foods high in fiber such as wheat bread,
salads, and apples.
94. The client in the long-term facility has had a stool
that is dark, watery, and shiny in appearance. Which
l 1. Check the client for a fecal impaction.
l 3. Send the client to the emergency department.
l 4. Place the client on a warmed bedpan.
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225
95. The client diagnosed with gastroenteritis is

experiencing voluminous diarrhea. Which intervention(s)
l 1. Monitor stools for character and consistency.
l 2. Assess the clients serum potassium level.
l 3. Provide the client with carbonated soft drinks.
l 4. Administer anti-diarrheal medication.
l 5. Cleanse the perianal area with warm water.
96. The nurse, a licensed practical nurse (LPN), and a
UAP are caring for clients on a medical floor. Which task
would be best to assign to the LPN?
l 1. Assist the UAP to learn how to insert an indwelling
catheter.
l 2. Clean the client who is incontinent and has diarrhea.
l 3. Administer an antidiarrheal medication to the
client.
l 4. Check the abdomen of a client who is constipated.
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ANSWERS
93. Correct answer 4: A high-fiber diet will help prevent constipations; therefore, this statement indicates
the client understands the teaching. Blood may indicate a hemorrhoid; it is not normal to expel blood
when having a BM. The Cred maneuver is used to
help expel urine from the bladder. Sitz baths will not
help the client have a BM. ContentMedical; Category
of Health AlterationGastrointestinal; Integrated Process
94. Correct answer 1: Dark, watery, shiny stools are

symptoms of diarrhea moving around an impaction
higher up in the colon; therefore, the nurse should
assess for an impaction and then place the client on
a warmed bedpan if needed. The nurse should document the finding and may need to send the client to
the emergency department, but this is not the first
action. ContentMedical; Category of Health Alteration
Page 226
226
95. Correct answer 1, 2, 4, 5: The nurse should monitor

the amount, color, and characteristics of all body fluids
lost. Diarrhea causes potassium loss, so the potassium
level should be monitored. Antidiarrheal medication is
appropriate, and the perianal area should be cleansed
with warm water. Carbonated soft drinks increase flatus in the gastrointestinal tract, and the increased sugar
will act as an osmotic laxative and increase the diarrhea. ContentMedical; Category of Health Alteration
96. Correct answer 3: The LPN can administer medications such as an antidiarrheal medication to the clients.
The LPN should not be teaching a UAP how to insert
an indwelling catheter; the UAP should be asked to
clean the client; and the nurse should not delegate
assessment. ContentMedical; Category of Health
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227
97. The client is placed on percutaneous gastrostomy

(PEG) tube feedings. Which data would warrant
l 1. The client tolerates 50 mL/hr feedings.
l 2. The client has no gastric residual.
l 3. The clients HOB is elevated.
l 4. The client has a green watery stool.

with infectious diarrhea. Which client problem would be
priority?
l 1. Risk for impaired skin integrity.
l 2. Potential for transmission of infection.
l 3. Fluid and electrolyte imbalance.
l 4. Knowledge deficit of prevention.
98. The client is complaining of frequent watery bloody

stools after eating some undercooked meat at a fast-food
restaurant. Which intervention should the nurse implement
first?
l 1. Obtain a stool sample to send to the laboratory.
l 2. Teach the client about the antibiotic therapy.
l 3. Request a serum sodium and potassium level.
l 4. Administer Lomotil, an anti-diarrheal medication.

Which client information should be brought to the
attention of the HCP immediately?
l 1. A serum sodium of 142 mEq/L on a client
diagnosed with obstipation.
l 2. The clients telemetry reading shows occasional
premature ventricular contractions (PVCs).
l 3. A serum potassium level of 3.2 mEq/L on a client
diagnosed with diarrhea.
l 4. The client diagnosed with diarrhea who has had
two semi-liquid stools totaling 300 mL.
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ANSWERS
Page 228
228
97. Correct answer 4: A green watery stool could be a
99. Correct answer 3: Fluid and electrolyte imbalance
complication of the tube feedings, and the client

needs to be assessed for dehydration and anal excoriation. Tolerating tube feedings, no gastric residual, and an elevated HOB are normal for a client
with tube feedings. ContentMedical; Category
is the clients priority problem. Remember to apply

Maslows hierarchy, in which a physiological problem takes priority over other problems. Impaired
skin integrity, transmission of infection, and
knowledge deficit are appropriate client problems,
but they are not priority over fluid and electrolyte
imbalance. ContentMedical; Category of Health

LevelSynthesis.
98. Correct answer 1: The client may have developed

an infection from the undercooked meat, and a stool
specimen should be sent to the laboratory for tests.
Antibiotic therapy is initiated for serious cases of
infectious diarrhea, but the diarrhea must be assessed
first. Sodium and potassium imbalances can occur
from diarrhea, and medication should be given.

Diagnosis; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelAnalysis.
100. Correct answer 3: The clients potassium level is low

(normal is 3.55.5 mEq/L), which could lead to cardiac dysrhythmias; therefore, the nurse should contact the HCP. The sodium level is within normal
limits (135145 mEq/L); occasional PVCs are not
life-threatening; and 300 mL of semi-liquid stool
is expected with a client diagnosed with diarrhea.
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SECTION FOUR
229
Management
101. The nurse has received the morning shift report.
l 1. The client diagnosed with peptic ulcer disease who
is complaining of acute epigastric pain.
l 2. The client diagnosed with acute gastroenteritis who
had four diarrhea stools during the night.
l 3. The client diagnosed with inflammatory bowel
disease who has a hard, rigid abdomen.
l 4. The client diagnosed with food poisoning who has
vomited several times during the night shift.
medical-surgical unit. Which task should be assigned to
the UAP?
l 1. Instruct the UAP to feed the 69-year-old client
who has dysphagia.
l 2. Request the UAP to turn and position the
89-year-old client who has a pressure ulcer.
3. Tell the UAP to monitor the 54-year-old client
4. Ask the UAP to perform chest physiotherapy on a
while performing occupational therapy.

72-year-old client with pneumonia.
103. The nurse on a medical unit is discussing a male

client with the case manager. Which information is most
appropriate for the nurse to share with the case manager?
l 1. Tell the case manager that the client is threatening
to sue a nurse who forgot his pain medication.
l 2. Provide the case manager with any information
about the clients required home care and financial
status.
l 3. Explain that the client does not want any
information given out to the public about his being
admitted to the hospital.
l 4. Have the case manager sign a confidentiality
agreement to not discuss the client in public.
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ANSWERS
230
101. Correct answer 3: A hard, rigid abdomen is abnor-
103. Correct answer 2: The case manager is part of the
mal in any circumstance and is a clinical manifestation of peritonitis, a potential life-threatening

condition. The nurse should assess this patient first
and should also assess for an elevated temperature.
health-care team and should be provided with the

information needed to perform the job. The case
manager should have already signed a confidentiality agreement with the facility. ContentMedical;

Category of Health AlterationGastrointestinal; Integrated ProcessPlanning; Client NeedsSafe Effective

LevelSynthesis.
102. Correct answer 2: The UAP can turn the client.

The UAP should not feed a client with difficulty
swallowing, monitor a client during therapy, or
perform chest physiotherapy. ContentMedical;
Category of Health AlterationGastrointestinal; Integrated ProcessPlanning; Client NeedsSafe Effective
LevelSynthesis.
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SECTION FOUR
104. The nurse and LPN are caring for a client diagnosed
with a bleeding peptic ulcer. Which intervention should
the nurse assign to the LPN?
l 1. Perform the pre-blood assessment.
l 2. Teach the client to stop smoking.
l 3. Administer the proton pump inhibitor PO.
l 4. Return the used blood bag to the laboratory.
105. The nurse on the GI unit is administering the
clients scheduled intravenous antibiotic when the client
shows the nurse a white, cheesy plaque on the tongue
that bleeds when removed. Which statement is the nurses
best response?
l 1. These white plaques happen sometimes with
antibiotics. I will tell your HCP.
l 2. Those white patches usually go away without
treatment within 2 weeks.
l 3. You need to rinse your mouth with a solution of
diluted hydrogen peroxide and water.
l 4. I can tell these plaques bother you. Would you
like to talk?
Page 231
231
106. The female client diagnosed with viral hepatitis C

is being discharged. Which instructions should the nurse
teach the client?
l 1. Discuss limiting alcohol consumption to two to
three beers or glasses of wine a day.
l 2. Teach the client to remain on strict bedrest for at
least 1 month.
l 3. Instruct the client to use a condom during sexual
intercourse.
l 4. Explain that the client is no longer contagious and
can resume normal activities.
107. The adolescent male client who has begun to use
tobacco tells this information to the clinic nurse. Which
statement is an example of the ethical principle of fidelity?
l 1. The nurse tells the clients parents that he uses
chewing tobacco.
l 2. The nurse tells the client that he is at risk for
developing oral cancer.
l 3. The nurse gives the client information on oral
cancers and the risks involved.
l 4. The nurse keeps confidential the information that
the client shared.
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ANSWERS
104. Correct answer 3: The LPN should be capable of

administering a proton pump inhibitor. Assessing
and teaching cannot be delegated or assigned to the
LPN. The UAP can return an empty blood bag
to the lab. ContentMedical; Category of Health
105. Correct answer 1: Oral candidiasis or thrush is a

fungal infection that presents as white, cheesy
plaques that bleed if rubbed. They can occur as a
side effect of antibiotic treatment. Clients with diabetes or immunosuppression have a high risk for
developing it. The HCP should be contacted to
obtain an antifungal solution. ContentMedical;
Physiological Integrity, Pharmacological and
232
106. Correct answer 3: The client can spread the virus

through blood and body fluids. The sexual contacts
of the client should be protected. Clients should
not drink any alcoholic beverages; strict bedrest
is not necessary; and the client is still contagious
until she seroconverts. ContentMedical; Category
ProcessPlanning; Client NeedsPhysiological
LevelSynthesis.
107. Correct answer 4: Fidelity is being faithful to the

relationship with the client. Telling the parents is
paternalism. Giving the client information is beneficence. ContentFundamentals; Category of Health
LevelApplication.
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SECTION FOUR
108. The elderly client in the long-term care facility

insists on receiving a cathartic laxative daily. Which
action by the nurse is the most appropriate?
l 1. The nurse administers the as-needed (PRN)
laxative per the clients request.
l 2. The nurse obtains an order for a bulk-forming
laxative daily.
l 3. The nurse refuses to administer the cathartic
laxative to the client.
l 4. The nurse discusses the problem with the chief
nursing officer.
109. The client presents to the emergency department
complaining of right upper quadrant pain after eating
supper. Which intervention should the nurse implement
first?
l 1. Schedule a gallbladder sonogram.
l 2. Draw a complete blood count.
l 3. Run a 12-lead electrocardiogram.
l 4. Send the client to radiology for a chest x-ray.
Page 233
233

l 1. The 45-year-old client diagnosed with peptic ulcer
disease whose Hgb is 10.2 mg/dL.
l 2. The 50-year-old client diagnosed with a hiatal
hernia who is complaining of severe indigestion.
l 3. The 67-year-old client diagnosed with
gastroenteritis who has dry mucous membranes.
l 4. The 78-year-old client diagnosed with obstipation
who had three hard dry stools on the last shift.
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ANSWERS
108. Correct answer 2: The client is fixated on the need

for a medication daily. A bulk laxative will provide
more fiber for the client to aid in a more normal
bowel movement. Cathartic laxatives stimulate
peristalsis and can cause laxative dependence.
109. Correct answer 3: Cardiac pain may mimic gallbladder pain. The nurse should make sure that the
client is having gallbladder problems and not cardiac problems. ContentMedical; Category of Health
LevelApplication.
234
110. Correct answer 3: This client is exhibiting symptoms of dehydration and should be assessed first. A
Hgb of 10.2 mg/dL is not life-threatening, and the
client with a hiatal hernia is expected to have indigestion. The client with obstipation is passing
stools, which means the problem is resolving.
ContentMedical; Category of Health Administration
SECTION FIVE
11/11/09
12:09 PM
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Endocrine Disorders
235
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12:09 PM
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Page 237
Endocrine Disorders
237
Type 1 Diabetes
suspect the client may have type 1 diabetes?
l 1. I have gained about 30 pounds in the last few
years.
l 2. I have to go to the bathroom and urinate all
the time.
l 3. I have a sore on my big toe that is not healing.
l 4. I have a granddaughter who had gestational
diabetes.
2. The client diagnosed with type 1 diabetes is complaining
of being jittery and nervous and has a headache. Which
l 1. Check the client's serum glucose level.
l 2. Determine the last time the client received insulin.
l 3. Give the client one glass of orange juice.
l 4. Assess the client's vital signs.
3. The nurse administered 20 units of NPH intermediateacting insulin to a client diagnosed with type 1 diabetes at
1630. Which intervention should the nurse implement?
l 1. Give the client the bedtime snack.
l 2. Ensure the client eats the evening meal.
l 3. Perform a glucometer check at 1800.
l 4. Check the client's urine for ketones.
4. The nurse is caring for a client diagnosed with diabetic
ketoacidosis (DKA) who has a blood glucose level of
510 mg/dL. Which priority intervention should the
intensive care nurse implement?
l 1. Administer intravenous regular insulin.
l 2. Monitor the client's intake and output.
l 3. Check the client's glucose level frequently.
l 4. Turn the client every 2 hours.
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ANSWERS
238
1. Correct answer 2: Polyuria, polyphagia, and polydip-
3. Correct answer 1: The intermediate-acting insulin
sia are the three classic symptoms of type 1 diabetes.

Being overweight and a non-healing wound are signs
of type 2 diabetes. ContentMedical; Category of Health
peaks in 68 hours, and the client needs glucose to

prevent hypoglycemia; therefore, the client needs to
eat a bedtime snack. ContentMedical; Category of
AlterationEndocrine; Integrated ProcessAssessment;


2. Correct answer 3: The client is having signs/symptoms

of hypoglycemia; therefore, the nurse should provide
the client with a simple carbohydrate. A serum glucose
level requires a venipuncture, and then the laboratory
must perform the test, which will take too long. The
nurse can check the last insulin administration and
assess vital signs after treating the client. Content
Medical; Category of Health AlterationEndocrine;
4. Correct answer 1: Administering intravenous regular

insulin is priority because the blood glucose must be
lowered to help reverse the client's metabolic acidosis.
Assessing the glucose level, urine output, and turning
the client are appropriate interventions, but they are
not priority over decreasing the glucose level. Content
Therapies Adaptation; Cognitive LevelApplication.
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Endocrine Disorders
SECTION FIVE
5. The nurse is teaching the client newly diagnosed with

type 1 diabetes. Which information should the nurse
include in the teaching plan? Select all that apply.
l 1. Discuss the importance of checking the feet weekly.
l 2. Encourage the client to walk for at least 30 minutes
a day.
l 3. Recommend the client to the American Diabetic
Association (ADA).
l 4. Explain the need to wear SPF 30 sunscreen when
in the sun.
l 5. Tell the client to get an ophthalmology check-up
yearly.
6. The client diagnosed with DKA asks the nurse, Why
are you checking my urine with that stick? Which
statement is the nurse's best response?
l 1. I am checking your urine to see if glucose is
spilling into the urine.
l 2. This test determines if ketones from fat
breakdown are in your urine.
239
3. Your doctor needs to know the specific gravity of
4. I need to find out if there is any protein in your
your urine.
urine output.
7. The nurse is discussing exercise with the client

diagnosed with type 1 diabetes. Which intervention
l 1. Instruct the client to eat a simple source of
carbohydrate before walking.
l 2. Tell the client to wear open-toed supportive shoes
when walking.
l 3. Explain that the client should carry hard candies
when exercising.
l 4. Recommend the client perform isometric exercises
three times a week.
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ANSWERS
5. Correct answer 2, 3, 5: The treatment for type

1 diabetes is insulin, exercise, and diet. The ADA is an
excellent resource for clients. Diabetic retinopathy is a
long-term complication; therefore, regular eye checkups are needed. The client should check the feet daily,
not weekly. Sunscreen is not a part of diabetic teaching. ContentMedical; Category of Health Alteration
Endocrine; Integrated ProcessPlanning; Client Needs
6. Correct answer 2: Fat breakdown results in ketone

production, and the urine is checked for ketonuria.
The glucose level is checked by glucometer readings,
not in urine output. ContentMedical; Category
of Health AlterationEndocrine; Integrated Process
Page 240
240
7. Correct answer 3: The client should carry a simple

carbohydrate, such as hard candies, while exercising in
case the client becomes hypoglycemic. The client
should eat a complex carbohydrate prior to walking,
wear closed toes tennis shoes, and perform isotonic
exercises. Isometric is weight-lifting. ContentMedical;
Category of Health AlterationEndocrine; Integrated
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SECTION FIVE
8. The intensive care nurse is caring for the client

diagnosed with DKA. Which data indicate the client
is responding to the medical regime?
l 1. The client is exhibiting Kussmaul breathing.
l 2. The client's serum glucose level is 220 mg/dL.
l 3. The client buccal mucosa is pink and moist.
l 4. The client's arterial blood gases (ABGs) are
pH 7.34, PaO2 90, PaCO2 44, HCO3 20.
9. The client diagnosed with type 1 diabetes called the
clinic and told the nurse, I am nauseated and vomiting.
I think I have a bug. Which statement should be the
l 1. I will make an appointment for you to come to
the clinic today.
l 2. Do not take your routine insulin dosage if you
cannot eat.
l 3. Is anyone else in your home nauseated and
vomiting?
l 4. Take your insulin and drink foods high in
carbohydrates such as Jello.
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Endocrine Disorders
241
10. The client newly diagnosed with type 1 diabetes

asks the nurse, Why am I hungry all the time? Which
l 1. You do not have enough insulin to allow sugar
into the cells.
l 2. The insulin you have circulating is not effective
for glucose metabolism.
l 3. The high sugar level in your blood causes the
brain to think you are hungry.
l 4. The high glucose level prevents carbohydrates
from being broken down.
Type 2 Diabetes
11. The nurse is caring for a client newly diagnosed with
type 2 diabetes. Which intervention should the nurse
implement?
l 1. Administer pancreatic enzymes.
l 2. Monitor the client's arterial blood gases.
l 3. Assess the client for ketonuria.
l 4. Administer oral hypoglycemic medications.
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ANSWERS
8. Correct answer 3: A pink and moist buccal mucosa

indicates the client is well hydrated, which means the
client is responding to the medical regime. Kussmaul
breathing, an elevated glucose level, and metabolic
acidosis indicate the medical regime is not effective.
Endocrine; Integrated ProcessEvaluation; Client
9. Correct answer 4: The client must continue to take

the routine insulin dosage because illness increases
the glucose level. The client should consume foods
high in carbohydrates, such as Jello, orange juice,
puddings, and regular Coke, to prevent hypoglycemia.
Endocrine; Integrated ProcessImplementation; Client
Page 242
242
10. Correct answer 1: Polyphagia occurs because there

is not enough insulin to allow glucose to enter the
cell; therefore, the cell is starved for glucose, which
makes the client feel hungry. ContentMedical;
Category of Health AlterationEndocrine: Integrated
LevelAnalysis.
11. Correct answer 4: The client diagnosed with type 2

diabetes is treated with oral hypoglycemics. Changes
in arterial blood gases and diabetic ketoacidosis
occur in a client diagnosed with type 1 diabetes.
Pancreatic enzymes are not administered to clients
with diabetes. ContentMedical; Category of Health
AlterationEndocrine; Integrated ProcessImplementation;
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Endocrine Disorders
SECTION FIVE
12. The nurse is teaching a client newly diagnosed with

type 2 diabetes. Which statement indicates the client
needs more teaching?
l 1. If I lose weight, it may help decrease my blood
glucose level.
l 2. I must start counting my carbohydrates to help
my diabetes.
l 3. I am so glad my children won't have to worry
about getting diabetes.
l 4. If I get any types of cuts on my feet, I need to
watch them closely.
13. The client newly diagnosed with type 2 diabetes tells
the nurse, "I don't understand why I need to keep my
sugar down. I don't feel bad. Which statement is the
l 1. You are concerned you don't feel bad because
your sugar level is high.
l 2. With time your high sugar level can cause
blindness or kidney failure.
243
3. If you don't keep your sugar down you may start
4. A high sugar level can cause you to gain weight
feeling bad.
over time.

hyperglycemic, hyperosmolar nonketotic (HHNK) coma.
Which intervention warrants immediate intervention by
the nurse?
l 1. The client's arterial blood gas reveals metabolic
acidosis.
l 2. The client's urine has 4+ ketones.
l 3. The client's skin turgor is tented.
l 4. The client has bilateral crackles in the lungs.
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ANSWERS
12. Correct answer 3: A risk factor for developing type

2 diabetes is a family history; therefore, this statement indicates the client needs more teaching.
Obesity, carbohydrate counting, and delayed wound
healing indicate the client understands the client
AlterationEndocrine; Integrated ProcessEvaluation;
13. Correct answer 2: Type 2 diabetes can lead

to long-term complications such as blindness,
diabetic nephropathy, peripheral neuropathy, and
heart disease. ContentMedical; Category of Health
Client NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelAnalysis.
244
14. Correct answer 4: Bilateral crackles indicate

the client is in fluid volume overload from fluid
replacement. This requires immediate intervention.
Metabolic acidosis and ketonuria occur in type
1 diabetes, not type 2 diabetes. The client in HHNK
would be dehydrated; therefore, tented skin turgor
would not warrant immediate intervention. Content
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SECTION FIVE
15. The nurse is administering metformin (Glucophage) to

the client diagnosed with type 2 diabetes. Which statement
best describes the scientific rationale for administering this
medication?
l 1. Glucophage prevents the breakdown of glucose in
the liver.
l 2. The medication increases the production of insulin
in the beta cells.
l 3. Metformin causes the muscle cells to be more
receptive to circulating insulin.
l 4. This medication slows the absorption of
carbohydrates in the intestines.
16. The nurse in the diabetes clinic is triaging phone
calls from clients. Which client should the nurse call first?
l 1. The client who needs to reschedule an
appointment as soon as possible.
l 2. The client who needs a prescription refill for oral
hypoglycemics.
l 3. The client who has a wound on the left foot that
looks infected.
l 4. The client who has had loose runny stools for the
last 2 days.
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Endocrine Disorders
245
17. The charge nurse noted that the primary nurse

administered metformin (Glucophage) to a client
diagnosed with type 2 diabetes who is scheduled for a
CT scan with contrast. Which action should the charge
l 1. Complete an adverse occurrence report.
l 2. Notify the client's health-care provider (HCP).
l 3. Call radiology and cancel the CT scan.
l 4. Do not take any action at this time.
18. The nurse is checking laboratory data for clients.
Which laboratory data warrant notifying the HCP?
l 1. The client with type 2 diabetes whose fasting blood
glucose is 185 mg/dL.
l 2. The client with type 2 diabetes who has negative
ketones in the urine.
l 3. The client with type 2 diabetes who has a serum
creatinine level of 1.8 mg/dL.
l 4. The client with type 2 diabetes who has a serum
potassium level of 3.3 mEq/L.
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ANSWERS
15. Correct answer 1: This is the scientific rationale for

administering metformin (Glucophage) to a client
with type 2 diabetes. ContentMedical; Category of
LevelAnalysis.
16. Correct answer 4: Acute illness leads to an increase

in the client's glucose level and may lead to dehydration; therefore, the nurse should return this client's
call first. Then, call the client who has an infected
foot. ContentMedical; Category of Health Alteration
Page 246
246
17. Correct answer 3: Glucophage must be held 2 days

before and 2 days after the contrast dye is administered to the client. The charge nurse should first cancel the CT scan, then notify the HCP, and complete
an adverse occurrence report. ContentMedical;
LevelEvaluation.
18. Correct answer 4: The client who has a low potassium

level (3.55.5 mEq is normal) is at risk for dysrhythmias; therefore, the nurse should contact the client's
HCP. A blood glucose level of 185 mg/dL is not
life-threatening. ContentMedical; Category of Health
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Endocrine Disorders
247
Thyroid Disorders
19. The unlicensed assistive personnel (UAP) tells the
nurse the client has a glucometer reading of 40. Which
action should the nurse implement?
l 1. Assess the client immediately.
l 2. Tell the UAP to give the client orange juice.
l 3. Prepare to administer an oral hypoglycemic
medication.
l 4. Contact the laboratory to confirm the client's
blood glucose level.
20. The clinic nurse is caring for a client newly diagnosed
with type 2 diabetes. Which referral would be most
appropriate for the nurse to discuss with the client?
l 1. Refer the client to an endocrinologist.
l 2. Refer the client to a registered dietitian.
l 3. Refer the client to the home health nurse.
l 4. Refer the client to a social worker.
21. Which signs/symptoms should the nurse assess for

the client diagnosed with Graves disease?
l 1. Fatigue and bradycardia.
l 2. Polyuria and polyphagia.
l 3. Diarrhea and heat intolerance.
l 4. Weight gain and thick brittle nails.
22. The client is postoperative bilateral thyroidectomy.
l 1. Place a tracheostomy tray at the bedside.
l 2. Have potassium chloride easily accessible.
l 3. Administer propylthiouracil (PTU), an antithyroid
medication.
l 4. Monitor the client's thyroid hormone levels,
T3 and T4.
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ANSWERS
19. Correct answer 1: The client's blood glucose level is

low (70100 mg/dL); therefore, the nurse should
assess the client immediately. The nurse cannot delegate an unstable client to the UAP. ContentMedical;
LevelApplication.
20. Correct answer 2: The client with type 2 diabetes

needs to be on a carbohydrate counting diet; therefore, a referral to the registered dietitian would be
most appropriate. The nurse does not refer a client
to an endocrinologist. A home health nurse or social
worker would not be appropriate referrals for a
newly diagnosed type 2 diabetic client. Content
Effective Care Environment, Management of Care,
248
21. Correct answer 3: Graves disease, a type of hyperthyroidism, results in an increase in metabolism
that results in symptoms that include weight loss,
increased appetite, diarrhea, heat intolerance, and
nervousness. ContentMedical; Category of Health
22. Correct answer 1: A postoperative complication

of a bilateral thyroidectomy is laryngeal edema;
therefore, a tracheostomy tray, oxygen, and a suction
machine should be placed at the bedside. PTU may
be administered preoperatively; the T3 and T4 levels
are not monitored after surgery. ContentMedical;
LevelEvaluation.
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SECTION FIVE
23. The nurse is caring for the client who is immediate

postoperative thyroidectomy. Which data would warrant
l 1. The client's hemoglobin/hematocrit is 12/36.
l 2. The client's vital signs are T 99.4, AP 98, R 20,
B/P 142/88.
l 3. The client is agitated and extremely anxious.
l 4. The client's surgical dressing is dry and intact.
24. The clinic nurse is caring for a client diagnosed with
hyperthyroidism. Which information should the nurse
l 1. Maintain a calm, restful environment.
l 2. Eat a low-calorie, low-protein diet.
l 3. Take the thyroid hormone with food.
l 4. Wear thick-weaved clothes in the sun.
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Endocrine Disorders
249
25. The client diagnosed with Graves disease received

iodine 131, radioactive iodine. Which statement indicates
the client needs more teaching?
l 1. I should not be around young children and
pregnant women.
l 2. It is important for me to flush my commode twice
after I urinate.
l 3. It is not uncommon to vomit after taking the
radioactive iodine.
l 4. I will have to wear a radioactive badge during the
treatment.
26. The client diagnosed with hypothyroidism is
prescribed levothyroxine (Synthroid), a hormone
replacement. Which data indicate the medication is
effective?
l 1. The client has lost 4 lb in 1 week.
l 2. The client's radial pulse is 88.
l 3. The client complains of being cold.
l 4. The client's temperature is 97.0F.
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ANSWERS
23. Correct answer 3: Thyroid storm is a life-threatening

event caused by an oversecretion of thyroid hormone.
It results in agitation, anxiety, fever, tachycardia, and
hypertension. ContentSurgical; Category of Health
24. Correct answer 1: The client is nervous and anxious;
250
twice after urinating. Iodine 131 is very irritating to

the gastrointestinal tract and the client may vomit.
Endocrine; Integrated ProcessEvaluation; Client
26. Correct answer 2: A radial pulse between 60 and
therefore, maintaining a calm, restful environment

is an appropriate intervention. The client should
eat a high-calorie, high-protein, low-caffeine diet.
100 indicates the medication is effective. Weight loss

indicates taking too much medication. Being cold
and having a subnormal temperature indicate not
enough medication. ContentMedical; Category of


LevelEvaluation.
25. Correct answer 4: The client is not radioactive and

does not have to wear a radioactive badge. The
client's body fluids are, however, radioactive; therefore, the client should not be around young children
or pregnant women and should flush the commode
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SECTION FIVE

suspect the client has hypothyroidism?
l 1. I wake up at night feeling hot all over.
l 2. I have a bowel movement once a day.
l 3. I keep putting lotion on my dry skin.
l 4. I have trouble going to sleep at night.
28. The clinic nurse is teaching the client diagnosed with
hypothyroidism. Which intervention should the nurse
l 1. Tell the client to decrease fluid intake to 1000 mL
a day.
l 2. Encourage the client to eat foods high in fiber.
l 3. Recommend the client take a daily laxative.
l 4. Discourage the client from eating fresh fruits and
vegetables.
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Endocrine Disorders
251
29. The client is diagnosed with myxedema coma.

Which signs/symptoms would the nurse expect the client
to exhibit?
l 1. The client's blood pressure is 110/70.
l 2. The client's serum sodium level is 138 mEq/L.
l 3. The client's respirations are 16 beats per minute.
l 4. The client's serum glucose level is 60 mg/dL.
30. Which medication teaching should the nurse discuss
with the client diagnosed with hypothyroidism who is
prescribed levothyroxine (Synthroid)?
l 1. Explain the need to monitor thyroid levels daily.
l 2. Inform the client to avoid foods high in iodine.
l 3. Instruct the client to monitor weight monthly.
l 4. Tell the client chest pain may occur while taking
medication.
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ANSWERS
27. Correct answer 3: The client with hypothyroidism

has dry skin; thin, dry hair; cold intolerance, constipation, dull emotions, and fatigue. ContentMedical;
28. Correct answer 2: The client with hypothyroidism

experiences constipation; therefore, the client should
have a diet high in fiber. The client should also increase
fluid intake to 3000 mL a day. The nurse should discourage daily laxatives or enemas. ContentMedical;

myxedema coma experiences hypotension, hypothermia, hypoglycemia, hyponatremia, and respiratory
failure. A serum glucose level of 60 mg/dL indicates
hypoglycemia. The blood pressure, sodium level, and
Page 252
252
respirations are within normal limits and would not

indicate myxedema coma. ContentMedical; Category
30. Correct answer 2: Foods high in iodine will cause

the levothyroxine not to be effective. Thyroid level is
monitored monthly, not daily. Weights should be
daily, not monthly. Synthroid should be administered cautiously in clients with cardiovascular disease.
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SECTION FIVE
Endocrine Disorders
253
Adrenal Disorders
31. The nurse is admitting a client who has been
diagnosed with primary adrenal cortex insufficiency
(Addison disease). Which signs and symptoms support
the diagnosis of Addison disease?
l 1. Bronze pigmentation, hypotension, and anorexia.
l 2. Moon face, buffalo hump, and hyperglycemia.
l 3. Hirsutism, fever, and irritability.
l 4. Tachycardia, bulging eyes, and goiter.
32. The nurse is caring for a client diagnosed with acquired
immune deficiency syndrome (AIDS) who has developed
an infection in the adrenal gland. Which client problem has
the highest priority?
l 1. Altered body image.
l 3. Impaired coping.
l 4. Fluid volume deficit.

Addison disease. Which nursing interventions should be
implemented?
l 1. Place the client in contact isolation.
l 2. Administer intravenous and oral steroid
medications.
l 3. Provide a brightly lit room and recreational
activities.
l 4. Consult occupational therapy for work retraining.
34. The nurse is admitting the client diagnosed with
rule-out Cushing syndrome. Which laboratory tests
would confirm the diagnosis of Cushing syndrome?
l 1. Complete blood count (CBC) and erythrocyte
sedimentation rate (ESR).
l 2. Plasma levels of adrenocorticotropic hormone
(ACTH) and cortisol.
l 3. 24-hour urine for metanephrine and catecholamine.
l 4. Early morning spot urine specimen for protein and
glucose.
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ANSWERS
31. Correct answer 1: Bronze pigmentation of the skin,

particularly of the knuckles and other areas of skin
creases, occurs in Addison disease. Hypotension
and anorexia also occur. Moon face, buffalo hump,
and hyperglycemia are due to Cushing syndrome,
which is hyperfunction of the adrenal gland. Content
Medical; Category of Health AlterationEndocrine; Integrated ProcessAssessment; Client NeedsPhysiological
Analysis.
32. Correct answer 4: Fluid volume deficit (dehydration)

can lead to circulatory impairment and hyperkalemia.
Fluid volume deficit is the only physiological problem and should be chosen for this reason. Content
254
33. Correct answer 2: Clients diagnosed with Addison

disease have adrenal gland hypofunction. The client
will require glucocorticosteroids, mineral steroids,
and androgens. ContentMedical; Category of
Health AlterationEndocrine; Integrated Process
34. Correct answer 2: The adrenal gland secretes cortisol;

the pituitary gland secretes adrenocorticotropic
hormone (ACTH), a hormone used by the body to
stimulate the production of cortisol. Twenty-four-hour
urine specimens for 17-hydroxycorticosteroids and
17-ketosteroids may be collected to determine the
client's urine cortisol level. ContentMedical; Category
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Endocrine Disorders
SECTION FIVE
35. The client admitted for chronic obstructive pulmonary

disease (COPD) has developed iatrogenic Cushing disease.
Which is a scientific rationale for the development of this
problem?
l 1. The client's chronic lack of oxygen has destroyed
the adrenal glands.
l 2. The client has a pituitary tumor that causes an
overproduction of cortisol.
l 3. The client has been taking steroid medications for
an extended time.
l 4. The HCP cannot explain why the client has this
problem.
36. The nurse is performing discharge teaching for a
client diagnosed with Cushing disease. Which statement
made by the client indicates the client needs further
discharge instructions?
l 1. I will be sure to notify my HCP if I start to run a
fever.
l 2. Before I stop taking the prednisone, I will be
taught how to taper it off.
255
3. If I get thirsty and urinate a lot, I should let my
4. I should be sure and take safety precautions to
doctor know.
prevent an injury.
37. The charge nurse of an intensive care unit (ICU) is

making assignments for the night shift. Which client
should be assigned to the least experienced ICU nurse?
l 1. The client with respiratory failure who is on a
ventilator who has a tension pneumothorax.
l 2. The client with iatrogenic Cushing disease with a
pH 7.35, O2 88, PCO2 44, and HCO3 22.
l 3. The client with Addison disease who is lethargic
and has BP 80/45, P 124, R 28.
l 4. The client who has undergone a thyroidectomy
and has a positive Trousseau sign.
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ANSWERS
35. Correct answer 3: Iatrogenic means that a problem

has been caused by the medical treatment or procedure
used to treat another problem. Clients taking exogenous steroids over a period of time, such as those with
COPD, develop the clinical manifestations of Cushing
disease. Disease processes for which long-term steroids
are prescribed include COPD, cancer, and arthritis.
36. Correct answer 2: The client has too much cortisol

and would not be on prednisone, a steroid medication. The nurse should clarify the instructions
with the client. ContentMedical; Category of Health
256
37. Correct answer 2: This client has normal arterial

blood gases. The nurse with the least experience
should be able to care for this client. A tension
pneumothorax is an emergency; the client diagnosed
with Addison disease may be in crisis; and a positive
Trousseau sign indicates hypocalcemia. Content
LevelSynthesis.
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SECTION FIVE
38. The nurse writes a problem of altered glucose

metabolism for a client diagnosed with Cushing disease.
l 1. Monitor blood glucose levels before meals and at
bedtime.
l 2. Perform a head-to-toe assessment every shift.
l 3. Use therapeutic communication to allow the client
to discuss feelings.
l 4. Assess bowel sounds and temperature every 4 hours.
39. The client diagnosed with possible Addison disease is
admitted to the emergency department. The client is
lethargic, confused, and weak. Which intervention should
the emergency department implement first?
l 1. Have the lab draw serum cortisol levels stat.
l 2. Check the client's medic alert bracelet to confirm
Addison disease.
l 3. Administer replacement steroids intravenously.
l 4. Start an intravenous line and administer normal
saline rapidly.
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Endocrine Disorders
257
40. The client diagnosed with Cushing disease has

developed 2+ peripheral edema in the last 24 hours. The
primary intravenous rate is 100 mL per hour, and he is
receiving an intravenous piggyback (IVPB) medication in
50 mL of fluid every 6 hours. He has an oral intake of
2450 mL and a recorded output of 3000 mL. Which
l 1. Convert the intravenous fluids to a saline lock.
l 3. Teach the client to measure all output.
l 4. Assess the lung fields and jugular vein.
Pituitary Disorders
41. The client diagnosed with a pituitary tumor has
developed syndrome of inappropriate antidiuretic hormone
(SIADH). Which intervention should the nurse implement?
l 1. Assess the client for tented skin turgor.
l 2. Weigh the client daily at the same time.
l 3. Monitor the client's serum potassium level.
l 4. Perform a fluid deprivation test on the client.
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ANSWERS
38. Correct answer 1: Blood glucose levels should be

obtained to monitor for the effects of insulin resistance caused by Cushing disease. ContentMedical;
258
+ 2450 mL oral intake = 5050 total intake, and total

output is 3000 mL. ContentMedical; Category of


LevelApplication.
39. Correct answer 2: The nurse should look for an iden-
41. Correct answer 2: The client with SIADH is pro-
tification band alerting the health-care professional of

a chronic disease and then start the intravenous line
and administer steroids. ContentMedical; Category
Implementation; Client NeedsSafe Effect Care Environment, Management of Care; Cognitive LevelAnalysis.
40. Correct answer 4: The nurse should first perform a

complete assessment to determine further evidence
of heart failure and make sure that all urine output is
measured before slowing the IV and notifying the
HCP. The 24-hour intake is 2600 mL of IV fluid
ducing a hormone that will not allow the client to

urinate; therefore, weighing the client daily would
be appropriate. The client experiences fluid volume
overload, not dehydration, so assessment for skin
turgor is not needed. Dilutional hyponatremia is
assessed to detect the level of sodium, not potassium,
in the blood, and a water challenge test is performed,
not a fluid deprivation test. ContentMedical;
LevelApplication.
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Endocrine Disorders
SECTION FIVE
42. The nurse is caring for a client who is 8 hours post

transphenoidal hyposphysectomy for a pituitary tumor.
Which data would warrant immediate intervention by
the nurse?
l 1. The client has clear straw-colored fluid draining
from the nose.
l 2. The client has an 8-hour urine output of 330 mL
and an input of 280 mL.
l 3. The client's vital signs are T 97.6F, P 88, R 20,
BP 130/80.
l 4. The client has a 3-cm amount of dark red drainage
on the turban dressing.
43. The nurse is discharging the client newly diagnosed
with diabetes insipidus (DI). Which statement made by
the client indicates the client understands the discharge
teaching?
l 1. I will keep a list of my medications with me and
wear a Medic-Alert bracelet.
l 2. I should take my medication in the morning and
leave it refrigerated at home.
259
3. I should weigh myself once a week and keep a
4. It is not uncommon to develop a tightness in my
journal of my weight.
chest early in the morning.
44. The client is admitted to the medical unit with a

diagnosis of rule-out diabetes insipidus (DI). Which
intervention should the nurse implement when
conducting a fluid deprivation test?
l 1. Have the client drink 500 mL of hyperosmolar
fluid and obtain a serum sodium level hourly.
l 2. Inject an antidiuretic hormone and measure the
client's urine output for 810 hours.
l 3. Keep the client NPO and check vital signs and
weight hourly until the end of the test.
l 4. Initiate an IV line with normal saline and do not
allow the client to urinate until the sonogram is
completed.
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ANSWERS
42. Correct answer 1: A transphenoidal hypophysectomy

is performed by surgical access above the gum line;
therefore, the nurse should test the drainage from
the nose to determine if it is cerebrospinal fluid. The
input and output is within normal limits; the vital
signs are stable; and the client does not have a
turban (head) dressing. ContentSurgical; Category
43. Correct answer 1: DI is a chronic illness that requires

daily medication; therefore, the client should keep a
list of medication being taken and wear a Medic-Alert
bracelet. DI medication is taken every 812 hours
and should be kept close at hand. The client should
weigh daily, and it is not common to have chest
tightness. ContentMedical; Category of Health
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260
44. Correct answer 3: The client is deprived of all fluids;

if the client has DI, the urine production will not
diminish. Vital signs and weights are taken every
hour to determine circulatory status. If a marked
decrease in weight or vital signs occurs, the test is
immediately terminated. ContentMedical; Category
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SECTION FIVE
45. The nurse is caring for clients in a medical department.

l 1. The client diagnosed with SIADH who is lethargic
and confused.
l 2. The client diagnosed with diabetes insipidus (DI)
who has urinated 10,450 mL of urine in the last
24 hours.
l 3. The client diagnosed with SIADH who is
complaining of being thirsty.
l 4. The client diagnosed with DI who is complaining
of urinating every hour during the night.
46. The HCP has ordered 60 g/24 hours of intranasal
vasopressin for a client diagnosed with diabetes insipidus.
Each metered spray delivers 10 g. The client takes the
medication every 12 hours. How many sprays are
delivered at each dosing time?
Answer: ____________________
Endocrine Disorders
261

diabetes insipidus (DI). Which interventions should be
implemented? Select all that apply.
l 1. Restrict fluid intake to no more than 1000 mL/day.
l 2. Administer DDAVP, an anti-diuretic hormone.
l 3. Assess the client for signs of water intoxication.
l 4. Place the client on seizure precautions.
l 5. Check the client's urine specific gravity.
diabetes insipidus (DI). Which nursing intervention
should be implemented?
l 1. Monitor blood glucose before meals and at
bedtime.
l 2. Restrict caffeinated coffee and colas.
l 3. Check the client's urine for ketonuria.
l 4. Assess the client's oral mucosa every 4 hours.
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ANSWERS
45. Correct answer 1: If the client with SIADH develops lethargy and confusion, it could lead to seizures
and coma. Therefore, this client needs to be assessed
first. The other options include signs/symptoms
associated with the disease process. ContentMedical;
Management, Management of Care; Cognitive
LevelSynthesis.
46. Correct answer 3 sprays per dose: 60 g of

medication every 24 hours to be given every
12 hours. Twelve hours into 24 hours = 2, so there
will be 2 dosing times. Sixty divided by 2 = 30 g of
medication per dose. 30 g divided by 10 g per spray
= 3 sprays per dose. ContentMedical; Category of
262
47. Correct answer: 2, 3, 5. The treatment for DI is

hormone replacement with DDAVP and assessment
for signs of hyponatremia, water intoxication, weight
gain, and headache, which indicate the medication is
not effective. Interventions for syndrome of inappropriate antidiuretic hormone include restricting fluids
and seizure precautions. ContentMedical; Category
48. Correct answer 4: The client is excreting large

amounts of dilute urine. If the client is unable to
take in enough fluids, the client will quickly become
dehydrated. DI is not diabetes mellitus, so glucose
levels and ketones are not checked. There is no caffeine restriction for DI. ContentMedical; Category
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SECTION FIVE
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263
Pancreatitis
49. The UAP complains to the nurse that the client keeps
asking for cold water to drink. The client is diagnosed
with a closed head injury. Which intervention should the
l 1. Tell the UAP to give the client cold water.
l 2. Evaluate the client's intake and output.
l 3. Ask the UAP to check the client's weight.
l 4. Check the client's BUN and creatinine levels.
syndrome of inappropriate antidiuretic hormone (SIADH).
Which laboratory data would warrant intervention by the
nurse?
l 1. The client has a serum sodium of 120 mEq/L.
l 2. The client has a serum potassium of 5.0 mEq/L.
l 3. The client has serum creatinine of 1.8 g/day.
l 4. The client has negative glucose in the urine.

rule-out (R/O) acute pancreatitis. Which laboratory
value should the nurse monitor?
l 1. Serum SGOT and serum SGPT.
l 2. Hemoglobin and hematocrit.
l 3. Serum amylase and lipase.
l 4. Serum bilirubin and calcium.
pancreatitis on a medical unit. Which client problems
should be included in the client's plan of care? Select all
that apply.
l 3. Imbalanced nutrition: less the body requirements.
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ANSWERS
49. Correct answer 2: Diabetes insipidus is a complication of head trauma; therefore, the nurse should
evaluate the client's intake and output to determine
if the client has increased urinary output. Then, the
nurse could document the client's weight, check
renal function (BUN and creatinine levels), and
give the client cold water. ContentMedical; Category
Application.
50. Correct answer 1: A serum sodium level of

120 mEq/L is dangerously low, and the client is at
risk for seizures; therefore, the nurse should intervene. All the other laboratory data are normal.
Endocrine; Integrated ProcessAssessment; Client
264
51. Correct answer 3: Serum amylase rises within

212 hours of onset of acute pancreatitis to two
to three times normal and returns to normal in
34 days; lipase elevates and remains elevated for
714 days. Amylase and lipase are produced by
the pancreas. ContentMedical; Category of Health
52. Correct answer 1, 2, 3, 4: Clients diagnosed with

pancreatitis are at risk for hemorrhage if the digestive
juices erode a blood vessel. Autodigestion of the
pancreas results in severe epigastric pain accompanied by nausea and vomiting. The client will have
nothing by mouth, so nutrition is a problem, and
acute problems usually have some knowledge deficit.
Endocrine; Integrated ProcessDiagnosis; Client Needs
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SECTION FIVE
53. The nurse is preparing to administer morning

medications to the following clients. Which medication
should the nurse question before administering?
l 1. The pancreatic enzymes to the client who is no
longer NPO.
l 2. The pain medication morphine to the client
diagnosed with pancreatitis.
l 3. The loop diuretic to the client diagnosed with
heart failure.
l 4. The beta-blocker to the client who has an apical
pulse of 78 beats per minute (bpm).
54. The nurse assessing the client diagnosed with
pancreatitis notes the client has a bluish discoloration
around the umbilicus. Which intervention should the
nurse implement next?
l 1. Assess the left flank for bruising.
l 2. Check the chart for the latest hemoglobin.
l 3. Note the finding in the chart.
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Endocrine Disorders
265
55. The charge nurse is transcribing orders for a client

diagnosed with chronic pancreatitis. The HCP ordered
Librium intravenously every 8 hours. Which action by
the charge nurse would be most appropriate?
l 1. Move the client to a room near the nurse's station.
l 2. Question the HCP about the medication.
l 3. Do nothing except transcribe the order as is.
l 4. Have the lab draw a serum Librium level.
56. The nurse is completing discharge teaching to
the client diagnosed with acute pancreatitis. Which
instruction should the nurse discuss with the client?
l 1. Instruct the client to decrease the amount of
smoking.
l 2. Explain the need to avoid all stress.
l 3. Discuss the importance of avoiding alcohol.
l 4. Teach the correct way to take pancreatic enzymes.
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ANSWERS
53. Correct answer 2: Morphine causes spasms of the

sphincter of Oddi; the pain medication of choice for
clients diagnosed with pancreatitis is meperidine.
54. Correct answer 1: Bluish discoloration around the

umbilicus (Cullen sign) is an indicator of intraperitoneal hemorrhage. Grey-Turner sign is bluish
discoloration in the left flank area. The nurse should
complete the assessment of the client before notifying
the HCP, documenting the finding, or looking at
lab values. ContentMedical; Category of Health
266
55. Correct answer 1: Chronic pancreatitis is frequently

caused by alcoholism. Librium is prescribed to limit
the neurological effect of alcohol withdrawal. The
client should be moved close to the nurse's station
for observation. ContentMedical; Category of Health
AlterationEndocrine; Integrated ProcessPlanning;
Client NeedsSafe Effective Care Environment, Safety
and Infection Control; Cognitive LevelSynthesis.
56. Correct answer 3: Alcohol must be avoided entirely

because it can cause stones to form, blocking pancreatic ducts and the outflow of pancreatic juice, which,
in turn, causes further inflammation and destruction
of the pancreas. The client should stop smoking.
Pancreatic enzymes are prescribed for chronic
pancreatitis. ContentMedical; Category of Health
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SECTION FIVE
57. The male client diagnosed with chronic pancreatitis

reports to the clinic nurse that he has been having a lot of
gas and frothy, foul-smelling stools. Which statement is
the nurse's best response?
l 1. How often and when do you take your pancreatic
enzymes?
l 2. Can you bring a stool specimen to the clinic for
analysis?
l 3. You must come into the clinic and see the HCP.
l 4. You should stay on low-fat diet or this will
continue to happen.
58. The nurse is caring for a client who has just returned
from an endoscopic retrograde cholangiopancreatogram
(ERCP). Which post-procedure intervention should the
nurse implement?
l 1. Have the client swallow some water.
l 2. Place the bed in a semi-Fowler position.
l 3. Assess for the gag reflex.
l 4. Prop the client in a side-lying position.
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Endocrine Disorders
267

pancreatitis. The client is complaining of mid-epigastric
pain unrelieved by narcotic pain medication administered
45 minutes ago. The narcotic medication is prescribed
every 4 hours prn. Which intervention should the nurse
implement next?
l 1. Tell the client to lie in the prone position with legs
extended.
l 2. Call the HCP for an increase in the pain
medication.
l 3. Place the client in side-lying position with knees
flexed.
l 4. Explain that the nurse cannot administer more
medication for 3 hours.
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ANSWERS
57. Correct answer 1: Clients diagnosed with chronic

pancreatitis are prescribed replacement enzymes
that should be taken with every meal and snack.
The nurse should assess if the client is compliant
with the medication regimen before telling the
client to come in to see the HCP. ContentMedical;
LevelAnalysis.
58. Correct answer 4: The client returning from this

procedure will have had twilight sleep, and the
throat will have been numbed. The client should be
allowed to sleep until the medication wears off.
Placing the client on the side will prevent aspiration
if the client should vomit. After client wakes up, the
nurse should check for the gag reflex prior to allowing the client to swallow water. ContentMedical;
268

LevelApplication.
59. Correct answer 3: The fetal position decreases

pain caused by stretching of the peritoneum due to
edema. If nonpharmacological methods fail to relieve
the client's pain, then the nurse should discuss the
client's pain level with the HCP. ContentMedical;
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Endocrine Disorders
SECTION FIVE

chronic pancreatitis has a nasogastric tube and is NPO.
all that apply.
l 1. Monitor serum amylase and lipase.
l 2. Weigh the client weekly.
l 3. Assess the intravenous site.
l 4. Provide perineal care.
l 5. Monitor blood glucose levels.
Management Questions
61. The nurse is teaching a class to teachers in an
elementary school about children diagnosed with
hyperinsulinemia. Which would explain the development
of hyperinsulinemia in children?
l 1. The islet cells in the pancreas stop producing any
insulin, leading to type 2 diabetes.
l 2. The child has an excessive intake of calories related
to the amount of energy the child uses.
269
3. The pituitary gland signals the pancreas to increase
4. Hyperinsulinemia is a precursor to developing type
the amount of insulin produced.

1 diabetes mellitus in children.
62. The charge nurse is reviewing laboratory data.

Which data require immediate intervention?
l 1. A creatinine level of 2.8 mg/dL in a client
diagnosed with primary hyperparathyroidism.
l 2. A serum calcium level of 9.2 mg/dL in a client
diagnosed with Addison disease.
l 3. A serum triglyceride level of 130 mg/dL in a client
diagnosed with diabetes mellitus type 2.
l 4. A sodium level of 135 mEq/L in a client diagnosed
with an acute exacerbation of diabetes insipidus.
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ANSWERS
60. Correct answer 1, 3, 5: Amylase and lipase are pancreatic enzymes and are monitored to assess the status of the problem. The nurse should assess the
IV for signs of infection or infiltration. Blood glucose levels are monitored because clients with
chronic pancreatitis can develop diabetes mellitus.
61. Correct answer 2: The pancreas responds to excessive caloric intake by secreting more insulin to maintain a normal blood glucose level. Hyperinsulinemia
can be identified by markers known as acanthosis
nigricans. This is a precursor to type 2 diabetes.
Clients with type 1 diabetes have no insulin production, and the pituitary gland does not stimulate
insulin production. ContentMedical; Category of
270
62. Correct answer 1: This would indicate the client

is in renal failure, which is a complication of hyperparathyroidism. Stones related to the increased
urinary excretion of calcium and phosphorus form
in the kidneys. This occurs in about 55% of clients
with primary hyperparathyroidism and can lead
to renal failure. All other values are within normal
limits. ContentMedical; Category of Health Alteration
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Endocrine Disorders
SECTION FIVE
63. The nurse and UAP are caring for a client diagnosed
with a pheochromocytoma. Which nursing task should
the nurse delegate to the UAP?
l 1. Instruct the UAP to show the client how to work
the call light system.
l 2. Inspect the client's skin for signs of lesions or
discoloration.
l 3. Talk to the client about providing a family history
of adrenal tumors.
l 4. Ask how the high blood pressure has made the
client feel in the past.
64. The nurse is caring for a client 3 days postoperative
unilateral adrenalectomy. Which statement by the client
indicates the client understands the discharge teaching?
l 1. I will need to taper off my steroid medications
when I no longer need them.
l 2. I will use my intranasal vasopressin when I start to
go to the bathroom a lot.
271
3. My urinary catheter will have to stay in until I can
4. I should call my surgeon if I start running a
develop bladder control.

temperature over 101F.
65. The female client diagnosed with Cushing disease

asks the nurse. How long will I look like this? I feel like
a freak. Which response by the nurse best illustrates the
ethical principal of fidelity?
l 1. You feel like you look abnormal? We should
discuss how you are feeling about your body.
l 2. Some of the changes to your body may improve
with treatment, but there is no guarantee.
l 3. Your body will return to the way it looked before
after your adrenalectomy surgery.
l 4. I am not sure what you mean by 'freak.' Tell why
you are bothered about your body.
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ANSWERS
63. Correct answer 1: The UAP can orient a new

client to the room and make sure the client is able
to work the call light system. The other options
include obtaining assessment data, and the nurse
must perform these tasks. A family history of adrenal
tumors is a risk factor for a pheochromocytoma.
64. Correct answer 4: Any temperature greater than

101F would indicate an infection, and the client
will need to be on antibiotics; therefore, the healthcare provider must be notified. The client still has
one adrenal gland and will not be on steroid medications. The client does not have diabetes insipidus
and will not be on vasopression. The client will
not go home with an indwelling catheter. Content
Surgical; Category of Health AlterationEndocrine;
272

LevelEvaluation.
65. Correct answer 2: The ethical principal of fidelity

means to treat all clients the same and how the nurse
would like to be treated. It is the principle on which
the nurse-client relationship is built. This option tells
the client the truth and provides the client with the
opportunity to ask for more clarification. Content
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Endocrine Disorders
SECTION FIVE

rounds after the shift report. Which client should the
charge nurse assess first?
l 1. The adolescent male client who uses anabolic
steroids to increase his muscle size for football.
l 2. The elderly client diagnosed with COPD who
expectorated rusty-colored sputum during the
night.
l 3. The female client who refuses to remove her gown
because of the striae from taking steroids.
l 4. The client whose blood glucose reading averages
140 mg/dL since being placed on steroids.
67. Which client should the charge nurse in the ICU
assign to the most experienced nurse?
l 1. The client diagnosed with thyroid storm who is
1 hour postoperative thyroidectomy.
l 2. The client diagnosed with end-stage renal failure
(ESRD) who had 30 mL of urine output on the
last shift.
3. The client diagnosed with diabetic ketoacidosis
4. The client diagnosed with pheochromocytoma
273
whose last serum glucose was 220 mg/dL.

whose blood pressure is 146/92.
68. The home health nurse is caring for a client recently

placed on thyroid hormone replacement medication.
Which signs/symptoms would indicate to the nurse the
client is taking too much medication?
l 1. Complaints of weight loss and fine tremors.
l 2. Complaints of excessive thirst and urination.
l 3. Complaints of constipation and being cold.
l 4. Complaints of delayed wound healing and
belching.
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ANSWERS
66. Correct answer 2: Clients diagnosed with COPD

are placed on long-term steroids because of the
inflammation in their lungs. This can mask
infection. Frequently the only sign of an infection
in these clients is a change in the character of the
sputum or a rusty color. The charge nurse should see
this client first. ContentMedical; Category of Health
67. Correct answer 1: This client has the greatest

potential for being unstable and requires an experienced ICU nurse. The nurse should assess for
signs/symptoms of complications. Any output in a
client with ESRD is good. A serum glucose under
240 mg/dL means the client is no longer in diabetic
ketoacidosis. A pheochromocytoma causes extremely
high blood pressure readings. This client is stable.
Page 274
274

68. Correct answer 1: This would make the nurse suspect the client is taking too much thyroid hormone
because these are symptoms of hyperthyroidism.
Excessive thirst and urination are symptoms of
diabetes. Constipation and feeling cold indicate that
the client is not taking enough thyroid hormone.
Delayed wound healing and belching would indicate
Cushing disease. ContentMedical; Category of Health
LevelAnalysis.
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SECTION FIVE
69. The nurse is planning the care of the client diagnosed

with acute pancreatitis. Which client problem is the
priority concern for the client?
l 1. Impaired nutrition.
l 2. Altered skin integrity.
l 3. Ineffective coping.
Page 275
Endocrine Disorders
275
70. Which laboratory data indicate the client's pancreatitis

is deteriorating?
l 1. The amylase and lipase serum levels are decreased.
l 2. The white blood cell count (WBC) is decreased.
l 3. The hematocrit has decreased by 5% in a 24-hour
period.
l 4. The blood urea nitrogen (BUN) serum level is
decreased.
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ANSWERS
69. Correct answer 4: The client with pancreatitis is in

excruciating pain because the enzymes are autodigesting the pancreas; severe abdominal pain is the
hallmark symptom of pancreatitis. ContentMedical;
Page 276
276
70. Correct answer 3: A 5% decrease in the hematocrit

level indicates the client is bleeding, probably from
the pancreatic enzymes eating into a blood vessel.
Hemorrhage indicates the client's condition is
deteriorating. Decreased amylase and lipase would
mean the client is improving. ContentMedical;
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277
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279
Osteoarthritis
1. The nurse is teaching clients at a community center
about the risk factors for developing osteoarthritis (OA).
Which is not a modifiable risk factor for developing OA?
l 1. Obesity.
l 2. Age.
l 3. Repetitive recreational use.
l 4. Joint pain.
2. Which signs and symptoms would the nurse assess in
the client diagnosed with osteoarthritis (OA)?
l 1. Severe bone deformity in the lower extremities.
l 2. Joint stiffness in the morning.
l 3. Enlarged joint space on x-rays.
l 4. Elevated temperature in the evening hours.
3. The client diagnosed with OA is a resident in a

long-term care facility. Which action by the unlicensed
assistive personnel (UAP) working with the client
warrants immediate intervention by the nurse?
l 1. The UAP allows the client to stay in bed and not
get up.
l 2. The UAP encourages the client to take a warm
shower.
l 3. The UAP performs passive range of motion on the
clients ankles.
l 4. The UAP assists the client to sit in the chair for
breakfast.
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ANSWERS
1. Correct answer 2: Obesity is a well-recognized risk

factor for the development of OA, and it is modifiable
in that the client can lose weight. The client can also
change the level of recreational activity. However, the
client cannot modify age. Pain is a symptom, not a
risk factor. ContentMedical; Category of Health
AlterationMusculoskeletal; Integrated Process
2. Correct answer 2: The classic symptoms of OA

include joint stiffness in the morning, pain, and
functional impairment. Severe bone deformity is seen
in clients diagnosed with rheumatoid arthritis (RA).
The joint space is narrowed on x-rays, but clients do
not have a temperature. ContentMedical; Category of
Health AlterationMusculoskeletal; Integrated Process
280
3. Correct answer 1: Clients with OA should be

encouraged to move, which will decrease the pain.
Encouraging movement gets the clients joints in
motion and will limit deformity and pain. The other
actions by the UAP are appropriate. ContentMedical;
Category of Health AlterationMusculoskeletal; Integrated
Application.
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SECTION SIX
4. The client who has been diagnosed with OA for 7 years

frequently uses over-the-counter (OTC) nonsteroidal
anti-inflammatory drugs (NSAIDs) for the pain. The
client is pale and short of breath. Which assessment
question should the nurse ask the client?
l 1. How long does the pain relief last after you take
the medicine?
l 2. Do you eat before taking the NSAID pain
medication?
l 3. Have you seen a rheumatologist for your
continuing pain?
l 4. Would you consider having someone to come in
and help around the house?
5. The nurse administered ibuprofen, an NSAID,
40 minutes ago to the client diagnosed with osteoarthritis.
Which interventions should the nurse implement at
this time?
l 1. Apply hot moist packs to the clients affected joints.
l 2. Encourage the client to ambulate in the hallway.
281
3. Teach the client how to take the NSAID
4. Assess the amount of relief achieved using a pain
medications safely.
scale.
6. The nurse is caring for clients diagnosed with OA in

a long-term care facility. Which equipment should the
nurse instruct the UAP to utilize when performing
activities of daily living (ADLs)?
l 1. The clients walking stick for ambulation.
l 2. Splint devices for feeding.
l 3. A shower chair for bathing the client.
l 4. A lap board over the clients wheelchair.
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ANSWERS
4. Correct answer 2: The client is experiencing

symptoms of anemia. NSAIDs can interfere with
prostaglandin production in the stomach and
predispose the client to ulcers, which can lead to
bleeding. Taking the medications with food helps to
prevent this. The nurse should assess how the client
takes the NSAIDs. ContentMedical; Category of
Health AlterationMusculoskeletal; Integrated
5. Correct answer 4: The nurse should evaluate any pain

as needed (PRN) medication administered within a reasonable time frame. Depending on the evaluation of the
effectiveness of the medication, the nurse might try hot
packs on the affected joints. Clients with osteoarthritis
should ambulate, but this is not evaluating the medication. ContentMedical; Category of Health Alteration
Musculoskeletal; Integrated ProcessAssessment; Client
Cognitive LevelImplementation.
282
6. Correct answer 3: The UAP should use a shower chair

for the safety of the client and UAP. The client should
use a walker or quad cane if needed, not a walking stick.
Lap boards are considered restraints. ContentMedical;
LevelApplication.
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SECTION SIX
7. The nurse is discussing the importance of an exercise

program for pain control with the client diagnosed with
OA. Which information should the nurse include in the
teaching plan? Select all that apply.
l 1. Wear supportive walking shoes with white socks
when walking.
l 2. Carry a complex carbohydrate while exercising.
l 3. Alternate walking briskly and jogging when
exercising.
l 4. Walk at least 2030 minutes every day.
l 5. Use a walker to ambulate if unsteady or weak.
8. The client diagnosed with OA asks the clinic nurse
Is there anything I can take to help treat my disease?
Which is the nurses best response?
l 1. No; nothing helps the disease once it has started.
l 2. Some clients use glucosamine and chondroitin.
l 3. You can take over-the-counter pain medications.
l 4. Daily exercise helps to decrease the pain and
stiffness.
283
9. The nurse is admitting the client with osteoarthritis to

the medical floor. Which statement by the client indicates
the client is using a complementary and alternative
medicine (CAM) form of treatment for OA?
l 1. I take ibuprofen every 46 hours for my pain.
l 2. I use a heating pad when my joints are stiff.
l 3. I wear my copper bracelet to help with my OA.
l 4. I always wear my ankle splints when I sleep.
10. The nurse is caring for the following clients. After
receiving the shift report, which client should the nurse
assess first?
l 1. The client who had a total knee replacement and is
complaining of pain.
l 2. The client who has a prophylactic antibiotic on call to
surgery.
l 3. The client diagnosed with back pain who is scheduled
for a laminectomy.
l 4. The client diagnosed with osteoarthritis who fell and
cannot move the leg.
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ANSWERS
7. Correct answer 1, 4, 5: Safety should always be

discussed when teaching about exercises; using a
walker and supportive shoes will prevent shin splints.
Colored socks have dye that may cause athletes feet;
that is why white socks are recommended. For
exercising to help control pain, the client must walk
daily. ContentMedical; Category of Health Alteration
Musculoskeletal; Integrated ProcessPlanning; Client
8. Correct answer 2: Glucosamine and chondroitin

improve tissue function and retard the breakdown of
cartilage. The client asked if there was something that
could be taken, not if there was something that could
be done to improve the disease. Over-the-counter
(OTC) pain medications do not treat the disease; they
simply alleviate the pain. ContentMedical; Category of
284
9. Correct answer 3: Alternative forms of treatment,

including wearing a copper bracelet, have no proven
efficacy in the treatment of a disease. The nurse
should be nonjudgmental and open to discussions
about alternative treatment unless it interferes with
the medical regimen. Medications and heating pads are
standard medical treatment. Ankle splints will not help
OA. ContentMedical; Category of Health Alteration
10. Correct answer 4: Inability to move the leg after a

fall indicates a possible fracture. The nurse should
assess this client first. Pain after surgery is expected.
Scheduled activities are not priority over a client
with an injury. ContentMedical; Category of Health
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285
Osteoporosis
11. The nurse is discussing osteoporosis with a group
of women. Which factor will the nurse identify as a
modifiable risk factor?
l 1. History of Crohn disease.
l 2. Tobacco use.
l 3. Being of childbearing age.
l 4. Lack of alcohol intake.
12. The client diagnosed with osteoporosis asks the nurse,
Why does lack of sun exposure cause my bones to be
brittle? Which response by the nurse would be most
appropriate?
l 1. Your body requires vitamin D from sunlight to use
the calcium you eat.
l 2. You can substitute vitamin C over-the-counter for
being out in the sun.
l 3. Calcium is produced by the sun when you are
exposed to sunlight.
l 4. Your bones need sunlight to become strong and
healthy.
13. The nurse is caring for clients in a long-term care

facility. Which signs/symptoms would make the nurse
suspect that a client has developed osteoporosis?
l 1. The elderly female client walks stooped over.
l 2. The elderly female client has lost 12 pounds in the
last year.
l 3. The elderly male clients hands are painful when
touched.
l 4. The elderly male clients serum uric acid level is
elevated.
14. The client is being evaluated for osteoporosis. Which
diagnostic test is the most accurate?
l 1. X-ray of the chest.
l 2. Serum alkaline phosphatase.
l 3. Dual-energy x-ray absorptiometry (DEXA).
l 4. Serum bone Gla-protein test.
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ANSWERS
11. Correct answer 2: Smoking is a modifiable risk factor

for developing osteoporosis, as is not participating
in weight-bearing exercises, alcohol consumption,
and lack of exposure to sunlight. Nicotine slows the
production of osteoblasts and impairs the absorption
of calcium, contributing to decreased bone density.
Malabsorption syndrome is a non-modifiable risk
factor, as is being of childbearing age. ContentMedical;
12. Correct answer 1: Vitamin D is required for the body

to be able to absorb calcium from foods consumed,
and an adequate intake of calcium is essential for bone
health. Vitamin C is not a substitute for vitamin D.
286
13. Correct answer 1: Osteoporosis is most common

in postmenopausal women. As the vertebrae lose
calcium, the client loses height and begins to walk
stooped over. A loss of height occurs as vertebral
bodies collapse. ContentMedical; Category of Health
Assessment; Client NeedsSafe Effective Care
Environment, Health Promotion and Maintenance;
14. Correct answer 3: The DEXA test measures bone

density in the lumbar spine or hip and is considered to
be highly accurate. Chest x-rays are most useful in
diagnosing lung problems. Serum alkaline phosphatase
serum blood studies are elevated after a fracture. The
serum bone Gla-protein test is most useful to evaluate
the effects of treatment of osteoporosis rather than as
an indicator of the severity of bone disease. Content
Medical; Category of Health AlterationMusculoskeletal;
LevelAnalysis.
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15. The nurse knows the client diagnosed with osteoporosis

understands the dietary teaching when the client makes
which menu selection?
l 1. Oatmeal with brown sugar, bacon, and orange
juice.
l 2. French toast with maple syrup, sausage, and coffee.
l 3. Whole wheat toast, poached eggs, and a diet cola.
l 4. Cold cereal with milk, yogurt, and decaffeinated
coffee.
16. The gynecological clinic nurse is caring for
postmenopausal clients. Which intervention is an
example of a primary nursing intervention when
discussing osteoporosis?
l 1. Obtain a bone density evaluation test.
l 2. Perform non-weight-bearing exercises regularly.
l 3. Increase the intake of dietary calcium.
l 4. Tell the client to limit smoking to one pack
per day.
287
17. The female client diagnosed with osteoporosis tells

the nurse that she is going to try to exercise regularly.
Which exercise should the nurse recommend?
l 1. Walk 30 minutes a day.
l 2. Swim several laps every day.
l 3. Perform isometric exercise every other day.
l 4. Passive range-of-motion exercises weekly.
18. The nurse is teaching a class to pregnant teenagers.
Which information is most important when discussing
ways to prevent osteoporosis later in life?
l 1. Perform pelvic stretching exercises twice a day.
l 2. Eat foods low in calcium and high in phosphorus.
l 3. Take at least 1200 mg of calcium supplements a day.
l 4. Remain as active as possible until the baby is born.
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ANSWERS
15. Correct answer 4: The best dietary sources of calcium,

which is needed for those with osteoporosis, are
milk, other daily products, yogurt, oysters, canned
sardines or salmon, beans, cauliflower, and dark
green leafy vegetables. ContentMedical; Category
of Health AlterationMusculoskeletal; Integrated
LevelSynthesis.
16. Correct answer 3: Primary nursing interventions are

aimed at prevention of the problem. Increasing
dietary calcium is a primary intervention to help
prevent osteoporosis or tertiary intervention that
helps treat osteoporosis. The client should perform
weight-bearing exercises and stop smoking
completely. ContentMedical; Category of Health
288
17. Correct answer 1: Weight-bearing activity, such as

walking, is beneficial in preventing or slowing
bone loss; the mechanical force of weight-bearing
exercises promotes bone growth. Swimming is not
as beneficial in maintaining bone density because of
the lack of weight-bearing activity. Isometric exercises
are for body building, and passive exercise requires
no effort by the client. ContentMedical; Category
18. Correct answer 3: The National Institutes of Health

recommend a daily calcium intake of 12001500 mg
per day for adolescents and young adults as well as
for pregnant and lactating women. Taking calcium
throughout the life span will help prevent osteoporosis.
Activity will not help prevent osteoporosis in the
teenager. ContentMedical; Category of Health
AlterationMusculoskeletal; Integrated ProcessPlanning;
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SECTION SIX
Herniated Disc Disease/Low
Back Pain
19. The 84-year-old client is a resident in a long-term

care facility. Which interventions should the nurse
implement to prevent complications secondary to
osteoporosis?
l 1. Administer 1 oz. of Maalox daily.
l 2. Perform passive range-of-motion exercises.
l 3. Turn the client every 2 hours.
l 4. Use a gait belt when ambulating the client.
20. The client is prescribed 3 g of calcium supplement a
day. The medication comes in 600 mg/tablet with added
vitamin D. How many tablets should the client take
daily?
Answer: ____________________
21. The clinic nurse is caring for an elderly client

diagnosed with lower back pain and possible ruptured
disc. Which discharge instructions should the nurse
teach the client?
l 1. When lifting heavy objects, hold them near
the body.
l 2. Perform lower-back strengthening exercises.
l 3. Use an antidiarrheal medication when taking
narcotics.
l 4. Return to the office to demonstrate the Cred
maneuver for voiding.
289
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ANSWERS
19. Correct answer 4: Gait belts will help prevent

the client from falling; fractures are the primary
complication of osteoporosis. Maalox does not treat
osteoporosis. ContentMedical; Category of Health
20. Correct answer 5 tablets: 1000 mg = 1 g; therefore,
3 g = 3000 mg; 1 tablet is 600 mg, so the client

will need 5 tablets to get the total amount of
calcium needed daily; 3000 mg 600 mg = 5 tablets.
Drug Administration; Integrated ProcessImplementation;
290
21. Correct answer 2: The client should be taught

exercises to strengthen the lower back muscles.
Clients with a possible ruptured disc should not be
lifting heavy objects. The Cred maneuver is for
clients with a neurogenic bladder; the client voids
because a rolling pressure is applied to the lower
abdomen. The client taking codeine is at risk for
developing constipation; antidiarrheals should not be
taken prophylactically. ContentMedical; Category of
LevelApplication.
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22. The 34-year-old male client presents to the

outpatient clinic complaining of numbness and pain
radiating down his left leg. Which intervention should
l 1. Ask the client to stand up and walk away from the
nurse.
l 2. Tell the client to bend over at the waist and stoop
to pick up a pencil.
l 3. Have the client lie down and lift his legs one at a
time into the air.
l 4. Request the client to twist from the waist and neck
to assess for mobility.
23. The employee health nurse in a hospital is preparing
an in-service for a group of nursing staff members. Which
statement provides information the nurse should teach
the staff members?
l 1. Back pain is caused when the discs between the
vertebrae dry out.
l 2. Always get assistance when lifting or turning a
large client.
3. Try not to use lifting devices because they can
4. Workers compensation will cover your living
291
weaken your back muscles.

expenses for on-the-job injuries.
24. The occupational health nurse is planning health

promotion activities for a group of factory workers.
Which activity is an example of primary prevention of
low back pain?
l 1. Provide instructions on how to complete incident
reports.
l 2. Arrange a pot-luck lunch program for the staff.
l 3. Administer a non-narcotic analgesic to a worker
complaining of back pain.
l 4. Teach proper use of body mechanics to all workers.
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ANSWERS
22. Correct answer 1: Posture and gait will be affected

if the client is experiencing sciatica, pain radiating
down a leg resulting from pressure on the sciatic
nerve. The client with pain and numbness would not
be able to bend or stoop and should not be asked to
do so. ContentMedical; Category of Health Alteration
23. Correct answer 2: This is a case of always being the

correct answer. The nurse should protect both the
staffs and the clients safety by getting lift assistance
before attempting to lift a heavy client. A back injury
can result in a permanent disability. Workers compensation covers part of the lost wages. There is no guarantee that it will cover all the nurses living expenses.
NeedsSafe Effective Care Environment, Safety and
Infection Control; Cognitive LevelApplication.
292
24. Correct answer 4: Primary interventions are

concentrated on preventing an illness or injury.
Teaching proper body mechanics will help prevent
low back pain. None of the other options will
prevent back pain. ContentMedical; Category of
LevelSynthesis.
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SECTION SIX

cervical neck injury. The client complained of pain of a
3 on a 1-to-10 pain scale, and the nurse positioned the
client and turned on the radio. After 25 minutes, the
client states the pain is still at a 3. Which intervention
should the nurse implement next?
l 1. Tell the client to wait a while to see if positioning
will work.
l 2. Obtain a heating pad for the client to use on
the neck.
l 3. Administer acetaminophen (Tylenol) ES, a
non-narcotic analgesic.
l 4. Prepare to administer morphine sulfate, a narcotic
analgesic.
26. The client diagnosed with cervical neck disc
degeneration has undergone a laminectomy. Which
apply.
l 1. Position the client supine with the head on a small
pillow.
l 2. Assess the client for difficulty speaking or breathing.
3. Measure the drainage in the Jackson-Pratt bulb
4. Encourage the family to give patient-controlled
5. Log-roll the client every 46 hours and prn.
293
every 8 hours.
analgesia (PCA) when needed.
27. The client is 12-hours post lumbar disc and fusion.

l 1. Place the client on a regular bedpan for voiding.
l 2. Keep the bed in the Trendelenburg position.
l 3. Place sand bags on each side of the head.
l 4. Administer subcutaneous anticoagulants.
28. The nurse is working with a UAP. Which nursing
task should the nurse not delegate to the UAP?
l 1. Feed a client 2 days postoperative for a cervical
laminectomy a regular diet.
l 2. Help a client who is 12-hours post lumbar
laminectomy sit on the side of the bed.
l 3. Assist the obese client diagnosed with back pain to
the bedside commode.
l 4. Place the call light within reach of the client who
has had surgery.
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ANSWERS
25. Correct answer 3: The clients pain is at a level 3,

indicating mild pain. The nurse should administer
Tylenol. ContentMedical; Category of Health
26. Correct answer 1, 2, 3: The client should be positioned supine with a very small pillow. Difficulty
speaking or breathing would indicate a potentially
life-threatening problem. The surgical position of the
wound places the client at risk for edema in the neck.
The drainage should be measured every shift. Only
the client pushes the PCA button. Turning is every
2 hours, not every 46 hours. ContentSurgical;
ProcessPlanning; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
294
27. Correct answer 4: Prophylactic anticoagulants

are prescribed to prevent deep vein thrombosis.
The client should use a fracture pan for voiding. The
bed in not kept head down in the Trendelenburg
position. The client had a lumbar procedure, not a
cervical procedure, so sand bags on each side of the
head are not required. ContentSurgical; Category of
28. Correct answer 2: This client should not be up until

the surgeon writes the order. At 12 hours the client
is still being log-rolled. The other options can be
delegated to a UAP. ContentMedical; Category of
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SECTION SIX
29. The charge nurse is caring for clients on an orthopedic

floor. Which client should be assigned to the most
experienced nurse?
l 1. The client diagnosed with back pain who is
complaining of a 4 on a 110 pain scale.
l 2. The client who has undergone a myelogram and
who is complaining of a slight headache.
l 3. The client who is 2 days postoperative disc and
fusion who has a T 100.4F, P 96, R 24, and
BP 138/78.
l 4. The client with back pain who is angry that he has
not gotten his pain medication.
30. The nurse is administering medications at 0730 to
clients on a medical orthopedic unit. Which medication
should be administered first?
l 1. The ACE inhibitor to a client diagnosed with
back pain and hypertension.
l 2. The heparin bag on a client diagnosed with
pulmonary embolus.
3. The oral proton pump inhibitor to a client
4. The IV antibiotic for a client diagnosed with a
295
scheduled for a laminectomy this morning.

postsurgical infection.
Fractures
31. The client is admitted to the emergency department
with an injury to the left leg. Which action should the
l 1. Assess the clients left dorsalis pedis pulse.
l 2. Elevate the left extremity on two pillows.
l 3. Call Radiology for a stat x-ray of the extremity.
l 4. Ask the client how the injury occurred.
32. Which intervention should the nurse perform for the
client diagnosed with a closed fracture of the left ankle?
l 1. Apply an immobilizer snuggly to prevent edema.
l 2. Apply a covered ice pack to the left ankle.
l 3. Place the extremity in the dependent position.
l 4. Administer tetanus 0.5 mL intramuscular (IM) in
the clients upper arm.
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ANSWERS
29. Correct answer 3: This client is postoperative and

now has a fever, possibly indicating an infection,
and should be assigned to the most experienced
nurse. The patient with pain rated as 4 has mild-tomoderate pain, and an angry patient can be assigned
to a less experienced nurse. The patient with a
headache following a myelogram can also be cared
for by a less experienced nurse. ContentMedical;
Category of Health AlterationMusculoskeletal;
30. Correct answer 2: Heparin has a short half-life, and

the infusion must be maintained at a continuous rate
to remain therapeutic. ContentMedical; Category of
LevelApplication.
296
31. Correct answer 1: The nurse should first assess

the foot for any neurovascular compromise before
taking any further action. Elevating the extremity
to decrease edema, obtaining an x-ray, and asking
how the injury occurred should be implemented but
not before assessing the extremity. ContentMedical;
32. Correct answer 2: Ice packs should be applied to

cause vasoconstriction to help decrease edema; ice
is a nonpharmacological pain management technique.
An immobilizer should not be applied snuggly because
it will impair circulation to the extremity; the leg
should be elevated; and tetanus is administered with
open fractures or wounds, not with closed fractures.
ContentMedical; Category of AlterationMusculoskeletal;
Physiological Integrity, Basic Care and Comfort;
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SECTION SIX
33. The nurse is caring for a client with a fractured left

tibia and fibula. Which data should the nurse report to
the health-care provider (HCP) immediately?
l 1. Ecchymosis of the left lower extremity.
l 2. Deep unrelenting pain of the left leg.
l 3. Capillary refill time of 2 seconds of the toes.
l 4. The left foot has a 2+ dorsalis pedal pulse.
34. The client with a fractured right femur is exhibiting
dyspnea, has adventitious breath sounds, and has
petechiae over the chest area. Which intervention
l 1. Assess the clients right leg for movement.
l 2. Obtain the clients arterial blood gases.
l 3. Notify the clients HCP immediately.
l 4. Encourage the client to cough and deep breathe.
297
35. The 85-year-old client admitted with a diagnosis of a

right fractured hip is in Buck traction and is complaining
of pain of 8 on a 110 pain scale. Which action should
the nurse take first?
l 1. Check the clients medication administration
record (MAR) to determine the last time pain
medication was administered.
l 2. Ensure that the weights of the Buck traction are off
the floor and hanging freely.
l 3. Administer the prn intravenous narcotic analgesic
diluted over 5 minutes.
l 4. Insert an abductor pillow securely between the
clients legs with two leg straps.
36. The nurse is discussing cast care with the parents of a
12-year-old male client with a fractured humerus. Which
statement indicates the mother understands the teaching?
l 1. I will keep my sons arm level with his chest.
l 2. There may be some hot areas on his cast.
l 3. If he complains of itching I will apply ice
to the cast.
l 4. After time the cast will probably start smelling.
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ANSWERS
33. Correct answer 2: Deep unrelenting pain may

indicate compartment syndrome, which is a
complication of a fracture and requires immediate
attention. Ecchymosis (bruising), capillary refill time
less than 3 seconds, and 2+ pedal pulse are all
normal data. ContentMedical; Category of Health
Evaluation; Client NeedsSafe Effective Care
LevelSynthesis.
34. Correct answer 3: These symptoms indicate a fat

embolism, which is a life-threatening emergency;
therefore, the HCP should be notified. The other
interventions will not treat a fat embolism. Content
298
35. Correct answer 2: Weights from traction should be

off the floor and hanging freely. Buck traction is
used to reduce muscle spasms preoperatively in
clients who have fractured hips; therefore, this
intervention should be implemented first to see
if the weights need adjustment. If the weights
are adjusted, determine if this relieves the pain,
before medicating an elderly client with a narcotic
analgesic. ContentMedical; Category of Alteration
Musculoskeletal; Integrated ProcessEvaluation; Client
36. Correct answer 3: Applying ice packs to the cast

will help relieve itching. Nothing should be placed
down a cast to scratch because the skin may be torn
easily, resulting in an infection. The arm should be
elevated above the chest. Hot areas and an odor may
indicate an infection. ContentMedical; Category of
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SECTION SIX

fracture of the distal right humerus. Which data should
the nurse assess? Select all that apply.
l 1. Ask the client if there is any tingling in the extremity.
l 2. Assess the clients brachial and radial pulses.
l 3. Check the clients pulse oximeter reading bilaterally.
l 4. Evaluate for point tenderness and crepitus.
l 5. Determine if the client can move the fingers of the
right hand.
38. An 88-year-old-client is admitted to the orthopedic
floor with the diagnosis of fractured pelvis. Which
assessment data would warrant immediate intervention?
l 1. The client has clear-colored, amber urine in the
indwelling catheter.
l 2. The client is complaining of pain in the lower
abdominal area.
l 3. The clients bowel sounds in all four quadrants are
hypoactive.
l 4. The clients lower extremities are warm and pink
bilaterally.
299
39. The orthopedic nurse is admitting a female client

with a compound fracture of the right fibula. Which
l 1. Prepare the client for insertion of skeletal traction.
l 2. Complete the clients preoperative checklist.
l 3. Discuss purchasing a wheelchair for mobility.
l 4. Place the client in a continuous passive motion
(CPM) machine.
40. The nurse is working on an orthopedic unit. Which
client should the nurse assess first after receiving the
morning shift report?
l 1. The client with a compound fracture of the fibula
who will not use the incentive spirometer.
l 2. The client with a fractured left humerus who
denies tingling and numbness of the fingers.
l 3. The client with a fractured right ankle that is
edematous and has ecchymotic areas.
l 4. The client with a fractured left femur who is
having chest pain and shortness of breath.
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ANSWERS
37. Correct answer 1, 2, 4, 5: The nurse should assess

for paresthesia, paralysis, pulses, point tenderness,
and crepitus, with the arm handled gently. The
clients peripheral oxygen level does not need to be
assessed. The clients capillary refill could be assessed.
38. Correct answer 3: Decreasing bowel sounds

could indicate a possible ileus, which is a common
complication of a fractured pelvis. Clear-colored urine,
pain, and warm extremities would be expected.
300
39. Correct answer 2: The client will be scheduled for

surgery; therefore, completing the preoperative check
list would be appropriate. The client would not have
skeletal traction or a CPM machine, which is used
for knee replacement, and a client with a fracture of
the arm would not need a wheelchair.
Musculoskeletal; Integrated ProcessImplementation;
40. Correct answer 4: Chest pain and shortness of

breath may indicate a fat embolus, which is a lifethreatening emergency; therefore, this client should
be assessed first. Not using the incentive spirometer,
edema, and ecchymosis are not life-threatening. No
paresthesia is a normal finding. ContentMedical;
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301
Amputation
41. The nurse is caring for a client who had a right
below-the-knee amputation (BKA) 2 days ago. Which
l 1. Keep the residual limb elevated on two pillows.
l 2. Place the client in the prone position frequently.
l 3. Put the prosthetic limb on when ambulating the
client.
l 4. Maintain the clients right leg in Buck traction.
42. The recovery room nurse is caring for a client who
has just had a left BKA. The clients surgical dressing is
saturated with blood, the apical pulse is elevated, and the
blood pressure is decreased. Which intervention should
l 1. Notify the clients surgeon immediately.
l 2. Place the client in the Trendelenburg position.
l 3. Place a large tourniquet proximal to the surgical
dressing.
l 4. Reinforce the surgical dressing with 4 4 gauze.
43. The 62-year-old client diagnosed with type 2

angiocatheter who has a gangrenous right toe is being admitted for a BKA amputation. Which intervention
l 1. Refer the client to the certified diabetic educator
(CDE).
l 2. Check the clients right pedal pulse.
l 3. Determine if the client is allergic to intravenous
(IV) dye.
l 4. Start an 18-gauge angiocatheter in the upper
extremity.
44. The male nurse is helping his friend Joe cut wood
with an electric saw. Joe accidently cut two fingers off his
right hand with the electric saw. Which action should the
nurse take first?
l 1. Wrap the right hand with towels and apply
pressure.
l 2. Instruct Joe to hold the right hand above his head.
l 3. Recover Joes two fingers if at all possible.
l 4. Drive Joe to the nearest emergency room.
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ANSWERS
41. Correct answer 2: The prone position will help
302
43. Correct answer 4: The nurse should start an 18-gauge
stretch the hamstring muscle, which will help prevent

flexion contractures that may lead to problems when
fitting the client for a prosthetic limb. The residual
limb should be elevated for 24 hours only, and the
client will not be fitted for a prosthetic limb until
46 weeks after surgery. ContentSurgical; Category of
angiocatheter because the client is having surgery and

may need to have blood products. This is not the appropriate time to refer the client to the CDE. The
clients right foot is being amputated, so there is no
reason to assess the right pedal pulse. Intravenous dye
is not used during this surgical procedure. Content

Application.
Surgical; Category of Health AlterationMusculoskeletal;

Effective Care Environment, Management of Care; Cognitive LevelApplication.
42. Correct answer 3: The client is hemorrhaging, and the

bleeding must be stopped first; placing a tourniquet
above the dressing will stop the arterial bleeding. Then
the nurse should notify the surgeon, reinforce the surgical dressing, and place the client in the Trendelenburg position. ContentSurgical; Category of Health
LevelSynthesis.
44. Correct answer 1: Applying pressure will help

decrease the bleeding, which is the first intervention.
Then have Joe elevate his right hand to further
decrease the bleeding, recover the amputated parts,
and get Joe to the emergency department. Content
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SECTION SIX
45. A man accidentally cut off his right big toe with
an axe. The mans wife is a nurse. Which action should
the nurse implement to preserve the big toe so that it
could possibly be reattached in surgery?
l 1. Place the right toe in a bowl with crushed ice cubes.
l 2. Take no action because the toe cannot be reattached.
l 3. Secure the toe in a plastic bag and bring it to the
hospital.
l 4. Put the toe in a clean piece of material and place
on ice.
46. The Jewish client with peripheral vascular disease is
scheduled for a left above the knee amputation (AKA).
Which information should the nurse obtain during the
admission interview?
l 1. Ask the client if the local rabbi has blessed the
left leg.
l 2. Determine if the client will accept any blood
products.
l 3. Ask if the client has seen the occupational
therapist (OT).
l 4. Determine if the client has arrangements for the
amputated limb.
303
47. The female client is 3 hours postoperative left AKA.

The client tells the nurse, My left foot is killing me.
Please do something. Which action by the licensed
practical nurse (LPN) would require intervention by
the RN?
l 1. The LPN tells the client that her left leg has been
amputated and that she cannot be in pain.
l 2. The LPN checks the MAR and medicates the
client with a narcotic analgesic.
l 3. The LPN checks the clients vital signs and the
surgical dressing for bleeding.
l 4. The LPN readjusts the residual limb and ensures it
is elevated on two pillows.
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ANSWERS
304
45. Correct answer 4: Placing the big toe in material and
47. Correct answer 1: Phantom pain is caused by severing
placing it on ice will help preserve it so that it may be

reconnected in surgery. The toe should not be placed
directly on ice because this will cause necrosis of
viable tissue. A surgeon will attempt to reattach a toe,
but not an entire leg. ContentSurgical; Category of
the peripheral nerves, and the pain is real to the client.

The RN must intervene when the LPN makes this
statement to the client. The nurse needs to medicate
the client immediately. Checking for complications,
medicating the client, and elevating the residual limb
are appropriate interventions. ContentSurgical;

Analysis.
46. Correct answer 4: Judaism believes that all body parts

must be buried together; therefore, many synagogues
will keep amputated limbs until death occurs. Rabbis
do not bless legs; blood product administration is
addressed on the operative permit; and OTs address
upper extremity amputation, not lower extremity
amputations. ContentSurgical; Category of Health
AlterationMusculoskeletal; Integrated ProcessPlanning;

Analysis.
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SECTION SIX
48. The nurse is caring for clients on a surgical unit.

Which nursing task would be appropriate for the nurse
l 1. Tell the UAP to assist the lower-extremity amputee
to ambulate down the hall.
l 2. Ask the UAP to take vital signs on a client who is
exhibiting signs of hypovolemia.
l 3. Request the UAP to change the dressing on the
client with a Syme amputation.
l 4. Instruct the UAP to obtain the height and weight
on a newly admitted client.
49. The client in the rehabilitation unit who is 1 week
postoperative right AKA is being taught how to prepare
the residual limb for a prosthetic device. Which
intervention should the nurse implement? Select all
that apply.
l 1. Instruct the client to push the residual limb against
a pillow.
l 2. Demonstrate how to apply an Ace bandage around
the residual limb.
305
3. Encourage the client to apply vitamin B12 to the
4. Tell the client to press the residual limb against a
5. Explain the importance of wearing a limb sock
surgical incision.
hard surface.
under the prosthesis.
50. The 27-year-old client has a right above the elbow

amputation secondary to a motor vehicle accident. Which
statement by the client indicates to the nurse the client
has accepted the amputation?
l 1. I am going to the vocational therapist to get
assistance with job retraining.
l 2. I know I will never be able to use my left arm to
write, eat, or brush my teeth.
l 3. I keep waking up at night and thinking this could
not have happened to me.
l 4. If I could just get my arm back I would be the
best person I could be.
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ANSWERS
48. Correct answer 4: The UAP can obtain height and

weight on a client who is stable. The amputee client
should ambulate with the nurse or physical therapist
only. The UAP cannot care for clients who are
unstable, such as one exhibiting signs of hypovolemia,
and cannot change surgical dressings. ContentSurgical;
Synthesis.
49. Correct answer 1, 2, 4, 5: Applying pressure against

a pillow will help toughen the limb, and then pushing
gradually against a harder surface will help prepare it
for a prosthesis. An Ace bandage applied distal to
proximal will help decrease edema and help shape the
residual limb into a conical shape for the prosthesis. A
limb sock should be worn to help prevent irritation to
the residual limb. Vitamin B12 will help decrease the
angriness of the scar, but it will not help with residual
limb toughening. ContentSurgical; Category of Health
306

50. Correct answer 1: Looking toward the future and

problem solving indicate that the client is accepting
the loss. Negative thinking, depression, denial, and
bargaining indicate the client is not accepting the
loss. ContentSurgical; Category of Health Alteration
Musculoskeletal; Integrated ProcessEvaluation; Client
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307
Joint Replacements
51. The nurse is caring for a client 3 days postoperative
total knee replacement (TKR) of the left knee. Which
l 1. Keep abduction pillow in place between the legs at
all times.
l 2. Place knee-high hose on the client to keep the
feet warm.
l 3. Feed the client in a semi-Fowler position.
l 4. Obtain a high-seated bedside commode for the
client to use.
52. The male client 4 days postoperative right total hip
replacement (THR) tells the nurse he heard a
popping sound when he was turned by the UAP.
Which question should the nurse ask the client?
l 1. Did the UAP keep you covered while turning you?
l 2. When did you notice the popping sound?
l 3. Do you have any groin pain on the right side?
l 4. Is the swelling at the incision site larger than
before?
53. The nurse is preparing the client who received a

THR for discharge. Which statement indicates the client
understands the discharge teaching?
l 1. I should not cross my legs to prevent the hip from
coming out of the socket.
l 2. I may expect a sudden increase in pain when I try
new activities.
l 3. I can sit in my soft, cushiony recliner when
I get home.
l 4. After 3 weeks, I dont have to worry about
infection.
54. When assessing the wound of a client who had a
THR, the nurse finds small, fluid-filled lesions along the
side of the dressing. Which intervention should the nurse
implement?
l 1. Notify the surgeon immediately.
l 2. Place the client in contact isolation.
l 3. Obtain a nonallergenic tape to use.
l 4. Use nonlatex gloves to change the dressing.
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ANSWERS
51. Correct answer 4: Using a high-seated bedside

commode and chair will help the client to be able to
sit down and rise up without placing pressure on the
knee. The abduction pillow is used for hip surgery.
The client may sit upright as tolerated. Nonskid
booties may be used. ContentSurgical; Category of
Application.
52. Correct answer 3: Groin pain or increasing discomfort in the affected leg and the popping sound
indicate that the leg is dislocated and should be
reported immediately to the physician. Protecting
the clients modesty is good but not important at
this time. The client told the nurse when he heard
the popping sound. The nurse should not ask the
client to assess himself. ContentSurgical; Category
of Health AlterationMusculoskeletal; Integrated Process
308
53. Correct answer 1: Clients should not cross their legs

because that position increases the risk for dislocation.
If the client experiences a sudden increase in pain in
the joint or surrounding area, the client should notify
the HCP. Clients should sit in chairs with firm seats
and high arms. These will decrease the risk of
dislocating the hip joint. Infections are possible
months after surgery. ContentSurgical; Category of
54. Correct answer 3: The small fluid-filled lesions are

mostly likely due to the tape used to adhere the
dressing. The nurse should change the type of tape
being applied to the clients skin. ContentSurgical;
Synthesis.
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309
55. Which interventions should the nurse include in the

discharge teaching for the client after having a THR?
l 1. Inform the client not to bear weight on the
affected side.
l 2. Demonstrate how to use a walker.
l 3. Attempt to resume normal activity on returning
home.
l 4. Instruct the client to use the pain medication when
the pain is at an 8 on a 110 scale.
l 5. Discuss planning for periods of rest.
57. The female client postoperative TKR asks the nurse

They did surgery on my knee, so why do I have tiny
bruises on my upper abdomen? Which intervention
l 1. Inform the client that the small bruises are from a
medication.
l 2. Check the MAR for parenteral anticoagulant
medication orders.
l 3. Report the data to the HCP on rounds.
l 4. Assess the clients abdomen and document the
finding in the chart.
56. The nurse is caring for a client 6 hours post right

TKR. Which data warrant immediate intervention
by the nurse?
l 1. 100 mL of red drainage in the auto-transfusion
drainage system.
l 2. The client falls asleep after using the patient-control
analgesia (PCA) pump.
l 3. Cool toes, absent pulses, and pale nailbeds on the
operative side.
l 4. Urinary output of 120 mL of clear yellow urine in
3 hours.
58. The nurse is caring for a client who had a TKR

2 days ago. Which is an expected client goal?
l 1. The client will ask for pain medication every
4 hours.
l 2. The client will attend a smoking cessation support
group.
l 3. The client will be turned every 2 hours.
l 4. The client will be able to ambulate with a walker.
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ANSWERS
55. Correct answer 2, 5: Clients are allowed to bear

weight but need to understand the level of weight
bearing they can tolerate without causing injury.
Teaching the safe use of assistive devices, such as a
walker, is necessary prior to discharge. The client
should be encouraged to rest periodically to promote
healing and energy. Increases in activity should occur
slowly to prevent complications. The client should not
wait to take pain medication until the pain is at 8.
56. Correct answer 3: The absence of pulses and a cool

extremity with pale nailbeds indicate circulatory compromise. The nurse must intervene. Drainage in the
first 24 hours can be expected to be 200400 mL,
so 100 mL in 6 hours is not abnormal. Sleeping after
using PCA is common. The urinary output is adequate. ContentSurgical; Category of Health Alteration
310

57. Correct answer 2: Many clients receive subcutaneous

anticoagulant medications, such as Lovenox, after
orthopedic surgery. The nurse should first determine
if the client is receiving this medication. This medication
could cause the tiny bruises on the upper abdomen.
58. Correct answer 4: The client should be ambulating

with assistance for short distances by 2 days post surgery. The client should ask for pain medication when
needed, not on a regimented time schedule. The client
being turned is a nursing goal, not a client goal. Smoking cessation is a good goal, but it is not specific to a
client who has had a TKR 2 days ago. ContentSurgical;
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311
Management
59. The nurse is caring for a client postoperative right
THR. Which assessment data warrant immediate
intervention by the nurse?
l 1. Temp 99F, HR 80, RR 20, and B/P 128/76.
l 2. Pain in the left leg during dorsiflexion of the ankle.
l 3. Bowel sounds heard intermittently in four
quadrants.
l 4. Pain in the right hip when turning.
60. The nurse is working on an orthopedic floor. Which
client should the nurse assess first after change of shift
report?
l 1. The 84-year-old female in Buck traction for a
fractured femur.
l 2. The 64-year-old female postoperative TKR who is
now confused.
l 3. The 88-year-old male who had a right THR who
has an abduction pillow.
l 4. The 50-year-old post TKR who has a CPM device.
61. The nurse is working in an orthopedic department.

l 1. The client with an open reduction and internal
fixation (ORIF) of the right hip who needs to be
removed from Buck traction.
l 2. The client with a total knee repair who is using a
CPM machine when lying in the bed.
l 3. The client with an L3L4 laminectomy who will
not allow the UAP to turn the client using the
log-rolling method.
l 4. The client who is being admitted to the orthopedic
department from the emergency department (ED).
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ANSWERS
59. Correct answer 2: Pain with dorsiflexion of the

ankle indicates deep vein thrombosis. The vital signs
are within normal limits. Bowel sounds are normally
intermittent. Pain at the operative site with movement is normal. ContentSurgical; Category of Health
60. Correct answer 2: This is an abnormal occurrence

from the information given. This client should
be seen first because confusion is a symptom of
hypoxia. Buck traction is expected for a fractured
femur. An abduction pillow is expected for a THR.
Continuous passive motion is an expected treatment
on an orthopedic unit. ContentMedical; Category
LevelSynthesis.
312
61. Correct answer 4: The client from the ED needs to

be assessed first to determine the needs of the client.
The client with a laminectomy needs to be log-rolled
to prevent injury to the surgical incision but not
before a new admission is assessed. The postoperative
ORIF client would not have Buck traction, and the
client with TKR should be on the CPM machine.
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SECTION SIX
62. The nurse is unable to assess the pedal pulse on a

client who had a right THR. The clients foot is cool, but
the client is able to move the toes. Which intervention
l 1. Place the abductor pillow between the clients legs.
l 2. Utilize the Doppler to auscultate the right pedal
pulse.
l 3. Elevate the clients right leg on two pillows.
l 4. Wrap the clients right leg in a warm blanket.
clients on the orthopedic unit. Which medication should
the nurse administer first?
l 1. The NSAID to the client diagnosed with
osteoarthritis.
l 2. The narcotic analgesic to the client with a BKA.
l 3. The intravenous antibiotic to the client with a TKR.
l 4. The biphosphonate to the client diagnosed with
osteoporosis.
313
64. Which client should the charge nurse on the

orthopedic unit assess first after receiving the morning
shift report?
l 1. The client with a right BKA who has a hemoglobin
and hematocrit (H&H) of 12/42.
l 2. The client with rheumatoid arthritis who has a
positive rheumatoid factor (RF).
l 3. The client with compound fracture of the right
ulna who has a white blood cell (WBC) count of
14,000.
l 4. The client with osteoarthritis who has an
erythrocyte sedimentation rate (ESR) of 18 mm/hr.
65. The UAP tells the nurse the client with a right AKA
has a large amount of bright red blood on the right leg
residual limb. Which action should the nurse take first?
l 1. Assess the clients residual limb dressing.
l 3. Place a large tourniquet proximal to the dressing.
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ANSWERS
62. Correct answer 2: To identify the location of the

pulse, the nurse should use a Doppler device to
amplify the sound first as the client is able to move
the toes. Using an abductor pillow and elevating or
wrapping the leg will not help the nurse assess the
pedal pulse. The nurse should place an X when the
pulse is heard. ContentMedical; Category of Health
63. Correct answer 2: The client in postoperative pain
Page 314
314
64. Correct answer 3: The client with a compound fracture should not have an infection, which a WBC
of 14,000 indicates; this client requires immediate
intervention. The H&H and ESR are within normal
limits, and a client with rheumatoid arthritis would
have a positive RF. ContentMedical; Category of
65. Correct answer 1: Because the UAP is informing
should receive the prn narcotic analgesic first. Pain is

priority over routine medications such as NSAIDs,
antibiotics, or a monthly medication for osteoporosis.
the nurse of pertinent information, the nurse should

assess the client to determine which action to take.
All the other interventions could be implemented
after the nurse assesses the client. ContentSurgical;

Category of Health AlterationMusculoskeletal; Integrated ProcessAssessment; Client NeedsPhysiological

LevelSynthesis.
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SECTION SIX
66. The nurse and a UAP are caring for clients in the
rehabilitation unit. Which action by the UAP warrants
immediate intervention?
l 1. The UAP calls for assistance when taking a client
to the shower.
l 2. The UAP is assisting the client who weighs 70 kg
to the bedside commode.
l 3. The UAP places the call light within reach of the
client who is sitting in the chair.
l 4. The UAP ties a sheet around the client who keeps
slipping out of the chair.
67. The charge nurse on the busy 36-bed orthopedic
unit must send one staff member to the ED. Which
staff member would be the most appropriate staff member
to send?
l 1. The RN who has worked on the orthopedic unit
for 5 years.
l 2. The RN who has worked on many medical units
over the last 8 years.
315
3. The graduate nurse who is completing the hospital
4. The RN who transferred from the surgical unit to
orientation.
the orthopedic unit.
68. The client who is scheduled for a L3L4 laminectomy

tells the orthopedic nurse, I do not trust my doctor.
I dont think he knows what he is doing. What do you
think about my doctor? Which statement is the nurses
best response?
l 1. I really cant give you an opinion on your doctor
since I work for the hospital.
l 2. What has your doctor done to make you not
trust him?
l 3. You have a right to a second opinion. Would you
like me to help you?
l 4. Since your surgery is scheduled you must keep
this surgeon.
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ANSWERS
66. Correct answer 4: The UAP is restraining the client

without an order; this is a violation of the clients
rights. The nurse needs to release the client immediately and discuss the behavior with the UAP. Assisting with a shower, assisting a client to a bedside
commode, and placing a call light within reach of
the client are all appropriate actions of the UAP.
Musculoskeletal; Integrated ProcessImplementation;
67. Correct answer 4: The charge nurse must send a

qualified nurse but not at the detriment of the
orthopedic unit. The RN with surgical unit and
orthopedic experience should be able to work in the
ED. The RN with 5 years experience on the orthopedic unit and the RN who has experience on many
units should be kept on a busy 36-bed unit. The
new graduate should not be transferred to the ED.
316

68. Correct answer 3: The nurse must be a client advocate. If the client does not trust the HCP, the client
has a right to a second opinion; therefore, the nurse
should help resolve this dilemma for the client. The
nurse cannot discuss personnel opinions of the HCP
and does not have to know what the HCP has done.
Many clients do not feel comfortable confronting
their HCP. ContentMedical; Category of Health
LevelApplication.
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SECTION SIX
69. The overhead page has issued a code black indicating

a tornado in the area. Which intervention should the
charge nurse of the orthopedic unit implement?
l 1. Instruct the staff to assist the clients and visitors to
the cafeteria.
l 2. Request the clients and visitors to go into the
bathroom in each clients room.
l 3. Move all clients and visitors into the hallways and
close all doors.
l 4. Request all clients and visitors stay in the rooms
and leave all doors open.
317
70. The primary nurse overhears the UAP telling a

family member of another client, A client was admitted
today who murdered his wife and tried to kill himself.
Which action should the primary nurse take first?
l 1. Notify the charge nurse of the UAPs comments.
l 2. Tell the UAP the comment is a violation of the
HIPAA.
l 3. Ask the family to please not repeat what the
UAP said.
l 4. Request the UAP to go to the nurses station
immediately.
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ANSWERS
69. Correct answer 3: The procedure for tornadoes is

having all clients, staff, and visitors stay in the hallway and close the doors to all the rooms. This will
help prevent any flying debris or glass from hurting
anyone. ContentMedical; Category of Health
LevelApplication.
318
70. Correct answer 4: The primary nurse needs to stop

the conversation immediately without embarrassing
the UAP; therefore, asking the UAP to go to the
nurses station is the nurses first action. Then the
primary nurse should tell the UAP that the UAP
committed a HIPAA violation, report the incident to
the charge nurse, and if necessary talk to the family
member who heard the gossip. ContentMedical;
SECTION SEVEN
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Page 319
Genitourinary Disorders
319
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Page 320
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321
Fluid and Electrolytes

1. The nurse is caring for a client with a serum sodium
level of 152 mEq/L. Which signs/symptoms should the
nurse expect the client to exhibit?
l 1. Sticky mucous membranes and thirst.
l 2. Anorexia, nausea, and muscle cramps.
l 3. Tingling of extremities and numbness.
l 4. Paresthesias, dysrhythmias, and fatigue.
2. The client is diagnosed with acute renal failure. The
nurse assesses peripheral edema, increased bounding
pulses, and jugular vein distention. Which interventions
l 1. Administer intravenous diuretics.
l 2. Provide the client with a regular diet.
l 3. Place the client on strict intake and output (I&O).
l 4. Put the client on fluid restriction.
l 5. Weigh the client weekly in the same clothes.
3. The client has a serum potassium level of 2.9 mEq/L.

l 1. Administer intravenous potassium.
l 2. Encourage foods high in potassium.
l 3. Place the client on cardiac telemetry.
l 4. Monitor the clients intake and output.
4. The client who has undergone an exploratory laparotomy
has a nasogastric tube (NGT) in place and an intravenous
(IV) line running at 150 mL/hr via an IV pump. Which
data would warrant intervention by the nurse?
l 1. The alarm on the IV pump keeps going off,
possibly indicating high pressure.
l 2. The client has an IV intake 1200 mL, output
700 mL, and NGT 350 mL.
l 3. The clients lungs are clear in all lobes on
auscultation.
l 4. The client has non-pitting edema and 1 kg
weight loss.
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ANSWERS
1. Correct answer 1: Hypernatremia, a serum sodium
322
3. Correct answer 3: The client has an extremely
level above 145 mEq/L, will cause the client to be thirsty,

to have a dry mouth and sticky mucous membranes,
to be irritable, and to have seizures. Option 2 could be
signs/symptoms of hyponatremia, option 3 of hypocalcemia, and option 4 of hypokalemia. ContentMedical;
low potassium level (3.55.5 mEq/L is normal); therefore, the client is at risk for life-threatening cardiac
dysrhythmias and should be placed on telemetry.
Replacing the potassium is important but not priority
over life-threatening dysrhythmias. ContentMedical;
Category of Health AlterationGenitourinary; Integrated


Synthesis.
2. Correct answer 1, 3, 4: The client is exhibiting fluid

volume overload; therefore, administering diuretics,
strict I & O, and fluid restriction are appropriate interventions. The client should be on a sodium-restricted
diet, not a regular diet, and the client should be weighed
daily, not weekly. ContentMedical; Category of Health
AlterationGenitourinary; Integrated Process
Application.
4. Correct answer 1: The nurse should assess the clients

IV pump because the alarm indicates a possible infiltrated
IV. The other data would not warrant intervention as
the intake and output are equal, considering insensible
loss; the lungs are clear; and non-pitting edema and
weight loss are not life-threatening. ContentSurgical;
Therapies; Cognitive LevelSynthesis.
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323
5. The client has a calcium level less than 7 mg/dL.

Which assessment data would the nurse expect the
client to exhibit?
l 1. Flushing of the face and hypoactive reflexes.
l 2. Constipation, polyuria, and polydipsia.
l 3. Dysrthymias with peaked T-waves.
l 4. Positive Trousseau sign and diarrhea.
7. The client is receiving total parental nutrition (TPN)

into a subclavian line at 73 mL/hr. Which intervention
l 1. Infuse the solution via gravity at 73 mL/hr.
l 2. Monitor the serum blood glucose daily.
l 3. Change the IV tubing every 3 days.
l 4. Check intake and output (I&O) every shift.
6. The client with gastroenteritis has tented skin turgor,

lightheadedness, and dizziness. Which intervention
l 1. Monitor the client for respiratory alkalosis.
l 2. Administer intravenous calcium supplements.
l 3. Infuse intravenous normal saline.
l 4. Provide a sodium-restricted diet.
8. The client who is 1 day postoperative bilateral

thyroidectomy complains of numbness and tingling
around the mouth and the tips of the fingers. Which
immediately.
l 2. Check the B/P and see if the hand makes a claw
shape.
l 3. Check the serum calcium and magnesium levels.
l 4. Prepare to administer calcium gluconate by
intravenous push (IVP).
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ANSWERS
5. Correct answer 4: The calcium level is low (911 mg/dL

is normal). Signs/symptoms of hypocalcemia include
diarrhea, numbness, tingling of extremities, and positive Trousseau and Chvostek signs. Option 1 could be
signs of hypermagnesemia; option 2 could be signs of
diabetes; and option 3 could be signs of hypokalemia.
Genitourinary; Integrated ProcessAssessment; Client
6. Correct answer 3: The client is dehydrated, and

isotonic fluids must be administered to a client who is
dehydrated so the fluid will remain in the vessels and
increase blood volume. The client would exhibit a
metabolic problem, not a respiratory one. Calcium is
not administered for dehydration, and sodium is
restricted for fluid volume overload, not for fluid
deficit. ContentMedical; Category of Health Alteration
Gastrointestinal; Integrated ProcessImplementation; Client
324
7. Correct answer 4: I&O is monitored to observe for

fluid balance. TPN should be administered via an
IV pump only. The glucose is checked every 6 hours,
and the IV tubing is changed with every bag of TPN.
8. Correct answer 2: Checking for the Trousseau sign is

the nurses first intervention because the client is
exhibiting signs of hypocalcemia. Then the nurse
can check electrolyte levels, administer appropriate
medication, and notify the HCP. ContentSurgical;
LevelSynthesis.
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325
Benign Prostatic Hypertrophy (BPH)

9. The client has a serum potassium level of 6.9 mEq/L.
Which HCP prescription should the nurse question?
l 1. Administer 50% glucose and intravenous regular
insulin.
l 2. Administer kayexalate, a cation exchange resin.
l 3. Administer intravenous loop diuretics.
l 4. Administer intravenous potassium over 8 hours.
10. The nurse and an unlicensed assistive personnel
(UAP) are caring for a group of clients. Which task
would be inappropriate to delegate to the UAP?
l 1. Measure the urine in the clients urinal.
l 2. Obtain the clients daily weight.
l 3. Discuss fluid restrictions with client.
l 4. Maintain the clients nothing by mouth (NPO)
status.
11. The UAP emptied 4000 mL from the drainage

bag of a continuous irrigation of a client who had a
transurethral resection of the prostate (TURP). The
amount of irrigation in the bag hanging was 3000 mL at
the beginning of shift. A second bag of 3000 mL was
hung midway through the shift, with 2500 mL left in the
bag at the end of the shift. Which is the corrected urine
output the nurse would document for the 12-hour shift?
Answer: _______________________
12. The nurse is caring for the client who had a TURP.
Which assessment data require immediate intervention by
the nurse?
l 1. The client is snoring after receiving a belladonna
and opiate (B&O) suppository.
l 2. The client has dark red drainage and large clots in
the urinary drainage system.
l 3. The client complains of backache from being in
the bed and wants to ambulate.
l 4. The client complains of a caffeine headache from
lack of coffee and colas.
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ANSWERS
9. Correct answer 4: The client is hyperkalemic;
326
11. Correct answer 500 mL: A total of 6000 mL of
therefore, the nurse should question administering

potassium supplements. Kayexalate removes potassium
from the bowel, and diuretics remove potassium
via the urine. Intravenous regular insulin transports
potassium in the bloodstream to the intracellular space.
irrigation solution was hung. That, minus the

2500 mL left in the bag, equals 3500 mL of irrigation solution in the drainage system. Subtract
3500 mL from 4000 mL equals the urine output
of 500 mL for the shift. ContentSurgical; Category

Administration; Integrated ProcessAssessment; Client
of Health AlterationGenitourinary; Integrated

LevelApplication.
10. Correct answer 3: The nurse cannot delegate teaching;

therefore, the nurse must discuss fluid restrictions
with the client. The UAP can measure urine from a
urinal, take daily weights, and make sure the client
does not drink any fluids. ContentMedical; Category
of Health AlterationManagement; Integrated Process
12. Correct answer 2: Dark red drainage indicates the

continuous bladder irrigation (CBI) rate needs to be
increased to decrease the chance of hemorrhaging. A
B&O suppository is a narcotic pain medication that
treats bladder spasms and causes drowsiness. The
client with a backache and the client with a headache
are not priority over a client who may be at risk of
hemorrhaging. ContentSurgical; Category of Health
AlterationGenitourinary; Integrated ProcessAssessment;
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SECTION SEVEN
13. Which data would indicate to the nurse the male

client has acute bacterial prostatitis?
l 1. Terminal dribbling.
l 2. Urinary frequency.
l 3. Stress incontinence.
l 4. Sudden fever and chills.
14. Which client problem is priority for the client who
had a TURP for benign prostatic hypertrophy (BPH)
1 week ago?
l 1. Altered sexual functioning.
l 2. Altered body image.
l 3. Chronic infection.
l 4. Hemorrhage.
15. The nurse is discharging a client who is postoperative
TURP. Which statement by the client indicates discharge
teaching is effective?
l 1. I will call the surgeon if I experience any difficulty
urinating.
l 2. I will take my saw palmetto the same as before my
surgery.
3. I should restrict my oral intake to keep from
4. I can mow my yard and do the rest of my yard
327
urinating so much
work when I get home.

urology floor. Which nursing task should the nurse
delegate to the UAP?
l 1. Increase the continuous bladder irrigation fluid.
l 2. Elevate the clients scrotum on a towel roll for
support.
l 3. Change the surgical dressing for the client 1 day
postoperative.
l 4. Teach the client to care for the continuous
irrigation catheter.
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ANSWERS
13. Correct answer 4: Clients with acute bacterial

prostatitis will frequently experience a sudden onset
of fever and chills. Options 1 and 2 are symptoms of
benign prostatic hypertrophy (BPH). Stress incontinence occurs when the bladder experiences the stress
of coughing, running, or jumping. ContentMedical;
14. Correct answer 1: The client may experience erectile

dysfunction after the surgery, and the nurse should
address the issue with the client. Chronic infections
occur prior to surgery, and hemorrhage occurs
immediately postoperatively, not 1 week after
the surgery. ContentSurgical; Category of Health
AlterationGenitourinary; Integrated ProcessDiagnosis;
328
15. Correct answer 1: The client should notify the

surgeon if he has difficulty urinating; this statement
indicates that the teaching was effective. Saw palmetto
is taken to shrink the prostate and the surgery has
removed prostatic tissue. The client should increase
fluid intake, and yard work is too strenuous immediately following surgery. ContentSurgical; Category of
Health AlterationGenitourinary; Integrated Process
16. Correct answer 2: The UAP can position a client.

The nurse cannot delegate teaching nor give medication to a UAP; the continuous irrigation should be
considered a medication. The surgeon changes the
first dressing. ContentMedical; Category of Health
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SECTION SEVEN
17. The client who had a TURP and has a CBI complains
he feels the need to urinate. Which intervention should the
l 1. Call the surgeon to report the clients complaint.
l 2. Administer a narcotic analgesic to help the client
urinate.
l 3. Tell the client the sensation is expected.
l 4. Assess the continuous irrigation catheter to
determine if it is patent.
18. The client asks the clinic nurse, What does an
elevated prostate-specific antigen (PSA) test mean? Which
l 1. An elevated PSA can be for different reasons.
You need to talk to your HCP.
l 2. An elevated PSA indicates prostate cancer only.
You should see an oncologist.
l 3. An elevated PSA is diagnostic for testicular cancer
and other male problems.
l 4. An elevated PSA is the only test used to diagnose
benign prostatic hypertrophy.
329
19. The client diagnosed with BPH tells the nurse,

I started taking saw palmetto 2 weeks ago, but I have
not noticed any difference when I urinate. Which
l 1. Saw palmetto must not be working. You should
take a prescription medication.
l 2. Why did you start taking saw palmetto? Herbs
can be very dangerous.
l 3. It may take weeks to see the results from herbs
that shrink prostate tissue.
l 4. Are you currently taking any other medications
with the saw palmetto?
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ANSWERS
17. Correct answer 4: The nurse should always assess
330
19. Correct answer 3: Saw palmetto works similarly to
any complaint before dismissing it as a commonly

occurring problem. The nurse should not call a
health-care provider until all assessment is complete.
Pain medication will not help the client urinate.
Telling a client that what he is experiencing is
normal without checking is unsafe. ContentSurgical;
finasteride (Proscar) to reduce the size of prostate

tissue, but it takes several weeks to months to see the
optimal effects. Saw palmetto has been proved to be
as effective as prescription medications to treat BPH.
Saw palmetto is well tolerated with few drug interactions. ContentMedical; Category of Health Alteration

Care Environment, Management of Care;
Genitourinary; Integrated ProcessImplementation;

18. Correct answer 1: An elevated PSA can result from

urinary retention, benign prostatic hypertrophy,
prostate cancer, or prostate infarct. An elevated
PSA test result indicates the need for further tests.
Risk Potential; Cognitive LevelApplication.
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SECTION SEVEN
20. The male client tells the clinic nurse he has to get up
to go to the bathroom frequently at night but when he
does, it takes a long time to get started. Which intervention
l 1. Prepare the client for a digital rectal exam (DRE)
by the HCP.
l 2. Have the laboratory draw a prostate-specific
antigen (PSA).
l 3. Encourage the client to not drink any fluids 2 hours
before bedtime.
l 4. Instruct the client to provide a clean-catch urine
specimen.
Urinary Tract Infection

21. The client from a long-term care facility is admitted
with a fever, hot flushed skin, and clumps of white
sediment in the indwelling catheter drainage bag. Which
l 1. Start an intravenous line with a 20-gauge catheter.
l 2. Initiate the antibiotic therapy intravenous
piggyback (IVPB).
l
l
331
3. Clamp the drainage tubing to obtain a culture.

4. Change the indwelling catheter.
22. The nurse is inserting an indwelling urinary catheter

into a female client. Which interventions should be
implemented? Rank in order of performance.
l 1. Explain the procedure to the client.
l 2. Set up the sterile field.
l 3. Test the catheter balloon.
l 4. Place absorbent pads under the client.
l 5. Ask the client if she is allergic to iodine.
23. The nurse performed a bladder irrigation through an
indwelling catheter. The nurse instilled 100 mL of sterile
normal saline. The catheter drained 1010 mL. What is
the clients output?
Answer: ________________________
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ANSWERS
332
20. Correct answer 2: The PSA must be done prior to
22. Correct answer 1, 5, 4, 2, 3: The nurse should first
the DRE or the results will be skewed. Then, the

client should have a DRE performed. A clean catch
urine specimen would be done because BPH causes
urinary stasis and predisposes the client to a urinary
tract infection (UTI). Decreasing fluid intake will
not help an enlarged prostate gland. Content
explain the procedure to the client and then ask the

client if she is allergic to iodine as that is the medium
used to cleanse the area. Then the nurse should place
absorbent pads under the client, set up the sterile
field, and test the catheter balloon before inserting the
catheter into the client. ContentMedical; Category of
Medical; Category of Health AlterationGenitourinary;


LevelApplication.
21. Correct answer 4: The nurse should first replace the
23. Correct answer 910 mL of urine: The amount of
catheter and obtain a urine specimen that will be

most accurate for an analysis. Then the nurse should
start an IV and antibiotic therapy. The nurse should
not get a urine specimen from the catheter bag.
sterile normal saline is subtracted from the total volume

removed from the catheter: 1010 100 = 910 mL.
Management of Care; Cognitive Level-Application.
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SECTION SEVEN
24. The nurse is assessing a 16-year-old female who is

complaining of pain, frequency, and urgency when
urinating. The nurse asked the mother to leave the
room. Which question should the nurse ask the client?
l 1. When was your last menstrual cycle?
l 2. Has there been a change in the color of the
urine?
l 3. Are you sexually active?
l 4. What have you done for the pain?
25. The client calls the clinic nurse reporting chills, fever,
and left costovertebral pain. Which diagnostic test should
be implemented first?
l 1. A midstream urine for culture.
l 2. A sonogram of the kidney.
l 3. An intravenous pyelogram.
l 4. An MRI of the kidneys.
333
26. The male client diagnosed with chronic pyelonephritis

is being admitted to a medical unit for intensive intravenous
therapy. Which statement made by the client indicates
a diagnosis of chronic pyelonephritis?
l 1. I woke up with fever, chills, pain in my side, and
burning when I urinated.
l 2. I am tired all the time, I have a headache, and
I have to urinate every hour.
l 3. I had a group B strep infection last week and my
doctor gave me antibiotics.
l 4. The doctor told me I had an acute case of viral
pneumonia infection.
27. The female client is diagnosed with a urinary tract
infection (UTI). Which instruction should the clinic
nurse teach the client to prevent a recurrence of a UTI?
l 1. Clean the perineum from back to front after a
bowel movement.
l 2. Take warm tub baths, instead of hot showers, daily.
l 3. Void immediately preceding sexual intercourse.
l 4. Avoid coffee, tea, colas, and alcoholic beverages.
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ANSWERS
334
26. Correct answer 2: Fatigue, headache, polyuria, weight
cystitis, a bladder infection, which is often caused by

sexual intercourse due to the introduction of bacteria
into the urethra during intercourse. A teenager may
not want to divulge this information in front of a
parent. The other questions could be asked in front
of the parent. ContentMedical; Category of Health
loss, anorexia, and excessive thirst are symptoms of

chronic pyelonephritis. Fever, chills, flank pain, and
dysuria are symptoms of acute pyelonephritis, not
chronic pyelonephritis. Group B beta-hemolytic
streptococcal infections and acute viral pneumonia
cause acute glomerulonephritis, not pyelonephritis.


25. Correct answer 1: Fever, chills, and costovertebral

pain are symptoms of a urinary tract infection (UTI)
and of acute pyelonephritis. A urine culture will
determine if the client has a UTI. The other tests are
more invasive and expensive. Intravenous pyelogram
studies are done to rule out renal calculi. Content
27. Correct answer 4: Coffee, tea, cola, and alcoholic

beverages are urinary tract irritants. The perineum
should be cleaned from front to back after a bowel
movement. The client should take showers instead
of baths to prevent bacteria in the bath water from
entering the urethra. The client should void after
sexual intercourse. ContentMedical; Category of
Planning: Client NeedsPhysiological Integrity,
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SECTION SEVEN
28. The nurse is discharging a client with a nosocomialacquired urinary tract infection. Which information
should the nurse include in the discharge teaching?
l 1. Explain the hospital will pay for the antibiotics
because it is a nosocomial infection.
l 2. Tell the client to bring a urine specimen to the lab
for analysis in 1 week.
l 3. Instruct the client to take all the antibiotics as
prescribed.
l 4. Tell the client to urinate every 56 hours.
29. The nurse is preparing a plan of care for the
client diagnosed with acute glomerulonephritis. Which
outcome would be a long-term goal for the client?
l 1. The client will maintain a BP of less than 160/90.
l 2. The client will maintain adequate renal
functioning.
l 3. The client will have no white blood cells in the urine.
l 4. The client will have a urinary output of >30 mL/hr.
335
30. The elderly client is diagnosed with chronic

glomerulonephritis. Which lab value indicates the
condition is improving?
l 1. The blood urea nitrogen (BUN) is 15 mg/dL.
l 2. The creatinine level is 3.0 mg/dL.
l 3. The glomerular filtration rate is 40 mL/min.
l 4. The 24-hour creatinine clearance is 60 mL/min.
Renal Calculi
31. Laboratory data reveal a calcium phosphate renal
calculus in a client diagnosed with renal calculi. Which
teaching?
l 1. I am going to eat liver and organ meats only once
a week.
l 2. I should drink at least two glasses of cranberry
juice a day.
l 3. I must limit how much milk and dairy products
I consume.
l 4. I will urinate at least every 2 hours so I wont
develop a stone.
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ANSWERS
28. Correct answer 3: The client should be taught to
336
30. Correct answer 1: For a client over age 60, the
take all the prescribed medication any time a prescription is written for antibiotics. The hospital will
not assume responsibility for payment. The client will
not bring in a specimen; the client usually provides
the specimen on site. The client should be taught to
void every 23 hours. ContentMedical; Category of
normal BUN is 820 mg/dL. Therefore, a BUN of

15 mg/dL indicates an improvement in the clients
condition. The other lab values are abnormal; normal
creatinine level is 0.61.2 mg/dL; normal glomerular
filtration level is approximately 120 mL/min; and
normal creatinine clearance is 75125 mL/min.


29. Correct answer 2: A long-term complication of acute

glomerulonephritis is chronic glomerulonephritis. If
acute glomerulonephritis is unresponsive to treatment,
it can lead to end-stage renal disease. Therefore,
maintaining renal function would be an appropriate
long-term goal. An elevated BP is an inappropriate
goal. Options 3 and 4 are short-term goals. Content
Integrated ProcessDiagnosis; Client NeedsPhysiological
Analysis.
31. Correct answer 3: Dietary changes for preventing

calcium phosphate renal calculi include limiting
vitamin D, which will, in turn, inhibit the absorption
of calcium from the gastrointestinal tract. Organ
meats should be limited in a client with uric acid
stones. Cranberry juice and urinating frequently will
not prevent the development of renal calculi. Content
Evaluation.
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SECTION SEVEN
32. The male client diagnosed with renal calculi is

admitted to the medical unit from the emergency
department. Which nursing intervention should the
l 1. Strain the clients urine.
l 2. Give the client a urinal.
l 3. Encourage oral fluids.
l 4. Monitor the intake and output.
33. The client with rule-out renal calculi is scheduled for
an intravenous pyelogram. Which intervention should the
nurse implement for this procedure?
l 1. Ask if the client is allergic to shellfish or iodine.
l 2. Keep the client nothing by mouth (NPO) 8 hours
prior to the procedure.
l 3. Insert an indwelling catheter 1 hour before the
procedure.
l 4. Explain that the client will have to drink a
special dye.
337
34. The client is being admitted to the hospital. Which

clinical manifestations would the nurse expect to assess
for the client diagnosed with renal calculi in the kidney?
l 1. Dull, aching flank pain and microscopic hematuria.
l 2. Increased hunger and thirst and abdominal pain.
l 3. Gross hematuria and dull suprapubic pain with
voiding.
l 4. Severe pain of 10 on a 110 pain scale when
urinating.
35. The male client diagnosed with renal calculi is
scheduled for a 24-hour urine specimen collection. Which
apply.
l 1. Keep the client NPO during the 24-hour urine
collection time.
l 2. Instruct the client to urinate and then discard this
urine when starting collection.
l 3. Tell the client to urinate into the urinal at the
bedside.
l 4. Insert an indwelling catheter in the client after
having client empty bladder.
l 5. Place all the urine in the specific urine containers.
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ANSWERS
32. Correct answer 2: The nurse should give the client
338
34. Correct answer 1: A client with renal calculi in the
a urinal and instruct him to put all urine into the

urinal. Then the nurse should strain the urine,
encourage oral fluids, and monitor the clients intake
and output but first ensure that all urine output
is strained. ContentMedical; Category of Health
kidney will have dull aching pain in the region of the

kidney (flank) and hematuria showing on urinanalysis.
Option 2 is hyperglycemia; option 3 is calculi in the
ureter; and option 4 is a calculus in the urethra
trying to pass. ContentMedical; Category of Health
AlterationGenitourinary; Integrated ProcessPlanning;


33. Correct answer 1: Iodine-based dye is used for an

intravenous pyelogram; therefore, determining if the
client is allergic to iodine is an appropriate intervention. The client is not NPO; there is no indwelling
catheter; and the client must have an intravenous
line for administering the dye. ContentMedical;
Care Environment, Reduction of Risk Potential; Cognitive
LevelApplication.
35. Correct answer 2, 3, 5: When the collection

begins, the client should urinate and discard the
urine. All urine for 24 hours should be saved and
put in a container with a preservative, be refrigerated,
or be put on ice (if indicated). Not following specific
instructions will result in an inaccurate test result.
The client does not have an indwelling catheter.
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SECTION SEVEN
339
36. Which priority client problem should the nurse address

when caring for a client diagnosed with an acute episode of
ureteral calculi?
l 1. Fluid volume excess.
l 3. Impaired urinary elimination.
38. The client diagnosed with renal calculi has undergone

lithotripsy. Which post-procedure nursing task would be
most appropriate to delegate to the UAP?
l 1. Tell the UAP to monitor the clients urine output.
l 2. Ask the UAP to discuss post-procedure care.
l 3. Instruct the UAP to encourage oral fluids.
l 4. Request the UAP to check the clients vital signs.
37. The client is diagnosed with uric acid calculi. Which

foods should the client eliminate from the diet to help
prevent reoccurrence?
l 1. Red wine and colas.
l 2. Asparagus and cabbage.
l 3. Sweetbreads and ham.
l 4. Cheese and eggs.
39. The client had surgery to remove a kidney stone.

Which laboratory assessment data would warrant
l 1. A serum sodium level of 144 mEq/L.
l 2. A urinalysis that shows microscopic hematuria.
l 3. A creatinine level of 0.8 mg/100 mL.
l 4. A white blood cell count of 12,000 mm.
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ANSWERS
36. Correct answer 4: Pain is priority; the pain can be

so severe that a sympathetic response, which causes
nausea, vomiting, pallor, and cool and clammy skin,
may occur. All the other client problems are pertinent,
but the priority is pain. ContentMedical; Category of
37. Correct answer 3: Sweetbreads (yeast), ham, venison,

sardines, goose, organ meats, and herrings are highpurine foods that should be eliminated from the diet
to help prevent uric acid stones. All the other foods
should be limited in clients with calcium oxalate stones.
Genitourinary; Integrated ProcessPlanning; Client
340
38. Correct answer 3: The UAP could encourage the

client to drink oral fluids. The urine must be assessed
by the nurse for bleeding and cloudiness, and the
nurse cannot delegate teaching. Because the kidney is
highly vascular, hemorrhaging and resulting shock
are potential complications of lithotripsy; therefore,
the nurse cannot delegate checking vital signs post
procedure to the UAP. ContentMedical; Category of
39. Correct answer 4: This white blood cell count is

elevated (normal is 500010,000 mm); this could
possibly indicate an infection. The serum sodium
level is normal (135145 mEq/L) as is the creatinine
level (0.81.2 mg/100 mL). Hematuria is not
uncommon after removal of a kidney stone. Content
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SECTION SEVEN
40. The client diagnosed with calculi in the ureter is

complaining of severe pain of 10 on a pain scale of 110.
l 1. Administer the intravenous narcotic analgesic.
l 2. Assess the client to rule out any complications.
l 3. Check the MAR to determine when the client was
last medicated.
l 4. Ensure the clients side rails are up and the call
light is within reach.
Cancer of the Bladder

41. The nurse is working on a renal surgery unit. After
receiving the change of shift report, which client should
be assessed first?
l 1. The client who left glasses in the x-ray department
and cannot see without them.
l 2. The client 1 day postoperative who has a large
amount of serosanguineous drainage on the dressing.
l 3. The client scheduled for surgery in the morning
who needs an explanation of the surgery.
l 4. The client who had ileal conduit surgery who has
sediment and urine in the drainage bag.
341
42. The nurse is teaching clients at a community center

about the risks of developing bladder cancer. Which
modifiable risk factor could lead to the development of
cancer of the bladder?
l 1. Previous exposure to chemicals.
l 2. Pelvic radiation therapy.
l 3. High cholesterol intake.
l 4. Previous cancer of the prostate.
43. The client diagnosed with cancer of the bladder
is scheduled to have a cutaneous urinary diversion
procedure. Which preoperative teaching should be
included? Select all that apply.
l 1. Demonstrate turn-and-cough and deep breathing.
l 2. Explain that a bag will drain the urine from now on.
l 3. Instruct the client about pain control after surgery.
l 4. Take the client to tour the intensive care unit
(ICU).
l 5. Show the client the deodorants that are used inside
the pouch.
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ANSWERS
342
40. Correct answer 2: The client in severe pain must be
42. Correct answer 3: High cholesterol and tobacco use
assessed to determine if the pain is a complication

that requires medical intervention or is expected
pain. If it is expected pain, the nurse should check
the MAR for the last pain medication administered
and, if appropriate, administer the narcotic analgesic
and ensure the safety of the client. ContentMedical;
are modifiable risk factors. Previous exposure to chemicals or previous cancer cannot be undone. Pelvic
radiation is done for cancer in the abdomen; it is a
life-saving procedure, but one of the risks of radiation
therapy is the development of a secondary cancer.

LevelSynthesis.
41. Correct answer 2: This client may be bleeding, and

the nurse should assess this client first. An ileal conduit drains urine, but mucus will also be present
because the tissue used to create the conduit normally produces mucus. ContentSurgical; Category
of Health AlterationGenitourinary; Integrated Process
Assessment; Client NeedsSafe Effective Care Environment,

LevelSynthesis.
43. Correct answer 1, 2, 3, 4: Any client undergoing

general anesthesia should be taught to turn, cough,
and deep-breathe. A urinary diversion procedure
involves the removal of the bladder. The nurse should
always explain pain control, and if the client is going
to the ICU, it is helpful for the client to become
familiar with it prior to surgery. Deodorants used to
counteract the odor are not included in preoperative
teaching. ContentSurgical; Category of Health
Alteration Genitourinary; Integrated ProcessPlanning;
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44. The client diagnosed with cancer of the bladder is

receiving intravesical chemotherapy. Which instruction
should the nurse provide the client about pre-therapy
routine?
l 1. Instruct the client to increase fluids just prior to
the therapy.
l 2. Encourage the client to attend a support group for
bladder cancer.
l 3. Teach the client how to perform Kegel exercises.
l 4. Indicate that the client will be turned every
15 minutes.
45. The nurse is planning the care of a postoperative
client who had a urinary diversion with a creation of an
ileal conduit. Which assessment data warrant immediate
l 1. The clients stoma is purple.
l 2. The clients pouch has a strong odor to it.
l 3. The clients urine pH is acidic.
l 4. The clients drainage is amber-colored.
343
46. The nurse and a licensed practical nurse (LPN) are

caring for a group of clients. Which nursing task should
be assigned to the LPN?
l 1. Assess the client who has had a Koch pouch
procedure.
l 2. Monitor the client who is 2 days postoperative who
has a white blood cell (WBC) count of 7000 mm.
l 3. Administer the prescribed antineoplastic
medications.
l 4. Discharge the client with a new ileal conduit.
47. The male client diagnosed with metastatic cancer of
the bladder is angry and states, I am going to kill
myself. Which statement is the nurses best response?
l 1. I can see you are upset. We should talk about it.
l 2. Did you tell your oncologist how you feel?
l 3. Do you have a plan on how you are going to kill
yourself?
l 4. Your treatments are going well. Dont talk about
suicide.
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ANSWERS
44. Correct answer 4: The client will be turned every

15 minutes to have the medication reach the entire
bladder surface. The chemotherapy is instilled in the
bladder and should remain in the bladder for a
prescribed time. The client receives nothing by mouth
prior to the procedure. Kegel exercises help prevent
stress incontinence, and referring to a support group
is not pertinent to pre-procedure teaching. Content
45. Correct answer 1: A purple stoma indicates a lack

of circulation to the stoma. This requires immediate
intervention. A strong odor and acidic and ambercolored urine would not warrant immediate intervention by the nurse. ContentMedical; Category of
LevelSynthesis.
344
46. Correct answer 2: This client is 2 days postoperative

with a normal WBC count; therefore the LPN could
care for this client. Assessment, administering antineoplastic medications, and discharge teaching for an
ileal conduit are the responsibility of the registered
nurse. ContentMedical; Category of Health Alteration
Management; Integrated ProcessPlanning; Client Needs
47. Correct answer 3: Anytime a client threatens

suicide, the nurse must determine how lethal the
clients threat is. A therapeutic response (option 1),
determining if the client discussed the thought with
the oncologist, and negating the clients comments
are not the best responses. ContentMedical; Category
Implementation; Client NeedsSafety and Infection
Control; Cognitive LevelApplication.
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SECTION SEVEN
48. The married client with a continent urinary diversion

is being discharged. Which instruction should the nurse
include in the discharge teaching?
l 1. Have the client return and demonstrate
catheterizing the stoma.
l 2. Tell the client to wear adult diapers to prevent
accidents.
l 3. Teach the client to irrigate the stoma once a day.
l 4. Encourage the client and spouse to see a marriage
counselor.
49. The nurse is preparing to discharge a client diagnosed
with a cutaneous ileal conduit. Which information
l 1. To measure the amount of urine in the pouch every
8 hours.
l 2. To change the pouch when it is three-quarters full.
l 3. To expect the skin around the stoma to be red at
times.
l 4. To instill a few drops of vinegar into the pouch.
345
50. The female client with a cutaneous urinary diversion

for cancer of the bladder states, Will I be able to have
children? Which statement is the nurses best response?
l 1. Cancer does not make you sterile, but sometimes
chemotherapy can.
l 2. You are concerned that you cannot have children
since you have cancer.
l 3. No, you will no longer be able to have children
because of the surgery.
l 4. I will let your HCP know about your concerns.
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ANSWERS
48. Correct answer 1: A continent urinary diversion is a
346
50. Correct answer 1: This client is asking for information
surgical procedure in which a reservoir holds urine

(acts as the bladder) until the client can self-catheterize.
There is no need for a diaper. Sigmoid colostomies are
irrigated, not urinary, diversions. A marriage counselor
may be needed, but the physiological need is priority.
and should be given facts, which is that the procedure

will not cause sterility, but chemotherapy can induce
menopause, and radiation therapy to the pelvis can
render a client sterile. Option 2 is a therapeutic
response, and option 3 is a false statement. Content


49. Correct answer 4: Vinegar will act as a deodorizing

agent in the pouch and help prevent a strong urine
smell. The pouch is emptied when it is half to
two-thirds full, but the pouch is only changed every
couple of days to prevent skin breakdown. The client
should notify the ostomy nurse if the skin around
the stoma becomes red. ContentSurgical; Category
of Health AlterationGenitourinary; Integrated
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347
Male Cancers
51. Which statement is the American Cancer Societys
recommendation for the early detection of cancer of the
prostate?
l 1. A yearly prostate-specific antigen (PSA) level followed
by a digital rectal exam beginning at age 50.
l 2. A biannual urinalysis beginning at age 40 to check
for the presence of seminal fluid.
l 3. An annual alkaline phosphatase level beginning at
age 45.
l 4. A yearly blood urea nitrogen (BUN) to determine
the damage to the kidneys.
52. The nurse is caring for a client diagnosed with early
cancer of the prostate. Which statement made by the
client supports the diagnosis?
l 1. I have urinary urgency and have to go all the time.
l 2. I do not have semen production during
intercourse.
l 3. I take a lot of ibuprofen for my lower back and
hip pain.
l 4. I havent had any problems going to the bathroom.
53. The 80-year-old male client has been diagnosed with

cancer of the prostate. Which treatment would the nurse
l 1. Radiation therapy every day for 4 weeks.
l 2. Radical prostatectomy with lymph node dissection.
l 3. The client may choose not to take any treatment.
l 4. Penile implants to maintain sexual functioning.
54. The nurse writes a client problem of urinary retention
for a client diagnosed with stage IV cancer of the prostate.
l 1. Prepare the client for a suprapubic catheter.
l 2. Obtain an order for a prophylactic antibiotic.
l 3. Teach the client to use the Cred maneuver.
l 4. Determine the clients normal voiding pattern.
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ANSWERS
51. Correct answer 1: The American Cancer Society

recommends that all men have a yearly PSA blood
level, followed by a digital rectal examination, beginning at age 50. ContentMedical; Category of Health
AlterationGenitourinary; Integrated ProcessPlanning;
52. Correct answer 4: In early-stage prostate cancer, the

man will not be aware of the disease. Early detection
is achieved by screening for the cancer. The other
statements indicate late disease. ContentMedical;
53. Correct answer 3: Some men with a life expectancy

of less than 10 years choose not to treat the cancer at
all and will die from causes other than prostate cancer.
If the client treats the cancer, then diethylstilbesterol
(DES), a hormone preparation that suppresses the
male hormones and slows the growth of the tumor,
348
may be prescribed. ContentMedical; Category of

Health AlterationGenitourinary: Integrated Process
54. Correct answer 4: Determining the clients normal

voiding pattern provides a baseline for the nurse and
client to use when setting goals. The client does not
need a suprapubic catheter or an antibiotic. Clients
with a neurogenic bladder use the Cred maneuver
to void. ContentMedical; Category of Health Alteration
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SECTION SEVEN
55. The 45-year-old client has undergone a bilateral

orchiectomy for cancer of the prostate. Which intervention
l 1. Teach the client how to use the patient-controlled
l 2. Administer testosterone replacement hormone
orally.
l 3. Apply a heating pad to the clients scrotum.
l 4. Have the client talk to another man with ejaculation
dysfunction (ED).
56. The school nurse is preparing a class for male high
school seniors on testicular cancer. Which information
regarding testicular self-examination (TSE) should the
nurse include?
l 1. Perform the examination after a cool shower.
l 2. Feeling a cord-like structure is normal.
l 3. Expect to find a small hard mass on one side.
l 4. TSE should be performed once a year.
349
57. The nurse enters the room of a 26-year-old client

diagnosed with testicular cancer. The client asks the nurse
Will I be able to have children? Which is the nurses
best response?
l 1. I can see you are concerned. Would you like to
talk about your concerns?
l 2. You may need to consider adopting children
because you will be sterile.
l 3. Sperm banking prior to treatment is an option so
that you can father children.
l 4. You should ask your HCP that question. It
depends on many things.
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ANSWERS
55. Correct answer 1: The nurse should make sure the

client knows how to use the PCA pump. The testes
have been removed to decrease the production of
male hormones, so replacing the hormones negates
the purpose of the surgery. The client would use ice,
not heat, and he does have ED. ContentSurgical;
Category of Health AlterationGenitourinary;
56. Correct answer 2: The client may note a cord-like

structure, which is the spermatic cord, and is normal.
Any lump or mass felt is abnormal and should be
checked by a health-care provider as soon as possible.
The client should perform TSE monthly after or
during a warm shower. ContentMedical; Category of
350
57. Correct answer 3: Sperm banking will allow the client

to father children through artificial insemination
with the clients sperm. The client needs information,
not a therapeutic conversation (option 1). The client
may or may not be sterile. ContentMedical; Category
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SECTION SEVEN
58. The client diagnosed with testicular cancer is scheduled

for a unilateral orchiectomy. Which information should
the nurse discuss with the client regarding his sexual
functioning?
l 1. You may have ejaculation difficulties and dribbling
after the surgery.
l 2. You will need to take testosterone, a male hormone,
following the surgery.
l 3. You may need to have penile implant surgery to
be able to have intercourse.
l 4. Your libido and orgasms are usually not affected
by this surgery.
59. The nurse and a UAP are caring for clients on a
genitourinary floor. Which intervention is inappropriate
for the nurse to delegate to the UAP?
l 1. Increase the drip rate on the Murphy drip
irrigation set.
l 2. Empty the drainage bag of the suprapubic catheter.
l 3. Encourage the client who is 1 day postoperative to
turn and cough.
l 4. Record the amount of drainage in the catheter on
the bedside record.
351
60. The nurse is assessing a client to rule out testicular

cancer. Which statement by the client supports the
finding of testicular cancer?
l 1. It hurts and burns when I try to urinate.
l 2. I have a small ulceration on my penis.
l 3. My scrotum feels full and heavy.
l 4. My scrotum has a rash that itches.
Renal Failure
61. The client diagnosed with chronic kidney disease
(CKD) received the initial dose of the biological response
modifier, erythropoietin-1, week ago. Which statement by
the client would indicate the need to notify the HCP?
l 1. I think I may have the flu. I dont feel well.
l 2. I just dont have any energy. I am tired all
the time.
l 3. I took my blood pressure, and it is higher than
normal.
l 4. I have been having pain in both my legs
and back.
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ANSWERS
58. Correct answer 4: Sex drive (libido) and orgasm are

usually unimpaired because the client still has one
functioning testicle. ContentSurgical; Category of
59. Correct answer 1: Increasing the drip rate on a

Murphy irrigation requires nursing judgment and
cannot be delegated. The UAP can empty a drainage
bag, turn a client, and record the amount of drainage
on the bedside record. ContentMedical; Category of
60. Correct answer 3: Classic signs of cancer of the

testes are a mass on the testicle, painless enlargement
of the testes, and heaviness of the scrotum or lower
abdomen. Burning on urination indicates a urinary
tract infection; an ulceration indicates a sexually
352
transmitted disease; and there is no rash associated

with cancer of the testes. ContentMedical; Category
61. Correct answer 3: Hypertension after the initial

administration of erythropoietin may require an
adjustment to initiate or increase antihypertensive
medications. Flu-like symptoms are expected; the
medication takes up to 26 weeks to become effective; and long-bone and vertebral pain is an expected
occurrence. ContentMedical; Category of Health
AlterationGenitourinary; Integrated ProcessEvaluation;
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SECTION SEVEN
62. The nurse is developing a nursing care plan for the

client diagnosed with chronic kidney disease (CKD).
Which client problem would have priority for the client?
l 1. Impaired skin integrity.
l 4. Excess fluid volume.
(CKD) is placed on a fluid restriction of 1200 mL per day.
On the 7 a.m.7 p.m. shift, the client drank 6 ounces of
coffee, 6 ounces of juice, 8 ounces of tea, and 6 ounces
of water with medications. What amount of fluid can the
7 p.m. 7 a.m. nurse give to the client?
Answer: ________________________
353
64. The client diagnosed with end-stage renal disease is

receiving peritoneal dialysis. Which assessment data
l 1. Inability to palpate a thrill over the fistula.
l 2. Abdomen is soft, nontender, and has bowel sounds.
l 3. The dialysate being removed from the abdomen is
cloudy.
l 4. The dialysate instilled was 1500 mL and removed
was 2100 mL.
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ANSWERS
62. Correct answer 4: Excess fluid volume is priority

because of the stress placed on the heart and vessels,
and this could lead to heart failure, pulmonary edema,
and death. Fistulas or grafts that are surgically
implanted to treat CKD (formally known as end-stage
renal disease [ESRD]) cause impaired skin integrity,
but that is not life-threatening nor is activity intolerance. Teaching is important but not priority over a
physiological problem. ContentMedical; Category of
63. Correct answer 420 mL: The nurse must add up

how many milliliters of fluid the client drank on the
7 a.m.7 p.m. shift and then subtract that amount
from 1200 mL to determine how much fluid the
client can receive on the 7 p.m.7 a.m. shift: 1 ounce
is equal to 30 mL; therefore, the client drank 780 mL
(180 mL + 180 mL + 240 mL + 180 mL = 780 mL)
of fluid on the 7 a.m.7 p.m. shift and can have
420 mL on the 7 p.m.7 a.m. shift (1200 - 780 = 420.
354

64. Correct answer 3: The dialysate return is normally

colorless or straw-colored but should never be cloudy,
which indicates an infection. The client does not
have a fistula; a soft non-tender abdomen would be
normal; and an output greater than intake indicates
the dialysis is effective. ContentMedical; Category of
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SECTION SEVEN
65. The client is diagnosed with acute renal failure.

Which laboratory value is most significant?
l 1. A creatinine level of 3.8 mg/dL.
l 2. A blood urea nitrogen (BUN) level of 22 mg/dL.
l 3. A potassium level of 5.5 mEq/L.
l 4. A sodium level of 144 mEq/L.
66. The client is admitted to the emergency department
after multiple knife wounds to the abdomen. Which
intervention should the nurse implement first to help
prevent acute renal failure?
l 1. Monitor the clients urine output.
l 2. Assess the clients blood pressure.
l 3. Insert an indwelling catheter.
l 4. Initiate intravenous fluids.
355
67. The client diagnosed with acute renal failure has a

serum potassium level of 6.5 mEq/L. Which collaborative
l 1. Administer a phosphate binder.
l 2. Type and cross-match for whole blood.
l 3. Administer a cation-exchange resin enema.
l 4. Prepare the client for dialysis.
(CKD) has a new arteriovenous fistula in the left forearm.
Which statement indicates the client needs more discharge
teaching?
l 1. I cannot carry any heavy packages on my left arm.
l 2. I should have my blood tests drawn from my
fistula.
l 3. I will lie on my back or right arm when I sleep.
l 4. I need to perform hand exercises on my left arm.
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ANSWERS
65. Correct answer 1: Creatinine is the laboratory

value most significant in diagnosing renal failure
(0.52.0 mg/dL is normal). Normal BUN is
1030 mg/dL but may be elevated in renal failure. The
potassium level is WNL (normal is 3.55.5 mEq/L),
but this does not diagnose renal failure. The sodium
level is normal (135145 mEq/L). ContentMedical;
66. Correct answer 4: Preventing and treating shock

with blood and fluid replacement will prevent acute
renal failure due to hypoperfusion of the kidneys.
Monitoring intake and output, assessing blood
pressure, and inserting a catheter would be appropriate
interventions, but maintaining circulatory status
is the nurses first intervention. ContentMedical;
LevelSynthesis.
356
67. Correct answer 3: A 6.5-mEq/L level is high and

life threatening, and kayexalate, a cation-exchange
resin, can be administered orally or rectally to decrease the potassium level. Phosphate binders are
used for elevated phosphorous levels; blood transfusions will not decrease the potassium level; and dialysis would not be prescribed for an elevated potassium
level. ContentMedical; Category of Health Alteration
68. Correct answer 2: The fistula should be used only

for dialysis access, not for routine blood draws.
Carrying heavy objects in the left arm could cause
the fistula to clot, and lying on the left arm may
cause clotting by putting pressure on the site. Hand
exercises are recommended to help mature the
fistula. ContentMedical; Category of Health Alteration
Genitourinary; Integrated ProcessEvaluation; Client
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SECTION SEVEN
357
Sexually Transmitted
Diseases (STDs)
69. The male client diagnosed with chronic kidney
disease (CKD) on hemodialysis has a blood pressure of
88/60. Which action should the nurse implement first?
l 2. Turn off the dialysis machine immediately.
l 3. Bolus the client with 500 mL of normal saline.
l 4. Ask the client if he feels lightheaded or dizzy.
(CKD) is on hemodialysis three times a week. Which
information should the nurse discuss with the client?
l 1. Notify the HCP when oral temperature is 103F
or greater.
l 2. Apply ice to the fistula if it starts bleeding at home.
l 3. Recommend a low-fat and low-cholesterol diet.
l 4. Discuss the importance of an advance directive.
71. The high school nurse is preparing a class for

junior- and senior-level students regarding sexually
transmitted diseases (STDs). Which high-risk behavior
information should be included in the class information?
l 1. Engaging in oral or anal sex decreases the risk of
getting an STD.
l 2. Use of a sterile latex barrier device ensures that the
client will not get an STD.
l 3. The more sexual partners, the less the chance of
contracting an STD.
l 4. A condom will not guarantee the student will not
get an STD.
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ANSWERS
69. Correct answer 4: Because the clients blood pressure

is low, the first intervention is for the nurse is to
determine if the client is symptomatic. Then, the
nurse should place the client in the Trendelenburg
position, bolus the client with normal saline, and
turn off the dialysis machine. ContentMedical;
LevelAnalysis.
70. Correct answer 4: End-stage renal disease is a chronic

illness. An advance directive with a durable power of
attorney for health care will ensure that the clients
end-of-life wishes will be honored by the clients
designate. The temperature should be no greater than
100F; a low-fat/low-cholesterol diet is for a cardiac
disease; and ice may cause clotting. ContentMedical;
358
71. Correct answer 4: Condom use provides a barrier to

contracting an STD, but it is not a guarantee. The
condom can break or come off during intercourse.
Engaging in oral and anal sex increases the risk of
contracting an STD. Condoms are not packaged to
be sterile. The more sexual partners, the greater the
risk for contracting an STD. ContentMedical;
ProcessPlanning; Client NeedsHealth Promotion and
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SECTION SEVEN
72. The female client diagnosed with human

papillomavirus (HPV) asks the nurse, What
problems can HPV cause? Which statement is the
most appropriate response by the nurse?
l 1. Your partner can develop chancre sores on his
penis.
l 2. HPV infection can lead to cancer of the cervix.
l 3. You will become sterile and not be able to have
children.
l 4. You can take oral antibiotics to cure the HPV
infection.
73. The public health nurse (PHN) notes a rash on the
trunk, palms of the hands, and soles of the feet of a male
client. Which assessment question should the nurse ask
the client?
l 1. Have you noticed a sore on your penis within the
last 2 months?
l 2. How many sexual partners have you had in the
past year?
359
3. Do you urinate immediately after intercourse and
4. Can you start and stop your stream without pain
wash your penis?

or difficulty?
74. The nurse is caring for a young adult client who

has been diagnosed with gonorrhea. Which statement
reflects an understanding of the transmission of sexually
transmitted diseases?
l 1. Only people of lower socioeconomic level are at risk
for gonorrhea and syphilis.
l 2. The longer a client waits to become sexually active,
the greater the risk for an STD.
l 3. Females can transmit infectious diseases more
rapidly than males.
l 4. If a client is diagnosed with an STD, the client
should be evaluated for other STDs.
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ANSWERS
72. Correct answer 2: Untreated HPV infection is a

cause of cancer of the cervix. Chancre sores indicate
syphilis. HPV does not cause sterility, and there is no
cure for HPV infections. ContentMedical; Category
73. Correct answer 1: A rash on the trunk, palms, and

soles suggests early-stage syphilis, so asking about
another sign of syphilisa sore on the penisis an
appropriate assessment question. A sore on the penis
is a sign of the second stage of syphilis. The PHN
may need to know the number of sexual partners the
client has had to be able to notify the partners of
their risk for infection. Urinating and washing after
intercourse and starting and stopping the urine
stream would not assess for syphilis. ContentMedical;
LevelAnalysis.
360
74. Correct answer 4: If a client is diagnosed with

one STD, there is a great likelihood the client has
another STD. Clients of all socioeconomic levels
contract STDs. The longer the client abstains from
sexual activity and the fewer partners the client has
usually lessen the risk of an STD. Both females and
males spread STDs. ContentMedical; Category of
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SECTION SEVEN
75. The young female client is admitted with pelvic

inflammatory disease (PID) secondary to a Chlamydia
infection. Which discharge instructions should the nurse
teach the client?
l 1. The client will develop antibodies to protect her
against a future infection.
l 2. This infection will not have any long-term effect
for the client.
l 3. Both the client and the sexual partner must be
treated simultaneously.
l 4. Once the infection subsides the pain will also go
away and not be a problem.
76. The nurse is assessing a male client for symptoms of
gonorrhea. Which assessment data support the diagnosis
of gonorrhea?
l 1. Presence of a chancre sore on the shaft of the penis.
l 2. The client may be asymptomatic.
l 3. A CD4 count of greater than 3500.
l 4. A urethral discharge and pain in the testes.
361
77. The nurse is planning the care of a client who has

post-PID secondary to a gonorrhea infection. Which
collaborative diagnosis is appropriate for this client?
l 1. Risk for infertility.
l 2. Knowledge deficit about the transmission of STDs.
l 3. Anxiety related to stigma of having an STD.
l 4. Noncompliance of recommended abstinence.
78. The nurse is caring for a female client diagnosed
with rule-out syphilis. Which intervention should the
l 1. Place the client in the lithotomy position.
l 2. Have the lab draw a blood sample for a serum
rapid plasma reagin (RPR).
l 3. Obtain a Gram stain specimen of the urethral
meatus.
l 4. Teach the client to abstain from intercourse.
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ANSWERS
362
75. Correct answer 3: If both the client and sexual partner
77. Correct answer 1: The diagnosis of risk for infertility
are not treated simultaneously, the sexual partner

can re-infect the client. Chlamydia does not cause an
antigen/antibody reaction, and it may have the longterm effects of chronic pain. There is an increased
risk for ectopic pregnancy, postpartum endometritis,
and infertility associated with PID. ContentMedical;
problems requires collaboration between the nurse

and the health-care provider. Knowledge deficit,
anxiety, and noncompliance are independent nursing
problems. ContentMedical; Category of Health

76. Correct answer 4: A urethral discharge, pain in the

testes, and scrotal edema can indicate epididymitis,
an inflammatory process of the epididymis frequently
associated with gonorrhea. A chancre sore is a symptom
of syphilis. Gonorrhea is more likely to be asymptomatic in females than in males. Option 3 is a normal
CD4 count. ContentMedical; Category of Health
AlterationGenitourinary; Integrated ProcessDiagnosis;

78. Correct answer 1: The conclusive diagnosis for

syphilis is made by direct identification of a spirochete
obtained from a lesion. Obtaining a specimen from
such a lesion requires that the client be in the lithotomy position. The RPR test and Venereal Disease
Research Laboratory (VDRL) test are diagnostic
for staging syphilis. ContentMedical; Category of
Level Analysis.
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Page 363
363
Management
79. The client is diagnosed with primary syphilis.
Which signs and symptoms would the nurse observe?
l 1. Lymphadenopathy and hair loss.
l 2. Multiple chancre sores in the genital area.
l 3. Dementia and psychosis.
l 4. No signs or symptoms are present.
80. The nurse is admitting a pregnant client diagnosed
with Chlamydia trichomatis to the labor and delivery
department. Which intervention should the nurse
implement?
l 1. Prepare the client for an emergency cesarean
section.
l 2. Administer an antibiotic ophthalmic ointment to
the neonate.
l 3. Ask the mother when she became infected with
Chlamydia.
l 4. Notify the postpartum unit of the mothers
infection.
81. The charge nurse has received laboratory data on

clients in the critical care unit. Which situation requires
the charge nurses intervention first?
l 1. The client with an indwelling urinary catheter who
has bacteria in the urine specimen.
l 2. The client with ESRD who has a creatinine level of
3.8 mg/dL.
l 3. The client who is 1 day postoperative thyroidectomy
with a 9.4 mg/dL calcium level.
l 4. The client who is receiving loop diuretics who has
a potassium level of 3.5 mEq/L.
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ANSWERS
79. Correct answer 2: Chancre sores occur in the

primary stage of syphilis infection. Lymphadenopathy
and hair loss are symptoms of secondary syphilis.
Aortitis and neurosyphilis (dementia, psychosis,
stroke, meningitis) are common manifestations of
tertiary syphilis. Absence of symptoms is latent
syphilis and occurs after 45 months. Content
Analysis.
80. Correct answer 2: Transmission of a Chlamydia

infection during delivery is common, and the neonate
should be given antibiotic ophthalmic ointment.
About 20%50% of neonates develop Chlamydia
conjunctivitis, and 20% develop pneumonia. The
client can deliver vaginally. The postpartum staff
should use standard precautions and would not be at
risk. ContentMedical; Category of Health Alteration
364

81. Correct answer 1: The client with the indwelling

urinary catheter who has bacteria in the urine
specimen may have developed a urinary tract
infection; therefore, this client should be seen first.
A client with ESRD would have an elevated creatinine
level. The calcium and potassium levels are within
normal limits (WNL). ContentManagement; Category
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SECTION SEVEN
82. The nurse and UAP are caring for clients on a medical
unit. Which task would be most appropriate for the nurse
l 1. Provide indwelling catheter care to a client who is
third spacing.
l 2. Evaluate the 8-hour I&O of a client who is receiving
a loop diuretic.
l 3. Collect urine for a client who is having a 24-hour
urine creatinine test.
l 4. Administer a cation-exchange resin enema to a
client in end-stage renal disease.
83. The charge nurse of a medical/surgical unit is making
assignments for the night shift. Which client should be
assigned to the graduate nurse who has just completed an
internship?
l 1. The client who is 1 day postoperative transurethral
resection of the prostate (TURP) who has light
pink urine in the catheter bag.
l 2. The client diagnosed with ureteral renal calculi who
is in pain and has bright red blood in the urine.
365
3. The client diagnosed with acute gastroenteritis who
is dehydrated and has arterial blood gases (ABGs)

of pH 7.48, PaCO2 44, HCO3 20, PaO2 95.
4. The client diagnosed with heatstroke who has a
serum sodium level of 150 mEq/L and is
hallucinating.
84. The nurse notices that the sharps container in the

clients room is above the fill line. Which action should
l 1. Complete an adverse occurrence report.
l 2. Discuss the situation with the charge nurse.
l 3. Change the sharps container immediately.
l 4. Notify the housekeeping department.
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ANSWERS
82. Correct answer 3: The UAP can collect the clients
366
84. Correct answer 3: The nurse should change the
urine and place in a special container for the 24-hour

urine test. The client who is third spacing (option 1)
is unstable. The UAP cannot evaluate the effectiveness of a medication (option 2), and the enema is a
medication, the administration of which cannot be
delegated to a UAP (option 4). ContentManagement;
sharps container because the container being filled

above the fill line is a violation of Occupational
Safety Health Administration (OSHA) rules and
can result in a financial fine. An adverse occurrence
report is completed for incidents occurring to clients.
No other person or department needs to be notified.

ProcessPlanning; Client NeedsSafe Effective Environment, Management of Care; Cognitive LevelSynthesis.
ContentManagement; Category of Health Alteration

83. Correct answer 1: The client with a TURP would

be expected to have light pink urine; therefore, this
client is stable and should be assigned to the new
graduate nurse. The clients with bright red blood,
metabolic alkalosis, and an elevated sodium level
are not stable and should be assigned to a more
experienced nurse. ContentManagement; Category
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SECTION SEVEN
85. The husband of a client diagnosed with chronic

kidney disease (CKD) tells the nurse, I have no idea how
I am going to take care of my wife. Which statement
would be the nurses best response?
l 1. I can contact the hospital social worker to talk
to you.
l 2. I will contact the hospital chaplain to talk to you.
l 3. Have you talked to your wifes doctor about your
concern?
l 4. Do you think your children could help take care
of your wife?
86. The nurse is caring for clients on a medical unit. For
which client should the health-care team utilize the clients
advance directive when needing to make decisions for the
client?
l 1. The client with bladder cancer who refuses to have
an ileal conduit.
l 2. The client with tertiary syphilis who has developed
dementia.
l 3. The client with CKD who is being placed on dialysis.
l 4. The client with terminal prostate cancer who is on
a ventilator.
367

(CKD) is receiving oral kayexalate, a cation exchange
resin. Which assessment data indicate the medication is
effective?
genitourinary unit. Which nursing task would be most
appropriate to delegate to the UAP?
l 1. Insert a 20-gauge angiocatheter in a client.
l 2. Empty the clients nephrostomy urine output.
l 3. Assist the client to ambulate with a gait belt.
l 4. Discuss safe sex practices with a client being
discharged.
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ANSWERS
85. Correct answer 1: A social worker is qualified to

assist the client with referrals to any agency or personnel that may be needed to care for the wife at home.
The chaplain addresses spiritual guidance; the nurse
does not need to refer this to the health-care provider;
and the nurse should not depend on the clients
children to care for the wife. ContentManagement;
Category of Health AlterationManagement; Integrated
LevelApplication.
86. Correct answer 2: The client must have lost decisionmaking capacity due to a condition that is not
reversible; dementia is not reversible. Refusing
surgery, being on dialysis, and being on a ventilator
does not mean the client has lost decision-making
capacity. ContentManagement; Category of Health
AlterationGenitourinary; Integrated Process
Implementation; Client NeedsPsychosocial Integrity;
368
87. Correct answer 3: Kayexalate is a medication that is

administered to decrease an elevated serum potassium
level; therefore, a potassium level within the normal
range of 3.55.5 mEq/L indicates the medication
is effective. ContentMedical; Category of Health
LevelAnalysis.
88. Correct answer 3: The UAP can use a gait belt to

ambulate the client. The UAP scope of practice
does not include starting IVs. A nephrostomy tube
is in the ureter, so emptying it cannot be delegated
to the UAP. Teaching also cannot be delegated.
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SECTION SEVEN
89. The primary nurse on the genitourinary unit tells

the clinical manager, Nurses are upset and arguing over
how the clients are being assigned by the charge nurse.
Which statement indicates the clinical manager has a
democratic leadership style?
l 1. The charge nurse makes the assignments and I will
not interfere.
l 2. Have you discussed your concerns with the charge
nurse?
l 3. All the nurses need to come and tell me how
they feel.
l 4. I will schedule a meeting so that the situation can
be discussed.
369
90. The female UAP on the genitourinary unit

reports low back pain after transferring a client from
the bed to the wheelchair. Which priority action should
the charge nurse implement first?
l 1. Reassign the UAPs unit assignment.
l 2. Send the UAP to the emergency department (ED).
l 3. Complete an employee occurrence report.
l 4. Notify the employee health nurse.
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ANSWERS
89. Correct answer 4: Democratic managers are peopleoriented and emphasize efficient group functioning.
The environment is open, and communication
flows both ways, which includes having meetings
to discuss concerns. ContentManagement; Category
370
90. Correct answer 4: The charge nurse should first

notify the employee health nurse as this is the chain
of command. Then the charge nurse should send
the UAP to the ED for evaluation by a health-care
provider. After that, the charge nurse can complete
the employee occurrence report and reassign
the UAPs clients to someone else if necessary.
SECTION EIGHT
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Mental Health Disorders
371
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373
Major Depression
1. Which statement indicates that the client diagnosed
with major depression and prescribed a tricyclic
antidepressant understands the nurse's medication
teaching?
l 1. I will take the medication in the morning with my
breakfast.
l 2. I should not eat any type of aged cheese or
chocolates.
l 3. If I don't start feeling better in a week I will call
my doctor.
l 4. I should not drink any type of beer, red wine, or
alcohol.
2. The client diagnosed with major depression is admitted
to the inpatient psychiatric unit. Which priority intervention
l 1. Monitor the client's nutritional status.
l 2. Assess the client for suicidal thoughts.
l 3. Assist the client with activities of daily living
(ADLs).
l 4. Allow the client to ventilate feelings.
3. The psychiatric nurse is caring for clients on an inpatient

psychiatric unit. Which task would be most appropriate to
delegate to the unlicensed assistive personnel (UAP)?
l 1. Instruct the UAP to watch the client on a
one-to-one suicide watch.
l 2. Identify alternate coping strategies with the client
who is depressed.
l 3. Discuss the side effects of the client's antidepressant
medications.
l 4. Make the client diagnosed with major depression
eat a meal.
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ANSWERS
1. Correct answer 4: The client on an antidepressant

medication should avoid any type of alcohol. The
antidepressant should be taken at night. Foods high in
tyramine should be avoided when taking monoamine
oxidase inhibitors (MAO), not a tricyclic antidepressant.
It takes 23 weeks for the therapeutic effect to be
achieved. ContentMental Health; Category of Health
AlterationPsychiatric; Integrated ProcessEvaluation;
and Parenteral Therapies; Cognitive LevelEvaluation.
2. Correct answer 2: The priority for the nurse is to

assess if the client is suicidal. All the other interventions are appropriate and pertinent, but the priority
intervention is the client's safety. ContentMental
Health; Category of Health AlterationPsychiatric;
374
3. Correct answer 1: The UAP could watch the client

who is suicidal and maintain an appropriate distance
from the client at all times. The UAP cannot teach,
and the client cannot be forced to eat without a
court order. ContentMental Health; Category of Health
AlterationPsychiatric; Integrated ProcessPlanning;
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SECTION EIGHT
4. The client diagnosed with major depression tells the

nurse, I just don't feel like living anymore. I am so
unhappy. Which response would be most appropriate
for the nurse?
l 1. You are feeling depressed. I will sit down and we
can talk.
l 2. You shouldn't be unhappy. You have a lot to be
grateful for.
l 3. Have you thought about hurting or killing
yourself?
l 4. I will need to tell the treatment team about your
comment.
5. The client diagnosed with major depression who is
taking paroxetine (Paxil), a selective serotonin uptake
inhibitor (SSRI), calls the clinic nurse and tells the nurse,
I have a high fever, my muscles are tight, and I am
sweating. Which statement is the nurse's best response?
l 1. You must notify your internal medicine doctor
about your symptoms.
l 2. You should take some Tylenol and go to bed and
call me tomorrow.
3. You need to have someone take you to the
4. When did you take your last antidepressant
375
medication?
6. The client diagnosed with major depression is crying

and tells the clinic nurse, I just don't find any pleasure
in life. Which priority intervention should the nurse
implement?
l 1. Administer the client's antidepressant medication.
l 2. Offer support by sitting quietly with the client.
l 3. Recommend the client join a support group.
l 4. Encourage the client to exercise daily.
7. The client diagnosed with major depression has put on
makeup for the first time since admission to the inpatient
psychiatric unit. Which statement would be the nurse's
best response?
l 1. You look very pretty today.
l 2. I noticed you put on makeup today.
l 3. Makeup can't be worn on the unit.
l 4. What made you decide to put on makeup?
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ANSWERS
4. Correct answer 3: If a client with major depression
376
6. Correct answer 2: Sitting quietly with the client offers
makes any comment that insinuates the client may

harm self, the nurse must ask directly if the client has
thought about suicide. That is the most important and
appropriate response. ContentMental Health; Category
the client support. Antidepressant medications take

23 weeks to become therapeutic. A support group and
exercise are appropriate interventions, but the priority is
to support the client. ContentMental Health; Category
of Health AlterationPsychiatric; Integrated Process


Implementation; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
5. Correct answer 3: The client is exhibiting signs/
7. Correct answer 2: Clients who are depressed have
symptoms of serotonin syndrome, which is a medical

emergency. The client should not take any more
medication and should be seen immediately in the
emergency department. ContentMental Health;
difficulty accepting compliments because of their low

self-esteem; therefore, commenting on a change in
behavior that suggests an improvement in the depression is the most appropriate intervention. Content
Category of Health AlterationPsychiatric; Integrated

Synthesis.
Mental Health; Category of Health AlterationPsychiatric;

Effective Care Environment, Management
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SECTION EIGHT
377
8. Which sign/symptom is most important when

assessing the client diagnosed with major depression?
l 1. The client does not find pleasure in life.
l 2. The client is unable to concentrate.
l 3. The client does not have any energy.
l 4. The client does not want to eat.
3. The client who was crying because her husband
4. The client who was threatening to take the entire
9. The nurse is caring for a client admitted to a medical

unit who is taking an antidepressant medication. Which
intervention is most appropriate when evaluating the
effectiveness of the antidepressant medication?
l 1. Assess the client's food intake for all meals.
l 2. Ask the client to rate the depression on a scale
of 110.
l 3. Notice what type of clothes the client is wearing.
l 4. Monitor the client's laboratory results.
11. The client diagnosed with bipolar disorder, manic

episode, is being admitted to the psychiatric unit.
Which signs/symptoms would the nurse expect the client
to exhibit?
l 1. Flight of ideas, extreme hyperactivity, and sleep
disturbances.
l 2. Feeling of well-being, feeling on a high, and
talkativeness.
l 3. Aggressive acting out without remorse and callous
behavior.
l 4. Overly dependent on others, makes suicidal
gestures, and argumentative.
10. The psychiatric clinic nurse is returning phone calls.

Which client should the nurse call first?
l 1. The client who needs a refill on the antidepressant
medications.
l 2. The client who reported having a runny nose and
puffy eyes.
left her.
bottle of sleeping pills.
Bipolar DisorderMania
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ANSWERS
8. Correct answer 1: The most important sign of depression is the client has a loss of pleasure in life. All the
other signs/symptoms are experienced by the client,
but the most important is loss of pleasure in life.
ContentMental Health; Category of Health Alteration
Psychiatric; Integrated ProcessAssessment; Client Needs
9. Correct answer 2: Because the nurse does not know

this client, the best way to make subjective data
objective is to put information on a 110 scale.
In an inpatient psychiatric unit, the nurse can notice
a change in appetite, dress, or activity level. Antidepressant medications do not have therapeutic serum
blood levels. ContentMental Health; Category of
Health AlterationPsychiatric; Integrated Process
LevelApplication.
378
10. Correct answer 4: The client threatening suicide is a

danger to self; therefore the nurse should call this
client first. ContentMental Health; Category of Health
AlterationPsychiatric; Integrated ProcessImplementation;
11. Correct answer 1: To be admitted to the psychiatric

unit, the signs/symptoms must be severe, such as
extreme hyperactivity. Mild mania with symptoms
described in option 2 would not require a psychiatric
unit admission; in fact, many clients like this
pleasurable feeling. Option 3 may indicate antisocial
personality, and option 4 is borderline personality.
Psychiatric; Integrated ProcessAssessment; Client
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SECTION EIGHT

bipolar disorder and prescribed lithium (Eskalith), an
antimania medication, needs more medication teaching?
l 1. My doctor will monitor my lithium level
frequently.
l 2. I need to drink at least 2000 mL of water a day.
l 3. I will have episodes of diarrhea while taking this
medication.
l 4. I should take my antimanic medication with
food.
13. The psychiatric nurse is caring for a client diagnosed
with bipolar disorder who is experiencing an acute manic
attack. Which priority intervention should the nurse
implement?
l 1. Decrease the client's environmental stimuli.
l 2. Provide finger foods that can be carried.
l 3. Use a consistent approach with caring for the
client.
l 4. Set limits for the client's intrusive behavior.
379
14. The nurse is preparing to administer lithium

(Eskalith), an antimania medication, to a client
diagnosed with bipolar disorder. The lithium level is
0.9 mEq/L. Which action should the nurse implement?
l 1. Administer the medication.
l 2. Hold the medication.
l 4. Verify the lithium level.
15. The psychiatric nurse is caring for a client diagnosed
with bipolar disorder who is in a manic state. The client
is wearing bizarre clothes, swearing at other clients, and
running around the dayroom. Which intervention should
l 1. Avoid giving attention to the client's behavior and
clothing.
l 2. Instruct the clients in the dayroom to go to their
bedrooms.
l 3. Administer an oral PRN antimania medication to
the client.
l 4. Provide a safe environment for the client away
from the dayroom.
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ANSWERS
12. Correct answer 3: Diarrhea is a sign of lithium

toxicity, and the client should notify the health-care
provider (HCP) so that a serum lithium level can
be evaluated; the client needs more medication
teaching. Monitoring the lithium level, preventing
dehydration, and taking medication with food
indicate the client understands the medication
teaching. ContentMental Health; Category of Health
13. Correct answer 2: The priority intervention is

meeting the client's physiological need, one of which
is nutrition. The other interventions are pertinent
but not priority over addressing the client's nutritional needs. Remember Maslow's Hierarchy of
Needs. ContentMental Health; Category of
LevelSynthesis.
380
14. Correct answer 1: The therapeutic serum level for

Eskalith is 0.61.5 mEq/L; therefore, the nurse
should administer the medication. ContentMental
15. Correct answer 4: Swearing at other clients and

running around the dayroom may result in a danger
to self or other clients; therefore, removing the client
and providing a safe environment is an appropriate
intervention. Avoidance, removing the other clients,
and an oral medication will not immediately help
the client. ContentMental Health; Category of Health
Client NeedsSafe Effective Care Environment, Safety and
Infection Control; Cognitive LevelSynthesis.
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SECTION EIGHT
16. The client with bipolar disorder who is taking

lithium (Eskalith), an antimania medication, has a
lithium level of 3.1 mEq/L. Which treatment would
the nurse expect the HCP to prescribe?
l 1. Keep the client nothing by mouth (NPO) and
obtain arterial blood gases (ABGs).
l 2. Initiate intravenous therapy with a 20-gauge
angiocatheter.
l 3. Prepare the client for a subclavian line insertion.
l 4. Administer the antidote for lithium toxicity.
17. The client diagnosed with bipolar disorder with
acute mania is being admitted to the psychiatric unit.
Which room should the charge nurse assign to the client?
l 1. The semiprivate room with a client who is
depressed.
l 2. The private room that is near the unit's dayroom.
l 3. The semiprivate room with the client who is
hallucinating.
l 4. The private room that is away from the nurse's
station.
381
18. The client with bipolar disorder is prescribed

carbamazepine (Tegretol), an anticonvulsant. Which data
l 1. The client is able to work daily and meet family
responsibilities.
l 2. The client takes the medication daily and has a
Tegretol level of 10 g/mL.
l 3. The client reports a 1 on a depression scale of
110 (10 severely depressed).
l 4. The client denies hearing voices and has no delusional
thoughts.
19. The client diagnosed with bipolar disorder is being
discharged home. Which intervention should the nurse
discuss with the client's significant other?
l 1. Ensure the client takes the prescribed medication
daily.
l 2. Explain the need to protect access to credit cards by
the client.
l 3. Encourage the client's significant other to take the
client to a support group.
l 4. Tell family members to act normally when around
the client.
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ANSWERS
16. Correct answer 3: Extremely high toxic levels of
382
18. Correct answer 1: Tegretol is prescribed as a mood
lithium require hemodialysis, which must be administered via a subclavian line. The therapeutic range of
Eskalith is 0.61.5 mEq/L. ABGs are not affected by
lithium, and intravenous fluids will not help this
toxic level. There is no known antidote for lithium
toxicity. ContentMental Health; Category of Health
stabilizer. Meeting family and employment responsibilities indicates the medication is effective. A therapeutic
level (for Tegretol, it is 812 g/mL) does not indicate
effectiveness. Tegretol is not an antidepressant medication, and the client does not have delusions and
hallucinations. ContentMental Health; Category of


LevelEvaluation.
17. Correct answer 4: The charge nurse should assign

the client to a quiet part of the psychiatric unit. The
client should not be assigned to a room with another
client or a room near the dayroom because it will be
too loud and busy. ContentMental Health; Category
19. Correct answer 2: If the client takes money, runs

up credit card bills, or sells community property
during the manic state, the significant other would
be responsible. The client should be responsible for
taking medication and attending support groups,
and the family members should act normally when
around the client. ContentMental Health; Category
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SECTION EIGHT
20. The male client is running and pacing in the

dayroom, is agitated with explosive behavior, and has
not slept for 2 days. Which intervention should the
nurse implement?
l 1. Take the client to the seclusion room.
l 2. Have the client throw balls in a hoop.
l 3. Talk therapeutically to the client.
l 4. Encourage the client to lie down.
Schizophrenia
21. The client is diagnosed with schizophrenia. Which
behavior would the nurse expect the client to exhibit?
l 1. Decreased energy and flat affect.
l 2. Manipulative behavior and overly dramatic.
l 3. Thought disturbances and difficulty with
communication.
l 4. Grandiosity and bizarre dress and grooming.
Page 383
383
22. The client diagnosed with schizophrenia frantically

tells the inpatient psychiatric nurse, The FBI is out to
get me. They are everywhere. Which statement is the
l 1. Why do you think the FBI is out to get you?
l 2. Let's sit down and play a game of cards.
l 3. I will get your medication and the FBI will
go away.
l 4. The FBI is not everywhere you're in the hospital.
23. The nurse is administering chlorpromazine (Thorazine),
a traditional antipsychotic medication, to the client
diagnosed with schizophrenia. Which intervention
should the nurse implement when administering this
medication?
l 1. Assess the client for akathisia and dystonia.
l 2. Administer the medication with cranberry juice.
l 3. Do not administer with foods high in tyramine.
l 4. Monitor the client's red blood cell count.
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ANSWERS
20. Correct answer 2: The client should be engaged in

noncompetitive physical activities that will help tire
the client. Secluding the client will further agitate
the client. The client is unable to talk rationally at
this time and is unable to lie down. ContentMental
Effective Care Environment, Safety and Infection
Control; Cognitive LevelSynthesis.
21. Correct answer 3: The client with schizophrenia has

delusions, hallucinations, and bizarre speech. Option
1 is depression; option 2 is personality disorder; and
option 4 is mania. ContentMental Health; Category
384
22. Correct answer 2: The nurse should not agree or

support the delusion. Distracting the client allows
the client to focus on something else. ContentMental
23. Correct answer 1: Extrapyramidal side effects, such

as akathisia and dystonia, are a major concern for
clients receiving antipsychotic medications. The
client's white blood cell (WBC) count, not the red
blood cell count, should be monitored for agranulocytosis. ContentMental Health; Category of Health
LevelApplication.
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SECTION EIGHT
24. The male client diagnosed with schizophrenia is

talking to the wall. Which action should the nurse
implement first?
l 1. Continue to monitor the client's behavior.
l 3. Ask the client if he is talking to someone.
l 4. Discuss the behavior with the treatment team.
25. The nurse is teaching the wife and the client
newly diagnosed with schizophrenia concerning the
antipsychotic medication. Which statement indicates
the client's significant other needs more teaching?
l 1. If my husband gets any flulike symptoms, I will
call his doctor.
l 2. My husband should not drink any alcohol when
taking this medication.
l 3. If my husband becomes drowsy or sleepy, I will
call his doctor.
l 4. It will take 23 weeks for the medication to work
properly.
385
26. The nurse is caring for a client in an inpatient

psychiatric unit. Which client warrants intervention
from the nurse?
l 1. The client with schizophrenia who is complaining
of hard-feeling muscles.
l 2. The client with schizophrenia who reports hearing
voices of his mother.
l 3. The client with schizophrenia who is refusing to
eat the breakfast meal.
l 4. The client with schizophrenia who is constantly
repeating words.
27. The nurse is caring for clients in an inpatient
psychiatric unit. Which intervention is the nurse's
priority intervention?
l 1. Establish a trusting relationship with the clients.
l 2. Set limits on the clients' behavior.
l 3. Praise a clients' socially acceptable behavior.
l 4. Provide a safe and secure environment.
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ANSWERS
24. Correct answer 3: If the nurse sees the client possibly
386
26. Correct answer 1: Hard rigid muscles and high
hallucinating, the nurse should discuss the observation

with the client first. Then the nurse can continue to
observe the client, document the findings, and share
the observation with the treatment team. Content
fever may indicate neuroleptic malignant syndrome,

which requires immediate intervention by the nurse.
Hallucinations and echolalia, or repeating words, are
expected behaviors of the client with schizophrenia.
Mental Health; Category of Health AlterationPsychiatric;

Client NeedsImplementation; Client NeedsSafe Effective
LevelSynthesis.

Psychiatric; Integrated ProcessAssessment; Client Needs
25. Correct answer 3: The client will experience drowsiness initially when taking the medication; the client's
wife does not understand the teaching. Flu-like
symptoms indicate agranulocytosis. ContentMental
Health; Category of Health AlterationDrug Administration; Integrated ProcessEvaluation; Client Needs
27. Correct answer 4: The nurse's priority is to provide

a safe and secure environment for all clients in the
inpatient psychiatric setting. Establishing trust, setting
limits, and praising good behavior are pertinent interventions but not priority over safety of the clients.
Psychiatric; Integrated ProcessImplementation; Client
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28. The psychiatric nurse is monitoring laboratory data

for clients. Which laboratory data require intervention by
the nurse?
l 1. The client taking valproic acid (Depakote) whose
serum drug level is 80 mcg/mL.
l 2. The client taking risperidone (Risperdal) whose
potassium level is 4.9 mEq/L.
l 3. The client taking haloperidol (Haldol) whose
platelet count is 150,000.
l 4. The client taking clozapine (Clozaril) whose
WBC count is 3000 mm3.
29. The psychiatric nurse and unlicensed assistive
personnel (UAP) are caring for clients on an inpatient
psychiatric unit. Which task would be most appropriate
l 1. Discuss the side effects of medication with a newly
admitted client.
l 2. Take vital signs on the client experiencing a high
fever and tachycardia.
387
3. Escort the client who has shuffling gait and tremors
4. Assist the client with physical hygiene and activities
to the dining room.

of daily living (ADLs).
30. The client is experiencing anticholinergic side effects

of the antipsychotic medication. Which intervention
l 1. Instruct the client to wear SPF 30 or higher when
outside.
l 2. Tell the client to chew sugarless gum and suck on
hard candy.
l 3. Encourage the client to eat a low-residue diet.
l 4. Recommend the client report this to the HCP.
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ANSWERS
28. Correct answer 4: The client with a decreased WBC

count is experiencing agranulocytosis, which requires
intervention by the nurse. All the other laboratory
data are within normal limits (WNL). ContentMental
Integrated ProcessAssessment; Client NeedsSafe Effective
LevelAnalysis.
29. Correct answer 4: The UAP can assist the client with
personal hygiene and ADLs. The client in option 2 is
exhibiting signs of neuroleptic malignant syndrome,
and the client in option 3 is exhibiting extrapyramidal
side effects. ContentMental Health; Category of Health
388
30. Correct answer 2: One anticholinergic side effect,

which is common, is a dry mouth; therefore, taking
sips of water, chewing sugarless gum, and sucking on
hard candy would be appropriate to discuss with the
client. ContentMental Health; Category of Health
Planning; Client NeedsPhysiological Integrity, Pharmacological and Parenteral Therapies; Cognitive
LevelSynthesis.
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SECTION EIGHT
389
Personality Disorders
31. The male client mistrusts others, is suspicious, and
blames others for his problems. Which type of personality
disorder is the client exhibiting?
l 1. Antisocial personality.
l 2. Paranoid personality.
l 3. Dependent personality.
l 4. Narcissistic personality.
32. The client diagnosed with an avoidant personality is
socially inhibited, feels inadequate, and is hypersensitive
to negative criticisms. Which priority intervention should
the clinic psychiatric nurse implement when caring for
this client?
l 1. Encourage the client to attend a weekly support
group.
l 2. Tell the client to socialize with others for 15 minutes
a day.
l 3. Talk to the client honestly and in a straightforward
manner to establish trust.
l 4. Identify the client's strengths and accomplishments.
33. Which individual would the nurse suspect has a

borderline personality?
l 1. The male college student who blames his parents
because he does not have enough money to live on.
l 2. The homeless woman who wears layers of clothing,
two or three knit hats, and unmatched shoes and
socks.
l 3. The high school student who suspects everyone in
the class is cheating because everyone makes a
better grade on the tests.
l 4. The woman who threatens killing herself when her
husband leaves but is out dating within the month.
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ANSWERS
390
31. Correct answer 2: A paranoid personality is charac-
33. Correct answer 4: This is an example of borderline
terized by pervasive, long-standing suspiciousness, a

mistrust of others, and fearfulness. ContentMental
personality. A person with a borderline personality

has impulsive behavior and makes suicidal gestures.
Option 1 is an example of a dependent personality;
option 2 is an example of schizotypal personality;
and option 3 is an example of paranoid personality.

Integrated ProcessDiagnosis; Client NeedsPhysiological
Analysis.
32. Correct answer 3: Establishing trust with the client is

the priority nursing intervention because without
trust the client will not be able to work with the
nurse. Encouraging weekly support groups, socialization, and identifying the client's strengths are appropriate interventions but not priority over establishing
trust. ContentMental Health; Category of Health

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SECTION EIGHT
34. The female client diagnosed with an antisocial

personality has an appointment in 30 minutes. She is
loud and obnoxious, will not sit down, and demands to
be seen immediately. Which intervention should the
clinic nurse implement when caring for this client?
l 1. Tell the client to sit down or she will not be seen at
her appointment time.
l 2. Escort the client back to the psychiatrist office so
that she can be seen next.
l 3. Ask the client to leave the waiting room and cancel
the appointment.
l 4. Request one of the staff to sit with the client in the
waiting room.
35. The wife of a client diagnosed with narcissistic
personality says to the clinic psychiatric nurse, I just
can't live with my husband anymore. Can anything be
done to help him? Which statement is the nurse's best
response?
l 1. If he would take his medication daily, this would
control his behavior.
l 2. You don't think you can live with your husband
anymore?
391
3. Individual and weekly group therapy may help
4. There is no definitive treatment to help a client
your husband.
with a personality disorder.
36. The female client has low self-esteem, is unable to

make decisions, and sees herself as stupid. Which type of
personality disorder would the nurse suspect the client as
having?
l 1. Dependent.
l 2. Histrionic.
l 3. Schizoid.
l 4. Obsessive-compulsive.
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ANSWERS
34. Correct answer 1: The nurse cannot allow the client

to manipulate the staff to be seen earlier. Setting and
maintaining limits is the most important intervention for the nurse. Allowing the client to see the
health-care provider allows the client to win.
Asking the client to leave and sitting with the client
are not appropriate interventions. ContentMental
35. Correct answer 4: There is no medication or specific

treatment to help control the symptoms for the client
with a personality disorder. A therapeutic response
(option 2) is not appropriate at this time; the wife
needs factual information. Therapy cannot help the
client with a narcissistic personality. ContentMental
392
36. Correct answer 1: The client is exhibiting the Cluster

C dependent personality. ContentMental Health;
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SECTION EIGHT
37. The client who is 3 days postoperative total knee

replacement is diagnosed with a borderline personality.
The client is demanding, yelling for the nurses, and
argumentative with the staff. The nursing staff does not
want to be assigned the client. Which intervention
should the charge nurse implement?
l 1. Request that the client be transferred to the
psychiatric unit.
l 2. Schedule a meeting to discuss the client's behavior.
l 3. Tell the staff members they have to take care of the
client.
l 4. Explain to the client to stop this behavior
immediately.
38. The husband of a client asks the nurse, Someone
told me my wife had a histrionic personality disorder.
What does that mean? Which statement is the nurse's
best response?
l 1. The person is flamboyant and always needs to be
the center of attention.
l 2. Histrionic personality means the person is very
orderly and very rigid.
393
3. Does your wife keep isolated to herself and have
4. This type of person is unable to conform to social
no close friends?
norms.
39. Which axis of the Diagnostic and Statistical Manual

of Mental Disorders (DSM-IV-TR) identifies if the client
has a personality disorder?
l 1. Axis I.
l 2. Axis II.
l 3. Axis III.
l 4. Axis IV.
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ANSWERS
37. Correct answer 2: The staff needs to be consistent

with the client and plan interventions to address the
manipulative behavior. The client cannot be transferred to the psychiatric unit, and the client cannot
help this behavior. Helping the staff deal with the
client's behavior will help the staff care for the
client. ContentMental Health; Category of Health
38. Correct answer 1: Flamboyant and a need to be the

center of attention are expressions often used to
describe a person with a histrionic personality.
Option 2 describes an obsessive-compulsive personality; option 3 describes a schizoid personality disorder; and option 4 describes an antisocial personality
disorder. ContentMental Health; Category of
394
39. Correct answer 2: Axis II contains the personality

disorders in adults. Axis I contains clinical disorders;
Axis III contains clients' general medical conditions;
and Axis IV contains psychosocial and environments
disorders. Axis V is the Global Functioning Assessment (GAF). ContentMental Health; Category of
Diagnosis; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelAnalysis.
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SECTION EIGHT
40. The Diagnostic and Statistical Manual of Mental

Disorders (DSM-IV-TR) identifies three types of personality
disorders. Which statement best describes the clusters for
clients diagnosed with personality disorders?
l 1. Clients with Cluster A disorders are odd and
eccentric.
l 2. Clients with Cluster B disorders are fearful and
anxious.
l 3. Clients with Cluster C disorders are dramatic and
emotional.
l 4. Clients with Cluster D disorders are delusional and
hallucinate.
Anxiety Disorders
41. Which signs/symptoms would the nurse expect to
assess in the client diagnosed with a generalized anxiety
disorder?
l 1. The client has repetitive behaviors that interfere
with normal functioning.
l 2. The client reports an abnormal fear of crowds or
open spaces.
395
3. The client is restless and tense and has difficulty
4. The client complains of having flashbacks and
concentrating and sleeping.

nightmares of a war.
42. The client diagnosed with a general anxiety disorder

is prescribed alprazolam (Xanax), a benzodiazepine.
medication teaching?
l 1. This medication can cause dependency so I will
only use it a short time.
l 2. I may experience some heightened excitement
while taking this medication.
l 3. I should not eat grapefruit or drink grapefruit
juice while taking this medication.
l 4. I need to take this medication four times a day
whether I am anxious or not.
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ANSWERS
40. Correct answer 1: Odd and eccentric are words

used to describe clients in Cluster A. Words that
describe Cluster B personality disorders are dramatic
and emotional. Cluster C personality disorders are
described as fearful and anxious. There are no
Cluster D personality disorders. ContentMental
41. Correct answer 3: The client with a generalized anxiety disorder has unrealistic, excessive, and persistent
(6 months or longer) anxiety and worry. Option 1
is obsessive-compulsive disorder; option 2 is claustrophobia; and option 4 is post-traumatic stress disorder.
396
42. Correct answer 1: Xanax has the potential for dependency, but this potential can be minimized by using
the lowest effective dosage for the shortest time necessary. It should not be taken routinely. Heightened excitement is a paradoxical reaction, which leads to discontinuing the medication. Grapefruit does not affect
this medication. ContentMental Health; Category of
Health AlterationPsychiatric; Integrated ProcessEvaluation; Client NeedsPhysiological Integrity, Pharmacological and Parenteral Therapies; Cognitive LevelEvaluation.
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SECTION EIGHT
43. The client diagnosed with a panic attack disorder

who is sitting in the waiting room of a psychiatric
clinic appears anxious, is starting to hyperventilate, is
trembling, and is sweating. Which intervention should
l 1. Encourage the client to take slow deep breaths.
l 2. Assess the client's vital signs.
l 3. Remove the client from the waiting room.
l 4. Administer alprazolam (Xanax), a benzodiazepine.
44. The female client who was viciously raped 1 year
ago is diagnosed with post-traumatic stress disorder
(PTSD). Which intervention should the psychiatric
nurse implement?
l 1. Encourage the client to go through a desensitization
process.
l 2. Recommend the client attend a support group for
rape victims.
l 3. Encourage the client to not talk about the
traumatic rape.
l 4. Tell the client to write her feelings in a journal and
keep it locked.
397
45. The male client with an obsessive-compulsive

disorder is washing his hands. The nurse calls the client
back to the office for his appointment, but he cannot
stop washing his hands. Which action should the nurse
implement?
l 1. Tell the client he must stop washing his hands.
l 2. Cancel the client's appointment and reschedule.
l 3. Notify the client's health-care provider (HCP) of
the situation.
l 4. Wait for the client to finish washing his hands.
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ANSWERS
43. Correct answer 1: The nurse should first tell the

client to take slow, deep breaths and then remove
the client from the waiting room. Then the nurse
can administer medication (will take 2030 minutes
to work) and assess the client's vital signs. Content
Mental Health; Category of Health Alteration
44. Correct answer 2: Support groups allow clients to

share their experience with other individuals who
have experienced similar traumatic events. Desensitization is recommended for the client with phobias.
The nurse should encourage the client to verbalize
the events, but journaling is not helpful for clients
with PTSD. ContentMental Health; Category of
LevelApplication.
398
45. Correct answer 4: This behavior is due to anxiety.

The nurse should allow the client to finish the ritual
because stopping it will increase the behavior and
may lead to violence by the client. The only time the
nurse should make the client stop the behavior is if
the client is a danger to selffor example, washing
the hands until they are raw. ContentMental Health;
LevelApplication.
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SECTION EIGHT
46. The client who was in a near-fatal car accident

3 weeks ago is diagnosed with post-traumatic stress
syndrome (PTSD) and prescribed paroxetine (Paxil), an
SSRI. The client asks the nurse, Will this medication really
help me? I don't like feeling this way. Which statement is
the nurse's best response?
l 1. Since the accident was within 1 month the Paxil
should be helpful.
l 2. The medication will make you feel better within a
couple of days.
l 3. You're worried the medication will not help
prevent the nightmares.
l 4. Individual and group therapy are the only
treatments for PTSD.
47. The client diagnosed with claustrophobia is undergoing
a desensitization process. Which intervention should the
nurse implement?
l 1. Progressively expose the client to closed-in places
along with support.
l 2. Provide negative reinforcement when there is an
increase in phobic reaction.
399
3. Discuss the desensitization process with members
4. Complete the admission assessment to the
of the support group.

psychiatric unit.
48. The client with an obsessive-compulsive disorder

must check to see if the windows are locked every
night for at least 2 hours before going to bed. Which
intervention would be most appropriate for the nurse to
l 1. Recommend the client's significant other check the
windows instead of the client doing so.
l 2. Ask why the client feels the need to check the
windows more than once.
l 3. Discuss the need to have an alarm system installed
in the client's home.
l 4. Tell the client to gradually decrease the amount of
time checking the windows.
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ANSWERS
46. Correct response 1: SSRIs reduce the three core
400
48. Correct answer 4: Gradually limiting the amount of
symptoms of PTSD: re-experiencing, avoidance/

emotional numbing, and hyperarousal. The medication is most effective when started within 3 months of
the traumatic event and may take up to 23 months
for maximal response. ContentMental Health;
time for the ritual helps the client with an obsessivecompulsive disorder. The compulsive act is due to
anxiety; therefore, the significant other checking the
windows or putting in an alarm system will not stop
the compulsive act. ContentMental Health; Category


47. Correct response 1: The treatment for phobias is

desensitization, which is gradually exposing the
client to the situation that triggers the irrational fear
while providing support. Positive reinforcement is
given when there is a decrease in the phobic reaction;
desensitization is not implemented in a group
setting; and inpatient treatment is not required.
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SECTION EIGHT
401
Cognitive Disorders
49. The client is having an acute anxiety attack. Which
priority intervention should the nurse implement?
l 1. Help the client recognize signs of an anxiety attack.
l 2. Provide the client with a safe environment.
l 3. Discuss alternate coping strategies with the client.
l 4. Determine if the client has had any caffeine or
nicotine.
50. The psychiatric nurse is working with clients
diagnosed with generalized anxiety disorders, phobias,
obsessive-compulsive disorders, and post-traumatic stress
syndrome. Which intervention is most important when
working with these clients?
l 1. Teach the client about the prescribed medications.
l 2. Allow the client to ventilate feelings about anxiety.
l 3. Avoid being judgmental when talking to the client.
l 4. Provide positive reinforcements when the client
makes progress.
51. The 78-year-old female client who is 1 day

postoperative right hip repair is confused and does not
recognize her family members. The client's son asks the
nurse, What is going on? She was fine before she fell.
l 1. Sometimes the anesthesia can cause the client to
become confused.
l 2. She may be experiencing delirium, which is
reversible with time.
l 3. Your mother may have developed dementia since
the accident.
l 4. You are concerned because you don't know what
is going on.
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ANSWERS
49. Correct answer 2: Safety for the client is the priority

intervention. During an acute attack the client is
unable to learn new information. Caffeine and
nicotine should be decreased, but it is not appropriate
to determine if the client had any caffeine or nicotine during an acute anxiety attack. ContentMental
50. Correct answer 3: The nurse must establish a trusting relationship with the client. This includes being
nonjudgmental, listening to the client, and providing
a calm environment. Teaching about medications,
verbalizing feelings, and providing positive reinforcements are appropriate interventions, but the most
important is to establish trust. ContentMental
Synthesis.
402
51. Correct answer 2: Delirium is caused by an acute

stressor (the fall and surgery) and is usually reversible.
The acute onset of confusion makes this delirium,
instead of dementia, which has a gradual onset of
confusion. Option 4 is a therapeutic response, but
the nurse should provide factual information to
the son. ContentMental Health; Category of Health
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SECTION EIGHT
52. The wife of an 81-year-old client newly diagnosed

with Alzheimer disease tells the nurse, My husband has
been getting more forgetful and lies to me so I won't
know he is forgetting things. Which statement is the
l 1. Your husband lies to you so that you won't realize
his is getting more confused.
l 2. Why do you think your husband is lying to you
after being married for 50 years?
l 3. Your husband is getting older and maybe he
should start writing down information.
l 4. He is using confabulation, which is not lying
but is making excuses to protect his ego.
53. The nurse is teaching the husband of a woman
diagnosed with Alzheimer disease about home care.
client's husband?
l 1. Provide a variety of activities to keep the client
occupied.
l 2. Tell him to help his wife dress in the morning.
403
3. Discuss the importance of providing a consistent
4. Tell the husband to have different people take care
environment.
of his wife.
54. The daughter of an 85-year-old woman calls the

clinic and tells the nurse, My mother is acting strangely.
She is not dressed, hasn't bathed in a few days, and is
acting like she is hearing and seeing things. Which
l 1. Instruct the daughter to take her mother to the
l 2. Schedule an appointment for the mother to be seen
in the clinic today.
l 3. Ask the daughter if the mother has any type of
substance abuse problem.
l 4. Determine when was the last time someone visited
the mother.
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ANSWERS
52. Correct answer 4: Confabulation is not lying, and it

is used by the client with dementia to help protect
the ego and decrease anxiety related to being confused and forgetful. The nurse should provide the
wife with facts. ContentMental Health; Category of
53. Correct answer 3: The client needs a consistent,

safe environment and a consistent caregiver. Change
increases anxiety and confusion. The client should
have simple tasks and activities with limited variety
because the client has difficulty making decisions.
The husband should encourage self-care as much as
possible. ContentMental Health; Category of Health
404
54. Correct answer 4: The first intervention is to try

and determine the onset of this behavior. The client
should be seen by a health-care provider either at
the clinic or the emergency department. Substance
intoxication or withdrawal could cause this behavior,
but the first intervention is to get an accurate history.
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SECTION EIGHT
55. The nurse is teaching the family and client who is

diagnosed with vascular dementia. Which statement best
describes this cognitive disorder?
l 1. This disorder has an abrupt, episodic onset with
multiple remissions.
l 2. It is a genetic, progressive, degenerative disorder
with motor and cognitive changes.
l 3. This dementia is caused by eating contaminating
beef and is called mad cow disease.
l 4. The client has extrapyramidal signs, visual
hallucinations, and fluctuating cognition.
56. The nurse and UAP are caring for clients in a locked
Alzheimer unit. Which action by the UAP would require
l 1. The UAP is calling the client honey and sweetie.
l 2. The UAP is assisting the client to take a shower.
l 3. The UAP is preparing the client's lunch tray.
l 4. The UAP did not lock the door after leaving
the unit.
405
57. The client with Alzheimer disease is prescribed

tacrine (Cognex), an acetylcholinesterase inhibitor.
client's family member who will be responsible for giving
the medication?
l 1. Instruct the family member to give the medication
with food.
l 2. Explain that this medication will prevent further
deterioration.
l 3. Recommend an increase in the client's fluid intake
to 3000 mL a day.
l 4. Administer the medication at night only to help
the client sleep.
58. The son of a 68-year-old client tells the clinic nurse
his mother has been becoming more confused lately.
l 1. Explain that confusion is common as people get
older.
l 2. Complete a Mini-Mental Status Examination
(MMSE).
l 3. Request the HCP to order a CT scan.
l 4. Assess the client's cranial nerve function.
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ANSWERS
55. Correct answer 1: In vascular dementia, brain tissue

is destroyed by intermittent emboli, which can range
from a few to more than a dozen. The emboli cause
focal neurological signs such as one-sided weakness
and emotional disturbances. Option 2 is Huntington
disease; option 3 is Creutzfeldt-Jakob disease; and
option 4 is dementia with Lewy bodies. Content
Mental Health; Category of Health Alteration
Psychiatric; Integrated ProcessDiagnosis; Client
56. Correct answer 4: This is a safety issue for the clients;
406
57. Correct answer 1: Administering the medication

with food will help decrease gastrointestinal upset.
The medication may help delay Alzheimer symptoms,
but it will not prevent further deterioration. Increasing fluids is not needed for this medication, and the
medication does not help the client sleep. Content
Mental Health; Category of Health AlterationDrug
58. Correct answer 2: Confusion in the elderly is often
therefore, this requires immediate intervention.

The UAP should call the clients by their names, not
honey, but this does not require immediate intervention. Assisting the client with a shower and preparing
a lunch tray are appropriate actions by the UAP.
accepted as normal, but it is not. The client who is

becoming confused should be evaluated for cognitive
functioning through use of the MMSE. Confusion
can have a physiological etiology, which may require
further testing, including a CT scan or complete
neurological examination. ContentMental Health;


Care Environment, Safety and Infection Control;
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SECTION EIGHT
59. The wife of a client with stage 3 Alzheimer disease

tells the nurse, I am physically and mentally exhausted.
I don't know what else to do. Which recommendation
would be most important for the nurse to discuss with
the wife?
l 1. Consider admitting the client to a long-term care
facility (LTCF).
l 2. Arrange for respite care to come to the home at
least 2 days a week.
l 3. Encourage the wife to attend an Alzheimer support
group.
l 4. Make an appointment with the HCP to have a
physical examination.
60. The nurse and UAP are caring for clients in a locked
Alzheimer unit. Which task would be most appropriate
l 1. Instruct the UAP to reorient a client to the
orientation board.
l 2. Ask the UAP to play a game of monopoly with
several clients.
407
3. Tell the UAP to give a client an antacid for
4. Ask the UAP to escort a client outside to smoke
indigestion.
a cigarette.
Eating Disorders
61. The 16-year-old female client in the clinic weighs
42 kg and is 67 inches tall. Which assessment data are
most important for the nurse to obtain?
l 1. Determine if the client participates in sports.
l 2. Have the client keep a 3-day food diary.
l 3. Talk with the parents about the client's weight.
l 4. Ask the client how she is doing in school.
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ANSWERS
59. Correct answer 2: Respite care arranges for someone

to come to the client's home so that the significant
other can have a break from caring for the loved
one. Admitting the client to an LTCF, attending a
support group, and having a physical examination
may be implemented but arranging for relief is
most important. ContentMental Health; Category
60. Correct answer 1: All staff should reorient the

clients to the orientation board, which has the
date, type of weather outside, and other pertinent
information. The client with Alzheimer should
participate in simple activities; the UAP cannot
administer any medications; and the UAP needs to
stay on the unit, not take a client outside to smoke.
408

what the client is eating and how much. A young
female who is 5'7" tall and weighs 92.4 pounds
should be evaluated for anorexia. ContentMental
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SECTION EIGHT
62. The 10-year-old overweight client complains of

being thirsty and tired all the time. Which assessment
data should the nurse evaluate?
l 1. Determine the amount of soft drinks and candy
bars the client consumes.
l 2. Check to see if the child's parents are overweight.
l 3. Obtain liver function studies and an
electrocardiogram.
l 4. Assess the client's blood pressure and the skin on
the client's neck.
63. The 40-year-old male client tells the nurse, I have
been overweight all of my life and have tried every diet
around, but I can't lose weight. Which intervention
l 1. Tell the client to ask the HCP for a diet drug
prescription.
l 2. Determine what specific diets the client has tried
and the results.
l 3. Refer the client to a bariatric clinic for surgery.
l 4. Assess the client's body mass index (BMI).
Page 409
409
64. The mother of an adolescent girl tells the nurse she

found several boxes of stimulant laxatives in the girl's room.
The adolescent is a normal body size for her height. Which
question should the nurse ask the mother?
l 1. How long has your daughter had problems with
her bowels?
l 2. How often does your daughter participate in
school activities?
l 3. Does your daughter spend a long time in the
bathroom after meals?
l 4. Has your daughter been feeling depressed about
how she looks?
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ANSWERS
62. Correct answer 4: The client should be checked for

signs of hyperinsulinemia, signs of which include
dark, dirty-looking skin on the neck and elevated
blood pressure. These are acanthosis nigricans (AN)
markers and indicate the client is at risk for type 2
diabetes mellitus. The amount of junk food the
client eats will not directly give the nurse information about AN. ContentMental Health; Category
63. Correct answer 2: The nurse should first assess what

the client has tried in order to determine where to
refer him. Then the nurse should assess the BMI and
possibly have the client discuss medications with his
HCP or consider surgery. ContentMental Health;
LevelSynthesis.
410
64. Correct answer 3: Use of laxatives and inducing

vomiting after a meal are signs of bulimia. The nurse
should assess for this disease. Clients with bulimia
are usually of a normal weight but go to extremes
to maintain their weight. ContentMental Health;
LevelAnalysis.
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SECTION EIGHT
65. The client diagnosed with anorexia-bulimia is admitted

to the medical unit for cardiac complications. Which task
should the nurse delegate to the UAP?
l 1. Instruct the UAP to show the client a high-calorie
meal plan.
l 2. Have the UAP sit with the client for 4560 minutes
after the meal.
l 3. Request the UAP to talk with the client about the
dangers of malnutrition.
l 4. Tell the UAP to work with the client to set
weight goals.
66. The nurse is working with obese clients. Which
information should the nurse include in the teaching?
l 1. Tell the client that to maintain weight there must
be a change in eating behaviors.
l 2. Recommend that the client lose at least 45 pounds
every week.
l 3. Encourage the client to exercise 1 hour on the same
day each week.
l 4. Instruct the client to weigh and measure foods
consumed at mealtimes only.
411
67. The female client tells the nurse that she is considering
using the over-the-counter medication orlistat (Xenical), a
lipase inhibitor. Which information is most important for
the nurse to teach the client?
l 1. Tell the client to adhere to a strict fat-free diet.
l 2. Teach the client to refrain from vitamins while
taking orlistat.
l 3. Remind the client of the importance of tapering off
the medication.
l 4. Discuss how much weight the client wants to lose.
68. The client with acquired immune deficiency syndrome
(AIDS) is diagnosed with protein calorie malnutrition and
prescribed megestrol (Megacel), a progestin. Which data
l 1. The client has no nausea and vomiting.
l 2. The client eats at least 50% of the meals.
l 3. The client gained 2 pounds in 1 week.
l 4. The client will drink Ensure at night.
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ANSWERS
65. Correct answer 2: The UAP can sit with the

client to make sure that the client does not induce
vomiting after a meal. The dietitian or nurse should
plan meals, discuss malnutrition, and set goals.
66. Correct answer 1: Behavior modification is necessary

if the client is to maintain weight loss. A 12 pound
weight loss every week is the appropriate goal.
Exercise should be for 30 minutes at least 3 days a
week. If the client is weighing and measuring food,
then all food, not just that eaten at mealtimes, must
be weighed and measured. ContentMental Health;
412
67. Correct answer 1: Orlistat works by interfering with

the absorption of fats in the gastrointestinal (GI) tract.
This can cause oily spotting, flatulence with discharge,
fecal urgency, and fecal incontinence when the client
eats fats. The client should take vitamins and does not
need to taper off the medication. ContentMental
68. Correct answer 3: Megestrol is a progestin that has

the side effect of appetite stimulation. A weight gain
indicates the medication is effective. Eating 50% of
meals, no nausea and vomiting, and drinking supplemental calories do not indicate the medication is
effective. ContentMental Health; Category of Health
LevelEvaluation.
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SECTION EIGHT
69. The nurse is counseling a female client diagnosed

with anorexia. Which psychosocial client goal should the
nurse and client set?
l 1. The client will state one positive physical attribute
about herself.
l 2. The client will not induce vomiting after meals for
1 week.
l 3. The client will exercise for 30 minutes three times
a week.
l 4. The client will gain 1 pound every 710 days.
70. After the holiday season the clinic nurse weighed
the client who is overweight, and the client had gained
2 pounds. Which statement is the nurse's best response?
l 1. You know that you should not overeat during the
holiday season.
l 2. Why would you get off your diet just because it
was a holiday?
413
3. Two pounds is not bad. Don't get discouraged;
4. I must document your 2-pound weight gain in
just start back eating properly.

your chart.
Substance Abuse Disorder

71. The client who has chronic alcoholism is admitted to
the hospital for a medical problem. Which medication
will the nurse administer to prevent neurological
complications from alcohol withdrawal?
l 1. Chlordiazepoxide (Librium), a benzodiazepine.
l 2. Clonidine (Catapres), an alpha-adrenergic blocker.
l 3. Disulfiram (Antabuse), an abstinence medication.
l 4. Thiamine (vitamin B1), a vitamin.
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ANSWERS
69. Correct answer 1: This is a psychosocial goal.

Inducing vomiting is done by clients with bulimia.
Weight gain is a physiological goal. The client
usually over-exercises to prevent weight gain.
Psychiatric; Integrated ProcessDiagnosis; Client Needs
70. Correct answer 3: The nurse should not discourage

the client. The nurse should encourage the client to
continue to lose weight. The client does not owe the
nurse an explanation as to why. Options 1 and 4
are judgmental and condescending. ContentMental
414
71. Correct answer 4: Thiamine is a vitamin prescribed

for clients with chronic alcoholism to prevent the
neurological complication of Wernicke encephalopathy. Librium prevents delirium tremens; Catapres
lessens withdrawal symptoms; and Antabuse is
administered to keep the client from consuming
alcohol. ContentMental Health; Category of Health
LevelSynthesis.
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SECTION EIGHT
72. The nurse is working in an inpatient drug and

alcohol rehabilitation program. Which referral is most
appropriate to help the client with a substance abuse
problem remain drug-free after discharge?
l 1. Obtaining employment in a drug-related field.
l 2. Having a supportive significant other to assist the
client.
l 3. Attending Narcotics Anonymous (NA) self-help
support meetings.
l 4. Counseling by a psychologist who specializes in
drug-abuse clients.
73. The female client who has smoked cigarettes since
she was an adolescent asks the clinic nurse Is there
anything I can take to help me stop smoking? Which
l 1. You should attend a smoking cessation support
group.
l 2. Reduce the number of cigarettes you smoke each
day by one.
415
3. You should try a nicotine patch to help with the
4. The drugs used to help alcoholics quit are helpful
craving.
with all addictions.
74. The male client is prescribed methadone, an opiate

agonist. Which intervention is most important for the
nurse to teach the client?
l 1. Take the medication with an antacid to prevent
nausea.
l 2. Teach the client to increase the fiber in the diet.
l 3. Discuss taking the methadone only if respirations
are greater than 16.
l 4. Instruct to rise slowly when changing positions
from lying to standing.
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ANSWERS
72. Correct answer 3: Attending regular NA meetings
416
74. Correct answer 4: Methadone causes lightheadedness,
will keep the client focused on remaining abstinent

from drugs. Significant others may or may not be
helpful. The client should not obtain a job in a
drug-related field, such as bartending. Counseling is
once a week at best, but the client must face the
problem daily. ContentMental Health; Category of
dizziness, and a transient fall in blood pressure; therefore, the nurse should discuss ways to prevent
orthostatic hypotension. Methadone also causes
gastrointestinal distress and constipation, but the
most important teaching is safety. The client does not
need to check respirations. ContentMental Health;

Planning; Client NeedsPsychosocial Integrity;

LevelSynthesis.
73. Correct answer 3: The client wants something to

take to help her stop. A nicotine patch or nicotine
gum will help with withdrawal from this drug.
Smoking cessation groups may help psychologically,
but not physically. Reducing the number of cigarettes will not help the physiological withdrawal, and
option 4 is a false statement. ContentMental Health;
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75. The client has been using crack cocaine daily for the
last 2 years and repeated outpatient interventions have
been unsuccessful. Which intervention should the clinic
nurse recommend at this time?
l 1. Use of daily acupuncture treatments.
l 2. Placement in an inpatient facility.
l 3. Intensive aversion therapy.
l 4. Persuasion and psychotherapy.
76. The client admitted to the intensive care unit from
the emergency department who was diagnosed with a
myocardial infarction (MI) is emaciated and appears
malnourished. Which assessment data are most important
for the nurse to obtain?
l 1. Ask the client to do a nutritional food recall diary.
l 2. Determine if the client drinks alcohol and
how much.
l 3. Obtain a current troponin level.
l 4. Request a STAT electrocardiogram (ECG).
417
77. The female client found wandering at the side of the

road is brought to the emergency department (ED) by
paramedics with complaints of being weak and sleepy.
The client cannot remember her name or where she was
prior to being brought to the ED. Which intervention
should the nurse prepare to implement first?
l 1. Prepare for a rape examination.
l 2. Institute a psychiatric consult.
l 3. Allow the client to sleep.
l 4. Schedule a CT scan of the head.
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ANSWERS
75. Correct answer 2: Treatment of crack cocaine is

extremely difficult. If outpatient treatments have
failed, then admission to an inpatient facility where
access to the drug is limited may be beneficial.
Acupuncture, persuasion, and psychotherapy can
be done on an outpatient basis. Aversion therapy is
useful with alcohol. ContentMental Health; Category
LevelApplication.
76. Correct answer 2: The emaciated client should be

assessed for chronic alcoholism to determine if the
client is at risk for withdrawal. A nutrition recall
diary would be inappropriate for a client newly diagnosed with an MI, requiring too much energy at this
time. The troponin level and ECG from the ED will
be sufficient at this time. ContentMental Health;
418

LevelAnalysis.
77. Correct answer 1: This client is exhibiting symptoms of the date rape drug Rohypnol and should
be given a rape examination. A psychiatric consult is
not needed at this time. The nurse should intervene,
not just allow the client to sleep. A CT scan may
or may not need to be done, but it is not the first
intervention. ContentMental Health; Category of
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SECTION EIGHT
78. The female student at a high school presents to the

school nurse complaining she has chest pain and feels
like her heart is racing. The nurse suspects the client has
taken amphetamines. Which intervention should the
l 1. Call 911 and have the paramedics transport the
client to the hospital.
l 2. Notify the parents that the student is taking
amphetamines.
l 3. Check the client's pulse, respirations, and blood
pressure.
l 4. Assess the client's mood elevation, appetite, and
progress in classes.
79. Which assessment data indicate to the nurse the
client is using marijuana?
l 1. Agitation, dizziness, and tremors.
l 2. Increased self-confidence and paranoid ideation.
l 3. Kaleidoscopic images and emotional mood swings.
l 4. Euphoria, sedation, and hallucinations.
419
80. The adolescent client is brought to the emergency

department from a party where it was determined the
participants were sniffing a chemical solvent with
chloroform as the main ingredient. Which intervention
l 1. Place the client on oxygen via nasal cannula.
l 2. Monitor the client's heart rhythm.
l 3. Obtain cardiac enzymes and an ECG.
l 4. Have the lab draw a STAT creatinine level.
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ANSWERS
78. Correct answer 3: Assessing for the cardiovascular

effects of amphetamines is priority. Notifying the
emergency medical services system should be done if
the nurse determines an irregular cardiac rhythm and
hypertension. Mood elevation, loss of appetite, and
class work could indicate taking amphetamines but
are not most important to assess. ContentMental
79. Correct answer 4: Euphoria, sedation, and hallucinations are the three principal subjective effects of
marijuana. Agitation, dizziness, and tremors are signs
of cocaine overdose. Increased self-confidence and
paranoid ideation are associated with amphetamines.
Kaleidoscopic images and mood swings are caused
by LSD. ContentMental Health; Category of Health
AlterationPsychiatric; Integrated ProcessAssessment;
420
80. Correct answer 1: The nurse would perform all

of the activities listed, but because respiratory
depression leading to death can occur after sniffing a
chemical solvent, placing the client on oxygen is the
first intervention. ContentMental Health; Category
LevelSynthesis.
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SECTION EIGHT
421
Management
81. The nurse in the outpatient psychiatric unit is
returning phone calls. Which client should the
psychiatric nurse call first?
l 1. The female client diagnosed with depression whose
significant other called to state the client is sleeping
20 hours a day.
l 2. The male client diagnosed with schizophrenia who
is hearing voices telling him he is Jesus Christ.
l 3. The male client diagnosed with major depression
whose wife left him and states he has nothing to
live for.
l 4. The client diagnosed with bipolar disorder whose
mania is now becoming depressive and the client
wants the mania back.
82. The nurse and a UAP are caring for children in
a psychiatric unit. Which client requires immediate
intervention by the psychiatric nurse?
l 1. The 10-year-old child diagnosed with oppositional
defiant disorder who is complaining the UAP does
not like him.
l
l
l
2. The 7-year-old child diagnosed with pervasive

developmental disorder who is practicing her
spelling words with the UAP.
3. The 9-year-old child diagnosed with conduct
disorder who is sitting and watching television
when he should be in class.
4. The 12-year-old mentally retarded girl who is
banging her head against the concrete floor and
has a nosebleed.
83. The female client diagnosed with major depression is

returning to the psychiatric unit after attending a music
therapy class. Which intervention should the nurse
implement first?
l 1. Request the client to sing a song in the dayroom.
l 2. Determine if the client took her medication.
l 3. Ask the client to share how the class went.
l 4. Check the client for sharps or dangerous objects.
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ANSWERS
81. Correct answer 3: The nurse should determine if

the client has a plan for suicide. This is the first
client the nurse should contact. Options 1, 2, and 3
are expected for the disease process. ContentMental
Health; Category of Health AlterationManagement;
82. Correct answer 4: This child has injured herself,

and the nurse should attend to this injury first.
Complaining that someone does not like them and
not attending class are expected with the disorders
the clients have. Interacting with a UAP is progress
for a client with pervasive developmental disorder
(autism). ContentMental Health; Category of Health
422
83. Correct answer 3: Asking the client to share her

thoughts about the therapy is supporting the therapy
and helps the nurse determine if the client is participating in therapy. The client may not want to sing a
song; the nurse is responsible for administering
medications; and the client is checked for sharps
returning from day/week-end passes. ContentMental
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SECTION EIGHT
84. The psychiatric nurse is working in an outpatient

mental health clinic. Which client should the nurse
intervene with first?
l 1. The client with postpartum depression who had a
baby 2 months ago and tells the nurse her baby is
at the day-care center.
l 2. The client with schizophrenia whose wife tells the
nurse that he is hearing voices telling him he
should be dead.
l 3. The client with antisocial personality disorder who
tells the nurse he should be the new vice president
of his company.
l 4. The client with obsessive-compulsive disorder
(OCD) who is rocking compulsively back and
forth in a chair by the window.
85. The charge nurse received laboratory data for clients
in the psychiatric unit. Which client data warrant
notifying the psychiatric HCP?
l 1. The client on lithium (Eskalith) whose serum
lithium level is 2.0 mEq/L.
l 2. The client on clozapine (Clozaril) whose white
blood cell count is 8000 mm3.
423
3. The client on methadone whose potassium level is
4. The client on donepezil (Aricept) whose glucose
4.0 mEq/L.
level is 128 mg/dL.
86. The clinical manager assigned the psychiatric nurse

a male client diagnosed with major depression who
attempted suicide by tying sheets together to hang
himself. Which intervention by the psychiatric nurse
would warrant intervention by the clinical manager?
l 1. The nurse places the client in the seclusion room
to sleep.
l 2. The nurse encourages the client to discuss his
feeling of despair.
l 3. The nurse allows the client to watch television in
the dayroom.
l 4. The nurse tells the client he is not allowed to have
sleeping medications.
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ANSWERS
84. Correct answer 2: This client should be assessed

for suicidal risk. The baby in day care is safe at the
moment. Clients with antisocial disorders think
they deserve the best, and rocking by the window
compulsively is a sign of OCD. ContentMental
Control; Cognitive LevelAnalysis.
85. Correct answer 1: The therapeutic serum level of

lithium is 0.61.5 mEq/L. This information should
be immediately relayed to the HCP. The white blood
cells and potassium are within normal limits, and the
glucose is only slightly elevated. ContentMental
424
86. Correct answer 1: The client who has attempted

suicide should be on one-on-one observation.
Placing the client in a room alone allows the client
to make another attempt at suicide. Encouraging
verbalization of feelings, watching television where
he is observed, and refusing to give the client
sleeping medications are appropriate activities.
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SECTION EIGHT
87. The charge nurse is caring for clients in an acute care

psychiatric unit. Which client would be most appropriate
for the charge nurse to assign to a licensed practical nurse
(LPN)?
l 1. The client diagnosed with Alzheimer disease who
has begun to seize.
l 2. The client diagnosed with schizophrenia who is
experiencing tardive dyskinesia.
l 3. The client diagnosed with bipolar disorder who has
a lithium level of 1.0 mEq/L.
l 4. The client diagnosed with alcoholism who is
experiencing Wernicke encephalopathy.
425
88. Which task would be appropriate for the psychiatric

charge nurse to delegate to the UAP?
l 1. Instruct the UAP to escort the client to the
multidisciplinary team meeting.
l 2. Ask the UAP to conduct a class on psychiatric
medications for the clients.
l 3. Tell the UAP to take care of the client who is
hallucinating and angry.
l 4. Request the UAP to draw the morning blood
studies on all the clients.
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ANSWERS
87. Correct answer 3: Because this client has a normal

level of lithium (0.61.5), the LPN can care for this
client. Clients with seizures; clients with tardive
dyskinesia, a potentially life-threatening complication; and clients with Wernicke encephalopathy, a
severe complication of chronic alcoholism, should be
assigned to an experienced registered nurse (RN).
Psychiatric; Integrated ProcessPlanning; Client Needs
426
88. Correct answer 1: The UAP can escort clients to

meetings. The UAP should not be delegated teaching, unstable clients, or work that is appropriate for
lab personnel. ContentMental Health; Category of
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SECTION EIGHT
89. The female client in the psychiatric unit requests the

male UAP to take her to the gift shop for a soda. Which
action would warrant intervention by the psychiatric
nurse?
l 1. The UAP checks to see what privileges the client is
allowed to have.
l 2. The UAP stops what he is doing and takes the
client to the gift shop.
l 3. The UAP tells the client that she can go when the
UAP takes all the clients.
l 4. The UAP reports the client's request to the charge
nurse of the unit.
427
90. The UAP on the psychiatric unit has tried to calm

the client who is angry and attempting to fight another
client. The nurse observes the UAP allowing the client to
continue the argument. Which intervention should the
l 1. Inform the UAP to perform a take down of the
client.
l 2. Discuss why the UAP did not intervene to stop a
fight.
l 3. Document the UAP's behavior in the personnel file.
l 4. Review procedures for dealing with out-of-control
clients.
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ANSWERS
89. Correct answer 2: Clients on a psychiatric ward

have to learn boundaries. The UAP should not interrupt work being done to immediately comply with a
social request. The UAP should check to make sure
the client has privileges and can take the client when
it is time for the outing, and the charge nurse should
be notified of the request. ContentMental Health;
428
90. Correct answer 1: Client safety is priority. The

first intervention is to perform a take down and
stop the aggressive behavior. Then the nurse should
review procedures, discuss the behavior, and
document the behavior for the file. ContentMental
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429
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SECTION NINE
Womens Health
431
Pelvic Floor Dysfunction

1. The nurse is instructing the female client experiencing
urinary incontinence. Which data should the nurse assess
when teaching Kegel exercises to the client?
l 1. Determine if the client can stop and hold her
stream of urine.
l 2. Ask the client if she uses tampons during her menses.
l 3. Palpate the clients lower abdomen for bladder
distention.
l 4. Request the client to keep a 24-hour log of voiding
times.
2. The nurse is caring for a 65-year-old female client who
requests a peri-pad. Which question would be most
appropriate for the nurse to ask the client?
l 1. How long have you been having your period?
l 2. I need to obtain a doctors order so it will be
paid for.
l 3. Are you experiencing any abdominal cramping?
l 4. Do you have stress incontinence when you cough?
3. A 56-year-old female client tells the clinic nurse,

I have low back pain and feel like something is falling
out between my legs. Which statement is the nurses best
response?
l 1. How often do you have sexual intercourse?
l 2. Are you experiencing vaginal dryness?
l 3. Your doctor should check for uterine prolapse.
l 4. It sounds like you may have a cystocele or
rectocele.
4. The nurse caring for an elderly female client suspects
the client is experiencing stress incontinence. Which
statement should the nurse make when discussing this
concern?
l 1. Do you have a bowel movement every day?
l 2. Do you ever unexpectedly lose urine?
l 3. Do you have to wear tampons all the time?
l 4. Do you experience anxiety when urinating?
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ANSWERS
1. Correct answer 1: The client will not be able to

perform Kegel exercises correctly if she is unable to
stop and hold her stream of urine. Tampon use,
assessing for bladder distention, and voiding times
are not pertinent assessment data when teaching
Kegel exercises. ContentMedical; Category of Health
AlterationGynecology; Integrated ProcessPlanning;
Client NeedsPsychological Integrity, Psychological
2. Correct answer 4: A 65-year-old female client would

not be having a period and the peri-pad would be
for urine incontinence; therefore, asking about stress
incontinence would be the most appropriate question.
Gynecology; Integrated ProcessAssessment; Client Needs
Psychological Integrity, Psychological Adaptation;
432
3. Correct answer 3: Symptoms of uterine prolapse

include feeling of pelvic fullness and pressure with low
back pain. The client may express these symptoms as
a feeling everything is falling out. ContentMedical;
Category of Health AlterationGynecology; Integrated
LevelAnalysis.
4. Correct answer 2: Clients may be reluctant to discuss

problems with urinary incontinence; therefore, the nurse
must ask the client direct questions to encourage the
client to discuss problems or concerns. ContentMedical;
ProcessAssessment; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelAnalysis.
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SECTION NINE
Womens Health
433
5. The nurse is discussing stress incontinence with the

female client. Which intervention should the nurse
l 1. Instruct the client to decrease fluid intake to
1000 mL/day.
l 2. Encourage the client to walk at least 30 minutes
every day.
l 3. Tell the client to refrain from consuming caffeinated
drinks.
l 4. Discuss the importance of increasing daily fiber
intake.
7. The client diagnosed with uterine prolapse is 6 hours

postoperative vaginal hysterectomy. Which intervention
l 1. Instruct the client not to insert anything into the
vagina for 46 weeks.
l 2. Notify the health-care provider (HCP) if the
incision is reddened or swollen.
l 3. Tell the client to expect a period-like blood flow for
2 weeks after surgery.
l 4. Discuss the need to take estrogen replacement
medication for life.
6. The elderly female client diagnosed with overactive

bladder is prescribed tolterodine (Detrol), a nonselective
muscarinic antagonist. Which statement by the client
would cause immediate intervention by the nurse?
l 1. I am so glad that I dont have to urinate every hour.
l 2. I suck on sugar-free hard candy because my
mouth is dry.
l 3. I get my blood pressure checked every time I go
to my pharmacy.
l 4. I have to use eyedrops every day for my glaucoma.
8. The client diagnosed with a rectocele is 8 hours

postoperative posterior colporrhaphy and has not
urinated since surgery. Which intervention should the
l 1. Perform an in-and-out urinary catheterization.
l 2. Assess urinary volume with a bladder scan.
l 3. Assist the client to ambulate to the bathroom.
l 4. Increase the clients oral fluid intake.
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ANSWERS
5. Correct answer 3: Alcohol and caffeine can irritate the

bladder and increase urinary incontinence. Decreasing
fluid intake may worsen the incontinence because the
bladder does not fill to its normal capacity. Walking and
increasing fiber intake would help decrease constipation.
Normal bladder capacity is individualized per client;
it is how much the client normally can contain in the
bladder, and not filling to capacity routinely will
decrease bladder size. ContentMedical; Category of
Health AlterationGynecology; Integrated Process
6. Correct answer 4: Detrol is an anticholinergic medication, which is contraindicated in clients diagnosed with
glaucoma because it causes a midratic reaction and can
further exacerbate glaucoma. Decreased urination is
the rationale for administering Detrol, and dry mouth
is an expected side effect. ContentMedical; Category
of Health AlterationGynecology; Integrated Process
Evaluation; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
434
7. Correct answer 1: The uterus is removed through the

vagina; therefore, nothing, including a tampon, a finger,
or a penis, should be inserted into the orifice until
healing has occurred. There is no incision the client
can see; there should be very little blood; and the
clients ovaries were not removed, so there is no need
for estrogen replacement. ContentSurgical; Category
Planning; Client NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelSynthesis.
8. Correct answer 2: By using the bladder scan, the nurse

can determine how much urine is in the bladder. The
nurse should implement a noninvasive procedure first,
not catheterization. Ambulating or increasing fluid
intake will not help the client urinate. ContentSurgical;
LevelAnalysis.
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Womens Health
SECTION NINE
9. The client diagnosed with pelvic floor dysfunction

asks the nurse, What did I do to cause this problem?
Which statement is the nurses best response?
l 1. No one really knows what causes pelvic floor
dysfunction.
l 2. I can see you are upset. Would you like to sit and
talk about it?
l 3. Many times it is due to multiple or traumatic
childbirths.
l 4. One cause may be having multiple sexual partners
over time.
10. The nurse is caring for a female client diagnosed with
uterine prolapse who has been prescribed a pessary. Which
intervention should the nurse discuss with the client?
l 1. Tell the client to use a spermicidal gel when using
the pessary.
l 2. Recommend lubricating the pessary with Vaseline
prior to insertion.
435
3. Discourage the client from using topical or systemic
4. Instruct the client to remove the pessary every
estrogen treatment.
night to reduce discharge.
Ovarian/Uterine Disorders
11. Which secondary intervention should the nurse
recommend to the female client who has had multiple
sexual partners?
l 1. Recommend the client schedule a routine Pap smear.
l 2. Teach the client to use a latex condom.
l 3. Tell the client to have a CA-125 tumor mark test.
l 4. Instruct the client to douche after sexual intercourse.
12. Which client should the clinic nurse recommend to
receive the vaccine Gardasil?
l 1. The 11-year-old client who is not sexually active.
l 2. The 21-year-old client who has genital warts.
l 3. The 35-year-old client who is diagnosed with
cervical cancer.
l 4. The 52-year-old client who is going through
menopause.
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ANSWERS
9. Correct answer 3: Pelvic floor dysfunction usually

occurs in the perimenopausal period. Multiple births,
traumatic births, having children within 1 year of each
other, and being overweight may exacerbate the condition. ContentMedical; Category of Health Alteration
Gynecology; Integrated ProcessImplementation; Client
10. Correct answer 4: A pessary is a device used to

support pelvic structures. It is inserted into the vagina
without using any gels or Vaseline. Removing the
pessary every night helps prevent vaginal discharge,
ulceration, and infection. Estrogen treatment will
not affect the pessary. Content Medical; Category of
Planning; Client NeedsPhysiological Integrity, Physiological Adaptation; Cognitive LevelSynthesis.
436
11. Correct answer 1: A routine Pap smear will detect

early changes in the cervical mucosa associated with
cancer or a sexually transmitted disease (STD).
A primary intervention is teaching, and a secondary
intervention is screenings. CA-125 is used to monitor
ovarian cancer. ContentMedical; Category of Health
12. Correct answer 1: Gardasil is an immunization that

prevents up to 70% of cervical cancer. The vaccine is
recommended for young women 914 years of age
prior to sexual activity. ContentMedical; Category
Planning; Client NeedsHealth Promotion and Maintenance; Cognitive LevelSynthesis.
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SECTION NINE
13. The client asks the clinic nurse, How would I know
that I had fibroid tumors in my uterus? Which response
would be most appropriate for the nurse?
l 1. You would probably have a feeling of something
falling out between your legs.
l 2. Many times fibroid tumors in the uterus do not
produce any symptoms.
l 3. Why do you ask this question? Are you having
any problems with your period?
l 4. Fibroid tumors of the uterus will block menses
and you will not have a period.
14. The nurse and the unlicensed assistive personnel (UAP)
are caring for clients on a gynecological unit. Which task
would be inappropriate for the nurse to delegate to the UAP?
l 1. Request the UAP to take the vital signs on a newly
admitted client.
l 2. Tell the UAP to obtain an intravenous pump and
pole for the client.
l 3. Ask the UAP to escort the client who had a vaginal
hysterectomy to the car.
l 4. Ask the UAP to document the number of peri-pads
used by the client.
Womens Health
437
15. Which statement by the client would indicate to the

nurse the client is at risk for developing ovarian cancer?
l 1. I started having a period when I was 15 years old.
l 2. I quit smoking cigarettes about 2 years ago.
l 3. I have never been able to have my own child.
l 4. I am glad I went through the change in my 40s.
16. The client diagnosed with ovarian cancer is crying
and tells the nurse, I have always had regular female
check-ups. Why didnt my doctor find my cancer earlier?
Which statement by the nurse is the best response?
l 1. A test was not available until recently to detect
ovarian cancer early.
l 2. Because the ovaries are deep in the pelvis, the
symptoms are vague.
l 3. Did you tell your doctor about having sharp pain
in the pelvic area?
l 4. It is only found if the person has menstrual
irregularities.
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ANSWERS
13. Correct answer 2: Uterine leiomyomas (fibroid

tumors) usually do not produce symptoms, but
increased uterine size, pelvic pain, and excessive
menstrual bleeding may occur. ContentMedical;
LevelApplication.
14. Correct answer 4: The nurse must assess the peri-pads

for amount and type of drainage; documenting the
number of peri-pads is not sufficient; therefore, this
task would not be delegated to a UAP. Taking vital
signs, discharging the client, and obtaining equipment
can be delegated to a UAP. ContentMedical; Category
438
15. Correct answer 3: Risk factors for ovarian cancer

include no child or first child after 30 years of age,
starting menses before 12 years old, and menopause
after 55 years old. Smoking is a risk factor for cervical
cancer, not for ovarian cancer. ContentMedical;
ProcessAssessment; Client NeedsHealth Promotion
and Maintenance; Cognitive LevelAnalysis.
16. Correct answer 2: Ovarian cancer is the number

one cause of gynecological death due to the fact that
ovarian cancer does not have early signs/symptoms
and there is no screening available. ContentMedical;
LevelApplication.
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SECTION NINE
17. The client diagnosed with an ovarian cyst is being

discharged from the ambulatory surgery center after having
a laparoscopy. Which discharge instruction should the
l 1. Tell the client to maintain pelvic rest for 46 weeks.
l 2. Instruct the client to perform Kegel exercises daily.
l 3. Demonstrate to the client how to splint the
abdominal incision when coughing.
l 4. Recommend the client take acetaminophen (Tylenol)
for pain.
18. The client diagnosed with ovarian cancer is receiving
chemotherapy in an outpatient clinic. Which data would
warrant the client not receiving chemotherapy?
l 1. The clients CA-125 has doubled.
l 2. The clients platelet count is 150,000.
l 3. The clients white blood cell (WBC) count is 1800.
l 4. The clients hemoglobin is 10 mg/dL.
Womens Health
439
19. The married client diagnosed with uterine cancer

who has had a total abdominal hysterectomy is crying and
tells the nurse, I always wanted children. Now it is too
late. Which statement would be the nurses best response?
l 1. You are sad because you cant have children.
Would you like to talk?
l 2. Have you ever thought about adopting a child?
So many children need parents.
l 3. You should be thankful because your cancer has
not metastasized.
l 4. I think you need to discuss your feelings with your
husband.
20. The client comes to the outpatient clinic for her
well-woman check-up. Which statement by the client
would warrant further investigation by the nurse?
l 1. I always know when I am going to start my period.
l 2. I take Tylenol to help my cramping during my
period.
l 3. I use a peri-pad because I dont like wearing
tampons.
l 4. I am having pain when my husband and
I make love.
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ANSWERS
17. Correct answer 4: This procedure produces only

mild discomfort because an incision less than 2 cm is
made into the abdominal wall; therefore, splinting is
not taught. The client is able to resume normal activities when awake and alert and may take Tylenol for
any discomfort. ContentSurgical; Category of Health
18. Correct answer 3: The clients WBC count of 1800 is

very low, and administration of chemotherapy would
increase the risk of infection; therefore, the client
would not receive chemotherapy. The CA-125 is a
tumor marker that is not used to determine if
chemotherapy is administered; the platelet count is
within normal limits (WNL), and the hemoglobin
is not critically low. ContentMedical; Category of
440
19. Correct answer 1: The nurse cannot teach or

problem-solve for the clients concern; therefore, the
nurse should help the client ventilate her feelings by
responding in a therapeutic manner. Content
Surgical; Category of Health AlterationGynecology;
Psychosocial Integrity, Cognitive LevelApplication.
20. Correct answer 4: Dyspareunia, or painful intercourse,

is a symptom that should cause the nurse to further
assess the client. ContentMedical; Category of Health
AlterationGynecology; Integrated ProcessAssessment;
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Infertility Disorders
21. The female client experiencing fertility problems tells
the clinic nurse that she is taking St. Johns wort for her
depression. Which statement would be the nurses best
response?
l 1. This herb is useful for depression. I hope it
will help.
l 2. Did you discuss taking this herb with your
fertility specialist?
l 3. This herb may cause more infertility problems.
l 4. Taking herbs is dangerous and you should not
take them.
22. The female client is taking clomiphene (Clomid),
an estrogen antagonist. Which statement indicates the
l 1. The medication may cause my child to be deaf at
birth.
l 2. There are very few risks associated with taking this
medication.
3. I should stagger the times that I take this
4. I will have to have many sonograms during my
medication.
pregnancy.
23. The nurse is counseling parents who have undergone

successful in vitro fertilization and have embryos remaining
from the first attempt. Which moral issue should the
nurse discuss with the parents?
l 1. Discuss the cost of the yearly storage fee for the
embryos.
l 2. Recommend donating the embryos to another
infertile couple.
l 3. Talk to the parents about destroying the embryos.
l 4. Tell the parents all embryos must be implanted
within 2 years.
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ANSWERS
21. Correct answer 2: The client should discuss taking

herbs with all health-care providers; therefore, recommending the client talk to the fertility specialist is the
nurses best response. St. Johns wort may affect sperm
cells, causing decreased sperm motility and viability;
therefore, the male client should not take this herb.
The herb is not known to affect a womans fertility.
Complementary Alternative Medicine; Integrated
22. Correct answer 4: Clomid is an ovarian stimulant

that promotes follicle maturation and ovulation.
Many follicles can mature simultaneously, resulting in
an increased possibility of multiple births; therefore,
the client will have serial sonograms. ContentMedical;
Category of Health AlterationObstetrics; Integrated
442
23. Correct answer 3: The moral issue is Does life occur

at conception? If so, then destroying the embryos
would be the same as having an elective abortion.
The cost is a financial issue, donating the embryos is
a personal preference, and the embryos can be frozen
for many years. ContentMedical; Category of Health
AlterationObstetrics; Integrated ProcessPlanning;
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SECTION NINE
24. The infertile client diagnosed with endometriosis has

been taking leuprolide (Lupron), a gonadotropin-releasing
hormone (GnRH) medication, for 2 months. She tells the
clinic nurse, I dont think the medication is working.
Which statement is the nurses most appropriate response?
l 1. This medication may take 36 months to work
effectively.
l 2. You need to relax and let the medication work so
that you can get pregnant.
l 3. Please tell me what makes you think the medication
is not working?
l 4. Has your husband been checked for any type of
infertility problems?
25. The female client has been taking infertility
medications. Which signs/symptoms would indicate
ovarian overstimulation syndrome?
l 1. Vague gastrointestinal discomfort.
l 2. Bright red vaginal bleeding.
l 3. A positive fluid wave.
l 4. An increase frequency in urinating.
Womens Health
443
26. The nurse administers human chorionic gonadotropin

(hCG) intramuscularly (IM) to the infertile female client.
Which statement indicates the client and significant other
understand the teaching?
l 1. We should not have sexual intercourse for 14 days
after receiving the medication.
l 2. My husband should not wear boxer shorts and
wear tight-fitting jockey shorts.
l 3. I will test my cervical mucosa the day after I start
my menstrual cycle.
l 4. We should have intercourse on the eve and 3 days
after receiving the medication.
27. The nurse is discussing fertility issues. Which statement
indicates the couple is knowledgeable of fertility issues?
l 1. Most insurance companies do not cover the cost
of the medications completely.
l 2. A multi-fetal pregnancy does not result in preterm
labor and birth.
l 3. There is an excellent probability we will get
pregnant the first time.
l 4. Most of the implanted zygotes will result in a live
birth.
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ANSWERS
24. Correct answer 1: The client should be aware it
444
may take up to 36 months for leuprolide therapy

to achieve maximum benefits; therefore, the nurse
should discuss the long-term possibility with the client.
promote ovulation; therefore, the couple should not

wait to have sexual intercourse. Wearing tight-fitting
underwear causes the scrotum to be close to the body,
and the heat reduces the sperm count. Content

Obstetrics; Integrated ProcessImplementation; Client
Medical; Category of Health AlterationObstetrics;

25. Correct answer 3: Ovarian hyperstimulation syndrome involves marked ovarian enlargement with
exudation of fluid into the womans peritoneal and
pleural cavities. This syndrome can result in an ovarian
cyst that may rupture, causing pain. ContentMedical;
26. Correct answer 4: The couple should have sexual

intercourse during this time because this is the probable period of ovulation; hCG acts immediately to
27. Correct answer 1: Infertility therapy is extremely

expensive and most insurance companies do not
cover it at all or cover only a small portion. Multifetal pregnancies can result in preterm labor; there is
no guarantee of pregnancy on the first attempt; and
most of the implanted zygotes do not result in a live
birth. ContentMedical; Category of Health Alteration
Obstetrics; Integrated ProcessEvaluation; Client
of Care; Cognitive LevelEvaluation.
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SECTION NINE
28. The male infertile client asks the clinic nurse Is there
anything I can do to increase my chances of fathering a
child? Which statement is the nurses best response?
l 1. Improving your overall health by exercising may
help you father a child.
l 2. You are concerned about not being able to father
a child?
l 3. There is medication that may help increase your
sperm count.
l 4. Massaging your testicles prior to intercourse may
help with sperm release.
29. The nurse is counseling a couple that is visiting the
infertility clinic for the first time. Which question would
be most important for the nurse to ask the couple?
l 1. Have you discussed your infertility with any
friends and family?
l 2. Has your relationship changed since you have not
been able to conceive?
l 3. Do you have any cultural or religious concerns
about not being able to get pregnant?
l 4. If you cannot conceive a baby, would you consider
adopting a child?
Womens Health
445
30. Which modifiable risk factor should the nurse discuss

with the female client who is infertile?
l 1. History of pelvic inflammatory disease (PID).
l 2. Smoking two packs of cigarettes a day.
l 3. Chronic urinary tract infections (UTIs).
l 4. Dysfunction of the pituitary gland.
Birth Control Issues

31. The nurse is counseling the female adolescent client
who confides in the nurse she is sexually active. Which
information is most important to discuss with the client?
l 1. Tell the client to discuss this important issue with
her parents.
l 2. Discuss using the female condom when having
sexual intercourse.
l 3. Recommend the client talk to her HCP about
taking birth control pills.
l 4. Encourage the client to make her sexual partner
wear protection.
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ANSWERS
28. Correct answer 3: Administration of testosterone

will improve hormonal levels, resulting in a potential
for increased production of sperm. ContentMedical;
446
they act on the ovaries. This can be modified by

administering supplemental medications. Cigarette
smoking, chronic UTIs, and PID are not risk factors
for infertility. ContentMedical; Category of Health

LevelApplication.

29. Correct answer 2: The most important question is
31. Correct answer 2: The female condom (vaginal
one that evaluates how infertility has affected the couples relationship with each other. This issue may cause
tension, fear, and guilt between the couple. Content
LevelAnalysis.
30. Correct answer 4: Dysfunction of the pituitary

gland may alter the secretion of the reproductive
hormonesGnRH, follicle-stimulating hormone
(FSH), and leutenizing hormone (LH)and how
pouch) can protect the client from pregnancy and

sexually transmitted diseases and does not rely on
the male for protection. Empowering the client to be
responsible for safe sex is the most important information to discuss with the client. ContentMedical;
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Womens Health
447
32. The couple has decided to use spermicide for birth

control. Which statement indicates the female partner
understands the teaching?
l 1. I must insert the foam prior to having sexual
intercourse.
l 2. I will douche with vinegar and water immediately
after having sex.
l 3. I should put the spermicidal foam on my partners
penis.
l 4. I must use the spermicide immediately after
having intercourse.
34. Which statement indicates the client that is prescribed

oral contraceptives for birth control understands the
medication teaching?
l 1. I need to get a Pap smear every 3 months because
I am on the pill.
l 2. If I have breakthrough bleeding, I will quit taking
my pill.
l 3. If I miss taking a pill, I will take it as soon as
I remember.
l 4. I should not drink alcohol because my birth
control pill will not work.
33. Which female client would the nurse not

recommend taking oral contraceptive pills for birth
control?
l 1. The 21-year-old client who has had irregular
periods for 3 years.
l 2. The 29-year-old client who is 65" tall and weighs
68 kilograms.
l 3. The 35-year-old client who smokes two packs of
cigarettes a day.
l 4. The 38-year-old client who has lymphoma and
taking chemotherapy.
35. The client tells the nurse, I am going to breastfeed

so I dont have to worry about getting pregnant. Which
l 1. Breastfeeding can be used as an effective form of
birth control.
l 2. I think you should talk to your HCP about other
forms of birth control.
l 3. Do you and your husband want to have more
children?
l 4. Breastfeeding is the least reliable form of birth
control.
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ANSWERS
448
32. Correct answer 1: Spermicide must be in place prior
34. Correct answer 3: The client should be instructed to
to intercourse because the foam is immediately active.

If a suppository or tablet is used, it must be inserted
1015 minutes before intercourse to allow time for
it to dissolve. ContentMedical; Category of Health
take any missed pill as soon as she remembers; therefore, the client could and should take more than one
pill in a day. To maintain ovulation suppression, the
client must take the medication routinely. Content
AlterationObstetrics; Integrated ProcessEvaluation;


33. Correct answer 3: A client who is older and smokes

cigarettes is at greater risk for cardiovascular complications of the pill. Clients with irregular periods are
prescribed birth control pills as are clients taking
chemotherapy who should not get pregnant. Content
35. Correct answer 2: A woman must breastfeed a mini-

LevelAnalysis.
gory of Health AlterationObstetrics; Integrated Process

mum of 10 times in 24 hours with no supplementary

feedings to possibly avoid ovulation, but it is the least
reliable form of birth control. ContentMedical; Cate-
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SECTION NINE
36. The male adolescent client tells the clinic nurse,

Last night when I used a condom with my girlfriend
I got a red itchy rash around my penis. Which question
would be the nurses best response?
l 1. How long have you had the condom?
l 2. Do you have any type of latex allergy?
l 3. Do you need to be tested for an STD?
l 4. Was the condom exposed to sunlight?
37. Which statement indicates to the nurse that the
client just prescribed a vaginal contraceptive ring needs
more teaching concerning this type of birth control?
l 1. I must change the ring every month.
l 2. I should insert the ring within 30 minutes of having
intercourse.
l 3. I will remove the ring 3 weeks after I have
inserted it.
l 4. I will continue to have my periods when using
the ring.
Womens Health
449
38. The client received an intrauterine device (IUD)

5 weeks ago. Which statement by the client would
warrant intervention by the clinic nurse?
l 1. My breasts get tender around my period.
l 2. I have not had a period since I had the IUD
inserted.
l 3. I am so hurt. My boyfriend is being treated for
syphilis.
l 4. I feel a thickening underneath my breast when
I examine them.
39. The client is prescribed the 21-day oral contraceptive
pack. Which statement best describes the scientific rationale
for this birth control product?
l 1. This ensures that the client will take a pill every day.
l 2. It has fewer side effects than other forms of birth
control.
l 3. This medication will limit the symptoms of
premenstrual syndrome.
l 4. This prescription allows for the client to have a
period.
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ANSWERS
36. Correct answer 2: The adolescents comments should
450
make the nurse consider an allergic reaction to the

condom, most of which are made of latex. Suggesting
a type of condom made of lambs intestines would
prevent an allergic reaction. ContentMedical; Category
indicates the client is at risk or may have an STD;

therefore, the nurse should intervene. The IUD
does not alter the womans body function, and the
thickening of the breasts would be the inframammary
ridge, which is normal. ContentMedical; Category
of Health AlterationObstetrics; Integrated Process


37. Correct answer 2: This statement is appropriate for
39. Correct answer 4: The lack of hormone medication
a client using a diaphragm; therefore, the client

needs more teaching. The ring works on the same
principle that oral contraceptives work. The method
provides 21 days of hormone suppression and then
7 days to allow for menses. ContentMedical; Cate-
during the 7 days off will cause the uterus to slough

off the built-up tissue resulting in menses. The
21-day pack makes the client have to remember to
restart the pill 7 days after completing the pack.
A 28-day pack contains 21 days of the hormone and
7 days of placebos, which ensures the client takes a
pill every day. ContentMedical; CategoryObstetrics;
gory of Health AlterationObstetrics; Integrated

ProcessEvaluation; Client NeedsPharmacological and
38. Correct answer 3: Women who have or are at risk

for a sexually transmitted disease (STD) should
not use an IUD for birth control. The comment

Cognitive LevelKnowledge.
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SECTION NINE
40. The adolescent client is prescribed the birth control

medication depot medroxyprogesterone (Depo-Provera).
Which interventions should the clinic nurse implement?
l 1. Instruct the client to schedule an appointment
every 6 months.
l 2. Explain that the client may not be able to conceive
for at least 1 year after discontinuing the Depo-Provera.
l 3. Administer the medication intramuscularly in the
deltoid area.
l 4. Discuss how to care for the intrauterine device
(IUD) inserted in her vagina.
l 5. Tell the client that she will not have to take a pill
every day.
Breast Disorders
41. The 54-year-old female client tells the nurse, My
doctor told me the lump in my breast is nothing and not
to worry, but I am scared. Which statement is the nurses
best response?
l 1. You should get a second opinion about the lump
in your breast.
451
2. I can see you are scared. Would you like to talk
3. Do monthly breast self-examinations and come
4. This is probably breast cancer and you need to
about your fears?

back if it changes.
have surgery.
42. The client is diagnosed with breast cancer and opted

for a modified radical mastectomy. Which intervention
l 1. Discuss care of the skin after radiation therapy.
l 2. Teach the client how to care for the surgical site.
l 3. Tell the client she is not a candidate for
reconstruction surgery.
l 4. Instruct the client to have a tumor marker study
done yearly.
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ANSWERS
40. Correct answers 2, 3, 5: When injections are discontinued, an average of 12 months is required for
fertility to return. The medication is administered
intramuscularly every 3 months, no pill is taken,
and no IUD is used. ContentMedical; Category
LevelApplication.
41. Correct answer 1: The client is entitled to a second

opinion, and a breast lump should be thoroughly
investigated, especially if the client is scared. Content
Medical; Category of Health AlterationGynecology;
Page 452
452
42. Correct answer 2: The client needs to know how

to care for the surgical wound. Follow-up can differ,
and the nurse should not assume which therapy is
planned. She can have reconstruction surgery, and
tumor markers are checked depending on the followup therapy, not yearly. ContentSurgical; Category of
Health AlterationCancer; Integrated ProcessPlanning;
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SECTION NINE
43. The client has undergone a wedge resection for

cancer of the left breast. Which discharge instruction
should the nurse teach?
l 1. Do not lift more than 20 pounds with the left hand
until released by the HCP.
l 2. Instruct the client not to have any blood drawn from
the left arm.
l 3. Explain the importance of follow-up radiation therapy
after the procedure.
l 4. The client should arrange an appointment with a
plastic surgeon for reconstruction.
44. Which is the American Cancer Society (ACS)
guideline for the early detection of breast cancer?
l 1. Beginning at age 20 have a mammogram every
5 years.
l 2. Beginning at age 30 perform monthly self breast
exams.
l 3. Beginning at age 40 get a yearly mammogram.
l 4. Beginning at age 50 have a breast sonogram yearly.
Womens Health
453
45. The client has had a mastectomy for cancer of the

breast and asks the nurse about reconstructive surgery
options. Which information should the nurse discuss
with the client?
l 1. The only option after a mastectomy is a saline breast
implant.
l 2. It is recommended to postpone reconstruction for
5 years after surgery.
l 3. Refer the client to the American Cancer Society for
information.
l 4. One option is for the surgeon to perform the
TRAM-flap procedure.
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ANSWERS
43. Correct answer 3: Clients with wedge resections

must have follow-up radiation therapy to the area to
make sure all cancer cells have been destroyed. The
client should not lift more than 5 pounds, and she
can have blood drawn. There is no need for reconstruction surgery. ContentSurgical; Category of
Health AlterationCancer; Integrated ProcessPlanning;
44. Correct answer 3: The ACS recommends a yearly

mammogram beginning at age 40 years for the early
detection of breast cancer. A mammogram can detect
a lump that will not be large enough to be felt.
Oncology; Integrated ProcessPlanning; Client Needs
Health Promotion and Maintenance; Cognitive
LevelSynthesis.
454
45. Correct answer 4: The TRAM-flap procedure is one

in which the clients own tissue is utilized to form
the new breast. Tissue and fat are pulled under the
skin, with one end left attached to the body providing circulation until the body builds collateral circulation in the area. There are multiple options for
reconstruction surgery. ContentSurgical; Category of
Health AlterationOncology; Integrated ProcessPlanning;
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SECTION NINE
46. The nurse is teaching a class on breast health to a

group of senior citizens. Which information should the
nurse discuss with the group of men and women?
l 1. Eight out of 10 women who develop breast cancer
have a family history.
l 2. Men can have breast cancer and should report any
breast lumps.
l 3. Monthly breast self-examination is the main
method of early detection.
l 4. The older a woman is, the least likely she is to
develop breast cancer.
47. The client is scheduled to have a sentinel node breast
biopsy. The client tells the nurse I dont understand.
What does a sentinel node biopsy do? Which statement
is the nurses best response?
l 1. A dye is injected into the tumor and traced,
determining the spread of the cancer.
l 2. The surgeon will palpate nodes that drain the
diseased portion of the breast.
3. A portion of your breast, along with the nodes,
4. Nodes will be frozen, and the surgeon will be
455
will be removed with a syringe.

notified if more should be removed.
48. The client who had a right modified radical

mastectomy 4 years before is being admitted for a
cardiac workup for complaints of chest pain. Which task
would be most appropriate for the nurse to delegate to
the unlicensed assistive personnel (UAP)?
l 1. Request the UAP to complete the clients
admission assessment.
l 2. Ask the UAP to prepare the client for a cardiac
catheterization in the morning.
l 3. Tell the UAP to put a sign at the bedside to not use
the right arm for blood pressure.
l 4. Instruct the UAP to draw the clients cardiac
enzymes and take them to the laboratory.
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ANSWERS
46. Correct answer 2: Men are diagnosed every year

with breast cancer, and it frequently goes undetected
because men consider this a womens disease. Most
women who develop breast cancer do not have a
family history of the disease; mammograms can detect
breast cancer earlier than breast self-examinations;
and the second greatest risk factor for breast cancer is
being elderly. ContentMedical; Category of Health
47. Correct answer 1: A sentinel node biopsy is a procedure in which a radioactive dye is injected into the
tumor and then traced by instrumentation and color
to try to identify the exact lymph nodes that the
tumor could have shed into. ContentSurgical;
Category of Health AlterationSurgical; Integrated
ProcessImplementation; Cognitive LevelPhysiological
LevelApplication.
456
48. Correct answer 3: The right arm should not be used

for blood pressures or lab draws because the client is
at risk for lymphedema. The UAP cannot assess,
teach the client, or draw blood. ContentSurgical;
Synthesis.
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457
Abuse
49. The client with a modified radical mastectomy has
a Hemovac. The Hemovac output for the 7 a.m.3 p.m.
shift is 78 mL, for the 3 p.m.11 p.m. shift 45 mL, and
for the 11 p.m.7 a.m shift 15 mL. Which amount
should the nurse document in the clients chart for the
24-hour total?
Answer: ____________________
50. The client is being discharged after a left modified

radical mastectomy. Which discharge instructions should
the nurse include? Select all that apply.
l 1. Explain an elevated temperature is expected after
this surgery.
l 2. Do not carry large purses and bundles with the
right arm.
l 3. Encourage the client to participate in group
activities.
l 4. Tell the client to elevate the left arm on two
pillows.
l 5. Recommend the client to Reach to Recovery.
51. A woman comes to the emergency department (ED)

and tells the triage nurse she was raped by her date. The
woman is crying, disheveled, and has bruises on her face.
l 1. Ask the client if she wants the police department
notified.
l 2. Notify a Sexual Assault Nurse Examiner (SANE)
to see the client.
l 3. Ask the client if she has any pain or discomfort at
this time.
l 4. Determine if the client has any support person to
notify.
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ANSWERS
49. Correct answer 138 mL: This is a simple addition

problem. The nurse should add the three shift
amounts to obtain the total 24-hour total. Content
Surgical: Category of Health AlterationOncology;
50. Correct answer 3, 4, 5: The client should be

encouraged to participate in activities, and elevating
the arm will decrease edema. Reach to Recovery is
a support group for clients with breast cancer. An
elevated temperature should be reported, and purses
should be carried in the right arm. ContentSurgical;
Category of Health AlterationCancer; Integrated
458
51. Correct answer 3: The nurses first intervention is

to assess the client for any physical injuries, which
includes asking if the client is in pain. The nurse can
then notify the SANE nurse and after that contact a
support person. The SANE nurse will notify the police
department. ContentMedical; Category of Health
AlterationPain; Integrated ProcessImplementation;
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52. The emergency department nurse is assessing a

female client who has abdominal bruising and small,
round burns on her trunk. The nurse asks the man who
is with the client to please leave the room. The man
refuses to leave the room. Which action should the nurse
implement?
l 1. Escort the client to the bathroom to collect a urine
specimen.
l 2. Request the emergency department physician to
complete the assessment.
l 3. Ask the client if it is all right if the man stays in
the room.
l 4. Give the client a slip of paper with the phone
number of a shelter.
53. The adolescent female tells the school nurse, I hate
to go home because my stepfather does stuff to me.
Which action should the nurse implement next?
l 1. Tell the mother about the childs allegations.
l 2. Contact Child Protective Services immediately.
l 3. Request the stepfather to come to the school.
l 4. Arrange for the client to be examined by an HCP.
Womens Health
459
54. The nurse is teaching a class about rape prevention

to a group of women at a community center. Which
information is a myth about rape?
l 1. Rape can occur at any age, including infants and
elderly.
l 2. If a woman says no, it means no, and the woman
has this right.
l 3. Rape is an attempt to exert power and control over
the client.
l 4. All victims of sexual assault are women; men cannot
be raped.
55. The nurse working in the emergency department is
admitting a female client who reported her husband beat
her up, but she does not want the police notified. Which
l 1. Notify the police department because it is the law.
l 2. Treat the clients wounds and take no further
action.
l 3. Try to talk the client into reporting her husband.
l 4. Give the client the number of a womans shelter.
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ANSWERS
52. Correct answer 1: The nurse needs to remove the

client from the room so that the nurse can talk to the
client and discuss probable abuse. The nurse should
not attempt to give information about a shelter to
the client in front of the potential abuser. Content
Medical; Category of Health AlterationPsychosocial;
53. Correct answer 2: Legally the nurse must notify

child protective services to protect the child from
further abuse. The nurse should not contact either
parent and does not have the authority to send the
child to an HCP. ContentFundamentals; Category
of Health AlterationPsychosocial; Integrated Process
Environment; Cognitive LevelApplication.
460
54. Correct answer 4: Men and children can be victims

of rape. Sexual arousal and orgasm do not imply
consent but may be a pathological response to
stimulation. ContentMedical; Category of Health
AlterationPsychosocial; Integrated ProcessPlanning;
LevelSynthesis.
55. Correct answer 4: The nurse should help the client

to devise a plan for safety, including giving the client
the number of a safe house or a womans shelter. The
nurse does not legally have to report spousal abuse,
and it is a Health Insurance Portability and Accountability Act (HIPAA) violation if reported. The nurse
cannot coerce the client into reporting her husband.
Psychosocial; Integrated ProcessImplementation; Client
NeedsSafe Effective Care Environment; Cognitive
LevelApplication.
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56. The 84-year-old female client who lives with her son
is admitted with multiple burn marks on the torso and
under the breasts, along with contusions in various stages
of healing. The client denies anyone abusing her. Which is
the most probable reason the client denies being abused?
l 1. The client may have accidently burned herself
smoking a cigarette.
l 2. The client may be afraid of being moved into a
long-term care facility.
l 3. The clients son may have been abused as a child
by the client.
l 4. The client may not be able to feel the burns due to
neuropathy.
57. Which is an appropriate interview question for the
nurse to use with clients involved in abuse?
l 1. I know you are being abused. Can you tell me
about it?
l 2. Did you allow your children to watch you being
abused?
3. What did you do that caused your spouse to
4. Do you have a safe place to go when the abuse
461
get mad?
starts?
58. The emergency department nurse writes the problem

of fear of pregnancy for a client who has been raped.
l 1. Discuss the possibility of the client taking the
morning after pill.
l 2. Refer the client to the social worker for a list of
adoption agencies.
l 3. Explain that one-time intercourse usually does not
result in a pregnancy.
l 4. Determine when the client last had her period to
determine if she may get pregnant.
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ANSWERS
56. Correct answer 2: Many times the elderly are

ashamed to report abuse because they raised the
abuser and feel responsible for their abusive actions.
The elder parent may feel financially dependent on
the child or be afraid of being placed in a long-term
care facility. ContentMedical; Category of Health
AlterationIntegumentary; Integrated ProcessEvaluation;
Client NeedsSafe Effective Care Environment; Cognitive
LevelKnowledge.
57. Correct answer 4: This statement assesses the abused

clients safety (or a plan for safety). These other questions do not assess for the clients safety in the home
and/or place blame for the abuse on the client.
Psychosocial; Integrated ProcessAssessment; Client
NeedsPsychosocial Integrity; Cognitive LevelAnalysis.
462
58. Correct answer 1: The RU 486, or the morningafter pill, prevents pregnancy from occurring. The
client should have the opportunity to prevent the
pregnancy. ContentMedical; Category of Health
AlterationObstetrics; Integrated ProcessImplementation;
Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelAnalysis.
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Womens Health
SECTION NINE
463
Management
59. The nurse writes a nursing diagnosis risk for injury
related to physical abuse by spouse for a client. Which
goal would be the most appropriate for this client?
l 1. The client will report the abuse to the police.
l 2. The client will confront her abuser.
l 3. The client will identify a plan for safety.
l 4. The client will attend a self-defense class.
60. The client who was raped 3 months ago tells the
clinic nurse, I just cant seem to quit thinking about the
rape. I cry all of the time. Which priority action should
l 1. Allow the client to ventilate her feelings of
helplessness.
l 2. Encourage the client to make an appointment with
a psychiatrist.
l 3. Refer the client to a rape crisis center for group
support.
l 4. Recommend the client seek pastoral support from
her church.
61. The client diagnosed with breast cancer has a

hemoglobin/hematocrit (H/H) of 12.8 mg/dL and 38%,
a WBC of 6800/mm3, and a neutrophil count of 80%.
Which action should the nurse implement?
l 1. Place the client in reverse isolation.
l 3. Make sure no flowers are taken into the room.
62. The clinic nurse has been named in a lawsuit by a
client who alleges professional negligence while being
seen for infertility issues. Which action should the nurse
take first?
l 1. Consult with the nurses malpractice insurance
attorney.
l 2. Review the clients clinic medical record.
l 3. Contact the client to try and resolve the issue.
l 4. Discuss the case with the HCP.
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ANSWERS
59. Correct answer 3: Ensuring the clients safety is the

most appropriate goal for the risk for injury problem.
Psychosocial; Integrated ProcessDiagnosis; Client
60. Correct answer 3: A rape support group will help

the client to discuss her feelings with people who are
trained to deal with crisis, and the client can talk to
other women who have been raped. After 3 months,
the client can ventilate feelings, see a psychiatrist, and
seek pastoral support, but the priority action is to
refer the client to a support group. ContentMedical;
Category of Health AlterationPsychosocial; Integrated
Integrity; Cognitive LevelSynthesis.
464
61. Correct answer 4: The clients lab work is within

normal limits; therefore, the nurse should continue to
monitor the client. Reverse isolation and no flowers
would be appropriate if the client was neutropenic.
Hematology; Integrated ProcessImplementation; Client
62. Correct answer 1: The nurse should first contact her

attorney and then familiarize herself with the clients
medical record in preparation for the deposition.
The nurse should not discuss the case with anyone,
especially not the client. ContentManagement;
LevelSynthesis.
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SECTION NINE
63. The nurse has accepted the position of clinic manager

for a womens health clinic. Which role is an important
aspect of the management position?
l 1. Ensure the clinic is appropriately staffed.
l 2. Be the sole decision maker for the unit.
l 3. Take responsibility for the nurses actions.
l 4. Complete insurance billing by end of the month.
64. The manager on the gynecological unit notices that
the charge nurse takes frequent smoke breaks and is not
available to clients, staff, and HCPs. Which priority action
should the manager implement regarding this employee?
l 1. Discuss the nurses actions with the chief nursing
officer.
l 2. Talk with the nurses at the next scheduled staff
meeting.
l 3. Informally talk to the charge nurse about the
behavior.
l 4. Complete a formal counseling record and place in
employees file.
Womens Health
465
65. The charge nurse observes a nurse and HCP talking

loudly about a client at the nurses station. Which action
should the charge nurse take first?
l 1. Notify the HIPAA officer of the breech in
confidentiality.
l 2. Take no action because it involves an HCP.
l 3. Have the individuals go to a private room to talk.
l 4. Tell the individuals their conversation can be
overheard.
66. The nurse on the gynecological unit has received the
shift report. Which client should the nurse assess first?
l 1. The client scheduled for a hysterectomy who
saturated four peri-pads during the last shift.
l 2. The client who had a mastectomy and refuses to
look at the site.
l 3. The client who is scheduled for an endometrial
biopsy for infertility issues.
l 4. The client who has just been given the diagnosis of
ovarian cancer.
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ANSWERS
63. Correct answer 1: One of the many jobs of a manager is to make sure the clinic operates efficiently,
which includes evaluating staff members to ensure
they are qualified for the position. A good manager
should be democratic and not the sole decision maker.
The manager does not take responsibility for nurses
action, and the financial department is responsible
for billing. ContentManagement; Category of Health
64. Correct answer 3: The first step in employee discipline is to confront the employee with the inappropriate behavior with objective data and give the
employee a chance to correct the behavior. Content
Management; Category of Health AlterationGynecology;
466
65. Correct answer 4: The first action is to address

the individuals with the inappropriate behavior so
confidential information is not being discussed in
public. Then the individuals could go to a private
room if needed. It does not matter who is violating
confidentiality. The charge nurse must intervene.
Gynecology; Integrated ProcessImplementation; Client
66. Correct answer 1: The client who is bleeding should be

assessed first. Remember Maslows Hierarchy of Needs:
physiological needs are first. ContentManagement; Category of Health AlterationGynecology; Integrated Process
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SECTION NINE
67. The female client tells the ambulatory surgery clinic

nurse that she had a reaction when her husband used a
latex condom. Which intervention should the nurse
implement first?
l 1. Notify the clinic supervisor of the allergy.
l 2. Label the clients chart with the allergy.
l 3. Place a red allergy band on the client.
l 4. Inform the client to tell all HCPs of the allergy.
68. Which task would be most appropriate for the nurse to
delegate/assign when caring for clients on a surgical unit?
l 1. Instruct the LPN to feed the client who is 1 day
postoperative vaginal hysterectomy.
l 2. Tell another LPN to administer an intravenous
push (IVP) pain medication for a client in
severe pain.
l 3. Request the UAP to check on a client whose last
AP was 112, R was 6, and B/P was 92/58.
l 4. Assign the RN to administer a unit of blood to the
4-hour postoperative client.
Womens Health
467
69. The clinic nurse is discussing upcoming surgery

with the elderly female client diagnosed with a uterine
prolapse. The client is worried about what will happen
if something goes wrong with the surgery. Which
l 1. Encourage the client to ventilate her feelings.
l 2. Determine if the client has an advance directive.
l 3. Assure the client that everything will be all right.
l 4. Ask the client if her family knows how she feels.
70. The nurse is triaging phone calls in a womens health
clinic. Which client should the nurse call first?
l 1. The client who reported her husband beat her up
and has gone to buy a gun.
l 2. The client whose uterus has prolapsed out of the
vagina and she does not know what to do.
l 3. The client with infertility issues who just started
her period and is crying.
l 4. The client whose vaginal ring fell out and she is
afraid she may be pregnant.
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ANSWERS
67. Correct answer 3: The nurse should first place the

allergy band on the client and then label the clients
chart. The nurse should also notify the operating
room director. ContentManagement; Category of
Synthesis.
68. Correct answer 4: An RN must administer blood

and blood products and assess the client for the first
15 minutes of the infusion for a possible reaction.
The UAP could feed a stable client; the LPN should
not administer an IVP medication; and the nurse
cannot delegate an unstable client. ContentSurgical;
Synthesis.
468
69. Correct answer 2: The nurse should determine if

the clients wishes are stated in an advance directive,
which includes a living will and durable power of
attorney for health care. The nurse should empower
the client to make her own decisions and then tell
the family of her wishes. ContentSurgical; Category
Analysis.
70. Correct answer 1: The client is in danger, and

her safety should be priority; therefore, the nurse
should contact this client by phone first. The nurse
should attempt to get her to a safe place. Content
Management; Category of Health Alteration
Gynecology; Integrated ProcessImplementation;
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Maternal Child Health
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471
Antepartum
1. The nurse working in a womens health clinic is
returning telephone calls. Which client should the nurse
contact first?
l 1. The 16-year-old client who wants to know the
results of her pregnancy test.
l 2. The 27-year-old primigravida client who is
complaining of severe headache.
l 3. The 32-year-old pregnant client who is concerned
because she has gained 2 pounds.
l 4. The 41-year-old client who wants a referral to an
infertility clinic as soon as possible.
2. The nurse is completing the admission assessment on a
client who is 12 weeks pregnant and is visiting the
womens health clinic. The client tells the nurse, I am a
vegan and will not drink any milk or eat any meat.
l 1. Recommend the client eat grains, legumes, and
nuts daily during the pregnancy.
l 2. Tell the client it is safe to adhere to the vegan diet
during her pregnancy.
3. Discuss the importance of eating meat and dairy
4. Inform the client that iron supplements should not
products during pregnancy.

be taken during pregnancy.
3. A client 36 weeks pregnant comes to the clinic and has

a blood pressure 160/102, 4+ proteinuria, and edematous
hands and feet. Which data should the nurse assess next?
l 1. The clients apical heart rate.
l 2. The clients urine-specific gravity.
l 3. The clients deep tendon reflexes.
l 4. The clients activity tolerance.
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472
1. Correct answer 2: A severe headache is a symptom of
3. Correct answer 3: The clients signs/symptoms suggest
pre-eclampsia; because this is the clients first pregnancy,

she requires further evaluation. The other clients are
not priority over a client who has an acute complaint.
pregnancy-induced hypertension (PIH), which if

worsening would cause hyperreflexia. Therefore, the
nurse should assess the clients deep tendon reflexes
(range 04+, with 2+ being normal). The heart rate,
urine specific gravity, and activity tolerance would not
yield information pertinent to possible PIH. Content
ContentObstetrics; Category of Health Alteration

Antepartum; Integrated ProcessAssessment; Client
2. Correct answer 1: The vegan diet does not include

any animal protein, which is needed for fetal development and growth. Vegetable proteins lack one or more
of the essential amino acids; therefore the vegan must
combine different plant proteins, grains, legumes, and
nuts to allow for intake of all essential amino acids.
Antepartum; Integrated ProcessImplementation; Client
LevelAnalysis.
Obstetrics; Category of Health AlterationAntepartum;

LevelAnalysis.
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SECTION TEN
4. The client at 28 weeks gestation tells the clinic nurse,

I do not want to have a sonogram because I am afraid it
will harm my baby. Which statement is the nurses best
response?
l 1. You are afraid the test will harm your baby.
l 2. The doctor would not order anything that would
hurt your baby.
l 3. What makes you think that this test will harm
your baby?
l 4. This test uses sound waves to check your baby,
not x-rays.
5. The client who is 2 weeks past her menses calls the
clinic and reports left upper quadrant pain. Which
assessment finding would cause the nurse to suspect an
ectopic pregnancy?
l 1. The client is 18 years old, and this is her first
pregnancy.
l 2. The client has taken oral contraceptives for 10 years.
l 3. The client is Rh-negative, and the father is
Rh-positive.
l 4. The client has a history of pelvic inflammatory
disease (PID).
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6. The client in her second trimester tells the clinic nurse

she is thirsty all the time and urinates every hour. Which
l 1. Check the clients urine protein.
l 2. Check the clients glucose level.
l 3. Check the clients blood pressure.
l 4. Check the clients oral mucosa.
7. The client in her first trimester of pregnancy asks the
clinic nurse, My husband wants to know if it is safe for
us to make love. Which statement is the nurses best
response?
l 1. During the first trimester, it is all right for you to
make love.
l 2. It is not recommended, but if your husband
insists then you should.
l 3. You can have sexual intercourse up until the time
you deliver.
l 4. As long as your husband uses a condom it will be
just fine.
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ANSWERS
4. Correct answer 4: The client needs factual information

to allay her fears; therefore, explaining the procedure
would be the nurses most appropriate response.
Antepartum; Integrated ProcessImplementation; Client
LevelSynthesis.
5. Correct answer 4: Scarring of the fallopian tubes can

prevent a fertilized ovum from progressing down the
tube to the uterus for implementation and is a risk
factor for ectopic pregnancy. PID causes scarring;
therefore, this assessment finding is pertinent. Content
Medical; Category of Health AlterationAntepartum;
474
6. Correct answer 2: The client is exhibiting polyuria

and polydipsia, which are signs of diabetes. The clients
glucose level should be checked to rule out gestational
diabetes. Protein in the urine and blood pressure are
used to evaluate for PIH. ContentObstetrics; Category
of Health AlterationAntepartum; Integrated Process
Analysis.
7. Correct answer 1: During the first trimester, the

pregnant woman can continue any activities that were
done prior to getting pregnant. During the second and
third trimesters, as the clients center of gravity shifts
and the babys head engages, activities must be curtailed.
The condom is used to prevent pregnancy. Content
Obstetrics; Category of Health AlterationAntepartum;
Integrated ProcessImplementation; Health Promotion
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Page 475
475
8. The 18-week gestational multigravida client asks the

nurse, Why would a doctor want to do an amniocentesis
on someone who is pregnant? Which situation would
indicate the need for an amniocentesis? Select all that
apply.
l 1. The pregnant mother is over the age of 35.
l 2. It is done to determine the gender of the fetus.
l 3. The client has a history of two elective abortions.
l 4. An elevated level of maternal serum alphafetoprotein (AFP).
l 5. The Rh-negative woman who did not receive
Rhogam after the first pregnancy with an Rh+ baby.
10. The client at 38 weeks gestation tells the clinic nurse,

My baby was really moving a lot yesterday, but I havent
felt any movements today. Which action should the
nurse implement?
l 1. Explain that this is normal before delivery.
l 2. Arrange for the client to have a non-stress test.
l 3. Have the client go home and call back in the
morning.
l 4. Perform Leopold maneuvers on the clients
abdomen.
9. The client at 14 weeks gestation calls the clinic and

tells the nurse, I am nauseated and vomit almost every
morning. Which instructions should the nurse provide
the client?
l 1. Make an appointment to be seen today.
l 2. Drink lukewarm coffee in the morning.
l 3. Eat crackers before getting out of bed.
l 4. Take an antiemetic ordered by the HCP.
11. The client is admitted to the labor and delivery unit

diagnosed with PIH and has pre-eclampsia. Which
l 1. Administer intravenous magnesium sulfate.
l 2. Check the clients blood pressure (BP) in both arms.
l 3. Perform the Snellen eye examination.
l 4. Notify the nursery of the impending delivery.
Intrapartum
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ANSWERS
8. Correct answer 1, 4, 5: An amniocentesis is performed when the maternal age is over 35 years, when
the woman has had three or more spontaneous abortions, when the serum AFP level remains elevated, and
when the woman has become sensitized to the Rh+
factor from exposure to the blood of the first baby. It is
performed to detect chromosomal abnormalities. It is
not used to determine the gender. ContentObstetrics;
Category of Health AlterationAntepartum; Integrated
9. Correct answer 3: Eating crackers tends to settle

the stomach, and crackers are easily digested. Being
nauseated and vomiting early in pregnancy are not
uncommon; therefore, the client does not need to be
seen. Caffeine beverages should be avoided. Medication
should be the last resort if the client becomes dehydrated.
Antepartum; Integrated ProcessPlanning; Client Needs
476
10. Correct answer 2: Vigorous movement by the

fetus followed by no movement may indicate fetal
demise and is cause for further assessment. Leopold
maneuvers are used to assess the fetuss position
in utero. ContentObstetrics; Category of Health
AlterationAntepartum; Integrated Process
LevelApplication.
11. Correct answer 1: The nurses first intervention is to

prevent the client from having a seizure during the
delivery of her baby; therefore, starting magnesium
sulfate intravenously is priority. Then, the nurse
should check the clients BP and notify the nursery.
The clients vision is not assessed (Snellen chart)
during labor and delivery. ContentObstetrics;
Category of Health AlterationIntrapartum; Integrated
LevelApplication.
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12. The client at 40 weeks gestation has just delivered a

stillborn infant. Which intervention should the nurse
implement first?
l 1. Discuss the importance of attending a grief support
group.
l 2. Arrange for the client to have a room in the
medical unit.
l 3. Notify the hospital chaplain of the fetal demise.
l 4. Offer the mother the chance to hold her baby.
13. The client in labor is showing late decelerations on
the fetal monitor. Which intervention should the nurse
implement first?
l 2. Instruct the mother to take slow deep breaths.
l 3. Place the client in the left lateral position.
l 4. Prepare for an emergency cesarian section
(C-section).
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14. The nurse in the labor and delivery department is

caring for a client who is having bright red painless
bleeding, and the fetal heart rate is 100. Which client
problem is priority?
l 2. Altered cardiac output.
l 3. Risk for fetal demise.
l 4. Risk for hemorrhaging.
15. The labor and delivery nurse is performing a vaginal
examination and has assessed a prolapsed cord. Which
l 2. Force the prolapsed cord back into the uterus.
l 3. Tell the client not to push during contractions.
l 4. Prepare the client for a vaginal delivery.
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ANSWERS
12. Correct answer 4: The mother should be allowed to
478
hold her infant in order to facilitate the grieving

process and to say good-bye. This is the nurses first
intervention. The client should not be placed on the
postpartum floor, where babies are crying and happy
people are reminders of her loss. ContentObstetrics;
placenta previa, and a decreased fetal heart rate

indicates a compromised fetus. These problems will
quickly lead to death of the fetus; therefore, this is
the priority problem. The mother is hemorrhaging;
it is an actual problem, not a risk problem. Content

Obstetrics; Category of Health AlterationIntrapartum;

13. Correct answer 3: The left lateral position will improve placental blood flow and oxygen supply to the
fetus; therefore, this is the nurses first intervention.
Then, the nurse should calm the mother, notify the
HCP, and prepare for an emergency C-section.
Intrapartum; Integrated ProcessImplementation;
15. Correct answer 3: The nurse does not want the

fetus to be delivered if the cord is compressed between
the babys head and the cervical os. Therefore, the
nurse must attempt to stop the delivery by telling the
client not to push. The client should be placed in
the Trendelenburg position and be prepared for an
emergency C-section. ContentObstetrics; Category
of Health AlterationIntrapartum; Integrated Process
LevelApplication.
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16. Which client should the labor and delivery charge

nurse assess first after receiving report?
l 1. The client receiving oxytocin (Pitocin) who is
having contractions every 4 minutes.
l 2. The client who is 10 centimeters dilated and 100%
effaced who is pushing.
l 3. The client whose husband is irate and threatening
to hurt his wife.
l 4. The adolescent client who may want to give her
baby up for adoption.
17. The nurse is caring for a client who is 38 weeks
gestation in the first stage of labor who is 2 cm dilated
and 30% effaced. Which intervention should the nurse
implement?
l 1. Check the clients progress every 10 minutes.
l 2. Assess the fetal heart rate every 30 minutes.
l 3. Prepare the client for epidural anesthesia.
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18. The client at 38 weeks gestation is 10 cm dilated and

100% effaced and has begun pushing. Which intervention
l 2. Administer 6 L of oxygen via nasal cannula.
l 3. Encourage the father to change into scrubs.
l 4. Place the client in the supine position.
19. The mother has just delivered the newborn. The
newborn has a pulse of 120, a lusty cry, a flexed body,
and spontaneous movements and responds promptly to
suctioning. Which APGAR score should this newborn
receive?
l 1. 0.
l 2. 4.
l 3. 8.
l 4. 10.
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ANSWERS
16. Correct answer 3: The charge nurse should address

safety and management issues, which include talking
with clients and family members who are upset and
may be a danger to the client. The client on Pitocin
and the client ready to deliver will have primary
nurses assigned to them. The social worker could
talk to the client who wants to put the child up for
adoption. ContentObstetrics; Category of Health
AlterationIntrapartum; Integrated ProcessAssessment;
17. Correct answer 2: At the beginning of the first stage

of labor, the mother and fetus should be monitored
every 30 minutes to assess for complications. The
client is checked every 10 minutes initially;
anesthesia is administered when the client is 78 cm
dilated; and the client can lie in any position of comfort. ContentObstetrics; Category of Health Alteration
Intrapartum; Integrated ProcessImplementation;
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18. Correct answer 1: This mother is going to deliver

this infant; therefore, the HCP (obstetrician or
midwife) should be notified immediately. The
mother should be in a high Fowler position. It is
too late for the father to be changing into scrubs
because the delivery is imminent. ContentObstetrics;
LevelApplication.
19. Correct answer 4: This infant meets the criteria for

an APGAR of 10, which indicates the infant was
born healthy. ContentObstetrics; Category of Health
AlterationIntrapartum; Integrated ProcessAssessment;
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20. The client at 38 weeks gestation has had a 6-hour

uncomplicated labor and has delivered a healthy baby
boy. Which intervention should the nurse implement?
l 1. Administer terbutaline (Brethine), a uterine
relaxant.
l 2. Ensure the placenta has been expelled intact.
l 3. Place the client in the lithotomy position.
l 4. Teach the client about pain control.
Postpartum
21. The nurse is caring for a postpartum client who is a
Jehovahs Witness and needs a Rhogam injection. Which
l 1. Inform the client that Rhogam is a blood product.
l 2. Determine if the client has signed the permit.
l 3. Obtain the Rhogam injection from the laboratory.
l 4. Document the lot number in the clients chart.
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481
22. The nurse is administering medications to clients on

a postpartum floor. Which medication should the nurse
l 1. The rubella vaccine to the postpartum client who
has a negative titer.
l 2. The yearly flu vaccine to a client who reports an
allergy to tomatoes.
l 3. The magnesium sulfate to the client with eclampsia
who is 4 hours post delivery.
l 4. The temazepam (Restoril), a sleeping medication,
to the client who is breastfeeding her infant.
23. Which client should the postpartum nurse assess first
after receiving the morning shift report?
l 1. The client who is complaining of cramps when
breastfeeding.
l 2. The client who used one peri-pad during the night.
l 3. The client who has an edematous and warm
right calf.
l 4. The client who is crying because her husband went
to work.
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ANSWERS
20. Correct answer 2: If the placenta is not expelled

intact, the client could develop complications.
Brethine is administered to stop preterm labor; the
lithotomy position is used during delivery, not after
the infant is delivered; and teaching about pain control is not appropriate at this time. ContentObstetrics;
LevelApplication.
21. Correct answer 1: Jehovahs Witnesses do not believe

in accepting blood products, but the nurse should
make sure the client is aware that, without the
injection, her next pregnancy could result in an
infant with erythroblastosis fetalis. However, with the
injection her religious belief might be compromised:
Rhogam is a blood product. ContentObstetrics;
Category of Health AlterationPostpartum; Integrated
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22. Correct answer 4: Restoril is a pregnancy category X

drug, which means it is teratogenic. Any medication
the client takes can be excreted in the breast milk,
affecting the infant. The client with a negative titer
needs the rubella vaccine; the flu vaccine is contraindicated in someone with an allergy to eggs, not tomatoes;
and magnesium sulfate is given up to 24 hours after
delivery. ContentObstetrics; Category of Health
23. Correct answer 3: A warm, edematous calf is a sign

of a possible deep vein thrombosis (DVT); therefore,
this client should be assessed first. Cramps when
breastfeeding are normal; using one peri-pad indicates
no abnormal bleeding; and the client crying can be
assessed after the nurse checks the other clients.
Postpartum; Integrated ProcessAssessment; Client
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SECTION TEN
24. The charge nurse has received laboratory results for

clients on the postpartum unit. Which client would
warrant intervention by the nurse?
l 1. The client whose white blood cell (WBC) count
is 18,000/mm3.
l 2. The client whose platelet count is 32,000 mm.
l 3. The client whose serum creatinine level is
0.8 mg/dL.
l 4. The client whose serum glucose level is 145 mg/dL.
25. The nurse on the postpartum unit is administering
morning medications. Which medication should the
nurse administer first?
l 1. The narcotic analgesic to the client complaining of
incisional pain of 8 on a 010 pain scale.
l 2. The oral hypoglycemic medication to the client
diagnosed with gestational diabetes.
l 3. The pain medication to the client complaining of
headache of 3 on a 010 pain scale.
l 4. The antacid to the client who is complaining of
heartburn and passing gas.
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483
26. The client is 1 day postpartum, and the nurse notes

the fundus is displaced laterally to the right. Which
nursing intervention should be implemented first?
l 1. Prepare to insert an indwelling urinary catheter.
l 2. Assess the bladder using the bladder scanner.
l 3. Massage the clients fundus for 2 minutes.
l 4. Assist the client to the bathroom to urinate.
27. The charge nurse is making assignments on the
postpartum unit. Which client should be assigned to the
licensed practical nurse (LPN)?
l 1. The client diagnosed with type 1 diabetes who has
erratic blood glucose levels.
l 2. The client who had a C-section yesterday and who
is on an oxytocin (Pitocin) drip.
l 3. The client who had a vaginal delivery this morning
who is complaining of perineal pain.
l 4. The client being discharged whose infant will be
on an apnea monitor at home.
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ANSWERS
24. Correct answer 2: Normal platelet count is

150,000450,000/mm3. This clients platelet count
is critically low and could indicate disseminated
intravascular coagulation (DIC). The WBC count
normally rises (up to 25,000) during labor and
postpartum; therefore, this does not warrant intervention. The creatinine and glucose levels are within
normal limits. ContentObstetrics; Category of Health
AlterationPostpartum; Integrated ProcessAssessment;
25. Correct answer 1: The client in pain is priority for

the nurse when administering medication. An 8 for
incisional pain is priority over a 3 for a headache.
Drug Administration; Integrated ProcessPlanning;
484
26. Correct answer 4: The primary reason for a displaced

fundus is a full bladder. The nurse should implement
the least invasive procedure, which is to ask the client
to attempt to void. The emptying of the bladder should
allow the fundus to return to the midline position.
Postpartum; Integrated ProcessImplementation; Client
27. Correct answer 3: Perineal pain is expected after

a vaginal delivery; therefore, this client could be
assigned to the LPN. The other clients require more
nursing judgment and should not be assigned to an
LPN. The client taking home a child on the apnea
monitor requires extensive teaching. Content
Obstetrics; Category of Health AlterationPostpartum;
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SECTION TEN
485

nurse the postpartum client has T 98.2F, P 124, R 30,
and BP 88/60. Which action should the nurse implement
first?
l 1. Ask the UAP when the last vital signs were obtained.
l 2. Go to the room and check the client immediately.
l 3. Notify the clients health-care provider (HCP).
l 4. Check the clients hemoglobin and hematocrit.
30.The postpartum nurse is assessing the client who is
29. The postpartum client who is being discharged home

has not bathed or brushed her hair and does not hold
or cuddle her infant. Which action should the nurse
implement prior to discharging the client?
l 1. Ask the chaplain to come talk to the client.
l 2. Insist the client dress and feed the infant.
l 3. Notify the hospital social worker.
l 4. Encourage the client to ventilate her feelings.
Newborn
1 day post vaginal delivery and notes that the fundus is at

umbilicus, and the client has moderate lochia on her
peri-pad. Which intervention should the nurse implement?
l 3. Assess the clients vital signs.
l 4. Place the client on intake and output.
31. Which newborn infant would warrant immediate

l 1. The 1-hour-old newborn whose heart rate is 128.
l 2. The 6-hour-old newborn who is jittery and
irritable.
l 3. The 12-hour-old newborn who took 2 ounces of
formula.
l 4. The 24-hour-old newborn who has passed
meconium.
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ANSWERS
28. Correct answer 2: Whenever anyone else reports

information to the nurse, the nurse must assess the
client in person; this clients vital signs indicate
hypovolemic shock. ContentObstetrics; Category of
Health AlterationPostpartum; Integrated Process
29. Correct answer 3: Because the client is being

discharged and is exhibiting signs of postpartum
depression, the nurse must ensure there will be
follow-up visits with the mother and infant. The
social worker is responsible for arranging the
follow-up. Helping the client ventilate feelings will
not ensure the infant is safe. ContentObstetrics;
Category of Health AlterationPostpartum; Integrated
Process Implementation; Client NeedsPsychosocial
Integrity; Cognitive LevelSynthesis.
486
30. Correct answer 1: These data are normal and

expected for a client who is 1 day post vaginal delivery;
therefore, the nurse should continue to monitor the
client. There is no need to take the vital signs more
frequently than usual, monitor intake and output, or
notify the HCP. ContentObstetrics; Category of
Health AlterationPostpartum; Integrated Process
31. Correct answer 2: The infant who is jittery and irritable may have hypoglycemia and should be assessed
immediately by the nurse. The normal heart rate for
a newborn is 120160 beats per minute (bpm);
2 ounces of formula is an adequate feeding for a
12-hour-old newborn; and the newborn should pass
meconium. ContentObstetrics; Category of Health
AlterationNewborn; Integrated ProcessAssessment;
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SECTION TEN
487
32. The nurse is assessing normal reflexes for a newborn.

Which finding should be documented in the chart as an
abnormal reflex?
l 1. The infant who extends one arm and curls the
opposite when supine.
l 2. The infants toes flare out when the lateral heel is
stroked.
l 3. The infant whose head does not turn toward the
cheek being stroked.
l 4. The infant who extends the arms when hearing a
loud noise.
34. The unlicensed assistive personnel (UAP) is assisting

the nurse in the newborn nursery. Which action by the
UAP would warrant intervention?
l 1. The UAP does not wipe down the crib with a
disinfectant.
l 2. The UAP protects the umbilical cord when
changing the diaper.
l 3. The UAP leaves the identity band on when giving
a bath.
l 4. The UAP does not use soap when bathing the
newborn.
33. The 16-year-old client with a 1-day-old infant wants

her son circumcised, but the clients mother does not
want the newborn to be circumcised. Which intervention
l 1. Determine if the clients mother must sign the
permit.
l 2. Request the chaplain to come and talk to the client
and mother.
l 3. Find out if the circumcision is covered by insurance.
l 4. Obtain informed consent for the procedure from
the client.
35. Which action by the nurse would warrant immediate

intervention by the charge nurse?
l 1. The nurse allows the mother to place the infant
skin to skin.
l 2. The nurse enlarges the hole in the nipple to feed
the infant with a cleft palate.
l 3. The nurse is performing the Barlowe maneuver on
the newborn.
l 4. The nurse notifies the HCP about an abnormal
laboratory value.
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ANSWERS
32. Correct answer 3: When the cheek is stroked, the
488
34. Correct answer 1: Not wiping down the crib increases
infant should turn toward the cheek being stroked;

this is the rooting reflex. Option 1 is the tonic-neck
reflex; option 2 is the Babinski reflex; and option 4 is
the Moro reflex, all of which are normal reflexes in a
newborn. ContentObstetrics; Category of Health
the infants risk for infection; therefore, this warrants

intervention from the nurse. Protecting the umbilical
cord, not removing the identity band, and not using
soap when bathing a newborn are all acceptable
actions by the UAP. ContentObstetrics; Category
AlterationNewborn; Integrated ProcessAssessment;

of Health AlterationNewborn; Integrated Process

33. Correct answer 4: The 16-year-old client has the

legal right to decide if her son will be circumcised.
The clients mother does not have the legal right to
make any decisions for the infant. ContentObstetrics;
Category of Health AlterationNewborn; Integrated
LevelApplication.
35. Correct answer 3: The Barlowe and Ortoloni

maneuvers are performed to assess developmental
hip dysplasia, and a pediatrician or a nurse practitioner must perform these maneuvers because they
can cause further damage if done incorrectly.
Kangaroo pouching is encouraged, and special
feeding is required for a child with a cleft palate.
Newborn; Integrated ProcessAssessment; Client
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SECTION TEN

when administering an intramuscular vitamin K injection
to the newborn?
l 1. Dilute the vitamin K with 1 mL normal saline.
l 2. Use a tuberculin syringe with a 5/8-inch needle.
l 3. Administer the injection in the dorsal gluteus.
l 4. Check the mother for any type of allergies.
37. The nurse is preparing to administer a 20-mL
intravenous piggyback (IVPB) to a 2-week-old infant.
The medication is to be infused over 1 hour. Which rate
should the nurse infuse the medication?
Answer: ______________________
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489
38. The client, whose child is 4 hours old and has a cleft
lip and cleft palate, is crying while holding her child. Which
intervention would be most appropriate for the nurse?
l 1. Stand quietly and support the client.
l 2. Refer the client to a parent support group.
l 3. Tell the client with surgery her child will look just fine.
l 4. Ask the client how her husband is dealing
with this.
39. The nurse is caring for a newborn who was just
brought from the labor and delivery area. Which
l 1. Take the neonates vital signs.
l 2. Bathe the neonate to remove the lanugo.
l 3. Complete the newborn assessment.
l 4. Place the infant under a radiant warmer.
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ANSWERS
36. Correct answer 2: The smallest amount of medication should be administered in the newborns vastus
lateralis, using a tuberculin syringe with a small,
short needle. ContentObstetrics; Category of Health
LevelAnalysis.
37. Correct answer 20 mL/hr: IV medication is always

administered on an IV pump to ensure safety for the
newborn. Fluid volume overload can be detrimental
to the newborn. ContentObstetrics; Category of
490
38. Correct answer 1: The mother is distraught, and

there is nothing the nurse can do but be supportive
of the client. At 4-hour post-delivery referral to a
support group is not appropriate. Telling the client
everything will be all right is false reassurance. The
nurse should support the client, not the clients
husband. ContentObstetrics; Category of Health
AlterationNewborn; Integrated ProcessImplementation;
Client NeedsPsychosocial Integrity; Cognitive Level
Application.
39. Correct answer 4: The neonates thermoregulatory

mechanism is immature; therefore, the nurse must
support the neonates body temperature. All the
other options should be implemented but not before
placing the infant in a warmer. ContentObstetrics;
Category of Health AlterationNewborn; Integrated
LevelSynthesis.
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40. Which newborn infant would the nursery nurse

assess first?
l 1. The 2-hour-old newborn whose APGAR scores
were 9 and 10.
l 2. The 4-hour-old newborn who has a respiratory rate
of 70.
l 3. The 6-hour-old newborn whose skin is jaundiced.
l 4. The 8-hour-old newborn who was born at
40 weeks gestation.
Management
41. The client being seen in the OB clinic tells the nurse,
My husband thinks this is his baby, but I am not sure who
the father is. What do you think I should do? Which response by the nurse supports the ethical principle of veracity?
l 1. I think you should talk to your husband about
your concern.
l 2. You could wait until the baby is born and have
DNA testing.
l 3. I would not tell your husband about your suspicions.
l 4. Do you have any idea who the father might be if
it is not your husband?
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491
42. The mother of a newborn infant tells the nurse

excitedly, Someone just tried to take my baby and they
didnt know the code word. Which action should the
l 1. Notify hospital security of the situation.
l 2. Interview the mother about the appearance of the
person.
l 3. Page a code pink, an infant abduction, overhead.
l 4. Notify the nurses station to account for all the
mothers and babies.
43. The estranged husband comes to the postpartum
unit requesting his wifes room number. The nurse can
smell alcohol on the mans breath. Which action should
l 1. Give the husband the clients room number.
l 2. Ask the client if she would like to see her husband.
l 3. Contact hospital security to come to the unit and
to talk to the husband.
l 4. Tell the husband that he cannot be here if he has
been drinking.
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ANSWERS
40. Correct answer 2: The normal respiratory rate for a

newborn is 3060; therefore, this infant should be
assessed first. Jaundice should be assessed but not
before an airway problem. A 910 APGAR is
normal, and a 40-week gestation is not post-mature.
Newborn; Integrated ProcessAssessment; Client Needs
41. Correct answer 1: Veracity is the ethical principle of

telling the truth. This response is encouraging the client
to tell the husband the truth. ContentManagement;
42. Correct answer 4: Ensuring the safety of the mothers

and babies on the unit is the nurses first priority.
Then, the nurse should notify security and interview
the mother for more specific information. A code
492
pink is not called until an abduction has occurred.

43. Correct answer 2: The nurse should ask the client if

she would like to see her husband because, even if
they are estranged, she may want to see him. The
nurse should not let the husband go into the room
unannounced. Hospital security should be notified if
the husband is causing problems. The nurse cannot
refuse the husbands wish to visit his wife. Content
Management; Category of Health AlterationObstetrics;
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SECTION TEN
44. The charge nurse is making assignments in the labor

and delivery department. Which client should be assigned
to the most experienced nurse?
l 1. The 36-week gestational client who is 9 cm dilated
and 90% effaced.
l 2. The 32-week gestational client who is having twins
and is on bed rest.
l 3. The 38-week gestational client who has contractions
3 minutes apart.
l 4. The 39-week gestational client who has non-reassuring
patterns on the monitor.
45. Which task would be most appropriate for the nurse
on the postpartum unit to delegate to the unlicensed
assistive personnel (UAP)?
l 1. Bring an infant back to the nursery.
l 2. Call the laboratory for a stat complete blood count
(CBC) results.
l 3. Show the mother how to bottle-feed the infant.
l 4. Check the 1-day postpartum clients fundus.
493
46. A nurse from the medical/surgical unit is assigned to

the postpartum unit. Which client should the charge
nurse assign to the medical/surgical (M/S) nurse?
l 1. The client trying to breastfeed her first-born child
who has developed mastitis.
l 2. The client with an abdominal hysterectomy who
has a hemoglobin of 10 mg/dL.
l 3. The client who is P6 G8 who has just delivered
twins who are healthy.
l 4. The unmarried client who is considering giving her
child up for adoption.
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ANSWERS
44. Correct answer 4: Nonreassuring patterns are a sign

of complications in the fetus; therefore, this client
should be assigned to the most experienced
labor and delivery nurse. The other three clients are
stable and could be assigned to any nurse. Content
Management; Category of Health AlterationObstetrics;
45. Correct answer 1: The UAP can transport an infant

to and from the nursery as long as the UAP knows
the security protocol. The UAP is not knowledgeable
about laboratory results, and the UAP cannot teach
or assess. ContentManagement; Category of Health
494
46. Correct answer 2: A hysterectomy is a routine

surgical procedure; even though this client has a low
hemoglobin level, an M/S nurse should be able to
care for this client. Mastitis is a complication requiring
an experienced nurse; the client who has had six
deliveries may experience postpartum complications;
and giving up a child for adoption is a complicated
situation. ContentManagement; Category of Health
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SECTION TEN
47. While making rounds the charge nurse notices that a

cup with medication in it was left at the clients bedside.
Which action should the charge nurse implement first?
l 1. Counsel the primary nurse about medication
delivery protocol.
l 2. Mandate the nurse to take a pharmacology course.
l 3. Take the cup of medications back to the nurses
station.
l 4. Ask the client who left the medication at the
bedside.
48. The day nurse has documented three medication
errors made by the night nurse in the last week and is
concerned that client safety is at risk. Which action
should the day nurse implement?
l 1. Discuss the numerous medication errors with the
unit manager.
l 2. Initiate the formal counseling procedure for
multiple medication errors.
l 3. Discuss the errors with the nurse to determine if
there is a systems problem.
l 4. Do not take any action because it is the night
charge nurses responsibility.
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495
49. The client who is 16 weeks pregnant calls and tells the
office nurse, My husbands insurance has changed. What
should I do? Which statement is the nurses best response?
l 1. This doctor takes all types of insurance so dont
worry.
l 2. Would you like the number of a free clinic in
our city?
l 3. I will transfer you to the clerk to check your new
insurance coverage.
l 4. You can keep your old insurance if you pay
COBRA payments.
50. Which client should the newborn nurse refer to the
hospital ethics committee?
l 1. The 24-week-old infant whose mother does not
have any insurance to pay for the infants care.
l 2. The 27-week-old infant who has multisystem
organ failure whose parents want everything done.
l 3. The 36-week-old infant who needs to be placed on
the extracorporeal membrane oxygenation pump
(ECMO).
l 4. The 40-week-old infant with Down syndrome whose
parents want to put the infant up for adoption.
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ANSWERS
47. Correct answer 3: The charge nurse should first

remove the medications from the bedside for the
safety of the client and visitors. The nurse may need
to be counseled, but the charge nurse must investigate
before assuming. ContentManagement; Category of
LevelSynthesis.
48. Correct answer 1: The day nurse should follow the

chain of command and share her concerns with the
unit manager. The day nurse has no authority to discuss the errors or initiate formal counseling with the
night nurse. The day nurse must voice her concerns
concerning safe client care to the unit manager.
Infection Control; Cognitive LevelApplication.
Page 496
496
49. Correct answer 3: The nurse should determine if the

clients new insurance will be valid at the office at
which the client works. The nurse should delegate
this task to the clerk. COBRA is available at a cost
to the individual who no longer works for the
employer where the person had insurance coverage.
50. Correct answer 2: A premature infant with multisystem organ failure has a poor prognosis. The infant
should be spared from painful invasive procedures
and provided with comfort. This situation could be
referred to the ethics committee. No insurance, an
infant needing to be placed on an ECMO, and an
adoption are not situations for the ethics committee.
Obstetrics; Integrated ProcessPlanning; Client Needs
SECTION ELEVEN
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Page 497
Pediatric Disorders
497
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Page 498
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Pediatric Disorders
SECTION ELEVEN
499
Health Promotion
1. The unlicensed assistive personnel (UAP) is transporting
a new mother and her infant to the automobile for discharge
home. Which statement by the UAP warrants immediate
l 1. The client is taking all the diapers in the hospital
crib when she goes home.
l 2. The mother is going to buy a car seat when her
husband gets paid.
l 3. The mother said she likes to put lotion on her
beautiful daughter.
l 4. The client says she always keeps the side rails up
on the baby's crib.
2. The new mother brings her 4-month old son to the
pediatric clinic for the well-baby check-up. Which
statement by the mother indicates the child is
developmentally on target for growth and development?
l 1. My baby babbles all the time and smiles at me.
l 2. My baby has difficulty holding his head up.
3. My baby eats four 6-ounce bottles of formula
4. My baby sleeps about 20 hours every day.
a day.
3. The nurse is caring for clients on a pediatric unit.

l 1. The 2-year-old child whose axillary temperature
is 99F.
l 2. The 4-year-old child whose apical pulse is 119 beats
per minute.
l 3. The 10-year-old child whose respirations are
22 breaths per minute.
l 4. The 16-year-old child whose blood pressure is
160/92 in the right arm.
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ANSWERS
1. Correct answer 2: Federal law mandates that all

infants be securely and correctly placed in a car seat
in the back seat of the automobile; therefore, this
statement would warrant intervention by the nurse.
All the other options are appropriate statements for
the client to make. ContentPediatrics; Category of
Health AlterationGrowth and Development; Integrated
and Maintenance; Cognitive LevelSynthesis.
2. Correct answer 1: A language developmental milestone for a 4-month-old is babbling, and the infant's
cry becomes more differentiated. The infant should be
holding the head up at 2 months, and at 4 months
the baby should be eating 6 ounces of formula five to
six times a day and sleeping 15 or 16 hours. Content
Pediatrics; Category of Health AlterationGrowth and
Development; Integrated ProcessAssessment; Client
LevelAnalysis.
500
3. Correct answer 4: A normal blood pressure for a

16-year-old child is systolic 93131 and diastolic
4985. This client's blood pressure is elevated. All
other vital signs are within normal limits (WNLs) for
the age of the child. ContentPediatrics; Category of
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Pediatric Disorders
SECTION ELEVEN
4. The pediatric clinic nurse is administering immunizations

to a 2-month-old infant. Which instructions should the
nurse discuss with the mother? Select all that apply.
l 1. Tell the mother slight redness at the injection site is
expected.
l 2. Instruct the mother to give the infant a baby
aspirin for comfort.
l 3. Inform the mother to notify the health-care
provider (HCP) of a temperature greater than
101F.
l 4. Explain the importance of keeping a record of her
child's immunization.
l 5. Discuss that the Haemophilus inflenzae type B (HIB)
vaccine will cause your baby to get a mild flu.
5. The pediatric clinic nurse notes some discoloration
and decay on the 9-month old male infant's teeth. Which
question would be most appropriate for the nurse ask the
mother concerning the child's teeth?
l 1. When is the last time your child saw a dentist?
l 2. At what age did your child begin to cut teeth?
3. Does your baby fall asleep with a bottle in his
4. Has your baby had many infections requiring
501
mouth?
antibiotics?
6. The pediatric clinic nurse is discussing poison control

awareness with the parents of a 10-month-old baby.
Which priority intervention should the nurse discuss
with the parents?
l 1. Instruct the parents to place the poison control
number by the phone.
l 2. Tell the parents to keep all household cleaners in a
locked cabinet.
l 3. Explain that some painted surfaces in older homes
have lead content.
l 4. Discuss the need to discard poisonous containers in
a special trashcan.
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ANSWERS
4. Correct answer 1, 3, 4: Common reactions to

immunizations include soreness, redness, and edema
at the injection site. A low-grade fever is also common, but a temperature greater than 101F could
indicate an adverse reaction to the vaccine and should
be reported to the HCP. A record of immunizations
should be kept because it must be shown when the
child starts school. Aspirin can cause Reye syndrome
and should be avoided. The HIB vaccine does not
cause the flu. ContentPediatrics; Category of Health
AlterationGrowth and Development; Integrated
5. Correct answer 3: The nurse should investigate

possible bottle/mouth caries caused by allowing
the infant to fall asleep with formula or juice in the
mouth. The other questions may be asked by the
nurse, but determining the cause of the discoloration
and decay is priority. Tetracyline, an antibiotic, may
cause discoloration of the teeth of a child, which is
502
why it is not prescribed for children. Content

Pediatrics; Category of Health AlterationGrowth and
Development; Integrated ProcessAssessment; Client
LevelAnalysis.
6. Correct answer 2: The most important intervention is

to prevent the child from gaining access to potentially
poisonous chemicals and substances. Having the
poison control number is appropriate, but prevention
is the initial priority. ContentPediatrics; Category of
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SECTION ELEVEN
7. Which information should the school nurse discuss

with the parents at a Parent-Teacher Association meeting
at an elementary school?
l 1. Explain the importance of keeping all electrical
wires hidden or out of reach.
l 2. Tell the parents the child must be appropriately
restrained while riding in the car.
l 3. Encourage the parents to discuss sexuality issues
with their children.
l 4. Recommend the parents use a gait belt when
teaching the child to skate
8. The pediatric clinic nurse is interviewing a 17-year-old
female client during a yearly physical examination. The
client's mother is in the room. Which action should the
nurse implement?
l 1. Ask the mother how she gets along with her
daughter.
l 2. Discuss the client's relationships with her parents.
l 3. Determine if the client wants her mother in
the room.
l 4. Request the client's mother to leave the room.
Pediatric Disorders
503
9. The mother of 7-year-old child calls the clinic and tells

the nurse, My daughter has a red rash on her face and
neck that is spreading down her body. She does not
have a fever, is not itching, and is not having trouble
breathing. Which intervention should the nurse
implement?
l 1. Instruct the mother to keep her daughter at home
isolated from other children.
l 2. Tell the mother the HCP will telephone a
prescription for antibiotics.
l 3. Encourage the mother to bathe the child in a
tepid-water oatmeal bath.
l 4. Discuss the need to administer Tylenol elixir every
8 hours around the clock.
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ANSWERS
7. Correct answer 3: Even children as young as 9 or
504
9. Correct answer 1: These are manifestations of rubella,
10 years old may engage in some type of sexual

activity with other children or adults. It is not too
early to discuss age-appropriate sexual issues with
children. Household and car safety issues should have
already been implemented. A gait belt is used when
ambulating a client. ContentPediatrics; Category of
which is a self-limiting viral infection that is contagious and usually mild in children of this age. Keeping
the child isolated is appropriate. Antibiotics are not
prescribed for a virus, oatmeal baths help decrease
itching, and Tylenol is only needed if the child is
uncomfortable. ContentPediatrics; Category of Health


LevelApplication.
8. Correct answer 4: A 17-year-old client may not feel

comfortable discussing personal issues in front of the
parent. Asking the 17-year-old if her mother can stay
in the room places the client at a disadvantage.
ContentPediatrics; Category of Health Alteration
Growth and Development; Integrated Process
LevelApplication.
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SECTION ELEVEN
10. The elementary school nurse is teaching a class on

health promotion to third-grade students. Which activity
should the nurse implement when teaching this age
group?
l 1. Show the students a video on the importance of
bicycle safety.
l 2. Have the students divide into groups and make
safety posters.
l 3. Provide a written handout discussing safety in
the home.
l 4. Give the students a pre- and post-test on the
information taught.
Cardiovascular System
to calm the 3-year-old child for an electrocardiogram
(ECG)?
l 1. Allow the child to play with the ECG leads.
l 2. Ask the parents to leave the child's room.
l 3. Encourage the mother to stroke the child's head
during the ECG.
l 4. Give the child a sucker if the child behaves.
Pediatric Disorders
505
12. The charge nurse on a pediatric cardiovascular unit is

checking laboratory values. Which laboratory result
would require intervention by the charge nurse?
l 1. The 1-year-old child's potassium level is 3.8 mmol/L.
l 2. The 2-year-old child's digoxin level is 2.5 mcg/L.
l 3. The 4-year-old child's sodium level is 140 mmol/L.
l 4. The 10-year-old child's lead level is 8 mg/dL.
13. The 2-year-old child diagnosed with tetralogy of

Fallot is playing in the room and suddenly squats. Which
l 1. Allow the child to stay in that position.
l 2. Pick the child up and place in the bed.
l 3. Place oxygen on the child immediately.
l 4. Ask the child if something is wrong.
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ANSWERS
10. Correct answer 2: Children of this age master skills
506
12. Correct answer 2: The therapeutic serum digoxin
by playing and working with their peers; therefore,

requiring group work covering the topic is most
appropriate when teaching this age group. Videos,
writing handouts, and tests are not the best
teaching/learning activities for 89-year-old children.
level ranges 0.82.0 mcg/L; therefore, this child's

level is elevated, and this requires intervention. The
normal potassium is 3.55.0 mmol/L; the normal
sodium level is 138145 mmol/L; and the lead level
should be less than 10 mg/dL. ContentPediatrics;

Growth and Development; Integrated ProcessPlanning;

11. Correct answer 3: The child must be kept quiet

and cooperative during an ECG to ensure accurate
results, and the mother would have the most calming
influence on the child. Suckers could lead to choking
and/or dental caries and are not appropriate for
children in the hospital. The child should be able to
see and touch the leads but not play with the leads.
13. Correct answer 1: The squatting position allows

blood to stay in the lower extremities, which
decreases the work load of the heart. The nurse
should stay with the child but leave the child in
the squatting position. ContentPediatrics; Category
LevelApplication.
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SECTION ELEVEN
14. Which signs and symptoms would the nurse expect

in the 1-year-old child diagnosed with an acyanotic
cardiovascular defect?
l 1. Buccal and peripheral cyanosis.
l 2. Clubbing of the fingers and barrel chest.
l 3. Increased urine output and tented tissue turgor.
l 4. Periorbital/facial edema and jugular vein distention
(JVD).
15. The 18-month-old child diagnosed with Kawasaki
disease, mucocutaneous lymph node syndrome, is
prescribed salicylate (aspirin) therapy. Which action
l 1. Contact the HCP to verify the order.
l 2. Administer the medication as prescribed by HCP.
l 3. Give an antacid when administering the medication.
l 4. Do not administer the aspirin because of Reye
syndrome.
Pediatric Disorders
507
16. The 4-year-old child is brought to the pediatric clinic

with complaints of a sore throat. Which priority action
l 1. Have the child gargle with salt water.
l 2. Obtain a throat culture for strep.
l 3. Give the child a throat lozenge.
l 4. Do not open the child's mouth.
17. The nurse is teaching the 10-year-old diagnosed with
hyperlipidemia about dietary food choices. Which school
cafeteria menu selection indicates the child understands
the teaching?
l 1. Chicken nuggets, mashed potatoes and gravy, and
whole milk.
l 2. Roast beef sandwich, potato chips, and 2% milk.
l 3. Baked fish, vegetable medley, and bottled water.
l 4. Pepperoni pizza, fruit cocktail, and juice.
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ANSWERS
14. Correct answer 4: Acyanotic cardiovascular defects
508
16. Correct answer 2: An untreated or partially treated
lead to congestive heart failure; if the defect is not

surgically corrected, the child will have edema and
JVD. Acynotic defects do not lead to cyanosis.
Clubbing and barrel chest are secondary to longterm hypoxia, and the child would have decreased
cardiac output. ContentPediatrics; Category of
group A beta-hemolytic streptococcal infection can lead

to rheumatic fever. The nurse should culture the throat
to determine if it is a strep infection. If the child is
drooling, the nurse should not open the child's mouth
because of possible epiglottitis. A 4-year-old child may
choke while gargling. ContentPediatrics; Category of


Implementation; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelApplication.
15. Correct answer 2: An anti-inflammatory medication, such as aspirin (acetylsalicylic acid) and intravenous gamma globulin are the treatments of choice
for Kawasaki disease. Even though there is a risk for
Reye syndrome associated with aspirin therapy in
children, the risk is greater for the child if the aspirin
is not administered. An antacid will neutralize the
acid and prevent breakdown of the medication.
17. Correct answer 3: The child with hyperlipidemia

should adhere to a low-fat, low-cholesterol diet.
Children with a family history of hyperlipidemia are
now being screened at an early age, and the treatment
is primarily diet, but some children may be on medication. ContentPediatrics; Category of Health Alteration
LevelEvaluation.
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SECTION ELEVEN
18. The nurse is caring for children on a pediatric unit.

Which client should the nurse assess first after receiving
change-of-shift report?
l 1. The 1-year-old child with ventral septal defect who
has 1+ pitting edema.
l 2. The 2-year-old child with bacterial endocarditis
who has a low-grade fever.
l 3. The 3-year-old child with rheumatic fever whose
white blood cell count is 8000 mm.
l 4. The 4-year-old child with heart disease whose pulse
is 138 and blood pressure is 70/38.
19. The 5-year-old is 1 hour post right femoral cardiac
catheterization. Which data would warrant immediate
l 1. The child's right foot capillary refill is greater than
3 seconds.
l 2. The child is very groggy and refuses to drink any
liquids.
l 3. The child's right foot is warm to touch and is pink.
l 4. The child is lying very still with the right leg
extended.
Pediatric Disorders
509
20. The nurse is teaching the parents of a 1-year-old

child diagnosed with congestive heart failure. Which
interventions should the nurse discuss with the parents?
l 1. Encourage the parents to limit the child's activities.
l 2. Teach the parents how to take child's pulse.
l 3. Discuss the signs/symptoms of digoxin toxicity.
l 4. Measure the child's daily intake and the output of
urine.
l 5. Tell the parents to feed the child a daily serving of
bananas.
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ANSWERS
18. Correct answer 4: The child is exhibiting signs

of shock: an increased pulse and decreased blood
pressure; therefore, this child should be evaluated
first. All other children are exhibiting signs/symptoms
expected for the disease process they have. Content
Pediatrics; Category of Health AlterationCardiovascular;
LevelAnalysis.
19. Correct answer 1: A capillary refill greater than

3 seconds indicates a possible obstruction of the
artery, which would require further evaluation by
the nurse. The right foot should be warm and pink;
the child is sedated during the procedure, so grogginess is expected; and the leg should be extended.
510
20. Correct answer 2, 3, 5: Digoxin administration is

held if the pulse is below normal limits; therefore,
teaching the parents how to take the child's pulse
and the signs/symptoms of digoxin toxicity are
appropriate interventions. Bananas are high in
potassium, which can be lost with diuretic therapy,
that the child is probably receiving. The parents
should not limit the child's activities, and daily
intake and output is not implemented at home, but
the parents may be asked to count the number
of diapers used. ContentPediatrics; Category of
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SECTION ELEVEN
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511
Respiratory System
21. Which intervention would be most appropriate for
the nurse to implement when caring for a 3-year-old
child diagnosed with cystic fibrosis?
l 1. Schedule the child's chest physiotherapy (CPT)
1 hour prior to meals.
l 2. Elevate the child's head of the bed on 6-inch
blocks when sleeping.
l 3. Apply continuous positive airway pressure (CPAP)
during the day.
l 4. Administer oxygen via nasal cannula at 6 L/min.
22. The 6-year-old child is brought to the emergency
department wheezing and short of breath. Which
l 1. Start an intravenous line.
l 2. Elevate the head of the bed.
l 3. Administer aminophylline, a bronchodilator.
l 4. Perform a peak flow meter test.
23. The mother of a 2-year-old diagnosed with pertussis,

or whooping cough, who is in the convalescent stage tells
the nurse her child is still coughing at night. Which
l 1. I will make an appointment for your child to see
the doctor today.
l 2. You should give your child an over-the-counter
cough suppressant.
l 3. Your child may have a cough for several months
after having pertussis.
l 4. Take your child into the bathroom and turn on
the hot shower.
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ANSWERS
21. Correct answer 1: CPT helps to remove the thick

tenacious secretions from the child's lungs. Parents
are taught to perform CPT at home prior to meals;
too close to a meal will spoil the child's appetite
due to the taste of secretions. The child has chronic
hypoxia and should have low-level oxygen. Content
Pediatrics; Category of Health AlterationRespiratory;
Integrated ProcessPlanning: Client NeedsPhysiological
Integrity, Physiological Adaptation: Cognitive
LevelSynthesis.
22. Correct answer 2: The priority intervention is to

ensure lung expansion; therefore, elevating the head
of bed is the first intervention. Then the nurse
should start an IV line, administer aminophylline
intravenously, and use a peak flow meter to assess
the extent of respiratory compromise. Remember,
if in distress, do not assess. ContentPediatrics;
LevelSynthesis.
512
23. Correct answer 3: Episodes of coughing, whooping,

and vomiting decrease in frequency and severity but
may persist for several months. The shower would be
appropriate during an acute asthma attack or croup.
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Pediatric Disorders
SECTION ELEVEN
24. The nurse is counseling parents of an infant who

died from sudden infant death syndrome (SIDS)
2 months ago. The parents have an older child at home.
Which intervention would be most appropriate for the
nurse to implement?
l 1. Recommend the older child to be evaluated as soon
as possible for SIDS.
l 2. Tell the parents to have genetic testing before
having another child.
l 3. Make an appointment for the family to receive
psychiatric counseling.
l 4. Provide the parents with information, including the
date and time of a SIDS support group.
25. The mother of a male child diagnosed with an upper
respiratory infection, a cold, asks the nurse, Why didn't
the doctor give my son antibiotics so he will be better?
Which statement is then nurse's best response?
l 1. You are worried your child will not get well
without antibiotics.
l 2. A cold is a virus that does not require antibiotic
therapy.
513
3. Antibiotic therapy causes diarrhea in most children
4. Antibiotics are very expensive and your insurance
who take it.

won't cover it.
26. The 8-year-old client is 2 hours post tonsillectomy.

Which intervention should the ambulatory care nurse
implement for the client?
l 1. Notify the dietary department to bring a soft
regular diet.
l 2. Keep the child in the supine position with head of
the bed elevated.
l 3. Encourage the client to drink clear liquids every
30 minutes.
l 4. Tell the child to cough and deep-breathe every
2 hours.
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ANSWERS
24. Correct answer 4: The nurse should recommend a

support group for the grieving process so the parents
can share feelings with others who have experienced
a loss of a child due to SIDS and receive information
concerning SIDS. SIDS is not known to be genetic,
and there is no test for the older child. Content
25. Correct answer 2: A virus does not respond

to antibiotic therapy; antibiotics kill bacteria.
Overprescribing antibiotics leads to resistant strains
of bacteria. Antibiotics may cause diarrhea, but
this is not the reason for not prescribing antibiotics
for a cold. The mother needs information, not a
therapeutic response. ContentPediatrics; Category
Pharmacological and Parenteral Therapies: Cognitive
LevelApplication.
514
26. Correct answer 3: Fluids are encouraged because

the throat is normally a wet environment, and
allowing the throat to dry out causes spasms of the
tissues, increasing the child's pain. A soft, regular
diet is provided the second day; the child should
be on the abdomen or side to facilitate drainage of
secretions; and coughing is discouraged because it
may aggravate the operative site. ContentPediatrics;
LevelApplication.
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SECTION ELEVEN
27. The nurse is caring for children on a pediatric unit.

Which child should the nurse assess first?
l 1. The 1-month-old child exhibiting substernal
retractions and nasal flaring.
l 2. The 3-month-old child whose mother reports a
salty taste on the skin.
l 3. The 6-month-old child whose respiratory rate is
42 breaths a minute.
l 4. The 8-month-old child who has a whooping
throaty cough.
28. Which clinical manifestations would the nurse expect
to assess in a child who has acute epiglottitis?
l 1. Snoring respirations and mouth breathing during
sleep.
l 2. Otalgia and purulent, foul-smelling otorrhea.
l 3. Bilateral crackles and grayish, green sputum.
l 4. Drooling, dyspnea, and high fever.
Pediatric Disorders
515
29. The child diagnosed with pneumonia is being

discharged home. Which intervention should the nurse
discuss with the child's parents?
l 1. Instruct the parents to assess the child's lungs every
2 hours.
l 2. Tell the parents not to allow anyone to smoke in
the child's room.
l 3. Encourage the parents to use a cool-mist
humidifier.
l 4. Recommend the parents limit the child's fluid
intake.
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ANSWERS
27. Correct answer 1: This child is in respiratory distress

and requires immediate intervention; therefore, the
nurse should assess this client first. Salty skin indicates cystic fibrosis. Normal respiratory rate for a
6-month-old is 3060 breaths per minute, and the
child with a cough is moving air and would not
be priority over a child in respiratory distress.
28. Correct answer 4: Drooling, because it hurts the

child to swallow, is the hallmark sign of acute
epiglottitis. Drooling results from difficulty or pain
from swallowing. Option 1 may be enlarged adenoids; option 2 could be otitis media; and option 3
could be pneumonia. ContentPediatrics; Category
516
29. Correct answer 3: Cool mist will help liquefy the

pulmonary secretions, which will help the child to
expectorate. Parents cannot assess lungs. No one who
smokes should be near the child; smoking in the
house should be prohibited; and smoke smell can be
on clothes when smoking outside. The child's fluid
intake should be increased to help liquefy the
secretions. ContentPediatrics; Category of Health
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SECTION ELEVEN
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517
30. The mother yells for the nurse, stating, I think my

child swallowed one of the little toys. The child is lying
in the bed. Which actions should the nurse implement?
Rank in order of performance.
l 1. Look in the mouth for any foreign object.
l 2. Perform a head-tilt/chin-lift maneuver.
l 3. Listen and assess for breath sounds.
l 4. Attempt to administer a rescue breath.
l 5. Shake the child and call the child's name.
32. The day shift nurse who has just come on duty
is assigned to care for a 3-year-old child who has a
ventriculoperitoneal shunt. After waking up, the child
complains of a headache. Which action should the nurse
implement?
l 1. Complete a neurological assessment.
l 2. Pump the hydrocephalic shunt.
l 3. Measure the child's head circumference.
l 4. Administer a non-narcotic analgesic.
33. The 7-year-old child diagnosed with a

myelomeningocele is attending the local elementary
school. Which intervention should the school nurse
anticipate implementing for this child?
l 1. Perform sterile wound dressing changes.
l 2. Assist the child with eating in the cafeteria.
l 3. Routine intermittent urinary catheterization.
l 4. Use a gait belt when assisting the child to
ambulate.
31. Which signs/symptoms would the nurse expect to

assess in a 9-year-old child diagnosed with absence seizure
(petit mal)?
l 1. Generalized stiffness of the muscles.
l 2. Blank facial expression for 510 seconds.
l 3. Unexplained feeling of fear or dread.
l 4. Teeth grinding, lip smacking, or chewing.
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ANSWERS

must first establish responsiveness (5) and an open
airway (2) and then determine if anything is visible in
the mouth (1) before assessing for respirations (3) and
administering breaths (4). The nurse does not want to
blow any foreign object further into the airway; therefore, the nurse must look in the mouth. Content
518
32. Correct answer 1: A headache upon awakening is a

sign of hydrocephalus; therefore, this complaint could
indicate a shunt malfunction and requires further
assessment. The nurse does not shunt pumps; head
circumference is assessed in children younger than
1218 months; and children do not commonly
complain of headaches, so the nurse should assess
before giving medications. ContentPediatrics; Category

Effective Care Environment, Management of Care; Cognitive LevelSynthesis.

31. Correct answer 2: Absence seizures have no muscle
33. Correct answer 3: The child with a myelomeningo-
activity except for eye fluttering or head bobbing

with blank facial expressions for a short time. These
seizures may go undiagnosed because there is little
change in the child's behavior. Option 1 is the tonic
phase of a generalized seizure; option 3 is a simple
partial seizure; and option 4 is a complex partial
seizure. ContentPediatrics; Category of Health
cele will be paralyzed below the level of the defect,

which usually causes the child to be a paraplegic,
requiring assistance with bowel and bladder function.
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SECTION ELEVEN
34. The nurse is caring for a 6-month-old infant who

was brought to the emergency department after a possible
seizure. The CT scan indicates a coup/contracoup head
injury. Which intervention should the nurse implement?
l 1. Ask the parents how the injury occurred.
l 2. Place the child in Trendelenburg position.
l 3. Close all the curtains in the child's room.
l 4. Notify child protective services (CPS).
35. The nurse is admitting a 12-year-old client diagnosed
with bacterial meningitis to the pediatric department.
l 1. Prepare the client for a CT scan of the brain.
l 2. Place an isolation cart outside the client's room.
l 3. Administer as-needed (prn) narcotic analgesic.
l 4. Initiate intravenous antibiotic therapy.
Pediatric Disorders
519
36. The nurse caring for a 7-year-old child diagnosed

with a head injury assesses purposeless movement with
painful stimuli. Two hours later the child assumes
decorticate posturing with painful stimuli. Which action
l 1. Reassess the client in another 2 hours.
l 2. Document the findings in the chart.
l 3. Notify the client's health-care provider (HCP).
l 4. Turn and position the client on the side.
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ANSWERS
34. Correct answer 4: A coup/contracoup head injury

indicates shaken baby syndrome, which is an incident where the child is shaken violently, leading to a
head injury. This is child abuse, which must legally
be reported to CPS. The parents brought the child
in for seizure activity, not for an injury. Content
Pediatrics; Category of Health AlterationNeurological;
35. Correct answer 4: The first priority of nursing care

of a client suspected of having meningitis is to
administer the antibiotic ordered as soon as possible.
Failure to do this can result in the death of the
client. The nurse can use a mask when entering
the room before the isolation cart is at the door. All
other interventions can be implemented but not
before starting the antibiotics. ContentPediatrics;
520

36. Correct answer 3: Decorticate posturing indicates a

worsening of the client's condition due to increased
intracranial pressure (ICP); therefore, the nurse
should notify the HCP. The nurse should document
the findings and continue to assess the client but not
before notifying the HCP. Positioning the client
helps prevent pressure ulcers. ContentPediatrics;
LevelSynthesis.
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SECTION ELEVEN
37. The 13-year-old adolescent diagnosed with epilepsy

is prescribed phenytoin (Dilantin). Which instruction
should the nurse discuss with the adolescent and parents?
l 1. Perform daily self-monitoring of Dilantin levels.
l 2. Explain the importance of flossing and dental care.
l 3. Do not drive or operate heavy machinery.
l 4. Be sure to eat prior to taking medication.
38. The 4-year-old child is being discharged home
following supratentorial brain surgery. Which discharge
instructions should the nurse discuss with the parents?
l 1. Discuss the importance of wearing a helmet.
l 2. Teach the parents about follow-up chemotherapy.
l 3. Tell the parents to keep the child in the prone
position.
l 4. Demonstrate how to feed the child through the
percutaneous endoscopic gastrostomy (PEG) tube.
Pediatric Disorders
521
39. The pediatric clinic nurse is discussing the care of

the 6-week-old infant diagnosed with trisomy-21, Down
syndrome. Which interventions should the nurse discuss
with the client's parents? Select all that apply.
l 1. Refer the parents to the Down syndrome support
group.
l 2. Ask the parents about their feelings of attachment
with their child.
l 3. Encourage the parents to use a cool-mist vaporizer.
l 4. Do not re-feed the child the baby food if thrust out
of the mouth.
l 5. Schedule the occupational therapist to visit the
child's home.
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ANSWERS
522
37. Correct answer 2: Dilantin causes gingival hyperpla-
39. Correct answer 1, 2, 3: A support group is helpful
sia; therefore, the client must floss regularly, brush

the teeth often, and see the dentist regularly.
Dilantin levels are not obtained daily, but monthly.
The client is 13-years-old and is not of age to drive.
There is no reason to take the medication with food.
to parents with special-needs children; the nurse

must ensure the parents are bonding with the
infant; and a cool-mist vaporizer keeps the mucous
membranes moist and the secretions liquefied. The
parents should re-feed the food spit out of the
mouth, and the child should be referred to early
childhood intervention, not occupational therapy.

38. Correct answer 1: A helmet is mandatory to

protect the surgical site and is worn when the child
is ambulatory. Most chemotherapy agents do not
cross the blood brain barrier and so are not usually
administered for brain tumors. There is no reason to
keep the child in the prone position, and the child
will not have a PEG tube. ContentPediatrics;

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Pediatric Disorders
SECTION ELEVEN
40. The mother of a child calls the clinic and tells the
nurse, I accidentally gave my child an aspirin for her
fever. How would I know if she gets Reye syndrome?
l 1. Your child may have a productive cough and
low-grade fever with Reye syndrome.
l 2. If your child is listless and doesn't want to play,
that could be Reye syndrome.
l 3. The child with Reye syndrome usually vomits
and becomes dehydrated.
l 4. Reye syndrome can cause swelling of the
extremities due to increased fluid volume.
41. The nurse observes the UAP taking an oral
temperature on a 1-year-old child who is 1 day
postoperative cleft palate repair. Which action should
l 1. Ensure the UAP documents the child's temperature
in the chart.
l 2. Instruct the UAP to take the child's temperature by
the axillary method.
523
3. Tell the UAP to remove the thermometer from the
4. Explain the correct way to take the temperature for
child's mouth immediately.

a client with a cleft palate repair.
42. The labor and delivery nurse is assisting with

the delivery of an infant diagnosed with congenital
diaphragmatic hernia (CDH). Which interventions
l 1. Notify the respiratory therapy to prepare a
ventilator.
l 2. Prime the extracorporeal membrane oxygenation
(ECMO) machine.
l 3. Prepare a crib for the newborn in the nursery.
l 4. Request the laboratory to type the infant's blood.
l 5. Do not allow the parents to visit the baby until
after the surgery.
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ANSWERS
40. Correct answer 2: Stage 1 of Reye syndrome is

characterized by lethargy followed by profound
unconsciousness and hepatic dysfunction. Content
Pediatrics; Category of Health AlterationNeurological;
41. Correct answer 3: The nurse should avoid the use

of suction or other objects in the mouth, such as a
tongue depressor, thermometer, spoons, or straws, of
a child who is 1 day postoperative cleft palate repair
because the object or suction may irritate or destroy
the incision line. ContentPediatrics; Category of
LevelSynthesis.
524
42. Correct answer 1, 2, 4: The infant will be placed

on a ventilator to manage acidosis, bicarbonate level,
and ventilation. The infant will be on ECMO until
surgical reduction of the hernia, and the infant will
be in the neonatal intensive care unit under a radiant
warmer, not in a regular crib in the nursery. The
ECMO requires multiple units of blood, so the
infant's blood should be typed. The parents should
be encouraged to visit the client before and after
the surgery. ContentPediatrics; Category of Health
LevelApplication.
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SECTION ELEVEN
43. Which sign/symptom would the nurse assess for an

8-year-old child who is admitted with the diagnosis of
congenital aganglionic megacolon, or Hirschsprung
disease?
l 1. Stools that look like currant jelly.
l 2. Ribbon-like, foul-smelling stools.
l 3. Loose, runny stools with undigested particles.
l 4. Nausea, vomiting, and abdominal pain.
44. The mother of an infant calls the pediatric clinic
reporting her child is having diarrhea. Which instructions
should the nurse discuss with the mother concerning the
child's diet?
l 1. Encourage the mother to give her child fruit juices.
l 2. Instruct the mother to feed the infant beef broth.
l 3. Recommend the mother give the infant a
regular cola.
l 4. Tell the mother to feed the infant Pedialyte.
Pediatric Disorders
525
45. The nurse overhears the UAP telling the mother of

a child diagnosed with gastroenteritis not to use the
bathroom in the child's room. Which action should the
nurse implement?
l 1. Tell the UAP not to discuss infection control with
the mother.
l 2. Notify the infection control nurse of the UAP's
statement.
l 3. Ask the UAP why the mother was told not to use
the bathroom.
l 4. Praise the UAP for reinforcing infection control
measures.
46. The 5-year-old child is 1 day postoperative emergency
appendectomy. Which intervention should the nurse
implement?
l 1. Remove the incisional staples carefully.
l 2. Assess the child's surgical dressing.
l 3. Keep the child on strict bedrest.
l 4. Maintain the child's nothing by mouth (NPO)
status.
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ANSWERS
43. Correct answer 2: The area of colon without ganglion does not have peristalsis; therefore, the stool
is narrow and foul-smelling due to the increased
time in the colon. Option 1 is intussusception,
and options 3 and 4 may be gastroenteritis. Content
Pediatrics; Category of Health AlterationGastrointestinal;
LevelAnalysis.
44. Correct answer 4: Pedialyte has electrolytes to

help replace those being lost through the diarrhea.
Fruit juices are high in carbohydrate content and
osmolality; beef broth is avoided because it has
increased sodium and is inadequate in carbohydrates;
and carbonated beverages are avoided because they
are a mild diuretic and may increase dehydration.
526
45. Correct answer 4: The nurse should encourage and

support the UAP's attempt to prevent the spread
of infectious disease. The UAP is part of the healthcare team. ContentPediatrics; Category of Health
LevelApplication.
46. Correct answer 2: Postoperative interventions

include assessing the surgical incision, turning the
client, asking the client to cough, ambulating the
client in the room, and increasing the diet as
tolerated. The staples are removed 710 days after
surgery. ContentPediatrics; Category of Health
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Pediatric Disorders
SECTION ELEVEN
47. Which statement by the mother of a 14-day-old

daughter would make the nurse suspect the infant had
pyloric stenosis?
l 1. My child has projectile vomiting after I feed her.
l 2. My daughter has not had a bowel movement in
2 days.
l 3. My child's abdomen is board-like and rigid.
l 4. My daughter has gained 6 ounces since last week.
48. The nurse is preparing to administer an antibiotic by
intravenous piggy back (IVPB) to an 8-year-old client.
The medication is prepared in a 50-mL bag, and the
child's IV is infusing at 50 mL/hr. At what rate should
the nurse set the intravenous pump?
Answer: ____________________
49. The child is diagnosed with extrahepatic biliary

atresia (EHBA). The parents are crying and ask the nurse,
What will happen to our baby? Which statement is
most appropriate by the nurse?
l 1. Your baby will have to have surgery to correct this
problem.
527
2. There is nothing you can do for this type of birth
3. Your baby will have to be on dialysis at least three
4. Medications are available to help cure this
defect.
times a week.
disease.
50. The 7-year-old child diagnosed with inflammatory

bowel disease (IBD) is scheduled for a temporary
colostomy surgical procedure. Which intervention should
the nurse implement preoperatively?
l 1. Take the child and parents to the operating room.
l 2. Give the child a doll with a colostomy appliance.
l 3. Discuss the numeric 110 pain scale with the
child.
l 4. Measure the child's legs for anti-thrombolism
stockings.
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ANSWERS
47. Correct answer 1: Projectile vomiting is the major

symptom of pyloric stenosis, because the pyloric
sphincter does not open, and the food is forcibly
ejected. ContentPediatrics; Category of Health
Evaluation; Client NeedsSafe Effective Care
LevelEvaluation.
48. Correct answer 50 mL/hr: The antibiotic IVPB

should be infused over 1 hour via the IV pump and
volume control chamber. ContentPediatrics; Category of Health AlterationDrug Administration;
49. Correct answer 1: The infant must have a hepatoportoenterostomy (Kasai procedure) as soon as
possible to help prevent liver damage, which will
occur over time even with the procedure. The
child will eventually require a liver transplant.
528

50. Correct answer 2: Demonstrating the postoperative

equipment with the child using a doll is an agespecific teaching strategy. The child and parents
can be shown the intensive care unit (ICU) or
post-anesthesia care unit (PACU), but only operating
room personnel in appropriate clothing are allowed
in the sterile operating room area. The 7-year-old
child would use the faces pain scale, not the numeric
scale. Children do not need to wear antithrombolism
stockings after surgery. ContentPediatrics; Category
LevelApplication.
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SECTION ELEVEN
Pediatric Disorders
529
51. The middle school nurse observes an 11-year-old
female student has a noticeable difference in the space
between the arms and the trunk. Which intervention
l 1. Notify the parents to have the child evaluated.
l 2. Perform a spinal screening check on the student.
l 3. Recommend the child have a spinal x-ray.
l 4. Discuss the possibility of spinal fusion surgery.
52. The mother of the infant born with bilateral clubfeet
is crying and tells the nurse, I am so scared my baby is
going to have to have surgery. Which statement is the
nurse's best therapeutic response?
l 1. Don't worry; your baby will not have to have
surgery.
l 2. Have you discussed your concerns with your
baby's doctor?
l 3. You sound frightened. Would you like to talk
about your baby?
l 4. You should not be worried. Clubfeet can be easily
corrected.
53. The 4-year-old client with a cast right below the

knee after having surgery for a compound fracture is
crying. The nurse determines the right toes are colder
than the left. Which interventions should the nurse
implement? Rank in order of performance.
l 1. Elevate the child's right leg on two pillows.
l 2. Explain to the mother what is happening.
l 3. Bifurcate the cast to relieve pressure.
l 4. Attempt to insert two fingers in the distal portion
of cast.
l 5. Notify the child's HCP.
54. The pediatric clinic nurse suspects a 6-week-old
baby may have developmental dysplasia of the hip. Which
intervention should the nurse implement to further assess
for hip dysplasia?
l 1. Perform the Ortolani maneuver.
l 2. Check for the Barlow response.
l 3. Measure the length of each leg.
l 4. Assess for asymmetrical gluteal folds.
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ANSWERS
51. Correct answer 2: A noticeable difference in the

space between the arms and the trunk indicates spinal
curvature, which should be further assessed by a spinal
screening check. Then, based on the findings of the
screening check, the parents should be notified,
further diagnostic tests completed, and then possible
treatments implemented, which may include bracing
or surgery. ContentPediatrics; Category of Health
52. Correct answer 3: A therapeutic response should

encourage the client to ventilate feelings and acknowledges the mother's feelings. Asking if she would like to
talk would encourage verbalization of feelings. Option
1 is providing factual information; option 2 is passing
the buck; and option 4 is denying the mother the
right to having feelings. ContentPediatrics; Category of
530

should first determine if the cast is too tight and
then elevate the leg to help decrease the edema.
Then, the nurse should elicit the mother's support
while bifurcating the cast and, finally, notify the
orthopedist. ContentPediatrics; Category of Health
Reduction of Risk Potential; Cognitive Level
Application.
54. Correct answer 4: Infants beyond the newborn

period exhibit asymmetry of the gluteal skin folds
when the infant is held upright with the feet
dangling. Measuring the length of the legs is not
pertinent assessment information. The Ortolani and
Barlow maneuvers can be done only by the HCP
or trained advanced nurse practitioner. Content
Pediatrics; Category of Health AlterationMusculoskeletal;
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SECTION ELEVEN
55. The 5-year-old child in the emergency department is

diagnosed with a spiral fracture of the right ulna. Which
l 1. Place the right arm in a dependent position.
l 2. Apply a heating pad to the right arm.
l 3. Contact child protective services.
l 4. Notify the hospital's physical therapist.
56. The child diagnosed with osteomyelitis of the
right leg is being discharged home. Which statement
by the mother indicates the discharge teaching has been
effective?
l 1. I will need to check my child's IV site for redness
and swelling.
l 2. The antibiotic therapy will make my child feel
nauseated.
l 3. I should encourage my child to ambulate around
the house.
l 4. I can throw the soiled dressings in my kitchen
trash can.
Pediatric Disorders
531
57. The 9-year-old client diagnosed with juvenile arthritis

is prescribed naproxen sodium (Naproxyn), a nonsteroidal
anti-inflammatory drug (NSAID). Which intervention
l 1. Tell the client to take the medication with an
antacid.
l 2. Instruct the client to take the medication with food.
l 3. Encourage the client to take the medication at
night.
l 4. Explain the medication will turn the stools black.
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ANSWERS
55. Correct answer 3: A spiral fracture, a twisted or

circular break, is frequently seen in child abuse;
therefore, this would be an appropriate intervention.
The fractured arm should be elevated, and ice
should be applied to it. ContentPediatrics; Category
LevelApplication.
56. Correct answer 1: The parents must be able to care

for the child's IV site as long-term antibiotic therapy
is the treatment of choice for osteomyelitis. IV
antibiotics will not make the child nauseated; the
child should be on bedrest; and the soiled dressings
must be removed in a biohazard bag and not in the
regular trash. ContentPediatrics; Category of Health
532
57. Correct answer 2: NSAIDs are very irritating to

the stomach lining and decrease the production of
prostaglandin, the protective barrier of the stomach;
they should be taken with food to minimize the
irritation. Antacids decrease the absorption of
medications, so they should not be used. The
medication is administered 4 times a day or around
the clock, not just at night. NSAIDs may cause
gastrointestinal bleeding, so if the stools are black,
the mother must call the health-care provider.
ContentPediatrics; Category of Health Drug
LevelSynthesis.
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Pediatric Disorders
SECTION ELEVEN
58. The pediatric nurse notices the 6-year-old male child

puts his hands on his knees and moves the hands up the
legs so that he can stand up. Which question should the
nurse ask the mother?
l 1. Do you have a history of Duchenne muscular
dystrophy?
l 2. Why does your son need to rise by using his
hands?
l 3. Do you have any other children who get up
this way?
l 4. Have you noticed your son getting weak after
walking?
59. The 5-year-old child diagnosed with developmental
dysplasia of the right hip has surgery to correct the
deformity. Which discharge teaching should the nurse
l 1. Show the parents how to apply and remove the
Pavlik harness.
l 2. Explain the care of the client with skeletal traction.
533
3. Demonstrate toileting procedures for the child in a
4. Teach the parents how to place the child on the
spica cast.
Stryker frame.
60. The 16-year-old child with a fractured left ankle is

ambulating on crutches and tells the nurse, My hands
feel like they are going to sleep. Which intervention
l 1. Observe the child ambulating on the crutches.
l 2. Ask the child to squeeze the nurse's fingers.
l 3. Evaluate the child's handwriting quality.
l 4. Tell the client to flex and extend the fingers.
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ANSWERS
58. Correct answer 4: The Gowers maneuver (walking

up the legs) is a hallmark sign of Duchenne muscular
dystrophy (MD). Muscle wasting and weakness occur
with MD; therefore, this is an appropriate question.
Duchenne is genetically linked, with the mother
passing it on to a son, but she does not have it
herself and may be unaware of a familial link.
59. Correct answer 3: After surgery, long-term

immobilization in a spica cast is necessary until
healing of the hip is achieved and specific toileting
procedures are needed. The Pavlik harness is used
for infants with congenital hip dysplasia; skeletal
traction is used for cervical or femur fractures; and
the Stryker frame is used for paralyzed clients.
534

60. Correct answer 1: The numbness may be due to

pressure on the axillary area and nerve compression,
which occurs when the axillary crutch pads are not
properly placed when ambulating. Observing ambulation can determine if the child is crutch-walking
properly. Squeezing fingers, evaluating handwriting,
and moving fingers will not determine if axillary
nerves are being compressed. ContentPediatrics;
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SECTION ELEVEN
Page 535
Pediatric Disorders
535
Hematological Disorders
61. The nurse is caring for clients on a pediatric
oncology unit. Which neutropenia precaution should
be implemented for the 6-year-old child diagnosed with
leukemia?
l 1. Perform all painful procedures in the treatment
room.
l 2. Limit the number of children visiting the client.
l 3. Use a tympanic thermometer to take the
temperature.
l 4. Have the client use a soft-bristle toothbrush.
62. The nurse is assessing a client diagnosed with acute
myeloid leukemia. Which assessment data support this
diagnosis?
l 1. Petechiae on the trunk.
l 2. Red raised rash on the legs.
l 3. Nausea, vomiting, diarrhea.
l 4. Inguinal lymph-node enlargement.
63. The 8-year-old child diagnosed with leukemia has

central nervous system involvement. Which instructions
should the nurse discuss with the parents?
l 1. Explain the need to keep the child away from other
children.
l 2. Give the child an analgesic medication for pain
only when the pain becomes severe.
l 3. Discuss the potential for possible learning
disabilities in the future.
l 4. Reassure the parents the child's hair will grow back
after treatment.
64. The 7-year-old child diagnosed with anemia is
prescribed one unit of packed red blood cells. The unit
has 125 mL of blood plus 15 mL of additives to be
infused over 3.5 hours. At what rate should the nurse set
the IV pump?
Answer: ____________________
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ANSWERS
61. Correct answer 2: Children are more prone to
536
63. Correct answer 3: Radiation therapy to the head
carry viruses and bacteria because of their immature

immune systems, and visiting children might expose
the client to these infections. All the other interventions are appropriate but do not address neutropenia
precautions. ContentPediatrics; Category of Health
and scalp area is the treatment of choice for central

nervous system involvement of any cancer. Chronic
illness and subsequent treatment in children can
impact the child's learning ability and social
interaction. ContentPediatrics; Category of Health
AlterationOncology; Integrated ProcessPlanning;

AlterationOncology; Integrated ProcessPlanning;

62. Correct answer 1: Petechiae, fever, bruising,

intermittent stomachache, and infections are hallmark symptoms of leukemia. All other data would
not support the diagnosis of acute myeloid leukemia.
Oncology; Integrated ProcessAssessment; Client
64. Correct answer 40 mL/hr: Pumps are set at an

hourly rate. The nurse must do the following:
125 + 15 = 140. Divide 140 by 3.5 = 40 mL/hr.
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SECTION ELEVEN
65. The adolescent who is diagnosed with anemia has the

following lab values: red blood cell (RBC) count: 3 mm
(106); white blood cell (WBC) count of 8.9 mm(103);
and platelets 150 mm(103). Which intervention should
l 1. Place the client in reverse isolation.
l 2. Continue to monitor the client's lab results.
l 3. Administer erythropoietin (Epogen), a biological
response modifier.
l 4. Institute bleeding precautions for the client.
66. The child diagnosed with sickle cell anemia comes
to the emergency department complaining of joint pain
after playing a game of soccer in 100F weather. Which
intervention should the emergency department nurse
implement first?
l 1. Check the pulse oximeter reading.
l 2. Document why the client came to the ED.
l 3. Administer intravenous pain medication.
l 4. Infuse intravenous fluids via pump.
Pediatric Disorders
537
67. The 8-year-old child diagnosed with sickle cell

anemia tells the nurse that her family is planning a skiing
trip. Which action should the nurse take?
l 1. Take no action because this sounds like an
enjoyable trip.
l 2. Talk to the parents about taking the child to the
mountains.
l 3. Tell the child she cannot go skiing because of her
disease.
l 4. Suggest the child talk to the parents about going
on this trip.
68. The nurse is caring for a 10-year-old child in a sickle
cell crisis. Which regimen should the nurse implement to
relieve the child's pain?
l 1. Frequent acetylsalicylic acid (aspirin) and a
non-narcotic analgesic.
l 2. Ibuprofen (Motrin), an NSAID, prn.
l 3. Meperidine (Demerol), a narcotic analgesic, every
4 hours.
l 4. A morphine via a patient-controlled analgesia
(PCA) pump.
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ANSWERS
65. Correct answer 3: The client's RBC count is low.

Therefore, the nurse should administer Epogen, a
biological response modifier that stimulates the
production of red blood cells. The WBC count
and the platelet count are within normal limits.
Hematology; Integrated ProcessImplementation;
Risk Potential; Cognitive LevelSynthesis.
66. Correct answer 4: The client is obviously dehydrated, which will cause the cells to sickle, resulting
in pain. The nurse should first administer fluids to
correct the dehydration. Then, the nurse should
administer pain medication and check the client's
oxygen level. After the client is treated, the nurse
can document what was done. ContentPediatrics;
Category of Health AlterationHematology; Integrated
LevelSynthesis.
538
67. Correct answer 2: High altitudes have decreased

oxygen, which could lead to a sickle cell crisis;
therefore, the nurse should discuss this with the
parents. The nurse should not directly talk to an
8-year-old child about where the child is going on
vacation. ContentPediatrics; Category of Health
AlterationHematology; Integrated ProcessPlanning;
68. Correct answer 4: A 10-year-old child who is in

severe pain can be allowed to administer pain
medication as needed; this is the best pain relief
regimen. The PCA pump has prescribed lock-out
mechanisms to prevent an overdose. Children's pain
is frequently undertreated, and this type of pain is
severe. Demerol is contraindicated because of the
metabolite normeperidine. ContentPediatrics;
Category of Health AlterationHematology; Integrated
LevelSynthesis.
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SECTION ELEVEN
Page 539
Pediatric Disorders
539
Psychiatric Disorders
69. Which nursing intervention should the nurse
implement when caring for a child diagnosed with
hemophilia A?
l 1. Encourage participation in noncontact sports.
l 2. Teach the mother how to insert rectal
suppositories.
l 3. Apply a Band-Aid when bleeding occurs.
l 4. Explain the importance of not flossing gums.
70. The 5-year child with hemophilia fell on the
playground and is experiencing hemarthros of the right
knee. Which intervention should the school nurse
implement?
l 1. Administer aspirin to the child.
l 2. Apply cold packs to the right knee.
l 3. Call 911 for emergency treatment.
l 4. Elevate the right child's right leg.
71. The 10-year-old child is diagnosed with attention

deficithyperactivity disorder (ADHD) and is taking the
central nervous stimulant methylphenidate (Ritalin).
Which assessment data would warrant intervention from
the pediatric clinic nurse?
l 1. The child has lost 3 kg in the last month.
l 2. The child's pulse is 96 and BP is 108/78.
l 3. The child has grown 2 inches in the last year.
l 4. The child sits quietly in the waiting room.
72. The 7-year-old child newly diagnosed with ADHD
is prescribed Adderall, an amphetamine mixture. Which
information should the nurse discuss with the parents?
l 1. Take the medication on an empty stomach.
l 2. Provide multiple activities for the child.
l 3. Administer the medication in the morning.
l 4. Allow the child to drink regular colas.
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ANSWERS
69. Correct answer 1: Even minor trauma can lead
540
71. Correct answer 1: ADHD medications are notorious
to serious bleeding episodes; safer activities such

as swimming or golf should be recommended.
Suppositories cause tissue damage and vascular
trauma, which can precipitate bleeding. Teach the
child and/or parents to apply direct pressure if
bleeding occurs. The child should floss the teeth.
for causing weight loss and stunting the child's growth.

A 6.6-pound weight loss in 1 month is significant. The
vital signs are within normal limits for a 10-year-old
child. Sitting quietly in the waiting room would indicate the medication is effective and would not warrant
intervention by the nurse. ContentPediatrics; Category

Hematology; Integrated ProcessImplementation; Client

70. Correct answer 2: Hemarthros is bleeding into the
72. Correct answer 3: The medication should be ad-
joint; applying ice to the area can cause vasoconstriction, which can help decrease bleeding. Aspirin will
destroy platelet aggregation and may cause Reye syndrome. The nurse cannot call 911 every time the child
with hemophilia injures himself. Elevating the leg will
not stop the bleeding. ContentPediatrics; Category
ministered in the morning and again, if prescribed,

no later than 5 hours after the first dose so that the
child can sleep at night. The medication should be
taken with food to help decrease gastrointestinal
upset and counteract anorexia. The child should try
to focus on one activity at a time. The child should
avoid caffeine. ContentPediatrics; Category of Health
of Health AlterationHematology; Integrated Process


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SECTION ELEVEN
73. The nurse is discussing ADHD with a parent of a

newly diagnosed male child. Which statement by the
mother would support this diagnosis?
l 1. My child is always engaging in repetitive-type
behavior.
l 2. My child use to hug and kiss me, but now he
doesn't.
l 3. My child insists on collecting all toys in a series
of toys.
l 4. My child is easily distracted and fidgets all the time.
74. The parents of a child newly diagnosed with
oppositional defiant disorder (ODD) tell the nurse,
We don't know what to do to help our child. Which
intervention should the nurse discuss with the parents?
l 1. Discuss administering antidepressant medication to
the child daily.
l 2. Recommend the parents attend a parent training
program.
l 3. Allow the parents to ventilate their feelings of
frustration.
l 4. Talk to the parents about placing their child in a
protective environment.
Pediatric Disorders
541
75. The 6-year-old male child is diagnosed with conduct

disorder. The mother asks the nurse, What will happen
to my child because they cannot cure him? Which
statement supports the ethical principle of veracity?
l 1. He will probably develop an antisocial personality
disorder.
l 2. With continued treatment your child will have a
normal life.
l 3. Sometimes the child will outgrow it even if it
can't be cured.
l 4. There are medications that can control it but not
cure it.
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ANSWERS
73. Correct answer 4: The DSM IV-TR diagnostic

criteria for ADHD state that six or more symptoms
of inattention and hyperactivity-impulsivity must be
present for at least 6 months; one of these symptoms
is being easily distracted and fidgety. The other
comments do not address inattention, hyperactivity,
or impulsivity. ContentPediatrics; Category of Health
74. Correct answer 2: The American Psychiatric Association recommends parent training programs to help
parents develop consistent parenting skills. There are
no medications for children with ODD. The parents
need help to figure out what to do, not to ventilate
their frustration. Placing a child in another environment is the last resort. ContentPediatrics; Category
542
75. Correct answer 1: Veracity is telling the truth. The

nurse must give facts, which include the fact that
after the age of 18, a conduct disorder may develop
into an antisocial personality disorder. There are no
medications for conduct disorders, and the child will
not outgrow it, nor will the child have a normal life.
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SECTION ELEVEN
76. The 13-year-old female child diagnosed with

bipolar disorder is admitted to the child psychiatric unit
diagnosed with mania. Which activity would be most
appropriate for the client?
l 1. Encourage the child to play checkers with a staff
member.
l 2. Recommend the child throw basketballs into a
hoop by herself.
l 3. Tell the client to sit in her room and read a book
quietly.
l 4. Ask the client to write her feelings in a journal.
77. The mother asks the nurse, What behavior would
my child have if the child were autistic? Which
l 1. Your child will not allow you to hold him when
he is angry.
l 2. Your child will have problems with authority
figures.
l 3. Your child may repeat the same word over and
over again.
l 4. You child will not be able to feed himself
independently.
Page 543
Pediatric Disorders
543
78. The father of a 13-year-old daughter tells the

pediatric nurse, My daughter has really changed. She
doesn't go to school, she wears black all the time, and
she won't talk to me. Which priority intervention
l 1. Tell the father this is normal adolescent behavior.
l 2. Determine if the father has talked to the school
counselor.
l 3. Suggest the father obtain a urine drug screen on his
daughter.
l 4. Discuss the possibility of his daughter being
depressed.
79. The mother of the 14-year-old child diagnosed with
autism tells the nurse, My child does not have any
friends. Which recommendation should the nurse
discuss with the mother?
l 1. Encourage the child to join a club at the school.
l 2. Recommend the child join an online autism
support group.
l 3. Tell the mother to take the child to church
activities.
l 4. Instruct the mother not to try to change her child.
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ANSWERS
76. Correct answer 2: The client should engage in

activities that will exhaust her physically, such as
continuously throwing and chasing a basketball, but
the nurse should discourage competitive and sedate
activities. ContentPediatrics; Category of Health
77. Correct answer 3: Autism is exhibited by age 3 and

includes a lack of emotional and social reciprocity,
repetitive use of language, and persistent preoccupation with parts of objects. Most children will not let
themselves be hugged when they are angry. Children
with conduct disorders have problems with authority
figures, and children with autism can feed themselves.
NeedsHealth Promotion and Maintenance;
544
78. Correct answer 4: These are typical symptoms of

depression, and the nurse should discuss this with
the father so the father will be informed. This is not
normal adolescent behavior. The father could talk to
the school counselor and get a drug screen, but the
father should understand the signs/symptoms of
depression. ContentPediatrics; Category of Health
79. Correct answer 2: Autistic individuals have

difficulty expressing themselves directly to people.
The Internet provides an avenue for the child to
interact with other people. The mother should
supervise the sites the child accesses. Content
Pediatrics; Category of Health AlterationPsychiatric;
Synthesis.
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Pediatric Disorders
SECTION ELEVEN
80. The male child who is out of control is admitted to

a psychiatric unit because he is a danger to himself.
l 1. Contact the client's family to come to the unit.
l 2. Place the client on a one-to-one observation.
l 3. Develop a plan for a therapeutic milieu.
l 4. Notify the client's school for assignments.
Management
81. The nurse is caring for children in a psychiatric unit.
Which client requires immediate intervention by the
psychiatric nurse?
l 1. The 10-year-old child diagnosed with oppositional
defiant disorder who refuses to eat what is on the
lunch tray.
l 2. The 5-year-old child diagnosed with pervasive
developmental disorder who refuses to talk and
will not make eye contact.
545
3. The 7-year-old child diagnosed with conduct
disorder who is standing in front of the television

in the dayroom.
4. The 8-year-old mentally retarded child who is
sitting on the playground and eating dirt and sand.
82. The male child diagnosed with conduct disorder on

the psychiatric unit is yelling at other children, throwing
furniture, and threatening the staff members. The
charge nurse determines the child is at imminent risk
for harming the other children or himself. Which
intervention should the charge nurse implement first?
l 1. Document the client's behavior in the nurse's
notes.
l 2. Place the client in the seclusion room with direct
observation.
l 3. Obtain a restraint/seclusion order from the
physician.
l 4. Ensure that none of the other clients are injured.
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ANSWERS
80. Correct answer 2: Safety is priority for the psychiatric
546
82. Correct answer 2: The nurse should first ensure the
client; therefore, placing the client on a one-to-one

observation until he is stabilized is the priority
intervention. Contacting the family and the client's
school and providing a therapeutic milieu are
appropriate interventions but not priority over safety.
safety of the child and then the other clients. Then,

the nurse should obtain an order for seclusion from
the physician immediately and document the reason
why the child had to be secluded, which must be
because the child is a danger to self or others.


81. Correct answer 3: The child with conduct disorder

is aggressive to people and animals. The child bullies,
threatens others, destroys property, and sets fires.
Because the child is in front of the television
antagonizing other children by blocking the television, the nurse should intervene with this client
first. ContentManagement; Category of Health
AlterationPsychiatric; Integrated ProcessAssessment;
Management of Care; Cognitive LevelAnalysis
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SECTION ELEVEN
83. The pediatric nurse is preparing to administer

digoxin elixir, a cardiac glycoside, to a 2-year-old client
with congenital heart disease who has an apical pulse rate
of 74. Which intervention should the nurse implement?
l 1. Administer the medication via a syringe.
l 2. Check the medication dose with another RN.
l 3. Ask the mother if the child is having any leg
discomfort.
l 4. Hold the medication and document it on the
medication administration record (MAR).
pediatric unit. Which nursing task should be assigned to
the UAP?
l 1. Instruct the UAP to feed the 3-year-old child who
has a gastrostomy tube.
l 2. Request the UAP to turn and position the 4-year-old
with a spica cast.
l 3. Tell the UAP to assist the mother who is changing
a wet diaper.
l 4. Ask the UAP to obtain vital signs on the child
diagnosed with sickle cell disease.
Pediatric Disorders
547
85. The charge nurse is making assignments for clients

on a pediatric unit. Which client should the charge nurse
assign to a new graduate nurse?
l 1. The 2-year-old child diagnosed with tetralogy of
Fallot who is having surgery.
l 2. The 4-year-old child who has been newly diagnosed
with cystic fibrosis (CF).
l 3. The 6-year-old child who has a fractured tibia and
is in a long leg cast.
l 4. The 8-year-old child diagnosed with an acute
exacerbation of ulcerative colitis.
86. The charge nurse is making assignments on a 30-bed
pediatric unit which is staffed with two registered nurses
(RNs), two licensed practical nurses (LPNs), and three
UAPs. Which assignment is most appropriate?
l 1. Assign the RN to pass out the breakfast trays.
l 2. Assign the UAP to orient a new nurse to the unit.
l 3. Assign the UAP to complete the morning care
l 4. Assign the LPN to write the care plans.
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ANSWERS
83. Correct answer 4: The normal pulse rate for a

2-year-old is 80125; because the client's heart rate
is below normal, the dose should be held. Content
Pediatrics; Category of Health AlterationDrug
and Parenteral Therapies; Cognitive LevelAnalysis.
84. Correct answer 2: The UAP can turn and position

a child who is stable, and a child in a spica cast
(from mid-abdomen to both knees) needs to be
turned. The UAP cannot feed through feeding tubes.
85. Correct answer 3: The new graduate should be

able to safely care for a child who has a fractured
extremity. The child going to surgery, the child
newly diagnosed with CF, and a child with an acute
exacerbation of ulcerative colitis should be assigned
548
to a more experienced nurse for the care of the child

and the comfort of the parents. ContentPediatrics;
LevelSynthesis.
86. Correct answer 3: The UAP is qualified and

expected to perform activities of daily living for the
clients. The UAP cannot assess, teach, evaluate, or
care for a client who is unstable. The UAP should
not be orienting nurses to the unit. The RN should
not be passing out meal trays, and the LPN does not
write care plans; the RN does. ContentPediatrics;
LevelSynthesis.
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SECTION ELEVEN
87. The nurse is working the emergency department of a

children's medical center. Which client should the nurse
assess first?
l 1. The 1-month-old infant who has angry-looking red
diaper rash.
l 2. The 2-year-old toddler whose father is demanding
his child be seen now.
l 3. The 6-year-old school-age child who was bitten by
a dog yesterday.
l 4. The 14-year-old adolescent whose mother suspects
has been raped.
88. The 8-year-old client diagnosed with a vaso-occlusive
sickle cell crisis is complaining of a severe headache.
l 1. Administer 6 L of oxygen via nasal cannula.
l 2. Assess the client's pupillary reaction.
l 3. Administer a narcotic analgesic intravenous push
(IVP).
l 4. Increase the client's IV rate.
Pediatric Disorders
549
89. The nurse is caring for clients on the pediatric medical

unit. Which client should the nurse assess first?
l 1. The child diagnosed with type 2 diabetes who has
a blood glucose of 60 mg/dL.
l 2. The child diagnosed with pneumonia who has a
l 3. The child diagnosed with gastroenteritis who has a
sodium level of 135 mEq/L.
l 4. The child diagnosed with cystic fibrosis who has
clubbing of the extremities.
90. The nurse has received morning shift report for
clients on a pediatric unit. Which medication should the
l 1. The third dose of the aminoglycoside antibiotic to
the child diagnosed with methicillin-resistant
Staphylococcus aureus (MRSA).
l 2. The IVP steroid methylprednisolone (Solumedrol)
to a child diagnosed with asthma.
l 3. The scheduled morning insulin to the child
diagnosed with type 1 diabetes mellitus.
l 4. The narcotic pain medication to the child who had
a postoperative spinal fusion.
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ANSWERS
87. Correct answer 4: The adolescent who has possibly

been raped must be assessed for physical injury,
and her emotional trauma must be addressed. In
addition, evidence must be obtained and preserved
for legal purposes. A diaper rash and a dog bite are
not life-threatening. The father must wait until the
child who was raped is assessed. ContentPediatrics;
Category of Health AlterationEmergency; Integrated
LevelAnalysis.
88. Correct answer 2: Because the client is complaining

of a headache, the nurse should first rule out a cerebral vascular accident (CVA) and determine if it is
a headache that can be treated with medication.
Administering oxygen, fluids, and pain medication
will help prevent the sickling, but the first intervention is to assess. ContentPediatrics; Category of Health
AlterationHematology; Integrated ProcessImplementation;
550
89. Correct answer 1: The client's blood glucose is low,

and the client is at risk for hypoglycemia; therefore,
this child should be assessed first. The pulse oximeter
reading and the sodium level are within normal
limits. Clubbing of the extremities occurs in children
with cystic fibrosis due to chronic hypoxemia.
90. Correct answer 4: The child who has postoperative

pain should be medicated prior to being given an
antibiotic, a steroid, or a routine dose of insulin.
S E C T I O N T W E LV E
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553
Cardiac Arrest/Codes
1. The nurse working on a medical unit finds the client
unresponsive in the bed. After establishing the client is
not breathing and giving two rescue breaths with a mask,
which action should the nurse implement next?
l 1. Check the client for airway obstruction.
l 2. Assess the carotid artery for a pulse.
l 3. Begin chest compressions.
l 4. Call a code via the call light.
2. Which behavior by the unlicensed assistant personnel
(UAP) who is performing cardiac compressions during a
code warrants immediate intervention by the nurse?
l 1. The UAP has two hands on the upper half of the
sternum.
l 2. The UAP notifies the team when getting tired of
performing compressions.
l 3. The UAP depresses the sternum 1.52 inches during
compressions.
l 4. The UAP counts out loud to keep the rhythm of
compressions.
3. Which is the primary responsibility of the supervising

nurse during a code?
l 1. Escort family members from the room.
l 2. Ensure that all roles are being performed.
l 3. Notify the clients health-care provider (HCP) of
the event.
l 4. Document what happened in the code.
4. The nurse is caring for clients on a telemetry floor.
Which client is most likely to experience sudden cardiac
death?
l 1. The client exhibiting uncontrolled atrial fibrillation
at a rate of 136 bpm.
l 2. The client exhibiting symptomatic sinus
bradycardia who received a pacemaker.
l 3. The client exhibiting multifocal premature
ventricular contractions.
l 4. The client exhibiting supraventricular tachycardia
at a rate of 110 bpm.
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ANSWERS
1. Correct answer 4: The nurse should notify the code

team to come to the room so that a defibrillator is
brought to the bedside. The earlier the client is defibrillated, the better the chance of success. Then, the
nurse should assess for a carotid pulse and then start
compressions. The nurse has already checked for airway obstruction before giving the two rescue breaths.
ContentEmergency; Category of Health Alteration
2. Correct answer 1: The correct hand placement is the

lower half of the sternum just above the xiphoid process.
The nurse should have the UAP reposition the hands.
The other actions by the UAP are appropriate. Content
Management; Category of Health AlterationCardiovascular;
Integrated ProcessEvaluation; Client NeedsSafe Effective
LevelSynthesis.
Page 554
554
3. Correct answer 2: The supervisor should make sure

that all the roles in a code are being performed: compression, ventilation, medication, equipment, and
documentation. Then, if needed, the supervisor
nurse can worry about crowd control. The HCP
will be notified by the staff at the nursing station.
4. Correct answer 3: Premature ventricular contractions

occur when the ventricle initiates a beat; when there
are several areas of the ventricles competing to initiate
a beat, then the client is at risk for cardiac arrest. The
client with bradycardia may have been symptomatic
but now has a pacemaker. Atrial problems are not lifethreatening as in options 1 and 4. ContentEmergency;
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5. The male client is experiencing a cardiac arrest, and

his wife is distraught. Which intervention should the
nurse implement at this time?
l 1. Notify hospital security to keep an eye on the wife.
l 2. Stay with the significant other until the clients
minister arrives.
l 3. Ask the UAP to talk to the wife.
l 4. Request the hospital chaplain to come to the
station and support the wife.
6. Which medication intervention is the most important
for the nurse to implement when functioning as the
medication nurse in a code?
l 1. Check the armband against the medication
administration record (MAR).
l 2. Administer the medications rapidly and then raise
the clients arm.
l 3. Feel for a pulse to make sure the medications are
being delivered.
l 4. Document the amount of medication administered
and the route.
Page 555
Emergency Nursing
555
7. The nurse is teaching cardiopulmonary resuscitation

(CPR) to a UAP class. Which statement best explains the
definition of sudden cardiac death?
l 1. Death that occurs after being removed from a
mechanical ventilator.
l 2. Cardiac death is the time that the physician declares
the heart has stopped.
l 3. Unexpected death occurring within 1 hour of onset
of cardiovascular symptoms.
l 4. The client is found unresponsive without a pulse or
respirations.
8. Which statement explains the scientific rationale for
administering epinephrine, a catecholamine, to a client
during a code?
l 1. It will prevent gastric distention resulting from
overventilation with the ambu-bag.
l 2. Epinephrine will treat any potential anaphylactic
reaction to the medications administered.
l 3. Epinephrine dries secretions and makes it easier for
the HCP to intubate the client.
l 4. It vasoconstricts the peripheral circulation and
shunts the blood to the central circulation.
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Page 556
ANSWERS
5. Correct answer 4: The chaplain should be called to

help address the concerns of the clients family and/or
significant others. A small community hospital would
not have a 24-hour pastoral service but may have a
chaplain on call. The nurse and UAP must see that the
other clients on the unit are cared for. Hospital security is called when there is a danger to self or others,
and this is not the case. ContentEmergency; Category
LevelApplication.
6. Correct answer 2: The medication nurse administers

the medications and then raises the clients arm to
help the medications reach the central circulation. The
MAR will not have the emergency medications, and
the nurse works from standard protocols and verbal
orders in a code. Another nurse will document the
medications in the record. This is an emergency.
556
ContentEmergency; Category of Health AlterationDrug

7. Correct answer 3: This is the definition of sudden

cardiac death. Removal from a ventilator is not sudden.
8. Correct answer 4: Epinephrine is a potent vasoconstrictor that keeps the blood in the central circulation
of the heart, lungs, and brain. It is given in allergic reactions, but this client has no pulse or respirations and is
not having an allergic reaction. ContentEmergency;
Category of Health AlterationDrug Administration; Integrated ProcessPlanning; Client NeedsPhysiological
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Emergency Nursing
557
Shock
9. The charge nurse is responding to a code on a surgical
unit. Which personal protective equipment should the
nurse utilize?
l 1. The nurse should glove and gown before entering
the room.
l 2. The nurse should use a bag/mask to ventilate the
client.
l 3. The nurse may not need any personal protective
equipment.
l 4. The nurse should don a face shield and mask when
in a code.
10. The client in a code is now in ventricular bigimeny.
The HCP orders a lidocaine drip at 4 mg/min. The
lidocaine comes prepackaged 2 g of lidocaine in 500-mL
D5W. At what rate will the nurse set the infusion pump?
Answer: ____________________
11. The client who is 1 day postoperative abdominal

surgery has a blood pressure (BP) of 88/60 and an apical
pulse of 122; is diaphoretic; and has pale, cold, and
clammy skin. Which intervention would the nurse
implement first?
l 1. Increase the clients intravenous fluid rate.
l 2. Administer an intravenous dopamine drip.
l 3. Obtain arterial blood gases (ABGs).
l 4. Assess the clients abdominal dressing.
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ANSWERS
9. Correct answer 3: The charge nurse is responsible

for ensuring that all the roles of the code team are
being performed. The charge nurse does not personally perform the roles. ContentEmergency; Category
of Heath AlterationCardiovascular; Integrated
LevelApplication.
10. Correct answer 60 mL/hr: The test taker could

remember the pneumonic which is: 1 mg, 2 mg,
3 mg, 4 mg is 15 mL, 30 mL, 45 mL, 60 mL. If the
test taker has not memorized the sequence, it is too
late to figure it out in an emergency situation. The
math follows:
2 g 1000 mg = 2000 mg per 500 mL
2000 mg 500 mL = 4 mg/mL
In algebraic terms:
4 mg : 1 mL = 4 mg : X mL
By cross multiplying: 4 mg = 4X
558
Divide each side by 4 to arrive at X = 4/4 = 1

Then, to set the pump at an hour rate, multiply
4
/4 x 60 = 60
ContentEmergency; Category of Health AlterationDrug
11. Correct answer 1: The client is exhibiting symptoms

of hypovolemic shock; therefore, the nurse should
maintain the clients circulatory volume by increasing
the fluid rate. Remember: do not assess when in distress. Assessing the abdominal dressing, obtaining the
ABGs, and administering dopamine are appropriate,
but the first intervention is to maintain fluid volume.
Shock; Integrated ProcessImplementation; Client Needs
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559
12. Which assessment data indicates the client diagnosed

with septic shock is responding to the medical regime?
l 1. Vital signs: T 100.4F, P 104, R 26, and BP 102/60.
l 2. A white blood cell count of 18,000 mm3.
l 3. A urinary output of 200 mL in the last 4 hours.
l 4. Dry, mucous membranes and tented skin turgor.
14. Which data would the nurse expect to assess in a

client diagnosed with neurogenic shock?
l 1. The client has cool, clammy skin.
l 2. The clients apical pulse is 56.
l 3. The client has bilateral wheezing.
l 4. The client urine will be diluted.
13. The client diagnosed with septicemia is admitted to

the emergency department. Which intervention should
l 2. Administer the intravenous (IV) antibiotic therapy.
l 3. Obtain a stat basic metabolic profile (BMP).
15. The nurse is preparing to administer dopamine, a beta

and alpha agonist, to a client in cardiogenic shock. has an
output of intervention should the nurse implement?
l 1. Request the respiratory therapist to perform a
12-lead ECG.
l 2. Assess the clients blood pressure (BP) every 2 hours.
l 3. Use an urimeter to evaluate the intake and output
every hour.
l 4. Cover the intravenous bag and tubing with foil.
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Page 560
ANSWERS
12. Correct answer 3: The client must have a urinary

output of at least 30 mL an hour; therefore, an output
of 200 mL in 4 hours indicates the clients kidneys are
functioning normally, which, in turn, indicates the
client is responding to the medical regime. The vital
signs, white blood cell count, and dehydration
indicate the client is not responding to the medical
regime. ContentEmergency; Category of Health
AlterationShock; Integrated ProcessAssessment; Client
13. Correct answer 2: The IV antibiotic is the priority

medication for the client with septicemia, a systemic
bacterial infection of the blood. Inserting an indwelling
catheter, obtaining a BMP, and placing the patient in
the Trendelenburg position are interventions used for
clients in hypovolemic shock, not septic shock.
Shock; Integrated ProcessImplementation; Client
560
14. Correct answer 2: The client diagnosed with neurogenic shock will have bradycardia, instead of the
tachycardia seen in other forms of shock. The clients
skin will be dry and warm, rather than the cool moist
skin seen in hypovolemic shock. Wheezing would be
associated with anaphylactic shock, and the client
would not have dilute urine. ContentEmergency;
Category of Health AlterationShock; Integrated
15. Correct answer 3: The urinary output should be

monitored via a urometer hourly to ensure the client
has an output of at least 30 mL/hr. Dopamine
is administered to increase the BP, so it should be assessed every 515 minutes, not every 2 hours. The
client should be on a cardiac monitor, not a one-time
12-lead ECG. The medication is not sensitive to light,
so the intravenous bag and tubing need not be covered with foil. ContentEmergency; Category of Health
AlterationShock; Integrated ProcessImplementation;
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16. The client in hypovolemic shock is receiving dextran,

a non-blood colloid. Which assessment data would
l 1. The client has a negative Chvostek sign.
l 3. The client refuses to cough and deep-breathe.
l 4. The client has bilateral jugular vein distention (JVD).
17. The nurse caring for a client with sepsis writes the
client diagnosis of alteration in comfort related to chills
and hyperpyrexia. Which independent intervention
should be included in the plan of care?
l 1. Place a hyperthermia blanket on the client.
l 2. Assess the clients vital signs every 2 hours.
l 3. Obtain blood sputum cultures.
l 4. Administer an antipyretic medication every
4 hours.
Emergency Nursing
561
18. The client diagnosed with septic shock has an

elevated temperature, a BP of 110/70, and a high cardiac
output with systemic vasodilation. Which phase of septic
shock is the client experiencing?
l 1. Hypodynamic phase.
l 2. Compensatory phase.
l 3. Hyperdynamic phase.
l 4. Progressive phase.
19. Which assessment data would indicate to the nurse
the client is experiencing hypovolemic shock?
l 1. The clients BP is 80/40 and apical pulse 128.
l 2. The clients cardiac output is 5 L/min.
l 3. The clients central venous pressure (CVP) is 8 cm
H2O pressure.
l 4. The client is hypertensive and bradycardic.
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ANSWERS
16. Correct answer 4: Because of the ability of all colloids

to pull fluid into the vascular space, circulatory overload is a serious adverse outcome; JVD is a sign of
circulatory overload. The Chvostek sign indicates
hypocalcemia; a pulse oximeter reading of greater than
93% is within normal limits (WNLs); and refusing to
cough and deep-breathe is a concern but does not warrant immediate intervention. ContentEmergency; Category of Health AlterationShock; Integrated Process
17. Correct answer 2: The client has an elevated temperature; therefore, taking the clients vital signs would be
an appropriate independent intervention. The client
would need a hypothermia blanket, not a hyperthermia
blanket, for a fever (hyperpyrexia). Administering medication and obtaining a blood culture are collaborative
interventions. ContentEmergency; Category of Health
AlterationShock; Integrated ProcessDiagnosis; Client
562
18. Correct answer 3: The hyperdynamic phase, the

first phase of septic shock, is characterized by high
cardiac output with systemic vasodilation. The BP
may remain within normal limits, but the heart rate
increases to tachycardia, and the client becomes
febrile. ContentEmergency; Category of Health
AlterationShock; Integrated ProcessDiagnosis; Client
19. Correct answer 1: The hallmark signs of hypovolemic shock are decreased blood pressure and
tachycardia. Normal cardiac output is 46 L/min,
and normal CVP pressure is 410 cm H2O pressure.
Shock; Integrated ProcessAssessment; Client Needs
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563
20. The nurse and a female unlicensed assistive personnel

(UAP) are caring for a group of clients on the medical
floor. Which action by the UAP would warrant immediate
l 1. The UAP places a urine specimen in a biohazard bag.
l 2. The UAP washes her hands with alcohol foam
hand cleanser.
l 3. The UAP puts soiled linen in a plastic bag in the
hallway.
l 4. The UAP uses a disposable stethoscope for a client
in the isolation room.
22. The school nurse has had five students in the last
3 hours present to the school health clinic with complaints
of severe abdominal cramping, nausea, vomiting, and
diarrhea. Which intervention should the nurse implement
first?
l 1. Notify the public health department of the situation.
l 2. Administer an antiemetic medication to the students.
l 3. Determine if the students ate the same food in the
cafeteria.
l 4. Contact the parents or legal guardians of the
students.
Bioterrorism
23. The nurse is caring for three clients who have botulism.
Which category of personal protective equipment (PPE)
should the nurse wear?
l 1. Level A
l 2. Level B
l 3. Level C
l 4. Level D
21. The Homeland Security Office has issued a warning

of suspected biological warfare using the Franciscella
tularensis (tularemia) bacteria. Which signs and symptoms
would support the initial diagnosis of tularemia?
l 1. Fever, chills, headache, and malaise.
l 2. Vomiting, diarrhea, and fatigue.
l 3. The nurse smells the odor of bitter almonds.
l 4. Visual and gastrointestinal disturbances.
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ANSWERS
20. Correct answer 3: Soiled linen should be put in a
564
22. Correct answer 3: These could be signs of botulism,
plastic bag in the clients room, not in the hallway.

Specimens should be put in biohazard bags; the UAP
should wash her hands with alcohol foam hand
cleanser; and using a disposable stethoscope is an
appropriate intervention. ContentManagement; Cate-
but the nurse should first assess to determine if all

the students ate the same food. The parents should
be notified, and the public health department may
need to be notified. The school nurse would not
have antiemetic medications in the nurses office.
gory of Health AlterationShock; Integrated Process

LevelSynthesis.

Bioterrorism; Integrated ProcessImplementation;
21. Correct answer 1: Tularemia is extremely contagious
23. Correct answer 4: Standard precautions are used
and is contracted by exposure to infected animals or

an aerosolized or biological weapon. Symptoms are
a sudden onset of fever, fatigue, chills, headache,
lower backache, malaise, rigor, and coryza. Option 2
lists signs/symptoms of radiation exposure, option 3
of cyanide poisoning, and option 4 of malathion
exposure. ContentEmergency; Category of Health
when caring for clients with botulism; therefore,

the nurse should wear the work uniform, which
is Level D. Level A protection is worn for the
highest-level protection, Level B protection when a
lesser level of protection is needed, and Level C
protection requires an air-purified respirator
(APR). ContentEmergency; Category of Health
AlterationBioterrorism; Integrated ProcessAssessment;

and Infection Control; Cognitive LevelAnalysis.
AlterationBioterrorism; Integrated ProcessPlanning;

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24. The emergency department (ED) has been notified

of an explosion in a chemical manufacturing plant.
Which intervention should be implemented first as the
clients arrive at the ED?
l 1. Triage the explosion victims in the ambulances.
l 2. Find out if family members have been notified.
l 3. Prepare charts for the clients as they come into
the ED.
l 4. Remove the clients clothes before entering the ED.
25. The Muslim client who was exposed to anthrax has
died. Which statement indicates the family understands
the information discussed concerning anthrax exposure?
l 1. We should cremate our loved one as soon as
possible.
l 2. We will take our loved one back to our homeland.
l 3. We need to be vaccinated against polio within
3 days.
l 4. We shall have an open casket ceremony for our
loved one.
Page 565
Emergency Nursing
565
26. The employee health nurse working in an industrial

plant has been informed employees smell the odor of
bitter almonds. Which intervention should the nurse
implement?
l 1. Notify security to evacuate all employees.
l 2. Tell the employees to continue working.
l 3. Instruct employees to wear face shields.
l 4. Assess the employees for respiratory distress.
27. The nurse is teaching a class on biological warfare.
Which statement indicates one of the students needs
more teaching concerning the information presented?
l 1. Anthrax, smallpox, and plagues are examples of
biological agents.
l 2. Chemical agents are more apparent and problems
occur more quickly than with biological agents.
l 3. Biological weapons are less of a threat than
chemical agents.
l 4. Biological agents can be released in one city and
affect cities thousands of miles away.
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ANSWERS
24. Correct answer 4: Removing the clothing is the first

step. Depending on the type of exposure, this step
alone can remove a large portion of exposure. Triage
is usually the first step, but preventing potential
chemical exposure to staff and clients in the ED is
the first step (safety of the hospital); therefore, the
clients must be decontaminated. ContentEmergency;
Category of Health AlterationBioterrorism; Integrated
25. Correct answer 1: Cremation is recommended

because the anthrax spores can survive for decades
and represent a threat to morticians and forensic
medicine personnel. There is no vaccination for
anthrax. ContentEmergency; Category of Health
AlterationBioterrorism; Integrated ProcessEvaluation;
and Infection Control; Cognitive LevelEvaluation.
566
26. Correct answer 1: The smell of bitter almonds is

associated with cyanide gas, a deadly poison. The
nurse should evacuate the area. Face shields will not
protect against cyanide poisoning. Cyanide poisoning includes respiratory muscle failure, but assessment will not save the employees lives. Content
Emergency; Category of Health AlterationBioterrorism;
Control; Cognitive LevelSynthesis.
27. Correct answer 3: Because of the variety of biological agents (anthrax, smallpox, plague), the means of
transmission, and the lethality of agents, they are
more of a threat and more dangerous than chemical
agents. Chemical agents (nerve agents, cyanide, vesicant agents, pulmonary agents) are more apparent.
Bioterrorism; Integrated ProcessEvaluation; Client
LevelSynthesis.
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28. The medical unit staff admitted seven clients who

were exposed to anthrax. Which type of precaution should
the infection control nurse implement on the unit?
l 1. Airborne precautions.
l 2. Standard precautions.
l 3. Contact precautions.
l 4. Droplet precautions.
29. The emergency department (ED) has been notified
of an accident at a chlorine chemical plant and to expect
1012 casualties. Which priority intervention should the
ED department implement?
l 1. Prepare to decontaminate the clients in a
decontamination room.
l 2. Discharge clients from the ED to make room for
victims.
l 3. Notify the respiratory therapy department of the
disaster.
l 4. Prepare to place clients on ventilatory support.
Page 567
Emergency Nursing
567
30. Which intervention should the nurse implement for

clients who have been exposed to a liquid form of the
chemical nerve agent sarin?
l 1. Prepare to administer sodium nitrate intravenously.
l 2. Wash the skin with copious amounts of soap and
water.
l 3. Instruct the clients not to burst any blister formation.
l 4. Administer the antibiotic penicillin intravenously.
Disaster/Triage Nursing
31. According to the North Atlantic Treaty Organization
(NATO) triage system, which situation would be considered
priority 4, color black?
l 1. Injuries are extensive, and chances of survival are
unlikely.
l 2. Injuries are life-threatening but survivable with
minimal interventions.
l 3. Injuries are significant but can wait hours without
threat to life or limb.
l 4. Injuries are minor, and treatment can be delayed
hours to days.
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ANSWERS
28. Correct answer 2: Standard precautions are all that

is necessary because the client is not contagious
and the disease cannot be spread from person to
person. Equipment should be cleaned using standard
hospital disinfectant. ContentMedical; Category of
Health AlterationBioterrorism; Integrated Process
LevelApplication.
29. Correct answer 3: Chlorine is a gas that, when inhaled, separates the alveoli from the capillary bed.
The respiratory therapy department is responsible for
oxygen therapy and setting up/maintaining ventilators; therefore, this would be the priority intervention. Clearing out the ED should be done but not
before preparing for clients. Clients would not need
to be decontaminated. ContentEmergency; Category
of Health AlterationBioterrorism; Integrated Process
LevelApplication.
568
30. Correct answer 2: Liquid forms of nerve agents evaporate into colorless, odorless vapors that can be inhaled
or absorbed through the skin; therefore, washing the
skin with soap and water is an appropriate treatment.
Sodium nitrate is used to treat cyanide exposure.
Vesicants cause blistering. Oral penicillin is the treatment for anthrax exposure. ContentEmergency; Category of Health AlterationBioterrorism; Integrated
Application.
31. Correct answer 1: A client tagged Priority 4, color

black, is considered expectant, which means the client
will probably die. Option 2 is color red, Priority 1;
option 3 is color yellow, Priority 2; option 3 is green,
Priority 3. ContentEmergency; Category of Health
AlterationDisaster/Triage; Integrated ProcessPlanning;
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32. Which situation would warrant the charge nurse in

a long-term care facility to obtain information from a
material safety data sheet (MSDS)?
l 1. The nurse was accidently stuck with a used insulin
syringe.
l 2. The custodian spilled bleach water on the floor of
the lobby.
l 3. The family member brought the residents dog into
the building.
l 4. The resident had a mercury thermometer that broke
in the bathroom.
33. The triage nurse is working in the emergency
department. Which client should be assessed first?
l 1. The 10-year-old child who has a compound fracture
of the right arm.
l 2. The 17-year-old adolescent who has a pencil sticking
out of his eye.
l 3. The 38-year-old female who accidently spilled hot
grease on her leg.
l 4. The 55-year-old man with hypertension who has
an occipital headache.
Emergency Nursing
569
34. The nurse in a disaster is triaging clients. Which

client should be triaged as a Minimal category, Priority 3,
and color green?
l 1. The client with a sucking chest wound who is alert.
l 2. The client with a head injury who is unresponsive.
l 3. The client with an abdominal wound and stable
vital signs.
l 4. The client with a sprained ankle that may be
fractured.
35. The triage nurse has coded a client as priority 2,
color yellow. Which action would warrant immediate
l 1. The American Red Cross (ARC) volunteer
documents the tag number in the disaster log.
l 2. The licensed practical nurse (LPN) documents the
clients vital signs on the tag.
l 3. The HCP removes the tag to examine the clients
injured right leg.
l 4. The UAP attaches the tag to the clients foot.
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ANSWERS
32. Correct answer 4: The MSDS provides chemical

information regarding specific agents, health information, and spill information for a variety of chemicals.
Mercury thermometers have been removed from
health-care facilities because of the risk of inhaling
the mercury. ContentEmergency; Category of Health
AlterationDisaster/Triage; Integrated ProcessPlanning;
33. Correct answer 2: This nurse should see this client

first because the pencil needs to be stabilized in the
eye, the operating room needs to be notified, and
more than likely the eye will be enucleated. The
compound fracture, the burned leg, and an occipital
headache are not potentially life-threatening.
Disaster/Triage; Integrated ProcessAssessment; Client
570
34. Correct answer 4: Minimal Category, Priority 3,

and color green are clients who could wait for days
until treated. An ankle, even if it is fractured, could
wait. Remember the traffic lightred needs to be
seen immediately, yellow should be seen within a
few hours, and green a few days. Black has a very
low survival rate. ContentEmergency; Category of
Health AlterationDisaster/Triage; Integrated Process
35. Correct answer 3: The tag should never be removed

until the client is admitted, and the tag becomes a
part of the clients record. The HCP needs to be
informed immediately of the action. The ARC
volunteer, the LPN, and UAP actions would not
warrant intervention. ContentEmergency; Category
of Health AlterationDisaster/Triage; Integrated
LevelSynthesis.
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571
36. Which situation would require the emergency

department manager to schedule and conduct a Critical
Incident Stress Management (CISM) session?
l 1. A policeman received a gunshot wound to the
abdomen in the line of duty.
l 2. A 4-year-old who had an accidental poisoning and
was admitted to the ICU.
l 3. A 22-year-old client who died after taking an
overdose of sleeping pills.
l 4. A school bus accident that resulted in 14 hospital
admissions and 11 deaths.
38. The nurse is triaging phone calls in an outpatient

clinic. Which client should the nurse inform to come to
the emergency clinic today?
l 1. The client who reports burning and pain upon
urination.
l 2. The client who calls complaining of severe
chest pain.
l 3. The client who has had a stuffy nose and cough for
2 days.
l 4. The client who needs a physical examination for
football.
37. The nurse in a disaster is triaging clients. Which client

would be triaged as an Expectant Category, Priority 4, and
color black?
l 1. The client who has a hard, distended abdomen.
l 2. The client who is exhibiting decerebrate posturing.
l 3. The client who has a possible L1L2 spinal cord
injury.
l 4. The client who has paresthesia in the left lower leg.
39. Which activity is most important for the hospital staff

when planning disaster preparedness and implementing
the hospitals emergency operations plan (EOP)?
l 1. Evaluate how other hospitals implement disaster
drills.
l 2. Discuss the disaster plan with small groups of
employees.
l 3. Instruct all staff to read the EOP disaster procedure.
l 4. Have community and hospital practice disaster
drills.
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ANSWERS
36. Correct answer 4: CISM is an approach to preventing and treating the emotional trauma that can affect
emergency responders as a consequence of their job;
a major accident is a traumatic experience. The ED
staff often care for gunshot wounds, survivors in
accidental poisonings, and clients who overdose.
Disaster/Triage; Integrated ProcessPlanning; Client
NeedsPsychosocial Integrity; Cognitive LevelSynthesis.
37. Correct answer 2: The client who is decerebrate

posturing has severe increased intracranial pressure
secondary to a head injury and has a very poor
prognosis; even with treatment, survival is unlikely.
A hard distended abdomen, a possible spinal cord
injury, and paresthesia in the lower leg are injuries
that could be treated. ContentEmergency; Category of
Health AlterationDisaster/Triage; Integrated Process
572
38. Correct answer 1: The client needs to come to the

clinic for a midstream urinalysis because the problem
sounds like a urinary tract infection and the client
will need antibiotics. The client with chest pain
should call 911 immediately; the client with a possible cold does not need to be seen today; and a physical examination does not need to be performed today.
Disaster/Triage; Integrated ProcessAssessment; Client
39. Correct answer 4: The most important activity is

to implement practice drills, which allow for troubleshooting any issues before a real incident occurs.
Reading the procedure, discussing the procedure,
and evaluating other facilities are not as important as
having a practice drill. ContentEmergency; Category
of Health AlterationDisaster/Triage; Integrated
LevelSynthesis.
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40. The emergency department (ED) has received a

phone call reporting an implosion of a building with
multiple injuries. Which action should the charge nurse
implement first?
l 1. Contact the local blood bank to report the
incident.
l 2. Call nurses off-duty to come into work.
l 3. Notify the house supervisor of the incident.
l 4. Instruct staff to check the supplies in the ED.
Poisoning
41. Which statement is the primary goal of the emergency department (ED) nurse in caring for a client who
has ingested a poison?
l 1. To stop the action of the poison and maintain
organ functioning.
l 2. To determine why the client ingested the poisonous
substance.
l 3. To document the interventions taken to treat the
clients condition.
l 4. To implement treatment that increases the
elimination of the poison.
Emergency Nursing
573
42. The client has ingested a corrosive solution containing

lye. Which intervention should the nurse implement first?
l 1. Monitor the clients neurological status.
l 2. Insert a nasogastric (NG) tube in the clients nares.
l 3. Assess for the clients ability to breathe.
l 4. Administer milk to dilute the corrosive solution.
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ANSWERS
40. Correct answer 3: The house supervisor should be

notified so that staff can be mobilized, client census
evaluated, and plans made for multiple admissions to
the ED. The blood bank may need to be notified,
off-duty nurses may need to be called in, and supplies should be checked, but the first intervention is
to notify the house supervisor. ContentEmergency;
Category of Health AlterationDisaster/Triage; Integrated
LevelSynthesis.
41. Correct answer 1: The primary goal is to inactivate

the poison before it is absorbed and causes permanent
organ damage or death. The nurse should attempt to
determine why the client ingested the poison, but this
is not priority. Documentation is vital, but the nurse
must first take care of the client. Eliminating the poison is not always priority; neutralizing the poison is
sometimes priority. ContentEmergency; Category of
574
Health AlterationPoisoning; Integrated ProcessPlanning;

42. Correct answer 3: Airway edema or obstruction can

occur as a result of the burning action of corrosive
substances. Neurological assessment is important but
not priority over airway. Inserting an NG tube and
administering milk are appropriate interventions, but
they are not prior to airway management. Content
Emergency; Category of Health AlterationPoisoning;
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43. The nurse hiking on a trail is providing first aid to a

victim of a poisonous snakebite on the right lower leg.
l 1. Remove the clients right shoe.
l 2. Instruct the client to lie very still.
l 3. Immobilize the clients right leg.
l 4. Keep the client warm as possible.
44. A gastric lavage has been ordered for a comatose
client who ingested a full bottle of sleeping pills in an
attempt to commit suicide. Which interventions should
l 1. Place the client supine with the head of the bed flat.
l 2. Insert a large-bore gastric tube into the clients
mouth.
l 3. Make sure there is standby suction at the bedside.
l 4. Withdraw all stomach contents and then instill
irritating solution.
l 5. Use gloves to dispose all stomach contents into the
commode.
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Emergency Nursing
575
45. Which statement indicates the client understands the

teaching concerning carbon monoxide poisoning?
l 1. I should install smoke detectors in my home.
l 2. Carbon monoxide will make you sick but it is not
lethal.
l 3. You can smell carbon monoxide, so it easy to detect.
l 4. I should have my furnace checked for leaks before
turning it on.
46. The client overdosed by taking too much narcotic
cough syrup. The nurse administers naloxone (Narcan).
l 1. Assess for signs of respiratory depression.
l 2. Monitor the clients pulse oximeter reading.
l 3. Place a tracheostomy tray at the clients bedside.
l 4. Determine if the overdose was accidental.
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ANSWERS
43. Correct answer 2: The client should lie down and

remove all restrictive items. Then, the wound should
be cleaned and covered with a sterile dressing. The affected body part should be immobilized, and the client
should be kept warm. ContentEmergency; Category
of Health AlterationPoisoning; Integrated Process
Implementation; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelAnalysis.
44. Correct answer 2, 3, 4: A large-bore tube is used

with a comatose client; suction is to prevent aspiration;
and removing stomach contents before the lavage
helps to prevent overdistention of the stomach. The
client should be placed on the left side to allow the
gastric contents to pool in the stomach, decreasing
passage of fluid into the duodenum during lavage.
Samples are sent to the lab to be analyzed for chemical
compounds. ContentEmergency; Category of Health
AlterationPoisoning; Integrated ProcessImplementation;
576
45. Correct answer 4: One of the major causes of accidental carbon monoxide poisoning is faulty furnaces; the
client understands the teaching. A smoke detector will
not detect carbon monoxide; the client should install
a carbon monoxide detector. Carbon monoxide is
colorless and odorless, and it can be lethal. Content
Emergency; Category of Health AlterationPoisoning;
Integrated ProcessEvaluation; Client NeedsHealth
Promotion and Maintenance; Cognitive LevelEvaluation.
46. Correct answer 1: Narcan has a short half-life and

may wear off before the effects of the cough syrup
wear off; this could result in the return of respiratory
depression. Monitoring oximeter readings is not priority over the client. An intubation tray may be needed
if the client does not respond to Narcan, and determining the cause of overdose is not priority. Content
Emergency; Category of Health AlterationDrug
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47. The toddler was brought to the emergency room

after taking her mothers prenatal vitamins. Which
interventions should the nurse implement? Select all
that apply.
l 1. Determine if the prenatal vitamins had iron.
l 2. Administer activated charcoal to the toddler.
l 3. Assess the toddlers vital signs frequently.
l 4. Notify child protective services of the situation.
l 5. Ask the parents if they have the vitamin bottle.
48. A 23-year-old male was brought to the emergency
department after trying to kill himself by drinking motor
oil. Which HCP order should the nurse question?
l 1. Initiate intravenous fluids with a 20-gauge
angiocatheter.
l 2. Insert an indwelling urinary catheter with a
urometer.
l 3. Place a nasogastric tube and perform gastric lavage.
l 4. Monitor the clients cardiac status on telemetry.
Page 577
Emergency Nursing
577
49. The health-care provider has prescribed edetate

calcium disodium (calcium EDTA), a chelating agent, for
a client diagnosed with lead poisoning. Which laboratory
data would warrant immediate intervention?
l 1. The clients ALT/GPT is 30 IU/mL.
l 2. The clients calcium level is 9.5 mg/dL.
l 3. The clients blood urea nitrogen (BUN) is 15 mg/dL.
l 4. The clients creatinine level is 2.4 mg/dL.
50. The female client took an overdose of Ambien CR, a
sedative hyponotic, and is admitted to the intensive care
unit (ICU). Which priority intervention should the ICU
nurse implement?
l 1. Refer the client to a psychiatric nurse practitioner.
l 2. Allow the client to ventilate her feelings.
l 3. Administer 1.5 L of Go-Lytely, a whole bowel
irrigation.
l 4. Ensure the client turns, coughs, and deep-breathes
every 2 hours.
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ANSWERS
47. Correct answer 1, 3, 5: Iron can destroy a toddlers

liver; vital signs must be assessed; and by looking at
the vitamin bottle the nurse can see how many
vitamins were in the bottle when it was purchased
and if the vitamins have iron. Activated charcoal is
administered for poisons, and at this time there is no
evidence to support that the parents are negligent or
unfit to care for their child. ContentEmergency;
Category of Health AlterationPoisoning; Integrated
Integrity, Reduction for Risk Potential; Cognitive
LevelApplication.
48. Correct answer 3: Gastric lavage should not be

attempted with ingestion of caustic agents such as
high-viscosity petroleum products. Intravenous
fluids, monitoring intake and output, and monitoring
the cardiac status are appropriate interventions.
Poisoning; Integrated ProcessImplementation; Client
Page 578
578
49. Correct answer 4: The creatinine level indicates renal

failure, and adequate renal function is required before
administering the drug as both the drug and the lead
will be excreted through glomerular filtration. The
clients liver, calcium, and BUN levels are all within
normal limits. ContentEmergency; Category of Health
AlterationPoisoning; Integrated ProcessAssessment;
50. Correct answer 3: Whole bowel irrigation is effective following ingestion of sustained-released medication, such as Ambien CR, lead, lithium, and iron.
Therapeutic communication, referrals, and preventing complications of immobility are all appropriate
interventions, but the most important intervention is
to rid the body of the sustained-release medication.
Poisoning; Integrated ProcessImplementation; Client
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Emergency Nursing
579
Management
51. A potential chemical spill has occurred on the
medical floor. Which intervention should the charge
l 1. Instruct the staff to evacuate the immediate area.
l 2. Contain the area where the chemical spill occurred.
l 3. Notify the hazard management team.
l 4. Contact the hospital shift supervisor.
52. The nurse and unlicensed assistive personnel (UAP)
are caring for clients in the ED. Which task would be
most appropriate to delegate to the UAP?
l 1. Tell the UAP to take the vital signs of a client with
a gunshot wound to the chest.
l 2. Instruct the UAP to flush the eyes of a client who
splashed bleach in the eyes.
l 3. Ask the UAP to use the Rule of Nines to determine
the percentage body surface burned.
l 4. Request the UAP complete the discharge teaching
for the client diagnosed with scabies.
53. The charge nurse is making assignments in the

medical department and has one RN, one recent graduate
nurse, two licensed practical nurses (LPN), and an
unlicensed assistive personnel (UAP). Which client
should be assigned to the graduate nurse who has just
completed orientation?
l 1. The client diagnosed with a snakebite who is
receiving antivenin.
l 2. The client who swallowed poison and is on a
one-to-one suicide watch.
l 3. The client who was exposed to the powder form of
anthrax.
l 4. The elderly client with septicemia who is receiving
IV antibiotic therapy.
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ANSWERS
51. Correct answer 2: The first intervention is to contain

the spill area and make sure no clients, staff, or visitors come near the area. The nurse should then notify
the shift supervisor (following chain of command)
and then the hazardous materials team. Evacuation is
done only if that team instructs that it be done.
52. Correct answer 2: The UAP could flush the eyes

continuously with normal saline because this take a
long time, and the nurse will not have to be tied up
with the client for an extended period. A client with
a gunshot wound would require assessment; the
Rule of Nines is assessment; and the UAP cannot
teach. ContentManagement; Category of Health
580
53. Correct answer 4: The newly graduated nurse has

the knowledge to care for a client receiving antibiotic
therapy. Antivenin administration requires specific
assessment, infusion rates, and has many complications, and anthrax is a biological agent; therefore, a
more experienced nurse should care for these clients.
The UAP could sit with a client on a one-to-one
suicide watch. ContentMedical; Category of Health
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Page 581
54. The emergency department (ED) nurse is caring for

a client with a head injury secondary to a motorcycle
accident who in response to painful stimuli assumes
decerebrate posturing. Which data would indicate the
clients condition is improving?
l 1. The client has purposeful movement when the
nurse rubs the sternum.
l 2. The client extends the upper and lower extremities
in response to painful stimuli.
l 3. The client is flaccid when the nurse applies painful
pressure to the sternum.
l 4. The client has a Glasgow Coma Scale Rating of
4 on a 115 scale.
55. The nurse is preparing to administer morphine sulfate
2 mg intravenous push (IVP) to a client complaining of
chest pain who has a saline lock in the left forearm. Which
interventions should the nurse implement? Rank in order.
l 1. Administer the medication over 5 minutes.
l 2. Sign out the medication from the narcotics cabinet.
l 3. Flush the saline lock with 2 mL of normal saline.
l 4. Ask the client about allergies to medications.
l 5. Draw up the medication in 10 mL syringe.
Emergency Nursing
581
56. The charge nurse is making client assignments in the

critical care unit. Which client should be assigned to the
most experienced nurse?
l 1. The client with diabetic ketoacidosis (DKA) with
arterial blood gases (ABGs) of pH 7.29, PaO2 98,
PaCO2 30, HCO3 15.
l 2. The client with chronic obstructive pulmonary
disease (COPD) with ABGs of pH 7.35, PaO2 78,
PaCO2 54, and HCO3 20.
l 3. The client with a myocardial infarction (MI) with
ABGs of pH 7.4, PaO2 91, PaCO2 43, and
HCO3 25.
l 4. The client with a pulmonary embolism (PE) with
ABGs of pH 7.35, PaO2 88, PaCO2 44.
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ANSWERS
54. Correct answer 1: Purposeful movement following

painful stimuli would indicate an improvement in the
clients condition. Extending the upper and lower
extremities is assuming a decerebrate posture. Flaccidity
and a Glasgow Coma Scale of 4 indicate a worsening
of the clients condition. ContentManagement;

should first sign out the appropriate medication from
the narcotics cabinet. Morphine should be administered over 5 minutes, so diluting the medication to
10 mL will allow for a controlled administration
time. Then, the nurse should make sure the client is
not allergic to morphine. After that, the nurse should
flush the saline lock and administer the medication
over 5 minutes. ContentManagement; Category of
582

56. Correct answer 1: This clients ABGs reflect that

the DKA has not resolved, and the most experienced nurse should care for the most unstable
client. The client with COPD has good ABGs for
the diagnosis, and the other ABGs are normal.
Safe Effective Care Environment, Management of
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583
57. The client has an advance directive for health care.

Which situation would require the nurse to consult the
surrogate decision maker?
l 1. The client with a head injury who has Glasgow
Coma Scale of 13.
l 2. The client with COPD who is having difficulty
being weaned from the ventilator.
l 3. The client in a hyperglycemic hyperosmolar
nonketotic coma.
l 4. The client in a hyperbaric chamber for nonhealing
wounds on the legs.
59. The nurse and an unlicensed assistive personnel

(UAP) are working in an ED. Which nursing task should
l 1. Instruct the UAP to take the client with a fractured
arm to the car.
l 2. Ask the UAP to escort the battered woman to the
restroom.
l 3. Tell the UAP to give the medication prescription to
the client.
l 4. Discuss having the UAP relay discharge
instructions to a client.
58. The nurse is triaging clients in the emergency

department (ED). Which client can wait to be seen by
the ED staff?
l 1. The 57-year-old client complaining of right-sided
chest pain and diaphoresis.
l 2. The 13-year-old client with a headache and a purple
spotted rash.
l 3. The 78-year-old client who became disoriented and
has slurred speech.
l 4. The 35-year-old client who has a possible fracture
of the right tibia.
60. The charge nurse of an emergency department (ED)

must send one nurse to the intensive care unit (ICU) for
the shift. Which nurse should be assigned to the ICU for
the day?
l 1. The RN who is orienting to the emergency
department from a medical unit.
l 2. The RN who frequently functions as charge nurse
of the emergency department.
l 3. The RN who has floated between the ED and ICU.
l 4. The RN who is interested in training for the ICU.
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ANSWERS
57. Correct answer 3: The client in a coma cannot

make decisions. A Glasgow Coma Scale of 13
indicates a cognizant functioning individual. A client
on the ventilator can relate wishes to the nurse, and
a client in a hyperbaric chamber can make decisions.
58. Correct answer 4: A fracture, although painful, is not

life-threatening. Chest pain, right- or left-sided, must
be assessed to make sure it is not cardiac pain. A client
with a headache and purple spotted rash is exhibiting
symptoms of meningitis, and if antibiotics are not initiated immediately, the meningitis could be deadly.
Disorientation and slurred speech are symptoms of a
cerebrovascular accident (CVA), or stroke. Content
Emergency; Category of Health AlterationDisaster/
Triage; Integrated ProcessAssessment; Client NeedsSafe
Page 584
584
59. Correct answer 1: The UAP can take a client to a car

for discharge after the nurse provides instructions. The
nurse should escort the battered woman to the restroom so that assessment of the clients situation can
be achieved when the client is alone. The nurse should
give the prescriptions to the client and answer questions about the medications. ContentManagement;
LevelSynthesis.
60. Correct answer 3: This RN will provide the most help

to the ICU for the shift. The RN in orientation should
stay and continue orientation. The relief charge nurse
is the strength of the ED, and the nurse who would
like to cross-train should be given a chance to orient to
the unit first before being assigned to take a client load
in the ICU. ContentManagement; Category of Health
SECTION THIRTEEN
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Immune Inflammatory Disorders
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SECTION THIRTEEN
Page 587
587
Acquired Immune Deficiency

Syndrome
1. The nurse is admitting a client diagnosed with protein
calorie malnutrition secondary to acquired immune
deficiency syndrome (AIDS). Which intervention should
l 1. Assess the client's body weight, and ask what the
client has been able to eat.
l 2. Place in contact isolation, and don a mask and
gown before entering the room.
l 3. Have the client collect a clean voided urine
specimen for culture.
l 4. Teach the client about the importance of
consuming adequate calories.
2. The nurse assesses white patchy lesions covering the
hard and soft palates and on the right inner cheek in a
male client diagnosed with AIDS. Which intervention
l 1. Provide a soft-bristle toothbrush for the client to use.
l 2. Obtain an order for an antifungal swish-and-swallow
medication.
3. Teach the client to gargle with an antiseptic
4. Ask the client if he has been eating a lot of yogurt
mouthwash several times a day.

recently.
3. The nurse is describing the human immunodeficiency

virus (HIV) infection to a female client who has been
told that she is HIV-positive. Which information
regarding the virus is important to teach?
l 1. The HIV virus is a retrovirus, which means it may
go dormant but remain in the body.
l 2. HIV is a virus that, with the correct treatment, can
be eradicated from the host body.
l 3. It is difficult for the HIV virus to replicate in
humans because it is a monkey virus.
l 4. The HIV virus uses the client's own red blood cells
to reproduce itself.
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ANSWERS
1. Correct answer 1: The client has a malnutrition

syndrome. The nurse should assess the body and what
the client has been able to eat. Standard precautions
are used for clients diagnosed with AIDS, the same as
for every other client. A urinary tract infection would
not cause malnutrition. The client does not need
teaching; there is a physiological reason for the
malnutrition. ContentMedical; Category of Health
LevelApplication.
2. Correct answer 2: This is most likely a fungal

infection known as oral candidiasis, commonly called
thrush. An antifungal medication is needed to treat
this condition. Brushing the teeth and patchy areas
will not remove the lesions and will cause considerable
pain. Antiseptic-based mouthwashes usually contain
588
alcohol, which would be painful for the client. Yogurt

did not cause this condition. ContentMedical; Category of Health AlterationInfectious Diseases; Integrated
LevelApplication.
3. Correct answer 1: Retroviruses never completely

leave the body. They may become dormant, only to be
reactivated at a later time. Eradicated means to be
completely cured or done away with; the HIV cannot
be completely eradicated. HIV originated in the
green monkey where it is not life-threatening. HIV
in humans replicates readily using the CD4 cells
as reservoirs. ContentMedical; Category of Health
Planning; Client NeedsPhysiological Integrity, Physiological
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4. The male client who engaged in needle-sharing drug

abuse activities has developed a flu-like infection. Which
l 1. Teach the client he did not contract HIV from an
infected needle this time.
l 2. Report the client to the public health department
for a diagnosis of AIDS.
l 3. Encourage the client to have an HIV antibody
test performed in a few weeks.
l 4. Have the family admit the client to a drug
rehabilitation center.
5. The female nurse caring for a client who is known to
be HIV-positive accidentally stuck herself with the stylet
used to start an intravenous line. Which action should
the nurse take first?
l 1. Notify the charge nurse, and fill out an incident
report.
l 2. Go to the employee health nurse to start on
prophylactic medication.
589
3. Follow up with the employee health nurse to have
4. Flush the skin with water, and try to get the area to
lab work drawn.

bleed.
6. The client on a medical floor is diagnosed with HIV

encephalopathy. Which client problem is priority?
l 1. Altered role performance.
l 2. Anticipatory grieving.
l 3. Knowledge deficit, procedures, and prognosis.
l 4. Risk for injury.
7. The client diagnosed with Pneumocystis carnii
pneumonia (PCP) is being admitted to the intensive
care unit. Which health-care provider (HCP) order
should the nurse question?
l 1. Have the client sign a permit for a bronchoscopy.
l 2. Oxygen therapy via nasal cannula at 56 L/min.
l 3. Administer trimethoprim sulfa, a sulfa antibiotic,
via intravenous piggyback (IVPB).
l 4. Place the client in respiratory isolation.
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ANSWERS
4. Correct answer 3: The primary phase of HIV infection ranges from being totally asymptomatic to severe
flu-like symptoms, but during this time the client may
test negative even though infected with HIV. The
nurse should encourage the client to be tested in a few
weeks, by which time antibodies have formed against
the virus and can be detected. The nurse cannot
know if the client has or has not developed an HIV
infection. The adult client must self-admit to a rehabilitation center. ContentMedical; Category of Health
LevelAnalysis.
5. Correct answer 4: The nurse should immediately attempt to get the area to bleed and to remove contaminated blood from the body before the HIV infects the
nurse. Flushing the area attempts to accomplish this.
Then, the nurse should notify the charge nurse, start
prophylactic medication, and follow up to have lab
work done. ContentMedical; Category of Health
590

Implementation; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
6. Correct answer 4: Safety is always an issue with

a client with diminished mental capacity. After physiological needs, safety is highest on Maslow's Hierarchy
of Needs. ContentMedical; Category of Health
7. Correct answer 4: The client diagnosed with PCP

should be placed on standard precautions. PCP is a
common fungus that is found in the lungs of most
adults. The infection is only a problem with a client
who is immunocompromised, such as one who is
HIV-positive. The other options are expected
orders. ContentMedical; Category of Health Alteration
Infectious Diseases; Integrated ProcessImplementation;
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8. The hospice nurse is caring for a client diagnosed with

AIDS. Which intervention should the nurse implement?
l 1. Perform a thorough head-to-toe assessment.
l 2. Encourage the client to drink nutritional
supplements.
l 3. Talk with the client about the funeral arrangements.
l 4. Request physical therapy to assist with strength
training.
9. Which client diagnosed with AIDS should the nurse
on a medical unit assess first after end-of-shift report?
l 1. The client who has flushed warm skin with tented
turgor.
l 2. The client who states that the staff ignores the call
light.
l 3. The client who has T 99.9F, P 101, R 26, and
BP 110/68.
l 4. The client who is unable to provide a sputum
specimen.
591
10. The nurse is caring for a female client diagnosed

with AIDS who has not told her significant other that she
is HIV-positive. Which interventions should the nurse
implement?
l 1. Tell the significant other to be tested for HIV
antibodies.
l 2. Notify the HCP to make the client tell her
significant other.
l 3. Call a meeting of the ethics committee to discuss
the situation.
l 4. Encourage the client to tell the significant other of
the infection.
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ANSWERS
8. Correct answer 3: The client on hospice should

prepare for death. The client should have an advance
directive in place and discuss funeral plans. Physical
assessment is not a priority at this time. Strength
training and nutrition are physiological needs which
are priority for a client expected to recover. A client on
hospice is encouraged to do and eat whatever he/she
desires. ContentMedical; Category of Health Alteration
Infectious Diseases; Integrated ProcessImplementation;
9. Correct answer 1: Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified
immediately so fluid orders or other orders to correct
the reason for the dehydration can be given. Clients
diagnosed with AIDS frequently have massive diarrhea,
which can cause dehydration, to the point where it
can be life-threatening. ContentMedical; Category of
Health AlterationInfectious Diseases; Integrated Process
592
10. Correct answer 4: The nurse should appeal to the

client to tell the significant other. The HCP, the
nurse, and ethics committee are all bound by Health
Insurance Portability and Accountability Act
(HIPAA) regulations and cannot force the client to
disclose her HIV status. ContentMedical; Category
of Health AlterationInfectious Diseases; Integrated
LevelApplication.
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593
Rheumatoid Arthritis
11. Which primary nursing intervention should the
nurse implement with the client diagnosed with
rheumatoid arthritis (RA)?
l 1. Perform joint x-rays to determine progression of
the disease.
l 2. Recommend the client knit as a recreational
activity.
l 3. Encourage the client to obtain flu and pneumonia
vaccines.
l 4. Assess the client's pain medication protocol.
12. Which assessment data would the nurse expect in
the client diagnosed with RA?
l 1. The client has symmetrical joint stiffness.
l 2. The client has bilateral ascending paralysis.
l 3. The client has reddened inflamed joints.
l 4. The client has a flat facial affect.
13. The nurse is caring for the female client diagnosed

with RA who is prescribed methotrexate, a diseasemodifying antirheumatic drug (DMARD). Which
statement indicates the client needs more medication
teaching?
l 1. I need to use an electric razor when I shave my legs.
l 2. I should get a wig to wear when my hair falls out.
l 3. I will rinse my mouth with water after every meal.
l 4. I must use sunscreen with an SPF 30 or above.
14. The client diagnosed with RA has developed
swan-neck fingers. Which intervention should the nurse
implement?
l 1. Instruct the client to soak the hands in cool water.
l 2. Refer the client to the occupational therapist.
l 3. Encourage the client to keep hands elevated.
l 4. Tell the client to wear arm braces daily.
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ANSWERS
11. Correct answer 3: A primary nursing intervention is

prevention. RA is a disease with many immunological
abnormalities, and there is an increased susceptibility
to infectious disease such as the flu or pneumonia.
Administering vaccines is prevention. Radiological
procedures, activity, and assessment are not preventive interventions. ContentMedical; Category of
Health AlterationImmune/Inflammatory Disorders;
12. Correct answer 1: Clients diagnosed with RA have

bilateral and symmetrical stiffness, edema, tenderness, and temperature changes in the joints. Other
symptoms include sensory changes, lymph-node
enlargement, weight loss, fatigue, and pain. A 1-kg
weight loss and fatigue are expected. ContentMedical;
Category of Health AlterationImmune/Inflammatory
Disorders; Integrated ProcessAssessment; Client Needs
594
13. Correct answer 2: Methotrexate does not cause

hair loss; the client needs more medication teaching.
Methotrexate can cause abnormal bleeding, mouth
ulcers, and photosensitivity. The client's other statements indicate that she understands the medication
AlterationImmune/Inflammatory Disorders; Integrated
14. Correct answer 2: Swan-neck fingers will cause the

client to have difficulty with activities of daily living
(ADLs). The occupational therapist assists the client
with fine-motor skills and ADLs. Warm water may
help the pain, but keeping the hands elevated and
bracing will not help the client with RA. Content
Medical; Category of Health AlterationImmune/
Inflammatory Disorders; Integrated Process
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15. The client with RA is taking phenylbutazone

(Butazolidin), a pyrazoline nonsteroidal anti-inflammatory
drug (NSAID). Which statement would make the nurse
question administering this medication?
l 1. I think I may have gotten the flu. I don't
feel well.
l 2. My hands have been very painful the last
day or so.
l 3. I am having burning and pain when I urinate.
l 4. I have been having trouble sleeping at night.
16. The home health nurse is caring for a client diagnosed
with RA. Which question would be most appropriate to
ask the client?
l 1. Are you walking at least 30 minutes a day?
l 2. Did you enjoy going to the coast last week?
l 3. Have you had any choking episodes when eating?
l 4. Are you having any trouble sleeping at night?
595
17. The female client with RA has been taking

methotrexate, a DMARD. Which laboratory would
l 1. A platelet count of 250,000 mm3.
l 2. A red blood cell (RBC) count of 3.2 million/mm3.
l 3. A white blood cell (WBC) count of 7000 mm3.
l 4. A sedimentation rate of 13 mm/hr.
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ANSWERS
15. Correct answer 1: The most dangerous adverse

reaction to this classification of medication is blood
dyscrasias, which may be manifested by flu-like
symptoms. NSAIDs are administered for pain.
Urinary tract infections and insomnia are not side
effects; therefore, the nurse would not question
administering the medication. ContentMedical;
Disorders; Integrated ProcessEvaluation; Client
16. Correct answer 4: Sleep deprivation due to pain is

common; therefore, this would be an appropriate
question. Strenuous exercise would place increased
pressure on the joints and increase pain. RA does not
put the client at risk for choking. The client receiving home health must be homebound, so a question
about a vacation is not an appropriate question.
Immune/Inflammatory Disorders; Integrated
596

17. Correct answer 2: This RBC count indicates anemia,

which would warrant intervention by the nurse
(4.66 million/mm3 is normal). Normal platelet
count is 150,000400,000; the WBC count is
within normal limits of 450010,000/mm3, and
the sedimentation rate for a woman is 015 mm/hr.
Immune/Inflammatory Disorders; Integrated Process
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18. The nurse is caring for a client diagnosed with RA.

Which outcome would be priority for the client?
l 1. Maintain full function of the extremities.
l 2. Participate in low-impact aerobic exercises.
l 3. Report pain as a 2 or less on a 110 pain scale.
l 4. Eat three nutritionally balanced meals a day.
19. The client recently diagnosed with RA is prescribed
4 g of aspirin daily. Which statement indicates the client
understands the medication teaching?
l 1. Ringing in my ears is expected when I take this
much aspirin.
l 2. I should take my aspirin with meals, food, or milk.
l 3. I need to take the entire aspirin dose at night
before going to bed.
l 4. Uncoated aspirin works better than enteric-coated
aspirin.
597
20. The 31-year-old female client diagnosed with advanced

unremitting RA is being admitted to receive a regimen of
immunosuppressive medications. Which question should
the nurse ask during the admission process regarding the
medications?
l 1. Is there any possibility you may be pregnant?
l 2. Have you had anything to eat in the last 8 hours?
l 3. When is the last time you had a bowel
movement?
l 4. Are you aware these are investigational drugs?
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ANSWERS
18. Correct answer 3: The client has chronic pain,

which alters the quality of life, often leading to
depression and feelings of hopelessness; therefore,
pain less than 2 would be priority. Full function is
an unrealistic expectation for a progressively degenerative disease. Lowimpact exercises and balanced
meals would be appropriate outcomes but not priority over control of pain. ContentMedical; Category
of Health AlterationImmune/Inflammatory Disorders;
LevelSynthesis.
19. Correct answer 2: Gastrointestinal side effects

are common with aspirin therapy; therefore, the
client should take aspirin with food. Tinnitus is not
expected, and the client should reduce the dose by
two to three tablets per day until the tinnitus disappears. The aspirin should be taken in divided doses.
Enteric-coated and uncoated are equally effective.
598

20. Correct answer 1: Many immunosuppressive drugs

are class C drugs (teratogenic) and should not be
taken while pregnant. The client does not have to be
nothing by mouth (NPO); bowel movements do not
affect the medication; and the drugs to be administered are not investigational drugs. ContentMedical;
Disorders; Integrated ProcessAssessment; Client
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599
Systemic Lupus Erythematosus

21. The 24-year-old female client is being seen in the
clinic to rule out (R/O) systemic lupus erythematosus
(SLE). Which assessment data would indicate to the
nurse the client has SLE?
l 1. A low-grade fever, arthralgia, and a facial rash.
l 2. A bronze suntan from a recent trip to Mexico.
l 3. Weakness that starts in her toes and moves upward.
l 4. Difficulty swallowing and her voice gives out.
22. The client diagnosed with SLE is being discharged
from the medical unit. Which discharge instructions
should the nurse teach the client? Select all that apply.
l 1. Use a sunscreen of SPF of 15 or greater when in
the sunlight.
l 2. Notify the HCP immediately if a low-grade fever
develops.
l 3. Some dyspnea is expected and does not need
immediate attention.
l 4. The hands and feet may change color if exposed to
cold or heat.
l 5. Notify the HCP if the urine has a pink or red color.
23. The nurse is discussing SLE with a 25-year-old

newly diagnosed client. Which is the most important
client goal for this disease?
l 1. Should be able to maintain reproductive ability.
l 2. Able to verbalize feelings of body image changes.
l 3. Body organs will remain functioning.
l 4. Skin will not have any breakdown.
rule-out SLE. Which assessment data warrant immediate
l 1. Pericardial friction rub and crackles in the lungs.
l 2. A butterfly rash across the bridge of the nose.
l 3. Complaints of joint stiffness in the morning.
l 4. Fatigue and weight loss of 2 pounds.
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ANSWERS
21. Correct answer 1: Low-grade fever, arthralgia, facial

rash, and fatigue are symptoms of SLE. No single
laboratory test diagnoses SLE, but the client usually
presents with moderate-to-severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear
antibody. Sunlight exacerbates symptoms. Option 3 is
Guillain-Barr syndrome, and option 4 is myasthenia
gravis. ContentMedical; Category of Health Alteration
22. Correct answer 2, 5: A fever may be the first indication

of an exacerbation of SLE, so even low-grade temperatures are reported to the HCP. Red or pink urine may
indicate renal involvement. An SPF of at least 30 should
be used. Dyspnea may indicate lung involvement and
should be reported to the HCP. Option 4 is Raynaud
phenomenon. ContentMedical; Category of Health
ProcessPlanning; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive LevelSynthesis.
600
23. Correct answer 3: SLE can invade and destroy any

body system or organ, so maintaining organ function
is the primary goal of SLE treatment. Reproduction,
body image, and skin breakdown are not priority
when organ destruction is a possibility. Content
Inflammatory Disorders; Integrated ProcessPlanning;
24. Correct answer 1: SLE can affect any organ. It can

cause pericarditis and myocardial ischemia as well as
pneumonia or pleural effusions. The nurse should
notify the HCP if friction rub and crackles in the
lungs are heard. A butterfly rash, joint stiffness, and
fatigue with weight loss are expected symptoms of
SLE. ContentMedical; Category of Health Alteration
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25. The female client diagnosed with an acute exacerbation

of SLE is placed on high-dose steroids. Which information
should the nurse teach the client regarding her therapy?
l 1. Take the steroid medications on an empty stomach.
l 2. Stop the medications if she notices a weight gain of
23 pounds.
l 3. Taper off the medications when they are discontinued.
l 4. Notify the HCP if she notices her face becoming
round.
26. The nurse on a medical unit enters the room of a
female client diagnosed with SLE to find the client
crying. Which is the nurse's most therapeutic response?
l 1. You're crying. Would you like to talk about your
feelings?
l 2. I can see you are upset. I will be back in a while to
check on you.
l 3. Would you like me to call someone for you to talk
to about your disease?
l 4. Tears and stress will make your disease worse.
Do you need a tranquilizer?
601

are caring for a client with cutaneous lupus erythematosus.
Which intervention should the nurse delegate to the UAP?
l 1. Cleanse the facial skin using an astringent lotion.
l 2. Inspect the skin for any signs of breakdown or rash.
l 3. Assist with the bath and thoroughly pat the skin dry.
l 4. Apply anti-itch medication between the toes.
28. The nurse is caring for clients on a medical floor.
Which client should be assessed first?
l 1. The female client diagnosed with SLE who is
complaining about chest pain.
l 2. The male client diagnosed with multiple sclerosis
(MS) who is complaining about muscle spasms.
l 3. The female client diagnosed with myasthenia gravis
(MG) who has dysphagia.
l 4. The male client diagnosed with Guillain-Barr
syndrome (GBS) who can barely move his toes.
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ANSWERS
25. Correct answer 3: Steroids must be tapered to prevent

adrenal insufficiency, a potentially life-threatening
complication of steroid medications. Steroids are
administered with food to prevent gastric upset.
Weight gain and a moon face are expected side effects
of steroids. ContentMedical; Category of Health
26. Correct answer 1: This is a therapeutic response

that encourages the client to verbalize her feelings.
Putting the client off, calling someone else, and
tranquilizers are not therapeutic. ContentMedical;
Disorders; Integrated ProcessImplementation; Client
602
27. Correct answer 3: This action can be performed by

the UAP. Moisturizing lotions are applied, not astringents. Inspection is another word for assessment,
and the nurse cannot delegate assessment. Lotions are
not applied between the toes because this would foster
the development of a fungal infection between the
toes. ContentMedical; Category of Health Alteration
28. Correct answer 1: Chest pain is always a priority

regardless of the admitting diagnosis. Clients diagnosed
with SLE can develop cardiac complications. Muscle
spasms are a priority but not above chest pain.
Dysphagia is expected in clients diagnosed with MG.
Clients diagnosed with GBS have ascending muscle
weakness or paralysis. This client's problem is still very
low. ContentMedical; Category of Health Alteration
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29. The nurse and a female UAP are caring for a group
of clients on a medical floor. Which action by the UAP
l 1. The UAP does not wash her hands after taking the
vital signs of a client.
l 2. The UAP dons unsterile gloves prior to removing
an indwelling catheter from a client.
l 3. The UAP uses an isolation set-up to take vital signs
of a client diagnosed with methicillin-resistant
Staphylococcus aureus (MRSA).
l 4. The UAP uses a fresh plastic bag to get ice for a
client's water pitcher.
30. The client recently diagnosed with SLE asks the
nurse What is SLE, and how did I get it? Which is the
l 1. SLE is thought to occur because the kidneys do
not filter antibodies from the blood.
l 2. SLE occurs after a viral or fungal illness as a result
of damage to the endocrine system.
603
3. I wish I could give you a reason but there is no
4. SLE is an autoimmune disease that may have a
identifiable reason for developing SLE.

genetic or hormonal component.
Multiple Sclerosis
31. The nurse is caring for a 46-year-old client diagnosed
with multiple sclerosis (MS). Which clinical manifestation
l 1. The client has a congested cough and dysphagia.
l 2. The client has scanning speech and diplopia.
l 3. The client has dysarthria and scotomas.
l 4. The client has muscle weakness and spasticity.
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ANSWERS
29. Correct answer 1: The UAP should wash her hands

before and after each client contact. Using unsterile
gloves to remove a catheter, using isolation set-ups,
and using a fresh plastic bag to get ice should
be praised. ContentMedical; Category of Health
LevelSynthesis.
30. Correct answer 4: There is familial and hormonal

evidence for the development of SLE. SLE is an
autoimmune disease process in which there is an
exaggerated production of auto-antibodies. Content
604
31. Correct answer 1: Dysphagia is a common problem

of clients diagnosed with MS, and this places the
client at risk for aspiration pneumonia. Some clients
diagnosed with MS eventually become immobile
and are at risk for pneumonia. The other options
contain expected symptoms of MS. ContentMedical;
Disorders; Integrated ProcessAssessment; Client Needs
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32. The clinic nurse is assessing a female client with

complaints of numbness, tingling, and double vision.
During the interview the client tells the nurse that these
symptoms come and go and no one seems to be able to
tell her what they mean. Which question would be
important for the nurse to ask the client?
l 1. Have you experienced any pain during sexual
intercourse?
l 2. Are your symptoms associated with your monthly
menstrual cycle?
l 3. Do you get tired easily and sometimes have
problems swallowing?
l 4. What type of birth control pills do you take to
prevent conception?
33. The client diagnosed with MS is crying and tells the
nurse, "Why me? I did not do anything to deserve this!
Which is the nurse's most therapeutic response?
l 1. Why are you crying? The medications will help
the disease.
l 2. This must be difficult for you. Would you like to
talk about your feelings?
605
3. Multiple sclerosis is a disease that has good times
4. I will have the chaplain come and stay with you
and bad times.

for a while.
34. The client diagnosed with multiple sclerosis is

scheduled for an outpatient magnetic resonance imaging
(MRI) scan of the head. Which question should the nurse
ask the client?
l 1. Do lights that flash off and on cause you to have a
seizure?
l 2. Do you have difficulty when you are in small
enclosed spaces?
l 3. Do you get sick when drinking contrast dye for
x-ray procedures?
l 4. Can you have someone drive you home after the
procedure is over?
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ANSWERS
32. Correct answer 3: The symptoms the client described

are symptoms of MS. Fatigue and difficulty swallowing are other symptoms of MS. Menses, sexual
intercourse, and birth control pills do not cause the
symptoms described. ContentMedical; Category of
Analysis.
33. Correct answer 2: This is stating a fact and offering

self. Both are therapeutic techniques for conversations.
Asking why is requesting an explanation, and the
client does not owe the nurse an explanation. The
client did not ask about the nature of MS. Therapeutic responses are aimed at allowing the client to
verbalize feelings. ContentMedical; Category of
Psychosocial Integrity; Cognitive LevelApplication.
606
34. Correct answer 2: Most MRIs are performed by

placing a client in a small tube in which the client
must lie very still while the machine performs the
procedure. If the client is claustrophobic, then the
nurse should arrange for the client to have an open
MRI or be sedated during the procedure. Content
Inflammatory Disorders; Integrated ProcessAssessment;
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35. The 45-year-old client is diagnosed with primary

progressive MS, and the nurse writes the nursing
diagnosis of anticipatory grieving related to progressive
loss. Which intervention should be implemented?
l 1. Consult the physical therapist for assistive devices
for mobility.
l 2. Ask the dietitian to provide thickening on each tray.
l 3. Teach the client self-catheterization and bowel
management.
l 4. Discuss the client's wishes regarding end-of-life care.
36. The home health nurse is making rounds on clients
diagnosed with MS. Which client should be seen first?
l 1. The 38-year-old male client who cannot perform
the gastrostomy feedings.
l 2. The 22-year-old female client who is deciding if
she should remain in college.
l 3. The 40-year-old male client who called to tell the
nurse that life is not worth living.
l 4. The 50-year-old female client who needs a
subcutaneous flu injection this morning.
607
37. The nurse and a licensed practical nurse (LPN) are

caring for a group of clients on a medical oncology unit.
Which client activity should not be delegated/assigned?
l 1. Administer an oral skeletal muscle relaxant to a
client with an exacerbation of MS.
l 2. Discuss bowel regimen medications with the HCP
for the client diagnosed with MS.
l 3. Draw the morning blood work on the client with
secondary progressive MS.
l 4. Administer cylcophosphamide (Cytoxan), an
immunosuppressant, IVPB to a client with MS.
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ANSWERS
35. Correct answer 4: The problem is grieving, and all
608
37. Correct answer 4: Cytoxan is an immunosuppressant
interventions should be directed at helping the client

with this process. The client should make personal
choices about end-of-life issues while it is possible to
do so. This client is progressing toward immobility,
loss of independence, and death. ContentMedical;
and an antineoplastic medication. A chemotherapycompetent registered nurse must administer this

medication. The LPN can administer a muscle relaxant. The LPN can talk with a HCP about medications, and LPNs can draw blood. ContentMedical;

NeedsPsychosocial Integrity; Cognitive LevelAnalysis.

Disorders; Integrated ProcessPlanning; Client Needs
36. Correct answer 3: The nurse should see this client

first to determine if the client has a plan to carry out
the threat of suicide. This situation requires further
assessment. A missed feeding is not life-threatening.
Making life decisions and a flu injection can wait.
Immune/Inflammatory Disorders; Integrated
LevelAnalysis.
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38. The male client diagnosed with MS discloses to the

nurse that he has been investigating alternate therapies to
treat his disease. What is an appropriate response by the
nurse?
l 1. Encourage the therapy if not contraindicated by
the medical regimen.
l 2. Tell the client that only the HCP should discuss
this with him.
l 3. Ask how his significant other feels about this
deviation from the medical regimen.
l 4. Suggest that the client try an investigational
therapy instead.
39. The nurse and UAP are caring for a client diagnosed
with an acute exacerbation of MS who is receiving
Solu-Medrol, a glucocorticosteroid, intravenous push
(IVP) every 6 hours. Which nursing intervention should
l 1. Show the client how to trim his toenails straight
across.
l 2. Discuss completing an advance directive with the
client.
l
l
609
3. Obtain bedside glucose readings before meals.

4. Give the client pancreatic enzymes to add to the
meals.
40. The nurse is administering methylprednisolone

(Solu-Medrol) IVP to a client diagnosed with MS. The
medication comes in an individual dose vial of 125 mg in
2 mL of solution. The order reads administer 60 mg
every 6 hours. How many milliliters of solution should
the nurse administer with each dose?
Answer: ____________________
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ANSWERS
38. Correct answer 1: The nurse should listen without

being judgmental about any practice. Then the client
will feel free to discuss what alternative therapy is
actually being used by the client. Alternative therapies such as massage and relaxation are frequently
beneficial and enhance the medical regimen.
39. Correct answer 3: Steroids interfere with glucose

metabolism by blocking the action of insulin. The
UAP can perform bedside glucose monitoring. The
nurse interprets the meaning of the results. The UAP
cannot teach (option 1) or administer medications
(option 4). The nurse, not the UAP, should discuss
advance directives with clients. ContentMedical;
Disorders; Integrated ProcessPlanning; Client
610
40. Correct answer 0.96 mL: The nurse should set up

the equation:
60 : X = 125 : 2
Then cross-multiply: 60 2 = 120 = 125X
120 = 125X
Divide each side of the equation by 125 to arrive at
the answer:
X = 0.96 mL
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611
Guillain-Barr Syndrome
41. The nurse and an LPN on a medical unit are caring
for a client diagnosed with Guillain-Barr syndrome
(GBS). Which instructions should the nurse provide
the LPN?
l 1. Instruct the LPN to call the nurse for assistance
when getting the client out of bed.
l 2. Have the LPN assess the client for cogwheel
motion, rigidity, and dysphagia.
l 3. Discuss the symptom of sudden severe unilateral
facial pain with the LPN.
l 4. Tell the LPN to notify the nurse if the client
becomes short of breath.
Guillain-Barr syndrome (GBS). Which question should
the nurse ask the client?
l 1. Did you recently go on a trip to Asia or Africa?
l 2. Have you had a viral illness in the last few weeks?
l 3. Could you have been exposed to GBS where
you work?
l 4. Do you take over-the-counter herbs or vitamins?
43. The nurse is caring for a client who is complaining

of weakness and tingling of the feet bilaterally. Which
assessment intervention should the nurse implement first?
l 1. Assess deep tendon reflexes.
l 2. Complete a Glasgow Coma Scale.
l 3. Check for Brudzinski reflex.
l 4. Take the client's vital signs.
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ANSWERS
41. Correct answer 4: Symptoms of GBS are ascending

paralysis and weakness. Dyspnea may indicate the
disease has progressed to the thoracic area, requiring
a transfer to the intensive care unit (ICU) and intubation. The LPN should ask the unlicensed assistive
personnel (UAP) for assistance when getting the
client out of bed. LPNs do not assess; these are
symptoms of Parkinson disease. Unilateral facial
pain is a symptom of trigeminal neuralgia. Content
Inflammatory Disorders; Integrated ProcessPlanning;
42. Correct answer 2: This syndrome is usually preceded by a respiratory or gastrointestinal infection
14 weeks prior to the onset of neurological deficits.
Visiting a foreign country is not a risk factor for
contracting this syndrome. This syndrome is not a
contagious or a communicable disease. Taking herbs
612
is not a risk factor for developing GBS. Content

43. Correct answer 1: Hyporeflexia of the lower extremities is the classic clinical manifestation of GuillainBarr syndrome; therefore, assessing deep tendon
reflexes is appropriate. A Glasgow Coma Scale is
used for clients with a head injury or central neurological dysfunction. The Brudzinski reflex evaluates
for meningitis. The client's vital signs will not give
the nurse information related to these symptoms.
LevelSynthesis.
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Page 613
44. The HCP scheduled a lumbar puncture for a client

admitted with rule-out Guillain-Barr syndrome (GBS).
Which post-procedure intervention is priority?
l 1. Start the client on clear liquids.
l 2. Instruct the client to void.
l 3. Keep the client flat in bed.
l 4. Assess the client's brachial pulses.
45. The ICU nurse is caring for the client diagnosed
with Guillain-Barr syndrome (GBS) whose paralysis has
reached the level of cranial nerve II. The nurse writes
the client problem impaired physical mobility. Which
interventions should the nurse implement?
l 1. Turn the client every 4 hours, and place the call
light within reach.
l 2. Perform passive range-of-motion (ROM) exercises,
and refer the client to physical therapy.
l 3. Refer the client for speech therapy consult and
teach about salt-restricted diets.
l 4. Encourage the client to verbalize feelings of
helplessness.
613
46. The married male client diagnosed with Guillain-Barr

syndrome (GBS) is on a ventilator. Which intervention
l 1. Provide an erasable slate board for the client to
write on.
l 2. Arrange a case conference with members of other
health-care disciplines.
l 3. Tell the client's wife that the client will not be able
to understand she is there.
l 4. Have the wife talk with the social worker regarding
role reversal problems.
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ANSWERS
44. Correct answer 3: The client should remain flat in

bed to prevent a possible spinal fluid leak resulting in
a headache. The client can resume a regular diet. The
client should void prior to the procedure. The pedal
pulses should be assessed post procedure, not the
brachial pulses. ContentSurgical; Category of Health
LevelSynthesis.
45. Correct answer 2: The client with GBS on a

ventilator will not be able to move the extremities,
and preventing muscle atrophy is important.
Passive ROM exercises and physical therapy would
accomplish this. The client should be turned every
2 hours or placed on a rotating bed. The client
will be on a ventilator and cannot speak with this
level of impairment. Salt is not restricted for
these clients. ContentMedical; Category of Health
614

Integrity, Basic Care and Comfort; Cognitive Level
Analysis.
46. Correct answer 2: GBS is a treatable disease that

requires care from many disciplines. The nurse
coordinates the care. The ascending paralysis has
reached his respiratory muscles; therefore, the client
will not be able to use his hands to write. The client
may not be able to respond to people in the room
but is fully aware of their presence. The nurse can
discuss role reversal problems with the spouse.
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47. The client diagnosed with Guillain-Barr syndrome

(GBS) asks the nurse, When will I be able to return to
work? I have responsibilities. Which statement would be
the best response by the nurse?
l 1. You may not be able to return to work for a few
months to a year.
l 2. Most clients with this syndrome go back to
normal activities in 2 weeks.
l 3. That is something you should discuss with the
health-care team.
l 4. The rehabilitation is short and you should be fully
recovered within a month.
48. The client admitted with rule-out Guillain-Barr
syndrome (GBS) has just had a lumbar puncture. Which
intervention should the nurse implement post procedure?
l 1. Take the client's vital signs every 15 minutes.
l 2. Apply a pressure dressing to the puncture site.
l 3. Label the specimens and send to the laboratory.
l 4. Place the client on fluid restriction.
615

(GBS) has arterial blood gases (ABGs) of pH 7.32,
PaCO2 51 mm Hg, HCO3 27 mm Hg, and PaO2
50 mm Hg. Which intervention should the nurse
implement?
l 1. Prepare to place the client on the ventilator.
l 2. Have the client cough and deep-breathe.
l 3. Confirm the results with a pulse oximeter.
l 4. Perform pulmonary toileting procedures.
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ANSWERS
47. Correct answer 1: Clients with GBS usually have a

full recovery, but it may take up to 1 year to recover
from the effects of the syndrome. The nurse should
answer the client's question. ContentMedical;
48. Correct answer 3: The nurse should label the specimens and send them to the laboratory for analysis.
Very little cerebrospinal fluid is removed; therefore,
postoperative vital signs are not required. A Band-Aid
is placed over the puncture site, and pressure does not
need to be applied. Increased fluid intake will help
prevent a post-procedure headache. ContentMedical;
616
49. Correct answer 1: This client is in respiratory failure

because of the inability of the nerves to stimulate
breathing. The client must be intubated and placed
on a ventilator immediately. Coughing and deep
breathing will not help the client who cannot
initiate respirations. Arterial oxygen levels are
accurate, so confirmation with a pulse oximeter is
not necessary. ContentMedical; Category of Health
LevelApplication.
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Page 617

(GBS) is admitted to the rehabilitation unit after several
weeks in the acute care hospital. Which interventions
l 1. Refer the client to the speech therapist.
l 2. Encourage the client to perform active ROM
exercises.
l 3. Request a social worker consult.
l 4. Provide the client with a patient-controlled
l 5. Refer the client to the Guillain-Barr Syndrome
Foundation.
Myasthenia Gravis
51. Which statement by the client supports the diagnosis
of myasthenia gravis (MG)?
l 1. I have weakness and fatigue in my feet and legs.
l 2. My eyelids droop, and I see double everything.
l 3. I get chest pain and faint after I walk in the hall.
l 4. I gained 3 pounds this week, and I am spitting up
pink frothy sputum.
617
52. Which response to the Tensilon (edrophonium

chloride) injection indicates the client has myasthenia
gravis?
l 1. The client has no apparent change in the
assessment data.
l 2. There is reduced amplitude of electrical stimulation
in the muscle.
l 3. The antiacetylcholine receptor antibodies are
present.
l 4. The client shows a marked improvement of muscle
strength.
53. The nurse is discharging a client diagnosed with
MG. Which statement by the client indicates an
understanding of the discharge instructions?
l 1. I can control the MG with medication, but an
adenectomy will cure it.
l 2. I should take a holiday from my medications
every 4 or 5 weeks.
l 3. I must take my medications on time every day, or
I could have problems.
l 4. I should take my steroid medications with food so
it won't upset my stomach.
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ANSWERS
50. Correct answer 2, 3, 5: The client will need physical

exercises to regain muscle strength. The social worker
could help with financial concerns, job issues, and
issues concerning the long rehabilitation associated
with this syndrome. The GBS Foundation is an
excellent resource for the client and the family. There
is no residual speech deficit. Pain may or may not be
an issue, but in the rehabilitation setting the route of
administration of pain-relieving medication would be
oral or topical, not via a PCA pump. ContentMedical;
51. Correct answer 2: These are ocular signs/symptoms

of MG. Ptosis is drooping of the eyelid, and diplopia
is unilateral or bilateral double vision. Weakness and
fatigue of upper body muscle occur with MG. Option
3 is angina. Option 4 is heart failure. ContentMedical;
Disorders; Integrated ProcessEvaluation; Client
618

52. Correct answer 4: Clients with myasthenia gravis

show a significant improvement of muscle strength
that lasts approximately 5 minutes when Tensilon
(edrophonium chloride) is injected. ContentMedical;
53. Correct answer 3: The anticholinesterase medications

used to treat MG must be taken on time in order to
prevent muscle weakness and respiratory complications. These medications are one of the very few that
the nurse should administer at the exact scheduled
time. Steroids are not prescribed for MG. Content
Inflammatory Disorders; Integrated ProcessEvaluation;
Management of Care; Cognitive LevelEvaluation.
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Page 619
54. The client diagnosed with MG is being discharged

home. Which intervention should the nurse teach the
significant other?
l 1. Discuss how to perform the Heimlich maneuver.
l 2. Explain how to perform oral hygiene on a
conscious client.
l 3. Teach how to perform isometric exercises.
l 4. Demonstrate correct hand placement for chest
compressions.
55. Which referral is appropriate for the client in the late
stages of myasthenia gravis?
l 1. The infection control nurse.
l 2. The occupational health nurse.
l 3. A vocational guidance counselor.
l 4. The speech therapist.
619
56. The male client with MG is undergoing plasmapheresis

at the bedside. Which assessment data would warrant
l 1. The client complains of being lightheaded and
dizzy.
l 2. The client can smile and clamp his teeth together.
l 3. The client states that his leg cramps have gone away.
l 4. The client has a small hematoma at the vascular
access site.
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ANSWERS
54. Correct answer 1: The client is at risk for choking,

and knowing specific measures to help the client
helps decrease the client's as well as significant
other's anxiety and promotes confidence in managing potential complications. The client should
perform oral care. The client should perform isotonic exercises, not isometric exercises, and the
client is not at an increased risk for cardiac complications, so teaching about chest compression is not
necessary. ContentMedical; Category of Health
AlterationImmune/Inflammatory Disorders;
55. Correct answer 4: Speech therapists address swallowing problems, and clients with myasthenia gravis
are dysphagic and at risk for aspiration. The infection control and occupational health nurses do not
consult with the client. A vocational counselor helps
with the client finding a position suited for the
disability, but clients with late-stage myasthenia
620
gravis are usually not able to work. ContentMedical;

Disorders; Integrated ProcessPlanning; Client Needs
56. Correct answer 1: Hypovolemia is a complication

of plasmapheresis, especially during the procedure
when up to 15% of the blood volume is in the cell
separator. The nurse should immediately assess for
shock. All other options are expected. ContentMedical;
Disorders; Integrated ProcessAssessment; Client
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Page 621
57. Which statement by the 20-year-old female client

diagnosed with MG indicates the client understands the
discharge teaching?
l 1. I can have children, but I will have to see my
neurologist during my pregnancy.
l 2. I have a new job at a children's day care center to
help with expenses.
l 3. I should not take a bath because I could pass out
and drown while in the tub.
l 4. I will drink at least 1000 mL of water or other
liquid every day.
58. The client diagnosed with MG is admitted to the
emergency department with a sudden exacerbation of
motor weakness. Which assessment data indicate the
client is experiencing a myasthenic crisis?
l 1. The serum assay of circulating acetylcholine
receptor antibodies is increased.
l 2. The client's symptoms improve when
administering on a cholinesterase inhibitor.
621
3. The client's blood pressure, pulse, and respirations
4. The Tensilon test does not show improvement in
improve after intravenous (IV) fluid.

the client's muscle strength.
59. The male client diagnosed with MG is prescribed the

cholinesterase inhibitor neostigmine (Prostigmin). Which
data indicate the medication is not effective?
l 1. The client is able to perform activities of daily
living (ADLs) independently.
l 2. The client states that his vision is clear.
l 3. The client cannot speak or look upward at the
ceiling.
l 4. The client is smiling and laughing with the nurse.
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ANSWERS
57. Correct answer 1: MG will not prevent conception

or delivery but can cause the client to experience an
exacerbation of the disease. The client should be seen
regularly by the neurologist and the obstetrician.
Young children are ill frequently, and infections
can result in an exacerbation for the client. Option 3
applies to clients who have seizures. The client is
not restricted to 1000 mL of fluid per day. Content
Inflammatory Disorders; Integrated ProcessEvaluation;
58. Correct answer 2: This assessment datum indicates

a myasthenic crisis that is due to undermedication,
missed doses of medication, or developing an infection. Serum assays are useful in diagnosing the
disease, not in identifying a crisis. Vital signs do
not differentiate the type of crisis. No improvement
after Tensilon indicates a cholinergic crisis, not a
622
myasthenic crisis. ContentMedical; Category of

59. Correct answer 3: Dysphonia and inability to utilize

the muscles of the eye and eyelid indicate the medication is not effective. Performing ADLs, having
clear vision, and smiling and laughing using the
facial muscles indicate the medication is effective.
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Page 623
60. The client is diagnosed with MG. Which intervention

should the nurse implement when administering the
anticholinesterase pyridostigmine (Mestinon)?
l 1. Assess for excess salivation and abdominal cramps.
l 2. Administer the medication before the client has
eaten.
l 3. Break the capsule and sprinkle the medication on
the food.
l 4. Assess the client's potassium level prior to
administering medication.
Allergies
61. The male nurse on the medical/surgical unit tells
charge nurse he is allergic to latex. Which intervention
should the charge nurse implement?
l 1. Tell the male nurse to use only sterile latex gloves
for nursing tasks.
l 2. Instruct the male nurse not to perform any tasks
requiring gloves.
3. Notify central supply to provide the male nurse
4. Refer the male nurse to the hospital's infection
623
with a box of non-latex gloves.

control nurse.
62. The client diagnosed with bee-sting allergy is being

discharged from the emergency department (ED). Which
question would be most important for the nurse to ask
the client?
l 1. Do you always carry an epi-pen with you?
l 2. Do you wear long-sleeved shirts and pants when
you go outside?
l 3. Do you have over-the-counter Benadryl at home?
l 4. Do you wear a Medic-Alert bracelet when going
outside?
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ANSWERS
60. Correct answer 1: Anticholinesterase medications

can cause the client to have excessive salivation and
abdominal cramping. When this occurs, the client
receives the antidote atropine simultaneously in
small doses. Mestinon is administered with milk
and/or crackers to prevent stomach upset. Mestinon
does not affect potassium levels. ContentMedical;
61. Correct answer 3: The nurse should be provided

with non-latex gloves that he can keep with him at
all times. The nurse cannot wear sterile or non-sterile
latex gloves. The charge nurse cannot have a nurse
caring for clients who cannot wear gloves. The infection control nurse would have no jurisdiction in
this situation. ContentMedical; Category of Health
624

62. Correct answer 1: The epi-pen can save the client's

life if the client is stung by a bee; therefore, this is
the most important question. Over-the-counter
Benadryl is used for allergies, but the client with a
bee-sting allergy may die before the medication is
effective. Protective clothing will not save the client's
life, and a Medic-Alert bracelet should be worn,
but it is not the most important question. Content
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Page 625
63. The male client comes to the emergency department

after eating shellfish. He is experiencing dyspnea and
wheezing, cannot speak, and has a bluish color around
the mouth. Which interventions should the nurse
implement? Rank in order of performance.
l 1. Initiate an intravenous line (IV) with normal
saline.
l 2. Obtain an intubation tray for the client.
l 3. Place nasal cannula with 100% oxygen on the
client.
l 4. Ask the client if he is allergic to iodine.
l 5. Administer subcutaneous epinephrine, an
adrenergic blocker.
64. The nurse is administering medications to
clients. Which medication would the nurse question
administering?
l 1. The H-1 receptor antagonist fexofenadine (Allegra)
to the client who has open-angle glaucoma.
l 2. The glucocorticoid steroid prednisone to the client
who has a moon face and buffalo hump.
625
3. The aminoglycoside antibiotic vancomycin to the
4. The antihistamine diphenhydramine (Benadryl) to
client who has a trough level of 10 mg/dL.

the client experiencing nasal congestion and
sneezing.
65. The client who is highly allergic to insect venom asks

the nurse, What is venom immunotherapy? My doctor
wants me to have this done. Which statement is the
l 1. It will help prevent you from having reactions
from insect bites.
l 2. The therapy provides special cream you should
apply to any insect bite.
l 3. It will cure you from having any type of allergic
reactions in the future.
l 4. The therapy is experimental and your doctor
should have explained it to you.
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ANSWERS
63. Correct answer 3, 5, 1, 2, 4: Because the client is

cyanotic with dyspnea and wheezing, the nurse
should first administer oxygen and then subcutaneously administer the epinephrine, the drug of
choice for an allergic reaction. Then the nurse
should start an IV line for medication administration
and obtain an intubation tray. Assessing the client
for any allergy is the last intervention. Content
LevelApplication.
64. Correct answer 1: Fexofenadine is used with caution

in clients with glaucoma because of the muscarinic
blockade effects on the eyes. The nurse should
question administering this medication. All the other
medication would be appropriate to administer to
the clients. ContentMedical; Category of Health
Alteration Drug Administration; Integrated
626

LevelAnalysis.
65. Correct answer 1: Immunotherapy does not cure

any type of allergic reaction, but it prevents an
anaphylactic reaction by providing passive immunity
to the insect venom. The therapy is not applied
topically, and this therapy is not experimental.
Environment, Reduction of Risk Potential; Cognitive
LevelAnalysis.
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66. The client exposed to poison ivy has a red raised rash
covering the forearms, neck, and face and is complaining
of itching. Which statement indicates the client needs
more discharge teaching?
l 1. I should wash my arms and neck with soap and
water.
l 2. I will use my epi-pen once a day until the rash
goes away.
l 3. I will take the medication in the steroid dose pack
as directed.
l 4. I should wear shirts with long sleeves when
working outside.
67. The female client tells the nurse in the holding area
of the operating room she is allergic to iodine. Which
l 1. Check to see if the allergy is noted on the client's
chart.
l 2. Notify the hospital pharmacy to make sure the
allergy is documented.
627
3. Call the medical surgical unit to notify the nurse of
4. Determine if the client has an allergy band stating
the iodine allergy.

the iodine allergy.
68. The nurse is discussing the topical steroid

hydrocortisone with a client diagnosed with allergic
dermatitis. Which statement indicates the client
l 1. I will keep the hydrocortisone cream in my
refrigerator at all times.
l 2. I need to cleanse the area with hydrogen peroxide
before applying the cream.
l 3. I should place sterile gauze over the affected area
after I apply the cream.
l 4. I will wash my hands before and after applying
the topical steroid cream.
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ANSWERS
66. Correct answer 2: The epi-pen is used for a

potential anaphylactic reaction at the time of the
sting/bite. It is not used daily; the client needs more
teaching. All the other statements indicate the client
understands the discharge teaching. Clients with
poison ivy are frequently prescribed a steroid
dose pack. ContentMedical; Category of Health
LevelEvaluation.
67. Correct answer 4: The nurse should first make

sure the client has an allergy band so that povidoneiodine (Betadine), the usual skin preparation used
for surgeries, will not be used on the client. The
chart, the pharmacy, and the medical surgical unit
should be aware of the allergy, but the first intervention is to make sure the client has the allergy band.
628

LevelAnalysis.
68. Correct answer 4: The client should have clean

hands before applying the cream to the affected area
to help prevent infection. Hydrocortisone cream
does not need to be refrigerated, and the area should
be washed with warm water, not hydrogen peroxide.
The area should be left open after the medication
is applied. ContentMedical; Category of Health
LevelEvaluation.
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629
Management
69. The client with allergies is prescribed diphenhydramine
(Benadryl), an antihistamine. Which information should
the nurse discuss with the client?
l 1. Inform the client to call the HCP if ringing in
the ears occurs.
l 2. Tell the client the medication may cause drowsiness.
l 3. Explain that hirsutism may occur when taking
Benadryl.
l 4. Instruct the client not to abruptly discontinue the
medication.
70. The clinic nurse is caring for a 26-year-old client
who is complaining of nasal congestion and sneezing.
Which assessment question is appropriate for the nurse
to ask the client?
l 1. Do you wear gloves when washing your dishes?
l 2. Do you have any animals that live in your home?
l 3. Have you changed the soap you use to wash your
clothes?
l 4. Is there any possibility you may be pregnant?
71. The charge nurse is making assignments on a medical

floor. Which client should be assigned to the most
experienced nurse?
l 1. The client with Guillain-Barr syndrome whose
paralysis is now at the client's waist.
l 2. The client with systemic lupus erythematosus who
has hematuria.
l 3. The client with rheumatoid arthritis who is receiving
IV antineoplastic drugs.
l 4. The client with scleroderma who has hard waxy-like
skin near the eyes.
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ANSWERS
69. Correct answer 2: Antihistamines cause drowsiness,

and the client should avoid driving or engaging in
hazardous activities. Tinnitus (ringing in the ears)
and hirsutism (facial hair on women) are not side
effects of antihistamines. This medication does
not require tapering when being discontinued.
70. Correct answer 2: The client may be having allergic

rhinitis, which can be caused by animal hair, pollen,
or mold; therefore, this is an appropriate question.
Gloves would be used for topical allergic reactions;
soap would cause topical allergic reactions; pregnancy
would not cause these symptoms, and the medications to treat the problem are not teratogenic.
630
71. Correct answer 1: The client with Guillain-Barr

syndrome who has paralysis at the waist should be
assigned to the most experienced nurse because the
paralysis is getting close to the respiratory muscles.
If the paralysis does reach the respiratory muscles,
the client may need to be placed on a ventilator.
None of the other clients' conditions are priority
over a client who may be having trouble breathing.
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631
72. The nurse and LPN are caring for clients in a clinic.
Which task should the nurse assign to the LPN?
l 1. Administer IVP methylprednisolone (Solu-Medrol)
to a client with multiple sclerosis.
l 2. Escort the client to the radiology department for
an MRI.
l 3. Demonstrate how to use clothing with Velcro
fasteners to the client with myasthenia gravis.
l 4. Discuss birth control with a client who is
prescribed a disease-modifying antirheumatic drug
(DMARD).
74. The charge nurse observes a staff nurse caring for a

client diagnosed with AIDS. Which action by the nurse
l 1. The staff nurse adheres to standard precautions
when caring for the client.
l 2. The staff nurse dons nonsterile gloves to administer
medications to the client.
l 3. The staff nurse checks the client for allergies prior
to administering medications.
l 4. The staff nurse requests the UAP to empty the
urinal at the client's bedside.
73. The nurse is preparing to administer morning

medications. Which medication should the nurse
administer first?
l 1. The anticholinesterase medication to the client
with myasthenia gravis.
l 2. The NSAID to the client with rheumatoid
arthritis.
l 3. The glucocorticosteroid to a client diagnosed with
polymyositis.
l 4. The appetite stimulant to a client diagnosed
with AIDS.
75. Which task would be most appropriate for the

medical/surgical nurse to delegate to the UAP?
l 1. Request the UAP to perform an electrocardiogram
(ECG) on the client with chest pain.
l 2. Ask the UAP to put oxygen on the client who is
having shortness of breath.
l 3. Instruct the UAP to clean the perineal area of a
client with an indwelling catheter.
l 4. Tell the UAP to transfer the client to the intensive
care unit.
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ANSWERS
72. Correct answer 3: The LPN can demonstrate to
632
74. Correct answer 2: The nurse should implement
the client how to use adaptive clothing. The LPN

cannot administer IVP medications without
additional training; the UAP could assist the client
to the radiology department; and teaching cannot be
delegated to the LPN. ContentMedical; Category of
standard precautions for a client with AIDS; therefore, the nurse does not have to wear gloves when
administering medications. Checking for allergies
and having the UAP empty a urinal would not warrant immediate intervention from the charge nurse.


Management; Integrated ProcessEvaluation; Client
73. Correct answer 1: Clients with myasthenia gravis

must take their anticholinesterase medication exactly
on time; therefore, this medication must be administered first. The NSAID and the steroid must be
administered with meals, but they are not the first
medication to be administered. The appetite stimulant would not be priority over a medication to help
prevent choking in a client with myasthenia gravis.
75. Correct answer 3: The UAP can provide perineal care

to a client with a catheter because this does not require
judgment. The clients with chest pain and shortness of
breath and the client being transferred to the ICU are
not stable; therefore the nurse cannot delegate these
tasks to the UAP. ContentMedical; Category of Health
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76. The nurse on a medical unit has received the morning

shift report. Which client should the nurse assess first?
l 1. The client who is receiving a unit of blood who has
2+ pitting edema.
l 2. The client who reports itching after receiving an
initial dose of an antibiotic.
l 3. The client who has rheumatoid arthritis with back
pain of 6 on a 110 scale.
l 4. The client who has AIDS who is crying and
threatening to kill himself.
77. The HCP orders an intravenous pyelogram for the
female client diagnosed with rule-out renal calculi. Which
priority intervention should the nurse implement?
l 1. Ask the client if she is allergic to shellfish.
l 2. Request her to sign a permit for the procedure.
l 3. Ask the client if she is having her menses at
this time.
l 4. Schedule the intravenous pyelogram with the
hospital's radiology department.
633
78. The clinical manager suspects one of the staff nurses

is stealing narcotics from the PIXIS (an automated
medication administration system). Which action should
the clinical manager implement first?
l 1. Notify the local police department.
l 2. Call the State Board of Nurse Examiners.
l 3. Notify the director of nurses immediately.
l 4. Talk to the staff nurse about the suspicion.
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ANSWERS
634
76. Correct answer 2: The client itching may be having
78. Correct answer 4: The clinical manager, the highest
an allergic reaction to the antibiotic and should be

seen first. The client with 2+ pitting edema may be
experiencing fluid volume overload, a client in pain,
and a psychosocial problem must be assessed, but
these clients are not priority over someone who
may go into anaphylactic shock. ContentMedical;
level of the chain of command on the unit, should

first talk to the staff nurse about the suspicion. If the
suspicion is verified, then the director of nurses or
peer review committee should be notified. Then,
depending on the circumstances, the local police
department or board of nurses should be notified.

LevelAnalysis.

77. Correct answer 1: The intravenous pyelogram dye

contains iodine; therefore, the nurse should determine if the client has an allergy to shellfish, which
has iodine. A permit specifically for an intravenous
pyelogram is not required. The client being on her
menses (period) would not affect the pyelogram.
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79. The client receiving the initial dose of an intravenous

antibiotic is having shortness of breath. Which intervention
l 1. Maintain a patent intravenous (IV) line.
l 2. Turn off the client's IV antibiotic.
l 3. Place oxygen on the client via nasal cannula.
l 4. Initiate the rapid response team (RRT).
635
80. The client diagnosed with allergic rhinitis has been

taking an antihistamine, a glucocorticoid, and calcium
channel blocker. Which statement by the client would
l 1. I take my antihistamine at night so I am not so
sleepy during the day.
l 2. I will taper off the steroids when I am discontinuing
the medication.
l 3. I am careful to get up slowly when I stand up
from my recliner.
l 4. I love to have half a grapefruit and buttered toast
for breakfast.
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ANSWERS
79. Correct answer 2: The first intervention is to stop
636
80. Correct answer 4: Grapefruit juice can cause
the IV antibiotic because the client may be having

an allergic reaction. Then the nurse could place
oxygen on the client, maintain a patent IV line, and
notify the RRT. The RRT is a team of hospital staff
that responds to client emergencies prior to the
client coding. ContentMedical; Category of Health
calcium channel blockers to rise to toxic levels.

Grapefruit juice inhibits cytochrome P450-3A4
found in the liver and intestinal wall. This statement
warrants intervention by the nurse. None of the
other statements would warrant intervention from
the nurse. ContentMedical; Category of Health

LevelSynthesis.

LevelSynthesis.
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637
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Integumentary
639
Burns
1. The client presents to the emergency room in severe
pain and reports falling asleep in the sun. The nurses
assessment reveals bright red skin that blanches with
pressure. Which depth of burn should the nurse
document?
l 1. Superficial partial-thickness.
l 2. Deep partial-thickness.
l 3. Full-thickness.
l 4. Third-degree burn.
2. The client with full-thickness burns to 43% of the
body, including both legs, is being transferred from a
community hospital to a burn center. Which intervention
should be implemented prior to transferring the client?
l 1. Place the clients legs in the dependent position.
l 2. Cover both legs with moist sterile petroleum-based
dressings.
l 3. Administer a tetanus toxoid injection to the client.
l 4. Initiate an 18-gauge intravenous line with Ringer
lactate.
3. The client was admitted to the burn unit 8 hours ago

with full-thickness burns to 60% of the body, including
the chest area. After establishing a patent airway, which
intervention is priority for the client?
l 1. Prevent the burns from getting infected.
l 2. Maintain the clients circulatory status.
l 3. Prevent contractures of extremities.
l 4. Prepare to assist with an escharotomy.
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ANSWERS
1. Correct answer 1: Sunburn is a superficial partial-thickness
640
3. Correct answer 2: Next to handling respiratory
burn that affects the epidermis, causing reddened skin

that blanches with pressure. Deep partial-thickness burns
cause pain and blistered mottled red skin along with
edema. Full-thickness (third-degree) burns affect the
epidermis and dermis and may affect connective tissue,
muscle, and bone. ContentMedical; Category of
difficulties, the most urgent need is preventing

irreversible shock by maintaining circulatory status.
Preventing infection, preventing contractures, and
assisting with an escharotomy are pertinent interventions, but the priority is maintaining circulation due
to third spacing that occurs with full-thickness burns.
Health AlterationIntegumentary; Integrated Process


Integumentary; Integrated ProcessImplementation;
2. Correct answer 4: An 18-gauge catheter with lactated

Ringer infusing should be initiated to maintain a urine
output of at least 30 mL/hr. The legs should be elevated; the wounds should be covered with a clean,
dry sheet; and a tetanus toxoid is not priority for a
client with 43% full-thickness burns. ContentMedical;
Category of Health AlterationIntegumentary; Integrated
LevelAnalysis.
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SECTION FOURTEEN
4. The nurse is applying mafenide acetate (Sulfamylon) to a

clients burn on the right lower extremity. Which assessment
data would require immediate attention by the nurse?
l 1. The client complains of pain when the medication
is administered.
l 2. The clients potassium level is 4.2 mEq/L and
sodium level 139 mEq/L.
l 3. The clients arterial blood gases (ABGs) are pH
7.38, PaO2 98, PaCO2 38, HCO3 24.
l 4. The client reports tingling and numbness of the
right foot.
5. The client is being scheduled for a homograft. The
client asks the nurse, What is a homograft? Which
statement would be the nurses best response?
l 1. The doctor will graft skin from your back to
your leg.
l 2. The skin from a donor will be used to cover
your burn.
l 3. The graft will come from an animal, probably a pig.
l 4. I think you should ask your doctor about the
graft.
Integumentary
641
6. The client was admitted 4 days ago to the burn unit

with severe full-thickness and deep partial-thickness burns
over half the body. Which client problem has priority?
l 1. High risk for infection.
l 2. Ineffective coping.
l 3. Impaired physical mobility.
7. The nurse writes the nursing diagnosis impaired skin
integrity for the client with full-thickness and deep
partial-thickness burns to the lower part of the clients
body. Which priority intervention would be appropriate
for this nursing diagnosis?
l 1. Provide analgesia before whirlpool treatments.
l 2. Clean the clients wounds, body, and hair daily.
l 3. Perform passive range-of-motion (ROM) exercises.
l 4. Do not allow visitors to bring plants and flowers.
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ANSWERS
4. Correct answer 4: Complaints of numbness and tingling indicate neurovascular compromise, which would
require immediate intervention. The client should be
pre-medicated with an analgesic before Sulfamylon is
administered because this agent causes severe burning
pain for up to 20 minutes. The electrolytes and ABGs
are within normal limits (WNL). Sulfamylon may cause
metabolic acidosis. ContentMedical; Category of Health
AlterationIntegumentary; Integrated ProcessAssessment;
5. Correct answer 2: A homograft is skin obtained

from a tissue donor. Option 1 is the explanation for
an autograft, and option 3 is the explanation for a
xenograft or heterograft, in which skin is taken from
animals, usually pigs. Option 4 is passing the buck;
the nurse can and should answer this question with
factual information. ContentMedical; Category of
642
6. Correct answer 1: Even though this is a potential

problem, it is priority because the protective barrier
of skin has been compromised, and there is an
impaired immune answer. Psychosocial client problems, potential joint contractures that can cause
mobility deficits, and teaching are important, but
not priority. ContentMedical; Category of Health
AlterationIntegumentary; Integrated ProcessDiagnosis;
7. Correct answer 2: Preventing infection is the priority

for the client with impaired skin integrity; therefore,
daily cleaning that reduces bacterial colonization is the
priority intervention. Analgesia would address pain,
and ROM exercises would address contractures. Plants
may bring bacteria, but this would be for clients who
are immunosuppressed. ContentMedical; Category
of Health AlterationIntegumentary; Integrated Process
LevelAnalysis.
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Integumentary
SECTION FOURTEEN
8. The client calls the emergency department (ED)

and tells the nurse, My husband just burned his right
hand really bad while burning the trash. Which
intervention should the nurse discuss first with the wife?
l 1. Instruct the wife to apply an ice pack to the
right hand.
l 2. Tell the wife to put her husbands hand under cool
running water.
l 3. Encourage the wife to bring her husband to the ED.
l 4. Recommend the wife place a clean white cloth on
the burned area.
9. The nurse is caring for a client with deep partialthickness and full-thickness burns to the chest area.
Which assessment data would warrant immediate
intervention?
l 2. The client is complaining of severe pain.
l 3. The clients telemetry exhibits sinus tachycardia.
l 4. The clients urinary output is 400 mL in 8 hours.
643
10. The husband calls the ED and tells the nurse, My

wife just splashed chlorine into her eyes. She is yelling
and says It burns, it burns. Which action should the
l 1. Instruct the husband to call 911 immediately.
l 2. Tell the husband to flush her eyes with tap water.
l 3. Have the husband place a cool cloth over his
wifes eyes.
l 4. Recommend his wife keep her eyes closed at all
times.
Pressure Ulcers
11. The nurse in a long-term care facility is teaching a
group of new unlicensed assistive personnel (UAP).
Which information regarding skin care should the nurse
emphasize?
l 1. Allow the skin to air dry after each bath.
l 2. Use only petroleum jelly on the clients skin.
l 3. Turn immobile clients at least every 2 hours.
l 4. The licensed nursing staff will be responsible for all
skin care.
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ANSWERS
8. Correct answer 2: Cool water gives immediate and

striking relief from pain and limits local tissue edema
and damage; therefore, this is the first intervention.
Ice should never be applied to a burn because this will
increase the tissue damage. Placing a clean white cloth
over the burned area and bringing the husband to
the ED are appropriate interventions, but not the
first intervention. ContentMedical; Category of
9. Correct answer 1: A pulse oximeter reading less than

93% indicates respiratory compromise; this reading
requires notifying the health-care provider (HCP).
Severe pain and sinus tachycardia require intervention
but are not priority over oxygenation problems.
Adequate urinary output would not require immediate
intervention. ContentMedical; Category of Health
AlterationIntegumentary; Integrated ProcessAssessment;
644
10. Correct answer 2: Anytime a chemical is splashed

into the eye, the client should flush with water or
normal saline. Calling 911 would allow emergency
medical technician (EMT) personnel to continue to
flush the eye. Cool cloth may ease some of the pain,
but the eye must be flushed first, and keeping the
eyes closed except when flushing is appropriate.
11. Correct answer 3: Clients should be turned at least

every 12 hours to prevent pressure areas on the
skin. The skin should be patted dry after a bath,
never left with moisture on it. The client can have
body lotion applied. All nursing staff, including
UAPs, should prevent skin breakdown. Content
Medical; Category of Health AlterationIntegumentary;
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SECTION FOURTEEN
12. The nurse is caring for a client who has developed

stage IV pressure ulcers on the left trochanter and coccyx.
Which independent nursing problem has the highest
priority?
l 1. Altered wound healing.
l 2. Altered nutrition.
l 3. Self-care deficit.
l 4. Altered coping.
13. The nurse is caring for clients in a long-term care
facility. Which is a modifiable risk factor for the
development of pressure ulcers?
l 1. Constant perineal moisture.
l 2. Decreased ability of the clients to reposition
themselves.
l 3. Decreased elasticity of the skin.
l 4. Impaired cardiovascular perfusion of the periphery.
Integumentary
645
14. The home health nurse is teaching the caregivers of

an immobile client about prevention of pressure ulcers.
Which is the most important information to teach the
caregivers?
l 1. Place a pad under the client to absorb any urinary
incontinence and contain stool.
l 2. Underpads do not need to be changed unless they
become saturated with urine.
l 3. Underpads will keep the caregiver from injuries
such as a pulled muscle.
l 4. The pads placed under the client will prevent
shearing when repositioning the client.
15. Which assessment tool addressing the condition of
the clients skin should be completed on admission to the
hospital?
l 1. Complete the Braden Scale.
l 2. Monitor the client on a Glasgow Scale.
l 3. Assess for a Babinski sign.
l 4. Initiate a Brudzinski flow sheet.
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ANSWERS
12. Correct answer 3: Self-care deficit is an independent

nursing problem. The nurse should institute measures
to ensure relief of pressure on bony prominences,
such as turning the client frequently. Altered wound
healing and altered nutrition are collaborative
problems. Altered coping is a psychological problem.
According to Maslows Hierarchy of Needs, physiological
problems are priority. ContentMedical; Category of
13. Correct answer 1: Impaired circulation, decreased

ability of the clients, and decreased elasticity are not
modifiable. Constant perineal moisture is modifiable.
Reduction of Risk Potential; Cognitive Level
Knowledge.
646
14. Correct answer 4: Lifting the client with a lift pad

rather than pulling the client against the sheets helps to
prevent skin damage due to friction shearing. The pads
should be changed when there is moisture of any kind
or feces noted. Underpads will also help prevent injuries
to the caregiver, but the most important consideration
is care of the client. ContentMedical; Category of Health
AlterationIntegumentary; Integrated ProcessPlanning;
Client NeedsSafe Effective Care Environment, Reduction
of Risk Potential; Cognitive LevelSynthesis.
15. Correct answer 1: The Braden and Norton scales

are tools that identify clients at risk for skin problems.
Clients are ranked on this scale, and appropriate
measures are initiated for controlling skin damage.
The Glasgow scale is a neurological coma scale to
determine the depth of neurological injury. The
Babinski and Brudzinski signs are signs of neurological
dysfunction. ContentMedical; Category of Health
Client NeedsPhysiological Integrity, Basic Care and
Comfort; Cognitive LevelSynthesis.
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Integumentary
SECTION FOURTEEN
16. The wound care nurse documented a clients pressure

ulcers on admission as 3.3 cm 4.0 cm stage II on the
coccyx. Which information indicates the treatment plan
is effective?
l 1. The skin now has an area 2.5 cm 3.5 cm with
undermining and 0.5 cm depth.
l 2. There is a blister 3.2 cm 4.1 cm that is red and
drains occasionally.
l 3. The skin covering the coccyx is intact, and no
erythema is noted by the nurse.
l 4. The coccyx wound extends to the subcutaneous
layer, and there is moderate drainage.
17. The nurse and a UAP on a medical unit are caring
for elderly, immobile clients. Which action by the UAP
l 1. The UAP empties the urinary drainage bag using
non-sterile gloves.
l 2. The UAP leaves a client lying on the left side for
3 hours.
l
l
647
3. The UAP uses a plastic bag to get ice for the clients.
4. The UAP leaves a glass of water with a straw at the
bedside.

After the shift report, which client should the nurse see
first?
l 1. The 34-year-old quadriplegic client who cannot
move the arms to use a call light.
l 2. The elderly client diagnosed with a cerebrovascular
accident (CVA), or stroke, who is weak on the
right side.
l 3. The 78-year-old client with pressure ulcers who
had a hyperbaric treatment this morning.
l 4. The young adult who is unhappy with the care that
was provided last shift.
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ANSWERS
16. Correct answer 3: This indicates healing of the area

and indicates the plan is effective. Option 1 is stage
IV; option 2 is stage II and probably indicates no
significant change; and option 4 is stage III. Content
Integrated ProcessEvaluation; Client NeedsSafe
17. Correct answer 2: It is important to turn bedfast

clients every 12 hours and to encourage the client
to make minor readjustments in position at least
every 15 minutes, if the client is able. The other
options contain acceptable practice. ContentMedical;
Category of Health AlterationIntegumentary; Integrated ProcessImplementation; Client NeedsSafe
648
18. Correct answer 1: The nurse should see the client

who cannot call for a need first. The other clients do
not have immediate or life-threatening problems.
After making sure this client does not need anything,
then the nurse can decide who to assess next. Content
Integrated ProcessAssessment; Client NeedsSafe Effective Care Environment, Management of Care; Cognitive
LevelAnalysis.
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Integumentary
SECTION FOURTEEN
19. The nurse is instructing the unlicensed assistive

personnel (UAP) on the care of an immobile client.
Which instructions should the nurse include?
l 1. Use a pillow to keep the heels raised off the bed
when the client is supine.
l 2. Order a low air loss therapy bed to be placed on
the clients bed.
l 3. Set up the supplies for the nurse to insert a
nasogastric feeding tube.
l 4. Turn the client every 15 minutes from one side to
the other.
20. The client diagnosed with stage IV infected pressure
ulcers on the coccyx is scheduled for a fecal diversion
operation. The nurse knows that client teaching has been
effective when the client makes which statement?
l 1. This surgery will create a skin flap to cover my
wounds.
l 2. This surgery will get all the old black tissue out of
the wound so it can heal.
649
3. The surgery is important to allow oxygen to get to
4. Stool will come out an opening in my abdomen
the tissue for healing to occur.

so it wont get in the wound.
Skin Cancer
21. The school nurse is preparing to teach a health
promotion class to high school seniors. Which information
regarding self-care should be included in the teaching?
l 1. Wear a sunscreen of 15 or greater when in the sun.
l 2. If you have acne, try to get a suntan on the face
and neck.
l 3. Individuals should perform a thorough skin check
yearly.
l 4. Caps and long sleeves should be worn at all times.
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ANSWERS
19. Correct answer 1: Using a pillow to suspend the

heels off the bed when a client is supine prevents
the development of pressure ulcers on the heels. Low
air loss therapy beds are normally only provided for
clients who have stage III or stage IV pressure ulcers.
Integumentary; Integrated ProcessPlanning; Client
NeedsPhysiological Integrity, Basic Care and Comfort;
20. Correct answer 4: A fecal diversion is changing

the normal exit of stool from the body. A colostomy
is created to keep stool from contaminating the
wound and causing infection. A skin flap covers a
large wound with intact skin. Dbridement removes
dead tissue to allow for healing. A hyperbaric chamber increases oxygenation of the wound. Content
LevelEvaluation.
650
21. Correct answer 1: The students should be taught to

use sunscreen when in the sun. An SPF of 15 is the
minimum; the higher the number, the better the
protection. Suntanning was recommended for
clients with acne in the past, but now research has
shown that this practice increases the clients risk of
developing skin cancer. Skin checks are performed
monthly. Caps and long sleeves are not worn all
the time. ContentMedical; Category of Health
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SECTION FOURTEEN
22. The nurse notes an irregular-shaped lesion with some

scabbed areas surrounding the lesion on the clients back.
l 1. Place a note on the clients chart for the HCP to
check the lesion on rounds.
l 2. Measure the lesion, note the color, and document
the finding in the chart.
l 3. Apply lotion to the lesion, and remind the client
not to scratch the area.
l 4. Instruct the client to make sure the HCP checks
the lesion.
23. The nurse is caring for clients in an outpatient
surgery clinic. Which client should be assessed first?
l 1. The client scheduled for a skin biopsy who has
decided not to have the procedure.
l 2. The client who had surgery 2 hours ago and is
beginning to wake up.
l 3. The client who needs to see the physical therapist
to be fitted for crutches.
l 4. The client who has been discharged but cannot pay
for the prescription for pain.
Integumentary
651
24. Which client is at the greatest risk for the development

of skin cancer?
l 1. The African-American male who lives in New York
City.
l 2. The Hispanic female who moved to Texas from
Mexico.
l 3. The client with a family history of basal cell
carcinoma.
l 4. The client with red hair and blue eyes who tries to
tan every year.
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ANSWERS
22. Correct answer 2: This is part of assessing the lesion

and should be completed. The ABCD of skin cancer
detection include: Asymmetry, Borders, Color, and
Diameter. The nurse should complete an assessment
on the lesion prior to notifying the HCP to check
it. Lotion may help as a comfort measure, but it is
not the first action. ContentMedical; Category of
LevelAnalysis.
23. Correct answer 1: This client has an unexpected

situation occurring and should be assessed before
any stable client. The client waking up and the client
needing to see a physical therapist or the social
worker to help with financial needs would not be
Integumentary; Integrated ProcessAssessment; Client
652
24. Correct answer 4: Clients with very little melanin

in the skin (fair-skinned clients) have an increased
risk due to the ultraviolet (UV) damage to the
underlying membranes. Damage to the underlying
membranes never completely reverses itself; a lifetime of damage causes changes at the cellular level
that result in the development of cancer. Basal cell
carcinoma is directly related to sun exposure and is
not associated with family history. ContentMedical;
Category of Health AlterationIntegumentary; Integrated ProcessDiagnosis; Client NeedsHealth
Promotion and Maintenance; Cognitive Level
Knowledge.
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SECTION FOURTEEN
25. The middle-aged client has had a basal cell carcinoma

removed. Which statement indicates the client understands
the discharge teaching?
l 1. I am so glad that I dont have to worry about skin
cancer anymore.
l 2. I need to see a prosthetic specialist to camouflage
the damaged area.
l 3. I will apply a sunscreen to the incision to make
sure no more cancer is found.
l 4. I will check my skin every month for any more
suspicious lesions.
26. The nurse and a UAP are caring for clients in a

dermatology clinic. Which interventions should be
delegated to the UAP? Select all that apply.
l 1. Stock the rooms with the equipment needed.
l 2. Obtain the clients weight and position the clients
for the examination.
l 3. Discuss problems the clients have experienced since
the previous visit.
l 4. Take the biopsy specimens to the laboratory.
l 5. Measure the skin lesions and document in the charts.
Integumentary
653
27. Which assessment data indicate a lesion is a malignant

melanoma?
l 1. The lesion is asymmetrical and has irregular borders.
l 2. The lesion has a waxy appearance with pearl-like
borders.
l 3. The lesion has a thickened and scaly appearance.
l 4. The lesion appeared as a thickened area after an
injury.
28. The client has had a squamous cell carcinoma removed
from the lip. Which discharge instructions should the
nurse provide?
l 1. Notify the HCP if a sore that does not heal
develops on the skin.
l 2. Squamous cell carcinoma tumors do not metastasize.
l 3. Limit foods to liquid or soft consistency for
1 month.
l 4. Apply heat to the area for 20 minutes every 4 hours.
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ANSWERS
25. Correct answer 4: The client should check for any

lesion that could be cancerous monthly. The client
has had one skin cancer removed, but not just that
area of skin has been damaged by UV rays. Prostheses are usually not needed. Sunscreen is not applied
to incisions and does not guarantee that more cancer
cells will not be found. ContentMedical; Category
of Health AlterationIntegumentary; Integrated Process
Evaluation; Client NeedsPsychological Integrity,
26. Correct answer 1, 2, 4: The UAP can restock rooms,

weigh and position clients, and take specimens to
the laboratory. The nurse must discuss the problems
the client has experienced and measure the skin
lesions as part of assessing the client. Content
654
27. Correct answer 1: Malignant melanomas are the

most deadly of the skin cancers. Asymmetry, irregular
borders, variegated color, and rapid growth characterize
them. Option 2 describes a basal cell carcinoma.
Option 3 describes a squamous cell carcinoma.
Option 4 describes a benign condition called a keloid.
28. Correct answer 1: The client should be aware of

symptoms that indicate development of another
skin cancer. Squamous cell carcinoma can develop
in all areas of the skin and mucous membranes.
Seventy-five percent of deaths from squamous cell
carcinomas occur because of metastasis. Food can be
of a regular consistency. The client should not apply
heat to the area. ContentMedical; Category of Health
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Integumentary
SECTION FOURTEEN
655
Skin Infections
29. The male client diagnosed with acquired immune
deficiency syndrome (AIDS) states that he has developed
a purple-brown spot on his calf. Which intervention
l 1. Refer the client to an HCP for a biopsy of the area.
l 2. Assess the lesion for size, color, and symmetry.
l 3. Ask the client to remove the clothing from the calf.
l 4. Report the sexually transmitted disease (STD) to
the health department.
30. The nurse participating in a health fair is discussing
malignant melanoma with a group of clients. Which
information regarding the prevention of skin cancer
should the nurse include?
l 1. Avoid being in the sun during the hottest time
of day.
l 2. Sunscreen increases the risk of skin cancer in
toddlers.
l 3. Sunscreen does not help prevent skin cancer.
l 4. The lower the number of the sunscreen, the more
it blocks UV rays.
31. The client presents to the ED complaining of sudden

onset of high fever, chills, and a headache, along with a
macular rash on the trunk. Which statement would make
the nurse suspect the client has Lyme disease?
l 1. A neighbors dog accidently bit me on my leg last
night.
l 2. I got a scratch on my arm while working in my
garden.
l 3. My buddies and I went deer hunting last week at
my deer lease.
l 4. I stepped on a rusty nail that punctured my
left foot.
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ANSWERS
29. Correct answer 3: The nurse must be able to see the

area that is to be assessed. Assessing the lesion is the
second step in deciding how to assist the client. The
nurse should assess the lesion to determine if the
lesion could be a Kaposi sarcoma or a healing contusion. The client may require a biopsy, but that is
not the first intervention. Reporting an STD is
not priority. ContentMedical; Category of Health
AlterationIntegumentary; Integrated Process
LevelAnalysis.
30. Correct answer 1: Client should be instructed to

avoid exposure to the sun during the hottest time in
the day. The times vary, depending on the area of
the country; for example, in the Southwest the times
period is longer than in the Northwest. Sunscreen
reduces the risk of skin cancer. The higher the
656
number of the sunscreen, the more UV rays are

blocked. ContentMedical; Category of Health
31. Correct answer 3: Deer ticks (Ixodes dammini)

are responsible for the spread of Borrelia burgdorferi,
the cause of Lyme disease, which, based on the
clients signs/symptoms, is what this client is
experiencing. Dog bites, scratches, and rusty nails
do not cause Lyme disease. ContentMedical; Category of Health AlterationIntegumentary; Integrated
LevelAnalysis.
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Integumentary
SECTION FOURTEEN
32. The school nurse is discussing how to prevent

spreading impetigo in the classroom where there is an
impetigo outbreak. Which information should the nurse
discuss with the teachers?
l 1. Instruct the teachers to wash their hands with
alcohol foam cleanser.
l 2. Tell the teachers to use soap and water if touching
any impetigo lesions.
l 3. Isolate the child with impetigo at a desk in the
classroom.
l 4. Recommend the teachers keep their fingernails
short.
33. The client with cellulitis of the left arm calls the
clinic and tells the nurse, I cant get my wedding ring off
my finger. Which instruction should the nurse discuss
with the client?
l 1. Tell the client to elevate the left arm on two
pillows.
l 2. Instruct the client to place an ice bag on the ring
finger.
l
l
657
3. Tell the client to go to the ED now.

4. Instruct the client to soak the hand in warm soapy
water.
34. The school nurse is discussing with a football player

how to prevent tinea curries. Which statement indicates
the football player understands the nurses teaching?
l 1. I will wear white socks with my football shoes.
l 2. I will wear tight-fitting nylon underwear under
my pants.
l 3. I will not share my hair brush or comb with any
other person.
l 4. I will wear a clean dry jockstrap after I take a
shower.
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ANSWERS
32. Correct answer 1: Cleanliness and good hand hygiene

can prevent the spread of impetigo. The lesions are
extremely contagious and should not be touched
except when wearing gloves. The child is kept at
home until on antibiotics for 48 hours and is not
isolated in the classroom. Short fingernails will not
help prevent the spread of impetigo. Content
Integrated ProcessPlanning; Client NeedsHealth
33. Correct answer 3: This indicates that the arm is edematous, and the ring must be removed immediately;
therefore, the client should go to the ED. Elevation,
cold, and soaking the hand in warm soapy water will
not help remove the ring immediately before it can
cause impaired circulation to the left ring finger, which
is a very dangerous situation. ContentMedical; Category of Health AlterationIntegumentary; Integrated
LevelSynthesis.
658
34. Correct answer 4: Tinea curries (jock itch) is due to

fungal infection in warm, moist areas of the body;
therefore, wearing a clean, dry athletic supporter will
help prevent jock itch. The player should avoid
wearing nylon underwear, tight-fitting clothing, and
a wet bathing suit. White socks help prevent tinea
pedis (athletes foot), and not sharing brushes would
help prevent lice. ContentMedical; Category of
Evaluation; Client NeedsHealth Promotion and
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SECTION FOURTEEN
35. The UAP is caring for a client with scabies in the

long-term care facility. Which action by the UAP would
l 1. The UAP wears gloves and a gown when changing
the clients linens.
l 2. The UAP prepares the client for treatment with a
medicated shampoo by the nurse.
l 3. The UAP provides regular eating utensils for the
clients breakfast meal.
l 4. The UAP places the client at a table isolated from
that of the other clients.
36. The client is complaining of burning, lancinating,
stabbing pain that radiates around the left rib-cage area.
The nurse cannot find any type of skin abnormality.
Which question would be most important for the nurse
to ask the client?
l 1. Are you having any trouble breathing?
l 2. Have you been under any stress lately?
l 3. What type of pain medication have you taken?
l 4. Have you ever had chickenpox?
Integumentary
659
37. The client is diagnosed with a viral infection, and

the HCP has prescribed an antiviral medication to be
administered by weight. The client weighs 110 pounds,
and the order reads 10 mg/kg/day to be administered
in equally divided doses every 6 hours. How many
milligrams will be administered in one dose?
Answer: ___________________________
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ANSWERS
35. Correct answer 2: Medicated shampoo would be a

treatment for lice. The client should be isolated
because of scabies and should not be allowed in the
dining room. Clients in long-term care facilities are
at high risk of developing scabies because of close
living quarters and transmission of the parasite by
the nursing staff. Plastic eating utensils will not help
prevent the spread of scabies; regular eating utensils
can be used. ContentMedical; Category of Health
LevelSynthesis.
36. Correct answer 4: The client is experiencing symptoms of shingles, or herpes zoster. Because herpes
zoster can erupt during times of stress from the
chickenpox virus (herpes varicella), a question about
chickenpox is appropriate. H. varicella is a retrovirus,
and a retrovirus never dies; it lives in the body along
nerve pathways. Therefore, the most important
question to help identify the cause of the pain is
660
asking about chickenpox. With the clients

symptoms, asking about breathing is not a priority
question. ContentMedical; Category of Health
37. Correct answer 125 mg per dose:

To determine client weight in kilograms: 110 lbs
2.2 (2.2 lbs/kg) = 50 kg
To determine dose in 24 hours: 50 kg 10 mg
(dose ordered) = 500 mg in 24 hours
To determine how many doses: 24 hours 6 hours =
4 doses
To determine milligrams in 1 dose: 500 mg 4
doses = 125 mg/dose
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SECTION FOURTEEN
38. The charge nurse is admitting a client diagnosed

with disseminated herpes zoster secondary to AIDS.
Which interventions should the charge nurse implement?
l 1. Place the client in a private room on standard
precautions.
l 2. Put a No Visitors sign on the clients door.
l 3. Assign nurses who have had chickenpox to the
client.
l 4. Notify the infection control nurse of the clients
admission.
l 5. Tell dietary services to provide an isolation tray for
the client.
39. The nurse is working in a long-term care facility.
l 1. The client who is complaining of a boil.
l 2. The client who has a skin tear over her arm.
l 3. The client who has nits in her hair.
l 4. The client who reports having poison ivy.
Integumentary
661

psoriasis understands the discharge teaching?
l 1. I will inspect my skin every week for redness with
tenderness.
l 2. I must take a photosensitizing agent 2 days before
the UV light therapy.
l 3. I will wear dark glasses all the time until my
psoriasis is cured.
l 4. The coal tar ointments and shampoos are messy
and will stain clothing.
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ANSWERS
38. Correct answer 3, 4, 5: Herpes zoster is the same

virus that causes chickenpox; therefore, nurses who
have had chickenpox should care for this client,
and the infection control nurse should be aware
of the clients admission. Herpes zoster lesions are
contagious, so the client should be in contact
isolation, not just standard precautions, and receive
an isolation tray from dietary department. The
client can have visitors as long as they do not have
an infection and comply with the isolation protocol.
39. Correct answer 3: Nits indicate the client has lice,

which is contagious; therefore, the nurse should
assess this client first. A head lice outbreak could
spread through the entire nursing home. A boil
and poison ivy are not easily spread to other clients.
662

40. Correct answer 4: Coal tar comes in lotions,

ointments, shampoos, and gels that can cause
staining; the client understands the teaching. The
skin should be checked daily, not weekly; a photosensitizing agent is administered 2 hours, not 2 days,
before the UV light therapy; and dark glasses protect
the eyes during the treatments but are not worn
all the time. ContentMedical; Category of Health
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SECTION FOURTEEN
663
Management
41. The nurse and UAP are caring for clients in a
long-term care facility. Which task would be most
appropriate for the nurse to delegate to the UAP?
l 1. Ask the UAP to change the dressing on a stage 4
pressure wound.
l 2. Instruct the UAP to turn the client every 4 hours,
including into the prone position.
l 3. Tell the UAP to place heel protectors on the client
who has a stage 2 pressure ulcer.
l 4. Request the UAP to ambulate the client who has
been sitting in a chair for 2 hours.
42. The client was admitted to the burn unit 3 days
ago with full-thickness and deep partial-thickness burns
covering 50% of the body. Which interventions should
l 1. Perform meticulous hand hygiene at all times.
l 2. Provide the client with a high-calorie, high-protein
diet.
l 3. Use the Rule of Nines to assess the burned area.
l
l
4. Encourage the client to ventilate feelings.

5. Recommend the clients family to bring favorite
foods.
43. The charge nurse is observing the LPN change a

dressing on an 88-year-old client with a stage 4 pressure
ulcer on the coccyx. Which intervention by the LPN
would warrant intervention by the charge nurse?
l 1. The LPN obtained all the needed equipment prior
to starting the procedure.
l 2. The LPN failed to use sterile gloves to remove the
clients old dressing.
l 3. The LPN did not explain the procedure prior to
starting the dressing change.
l 4. The LPN administered a pain medication 30 minutes
before the procedure.
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ANSWERS
41. Correct answer 4: The UAP can ambulate a client

in a long-term care facility; therefore, this task
would be appropriate to delegate. The stage 4
pressure wound should be assessed by the nurse; a
stage 2 pressure ulcer is an open wound and should
be assessed by the nurse, and the client should be
turned every 2 hours, not every 4 hours, and most
clients are not placed in the prone position.
Integumentary; Integrated ProcessIntervention; Client
42. Correct answer 1, 2, 4, 5: Hand washing is the primary intervention in preventing infection. The client
needs 40005000 calories a day for wound healing
and increased metabolic requirements; homemade
nutritious foods are usually better than hospital food
and allow the family to feel part of the clients
recovery. The Rule of Nines is used initially to
determine amount of skin burned, not 3 days after
664
the burn. ContentMedical; Category of Health

Physiological Adaptation; Cognitive LevelSythesis.
43. Correct answer 3: Even if the client is 88 years old,

the LPN should explain the procedure to the client;
therefore, this would warrant intervention by the
charge nurse. The LPN should obtain all the
equipment before beginning the procedure, should
use non-sterile gloves when removing the dressing
(sterile gloves are not needed and are expensive), and
should pre-medicate the client because the dressing
change can be painful. ContentMedical; Category
of Health AlterationIntegumentary; Integrated
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SECTION FOURTEEN
44. The charge nurse has just received a shift report.

Which client would warrant immediate intervention by
the nurse?
l 1. The client with full-thickness burns who has a
l 2. The client with a stage 4 pressure ulcer whose
dressing has a large amount of drainage.
l 3. The client who was admitted during the night who
has head and body lice.
l 4. The client diagnosed with shingles who is
complaining of pain of 5 on a 110 pain scale.
45. The wound care nurse in a long-term care facility
asks the UAP for assistance. Which task would be most
appropriate to delegate to the UAP?
l 1. Apply the wound dbriding paste to the wound.
l 2. Place a cushion in the clients wheelchair.
l 3. Secure a trapeze bar for the clients bed.
l 4. Notify the family the client has a pressure ulcer.
Integumentary
665
46. The client weighing 185 pounds has 50% of total

body surface (TBSA) burned. The nurse is to infuse
fluid resuscitation based on the Parkland burn formula:
lactated Ringer at 4 mL kg body weight % TBSA
burned. Half of the total amount is to be infused in the
first 8 hours. What rate should the nurse set the pump
for the first 8 hours?
Answer: ____________________________
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ANSWERS
44. Correct answer 1: A pulse oximeter reading less

than 93% indicates the client is in respiratory distress, which would warrant immediate intervention
by the nurse. Drainage on the dressing would be
expected; head and body lice are not life-threatening;
and the client with shingles is expected to have pain.
Oxygenation is priority over pain. ContentMedical;
Category of Health AlterationIntegumentary; Integrated
LevelSynthesis.
45. Correct answer 2: The UAP could place a cushion

in the clients wheelchair. Wound dbriding agents
are medications whose administration cannot be
delegated to a UAP. The trapeze bar must be secured
safely; unless the UAP has had training, this task is
not the most appropriate to delegate, and the nurse
should notify the family, not the UAP. Content
666

46. Correct answer 1050 mL/hr:

First, determine clients weight in kilograms:
185 2.2 = 84 kg
Then, determine the total amount to be infused:
4 mL 84 kg 0.50 = 16,800 mL
Half is to be infused in first 8 hours: 16,800 2 =
8400 mL
Determine amount to be infused each hour:
8400 mL 8 hours = 1050 mL/hr
This is a large amount to be infused hourly, but it is
expected because of the loss of fluid from the interstitial space. ContentMedical; Category of Health
LevelApplication.
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SECTION FOURTEEN
47. The nurse is caring for clients in an outpatient clinic.

Which client should the nurse see first?
l 1. The client who has had a skin biopsy to rule out
skin cancer.
l 2. The client with an edematous reddened right leg
with streaks.
l 3. The client who has a severe sunburn who is having
severe pain.
l 4. The elderly client who reports being exposed to
chickenpox.
Integumentary
667
48. The nurse is working on a medical unit. Which

situation would warrant the nurse being reported to the
state board of nursing?
l 1. The nurse fails to administer a beta blocker on
time to the client diagnosed with hypertension.
l 2. The nurse violates the Health Insurance Portability
and Accountability Act (HIPAA) by discussing
confidential information with another client.
l 3. The nurse does not contact the HCP for a client
who is upset and angry.
l 4. The nurse fails to assess the client with full-thickness
burns who goes into shock and dies.
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ANSWERS
47. Correct answer 2: This client is exhibiting signs of

cellulitis, which could result in life-threatening complications. Therefore, this client should be seen first.
The biopsy, a sunburn, and exposure to chickenpox
are not life-threatening; if the elderly client contracts
chickenpox, that could be life-threatening. Content
668
48. Correct answer 4: A nurse who fails to provide

the client with the minimal standard of care can be
reported to the state board of nursing; identifying
shock is a minimal standard of care. The nurse
failed to rescue. Not administering a medication,
violating the HIPAA, and not contacting an HCP
for an upset client are not incidents reportable to
the state board of nursing. ContentFundamentals;
LevelApplication.
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SECTION FOURTEEN
49. The nurse is presenting a class to students concerning

the prevention of skin cancer. Which statement indicates
the student understands a primary nursing intervention
for skin care?
l 1. I will lie in a tanning bed for only 30 minutes
a day.
l 2. I should have my mother check my skin for any
changes in my moles.
l 3. If I have any suspicious moles or skin tags, I will
see a dermatologist.
l 4. I need to wear at least SPF of 30 or above when
out in the sun.
Integumentary
669
50. Which client situation would be most appropriate

for the nursing staff to refer to the hospital ethics
committee?
l 1. The client with full-thickness burns who is refusing
whirlpool treatments.
l 2. The client diagnosed with a rare skin infection who
wants experimental medication.
l 3. The family who is demanding the client have a
colostomy due to a stage 4 pressure ulcer in the
coccyx area.
l 4. The wife of a client who wants to take her
terminally ill husband home and be placed on
hospice care.
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ANSWERS
49. Correct answer 4: Teaching is a primary nursing

intervention that addresses prevention; telling the
client to wear SPF 30 is appropriate teaching. Using
the tanning bed is a risk factor for developing skin
cancer (do not use a tanning bed); inspecting the
skin is a secondary screening attempt to detect
changes early; and going to a dermatologist will not
prevent skin cancer. ContentMedical; Category
of Health AlterationIntegumentary; Integrated
ProcessEvaluation; Client NeedsHealth Promotion
and Maintenance; Cognitive LevelEvaluation.
670
50. Correct answer 3: The family does not have a

right to force the client to do something against the
clients wishes; therefore, this situation should be
referred to the hospital ethics committee. The client
has a right to refuse any treatment; experimental
medication is not an ethical dilemma; and hospice
care is for the terminally ill. ContentFundamentals;
LevelApplication.
SECTION FIFTEEN
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Operative Care
SECTION FIFTEEN
673
Preoperative Care
1. Which statement made by the client scheduled for an
exploratory laparotomy indicates to the nurse the client
needs more information prior to signing an informed
consent for the abdominal operation?
l 1. I will be glad to get back to my gardening when
I get home.
l 2. I should not lift more than 5 pounds after my
surgery.
l 3. I should tell the nurse if I am having pain after
my surgery.
l 4. I will have to take deep breaths and cough after
I wake up.
2. The client in the preoperative holding area is wearing
an amulet. Which is the most appropriate intervention
for the nurse to implement?
l 1. Tell the client the amulet cannot go into the
operating room (OR).
l 2. See that the amulet is pinned to the clients pillow
in the OR.
l
l
3. Ask the client to explain the meaning of the amulet.

4. Wait until the client is put to sleep and then give
the amulet to the family.
3. The nurse is obtaining informed consent for surgical

procedures. Which client requires a valid co-signature?
l 1. The 16-year-old primigravida mother who wants
her son to have a circumcision prior to discharge
from the hospital.
l 2. The 30-year-old client going for an emergency
appendectomy who had a narcotic pain medication
30 minutes ago.
l 3. The 46-year-old client who fractured an ankle
while participating in an athletic event on city
property.
l 4. The 80-year-old client who is not sure about
having an abdominal perineal resection for cancer.
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ANSWERS
1. Correct answer 1: When recuperating from surgery,
674
3. Correct answer 2: A narcotic pain medication can
there will be a limit on activities even for a short time.

This statement indicates that the client needs more
teaching. The other statements indicate the client
understands the preoperative teaching. Content
cloud the clients judgment of the procedure. In an

emergency, it can be dangerous to wait until the
pain medication wears off. A 16-year-old can sign for
her infant. ContentSurgical; Category of Health
Surgical; Category of Health AlterationPreoperative;

Integrated ProcessEvaluation; Client NeedsSafe
AlterationPreoperative; Integrated ProcessAssessment;

2. Correct answer 2: The client cannot have metal touching the body during an operation because of the use
of cautery to seal off bleeding vessels. The amulet can
be pinned close to the client. The client does not owe
the nurse an explanation for the amulet. Removing
the amulet and giving it to the family without the
clients permission could cause distress to the client
and family. ContentSurgical; Category of Health
AlterationPreoperative; Integrated ProcessImplementation;
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SECTION FIFTEEN
4. The nurse is preparing a client for surgery. Which

intervention is priority for the nurse?
l 1. Make sure the antiseptic bath was given on the
previous shift.
l 2. Label the outside of the chart with allergies.
l 3. Obtain the on call antibiotic to send to the
operating room (OR).
l 4. Complete the preoperative checklist.
5. Which information should the holding area nurse
report to the operating room team?
l 1. The client has a permanent bridge in the back of
the mouth.
l 2. The client reports being made to go without water
since last night.
l 3. The client states smoking two packs of cigarettes a
day for years.
l 4. The client has had a chest x-ray (CXR) showing
no infiltrates.
Operative Care
675

are working on a surgical unit. Which intervention
should the nurse delegate to the UAP?
l 1. Place a surgical gown and cap on the client, and
request the client to void.
l 2. Assist the postanesthesia nurse to care for the client
returning from the postanesthesia care unit (PACU).
l 3. Check the blood glucose reading on the client with
diabetes going to the OR.
l 4. Explain the procedure for turning and deep breathing
after the operation.
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ANSWERS
4. Correct answer 4: The preoperative checklist ensures

that all the necessary requirements have been completed in order to send the client to the OR safely.
These requirements include a signed permit, nothingby-mouth (NPO) status, vital signs, information
about allergies, and other pertinent information.
Preoperative; Integrated ProcessImplementation; Client
5. Correct answer 3: Smokers are at a higher risk for

complications of anesthesia. A permanent bridge
should be firmly in place. The client should have had
nothing by mouth and not have infiltrates on a CXR.
Preoperative; Integrated ProcessAssessment; Client
676
6. Correct answer 1: The UAP can assist the client

to prepare for surgery by putting on the appropriate
apparel and help the client to void. The nurse should
assist the PACU nurse and get a report on the clients
status. The nurse should check the blood glucose to
determine the status of the client with diabetes. The
UAP cannot teach. ContentManagement; Category
of Health AlterationPreoperative; Integrated Process
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Operative Care
677
7. The client is scheduled for right eye cataract removal

surgery in 5 days. Which preoperative instruction should
the nurse teach the client?
l 1. Get a new eyeglass prescription prior to surgery
and bring it to the hospital.
l 2. Practice isotonic exercises to perform after the
cataract is removed.
l 3. Make arrangements to be out of work for 6 weeks
postoperatively.
l 4. Avoid taking any type of medication that causes
bleeding such as aspirin.
9. The client is scheduled for laser in situ keratomileusis

(LASIK) surgery for severe myopia. Which teaching
should the office nurse discuss prior to scheduling the
procedure?
l 1. The client will wear eye patches for 3 weeks after
the surgery.
l 2. The client will need new glasses after the procedure.
l 3. The client should increase the amount of artificial
light in the home.
l 4. The client will need to administer eyedrops after
surgery.
8. The client is preoperative retinal detachment surgery

with gas tamponade to flatten the retina. Which
l 1. Determine when the client last ate or drank.
l 2. Position the client as prescribed by the surgeon.
l 3. Assess the eye for signs/symptoms of complications.
l 4. Explain the importance of follow-up visits.
10. The 10-year-old client with a profound hearing loss

is scheduled for a cochlear implant. Which referral is
priority for this surgery?
l 1. The child life therapist.
l 2. A speech therapy consult.
l 3. A visit with the anesthesiologist.
l 4. A neurology consult.
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ANSWERS
7. Correct answer 4: To reduce the possibility of

retrobulbar hemorrhage, any anticoagulation
therapy is withheld, including aspirin, nonsteroidal
anti-inflammatory drugs (NSAIDs), and warfarin
(Coumadin). A new eyeglass prescription may be
needed after surgery but not before. Isotonic exercises
are body-building and would increase intraocular
pressure. The client can return to work within a few
days. ContentSurgical; Category of Health Alteration
Preoperative; Integrated ProcessPlanning; Client Needs
8. Correct answer 1: Retinal detachment surgery is

frequently an emergency procedure, and the nurse
should determine if the client has food or liquid in
the stomach that could cause problems during the
procedure. The remaining options are postoperative
interventions. ContentSurgical; Category of Health
AlterationPreoperative; Integrated ProcessImplementation;
678
9. Correct answer 4: LASIK surgery is an effective,

safe, predictable surgery that is performed on an
outpatient basis. There is minimal postoperative care
except for eyedrops in the immediate postoperative
period. Eye patches are not used. The purpose of this
surgery is to ensure the client does not have to wear
any type of corrective lens. Increasing light is for
cataracts. ContentSurgical; Category of Health
AlterationPreoperative; Integrated ProcessPlanning;
10. Correct answer 2: This client must participate in

speech therapy to benefit from this surgery. The
client must have access to therapy and be willing to
cooperate in the therapy. A child life therapist is an
appropriate consult, but the most important referral
is to speech therapy. ContentSurgical; Category of
Health AlterationPreoperative; Integrated Process
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Operative Care
679
Postoperative Nursing
11. The nurse in the postanesthesia care unit (PACU)
received a client from the operating room who had
general anesthesia. Which interventions should the PACU
l 1. Assess the clients breath sounds.
l 2. Place oxygen on the client via a nasal cannula.
l 3. Change the intravenous line to a saline lock.
l 5. Keep the clients head of the bed flat.
13. The client is admitted to the surgical unit from the

postanesthesia care unit (PACU). The clients vital signs
are T 98.4F, AP 110, R 28, BP 86/48, and the skin is
cool and clammy. Which intervention should the nurse
implement first?
l 1. Notify the hospitals rapid response team (RRT).
l 3. Increase the clients intravenous (IV) rate.
l 4. Assess the clients surgical dressing.
12. The PACU nurse is caring for a client who received

spinal anesthesia. Which assessment data would warrant
intervention by the PACU nurse?
l 1. The clients respiratory rate is 10 breaths a minute.
l 2. The client has loss of sensation in the L5 dermatome.
l 3. The client has a palpable posterior tibial pulse.
l 4. The client is able to move the lower extremities.
14. The client in the PACU has a T of 100.8F and

AP of 110 and is complaining of stiff muscles. Which
l 1. Notify the clients anesthesiologist.
l 2. Apply ice packs to axillary and groin areas.
l 3. Prepare to administer dantrolene, a smooth muscle
relaxant.
l 4. Place a hyperthermia blanket on the client.
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ANSWERS
11. Correct answer 1, 2, 4: The nurses priority is to

maintain the clients airway and adequate oxygenation. The client should receive intravenous fluids,
and the head of the bed (HOB) should be elevated
for a client with general anesthesia. ContentSurgical;
Category of Health AlterationPostoperative; Integrated
LevelApplication.
12. Correct answer 1: A respiratory rate of less than

12 breaths a minute should warrant intervention by
the nurse because it may indicate that the spinal
anesthesia is ascending the spinal cord. Loss of
sensation in the L5 dermatome is expected from
spinal anesthesia. A palpable pulse and moving
extremities would not warrant intervention. Content
Surgical; Category of Health AlterationPostoperative;
LevelAnalysis.
680
13. Correct answer 3: The client is exhibiting signs/

symptoms of hypovolemia; therefore, the first intervention should be to increase the IV rate to maintain
circulatory volume. Then, the nurse should place the
client in Trendelenburg position, assess the dressing,
and notify the RRT, which will bring assigned hospital
staff to the bedside to assist with the emergency.
Postoperative; Integrated ProcessImplementation; Client
14. Correct answer 2: The client is exhibiting malignant

hyperthermia, which is a medical emergency. Applying
ice packs helps keep the temperature down. Then,
administering dantrolene and notifying the healthcare provider are appropriate. A hypothermia blanket,
not a hyperthermia blanket, should be placed on
the client. ContentSurgical; Category of Health
AlterationPostoperative; Integrated Process
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SECTION FIFTEEN
15. The PACU nurse is caring for a client who has had
general anesthesia. Which assessment data indicate the
client is postoperatively unstable?
l 1. The clients urine output is 45 mL/hr.
l 2. The clients bowel sounds are 12 per minute.
l 3. The clients lungs are clear bilaterally.
l 4. The clients pupils respond sluggishly to light.
nurse the intravenous pump is alarming in the room of a
client who has just been admitted. Which intervention
l 1. Instruct the UAP to turn off the alarm.
l 2. Assess the clients intravenous site.
l 3. Request the UAP to get the charge nurse to check
the client.
l 4. Tell the UAP to check the clients intravenous
pump.
Operative Care
681
17. Which outcome should the nurse expect for the

client who has received spinal anesthesia?
l 1. The client is able to discern sharp and dull
sensations.
l 2. The client complains of low-back discomfort.
l 3. The clients bladder is palpable in the lower
abdomen.
l 4. The client reports a headache of 4 on a 110 pain
scale.
18. The client is 3 hours postoperative laser in situ
keratomileusis (LASIK) surgery for severe myopia.
discharge teaching?
l 1. I will have to wear patches on both eyes for
24 hours.
l 2. I should not read my newspaper for at least 1 week.
l 3. I will instill the prescribed eyedrops in my
lower eye.
l 4. I will cough and deep-breathe every 2 hours.
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ANSWERS
682
15. Correct answer 4: The clients sluggish pupil response
17. Correct answer 1: The spinal anesthesia may cause
may indicate the neurological system is not stable.

The urine output is more than 30 mL/hr; the bowel
sounds are sluggish but present; and clear lung
sounds indicate the client is stable. ContentSurgical;
neurovascular compromise to the lower extremities;

the ability to feel sharp and dull sensations means
the anesthesia is wearing off and is an expected
outcome. Low-back pain, bladder distention, and
a headache are not expected outcomes of spinal
anesthesia. ContentSurgical; Category of Health

16. Correct answer 2: Anytime the UAP tells the nurse

something is wrong with the client or the clients
equipment, the nurse needs to assess the situation.
The UAP should not be requested to check or
turn off the alarms. The nurse should assess the
client, not ask the UAP to ask the charge nurse
to check the client. ContentSurgical; Category of
Health AlterationPostoperative; Integrated Process
LevelApplication.
AlterationPostoperative; Integrated ProcessDiagnosis;

18. Correct answer 3: LASIK surgery is an effective,

safe, predictable surgery that is performed in day
surgery; there is minimal postoperative care except
for topical corticosteroid drops. The client does
not have to wear patches and can read immediately,
and there is no risk for developing pneumonia.
Postoperative; Integrated ProcessEvaluation; Client
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Operative Care
SECTION FIFTEEN
19. The night shift nurse is caring for clients on the

surgical unit. Which client situation would warrant
immediate intervention?
l 1. The client who had total gastrectomy who has green
bile draining from the nasogastric (NG) tube.
l 2. The client who had a transurethral resection of
the prostate (TURP) who has pink urine in the
catheter bag.
l 3. The client who had a vaginal hysterectomy who
has saturated 1 peri-pad in 4 hours.
l 4. The client who had a bowel resection 24 hours
ago who has absent bowel sounds.
20. The client who had exploratory abdominal surgery is
complaining of pain of 8 on a 110 pain scale. As the
nurse enters the room with the pain medication, the
client says I felt a pop, and now the pain is gone.
l 1. Administer the pain medication as requested by the
client.
l 2. Notify the clients surgeon of the clients statement.
683
3. Inform the client to let the nurse know if the pain
4. Encourage the client to sit in the chair at the
returns.
bedside.
Acute Pain
21. The clinic nurse is assessing a client complaining
of shoulder pain. Which question should the nurse ask
the client first?
l 1. How long has the pain been present and what
makes it better or worse?
l 2. Have you seen a health-care provider (HCP)
for this problem before?
l 3. Are you here to obtain a prescription for pain
medication for your shoulder?
l 4. Can someone come to the clinic and drive you
home if we treat your shoulder?
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ANSWERS
19. Correct answer 4: Absent bowel sounds would

warrant intervention. Green bile in an NG tube,
pink urine after a TURP, and one saturated pad in
4 hours would not warrant immediate intervention.
Postoperative; Integrated ProcessAssessment; Client
20. Correct answer 2: This information indicates a

possible wound dehiscence, which is a surgical
emergency and requires the nurse notifying the
surgeon via telephone. The nurse should first assess
the incision site and then notify the surgeon.
Postoperative; Integrated ProcessImplementation;
684
21. Correct answer 1: This question directly assesses

the clients complaint of pain. The nurse should
assess for location, duration, intensity, and alleviating
and aggravating factors. Who the client has seen for
the problem is not relevant at this point. Asking the
client if he/she wants a prescription is accusing the
client of drug-seeking behavior. ContentSurgical;
Category of Health AlterationPain; Integrated
LevelAnalysis.
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SECTION FIFTEEN
Operative Care
685
22. The nurse is caring for a client complaining of acute

pain in the right lower quadrant of the abdomen. Which
l 1. Ask the client to describe the character of the pain.
l 2. Assess the client for a hard rigid abdomen.
l 3. Check the medication administration record
(MAR) for the time of the last medication.
l 4. Administer the clients as-needed (prn) pain
medication.
24. The nurse is assessing a client 2 hours postoperative

open cholecystectomy. The clients vital signs are T
98.8F, P 114, R 18, BP 168/92. Which intervention
l 1. Re-check the clients vital signs in 15 minutes.
l 2. Check the MAR for prn blood pressure
medication.
l 3. Ask the client to rate the pain on the pain scale.
l 4. Position the client on the right side with pillows.
23. The nurse administered a narcotic pain medication

30 minutes ago to a client complaining of mid-epigastric
pain. Which intervention should the nurse implement at
this time?
l 1. Position the client in a semi-Fowler position.
l 2. Turn on the radio to soft soothing music.
l 3. Administer 30 mL of an antacid orally.
l 4. Assess the clients pain relief at this time.

are caring for clients. Which intervention should the
nurse delegate to the UAP?
l 1. Take the oral acetaminophen (Tylenol) to a client
with a headache.
l 2. Apply an ice pack to the left knee of a client who
had an arthroscopy.
l 3. Check on the client 30 minutes after the nurse
administered pain medication.
l 4. Explain how to use the PCA pump to the client
returned from surgery.
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ANSWERS
22. Correct answer 2: The nurse should assess the area

in question and then quantify the information by
asking the client to describe the pain. Then, the
nurse should check the MAR and, finally, administer
the medication. ContentSurgical; Category of Health
23. Correct answer 4: The nurse should assess the

effectiveness of the pain medication administered
30 minutes ago. Turning the radio on and positioning the client are non-pharmacological interventions,
but the nurse should assess the intervention already
initiated. An antacid may help the client, but the
important intervention is to assess. ContentSurgical;
LevelApplication.
686
24. Correct answer 3: Acute pain will cause a physiological response of elevating the blood pressure and
pulse. The vital signs do not have to be rechecked.
Pain control should relieve the elevated blood
pressure. Positioning the client on the operative
site would increase pain. ContentSurgical; Category
of Health AlterationPain; Integrated Process
LevelSynthesis.
25. Correct answer 2: The UAP can apply an ice pack.

The UAP cannot administer medication, teach,
or evaluate interventions. ContentManagement;
LevelSynthesis.
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SECTION FIFTEEN
26. The nurse is administering morphine, an opioid

narcotic, intravenous push (IVP) to a client with acute
lower back pain. Which interventions should the nurse
implement? Select all that apply.
l 1. Obtain the medication from the clients medication
drawer.
l 2. Rule out neurological deficits.
l 3. Administer the morphine slowly over 5 minutes.
l 4. Ask the client to identify his/her place of birth.
l 5. Check the MAR against the clients identification
band.
27. The nurse on a pediatric unit is caring for a 4-year-old
child. Which intervention should the nurse implement?
l 1. Ask the child to describe the pain in his/her own
words.
l 2. Check with the parents to see if the child can
count.
l 3. Have the child point to the pain scale face that
describes the pain.
l 4. Assess to see if the child grimaces and lies very still.
Operative Care
687
28. The client diagnosed with appendicitis is complaining

of pain as a 9 on the 110 pain scale. Which intervention
l 1. Determine if the operative permit has been signed.
l 2. Check the MAR to see if it is time for pain
medication.
l 3. Administer the clients pain medication and
evaluate the pain in 30 minutes.
l 4. Teach the client to splint the right lower quadrant
when coughing.
29. The nurse is caring for an elderly client diagnosed
with dementia who is having pain in the abdomen.
l 1. Assume the client is in pain and medicate the
client.
l 2. Ask the client to identify the pain on a faces pain
scale.
l 3. Tell the family to let the nurse know when the
client is hurting.
l 4. Request the UAP to check on the clients pain
frequently.
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ANSWERS
26. Correct answer 2, 3, 5: The nurse should rule out

complications before masking symptoms with a
narcotic medication. Morphine is administered
slowly IVP, and the nurse should check the MAR
against the clients identification band. The medication
comes from the narcotics cabinet, and the clients
date of birth is frequently used as the second
identifier. ContentMedical; Category of Health
27. Correct answer 3: The faces pain scale was developed

for children to identify their pain. A 4-yearold
child does not have the concept of numbers to rate
pain reliably on a numeric scale. ContentPediatrics;
Category of Health AlterationPain; Integrated Process
LevelApplication.
688

appendicitis should be scheduled for surgery.
A surgical permit cannot be signed after narcotic
medication. ContentSurgical; Category of Health
29. Correct answer 2: The client can identify the pain

using the pediatric pain scale. Assuming the client is
in pain or having anyone else other than the client
identify the clients pain places the client at risk for
an overdose of pain-relieving medication. Content
Medical; Category of Health AlterationPain; Integrated
LevelApplication.
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Operative Care
SECTION FIFTEEN
30. The nurse is clearing the patient-controlled analgesia

(PCA) pump at the end of the shift. The client had
4 mL of medication left at shift change. Midway through
the shift, the nurse changed the cartridge with a new
30-mL cartridge of morphine 1 mg/mL. The current
cartridge has 24 mL left. How much morphine did the
client receive during the shift?
Answer: ____________________
Management
31. The nurse has received the morning shift report on a
surgical unit. Which client should the nurse assess first?
l 1. The elderly client diagnosed with a left fractured
hip who is crying and is frightened about the
surgery.
l 2. The school-aged client who has an open reduction
and internal fixation of the right ulna that has 1+
edema.
l 3. The middle-aged client who is 1 day postoperative
abdominal surgery who has a 3-cm spot of blood
on the dressing.
689
4. The adolescent client 2 days postoperative emergency

appendectomy who is complaining of abdominal
pain of 8 on a 110 scale.
32. The client diagnosed with laryngeal cancer had a

radical neck dissection 4 days ago. Which intervention is
priority for the nurse?
l 1. Assess for wound infection.
l 2. Refer the client to a speech therapist
l 3. Maintain the clients IV lines.
l 4. Determine if the client is hoarse.
33. The client who is 3 days postoperative Whipple
procedure has an AP 132 and a BP 90/58. Which
l 1. Notify the health-care provider (HCP)
immediately.
l 2. Assess the clients abdomen incision.
l 3. Administer dopamine, a vasopressor.
l 4. Increase the clients intravenous rate.
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ANSWERS
30. Correct answer 10 mg: The cartridge is not changed

until it has been used, so the client received 4 mL +
6 mL (30 - 24 = 6 = 10 mL or 10 mg. Content
Medical; Category of Health AlterationDrug Administration; Integrated ProcessImplementation; Client

31. Correct answer 1: This is a psychosocial need, but

the other clients have expected results for their
diagnosis. ContentManagement; Category of Health
AlterationPain; Integrated ProcessAssessment; Client
690
32. Correct answer 1: This client is at risk for infection.

The speech therapy referral should have been made
preoperatively. Maintaining the IV line is not
priority over wound infection. The client does
not have a larynx to be hoarse. ContentSurgical;
LevelSynthesis.
33. Correct answer 4: The first intervention is to

maintain the clients circulatory status; increasing
the intravenous rate will do this. Then, the nurse
should notify the HCP, assess the incision, and
administer dopamine. ContentSurgical; Category
of Health AlterationPostoperative; Integrated Process
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Operative Care
SECTION FIFTEEN
34. The charge nurse is reviewing the morning laboratory

results. Which data should the charge nurse report to the
health-care provider via telephone?
l 1. The client who is 4 hours postoperative gastric
resection who has a white blood cell (WBC) count
of 10,000 mm3.
l 2. The client who is 1 day postoperative total hip
replacement with a hemoglobin and hematocrit
(H&H) of 12 mg/dL/36%.
l 3. The client who is 4 days postoperative mitral valve
replacement whose glucose is 580 mg/dL.
l 4. The client who is 8 hours postoperative lap
cholecystectomy who has a potassium (K) level
of 3.9 mEq/L.
35. The nurse is administering medications to clients
on a surgical unit. Which medication should the nurse
administer first?
l 1. The narcotic analgesic meperidine IV to the client
2 days postoperative who is complaining of pain of
3 on a 110 scale.
l
l
l
691
2. The first dose of the cephalosporin antibiotic

Rocephin intravenous piggyback (IVPB) to the
client with an infected abdominal wound.
3. The histamine 2 blocker ranitidine (Zantac) to the
client who is at risk for developing a stress ulcer.
4. The cardiotonic digoxin intravenous push (IVP) to
the client who has congestive heart failure and had
a dbridement of the right lower limb.

Which client would warrant immediately notifying the
surgeon?
l 1. The client who is postoperative bowel resection
who refuses to turn, cough, and deep-breathe.
l 2. The client who is postoperative vaginal hysterectomy
who saturated a peri-pad with bright red drainage
within 65 minutes.
l 3. The client who is postoperative total knee replacement
who has bruising around the surgical site.
l 4. The client with bilateral thyroidectomy who has a
negative Chvostek sign and a blood pressure of
110/78.
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ANSWERS
34. Correct answer 3: This client has a very high glucose

level (normal is 70120 mg/dL). The remaining
values are within normal limits (WNL). Content
35. Correct answer 2: The first dose of IVPB antibiotic

is priority. The nurse should investigate a different
medication for the client with a pain level of 3. The
other medications can be given within the acceptable
time frame of 30 minutes before and after scheduled
time. ContentSurgical; Category of Health Alteration
Drug Administration; Integrated ProcessAssessment;
Therapies; Cognitive LevelAnalysis.
692
36. Correct answer 2: This client should be assessed for

hemorrhage. Bright red drainage is not expected
post vaginal hysterectomy. The remaining situations
are expected. ContentSurgical; Category of Health
AlterationPostoperative; Integrated ProcessAssessment;
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Operative Care
693
37. The nurse is caring for a client who had an abdominalperitoneal resection with a permanent sigmoid colostomy.
Which data warrant intervention by the nurse?
l 1. The clients stoma is pink and moist.
l 2. The clients ostomy bag is loose.
l 3. The clients ostomy bag has brown drainage.
l 4. The client does not want to look at the stoma.
39. The charge nurse on a 20-bed surgical unit has one

RN, two LPNs, and two UAPs for a 12-hour shift. Which
task would be an appropriate delegation of assignments?
l 1. The RN will perform the shift assessments.
l 2. The LPN should administer all IVP medications.
l 3. The LPN will complete all the morning care.
l 4. The UAP will monitor laboratory values.

l 1. The client who is 1 day postoperative mastectomy
who has a Reach to Recovery volunteer coming to
see her.
l 2. The client who is 8 hours postoperative splenectomy
who is complaining of abdominal pain of 5 on the
110 scale.
l 3. The client who is 12 hours postoperative
adrenalectomy who has vomited 100 mL of
dark green bile.
l 4. The client who is 2 days postoperative hiatal hernia
repair who is complaining of chest pain radiating
down the left arm.
40. The client in the postanesthesia care unit (PACU)

complains of being nauseated. Which intervention should
the PACU nurse implement?
l 1. Increase the clients oxygen rate via nasal cannula.
l 2. Notify the surgeon immediately.
l 3. Administer the narcotic pain medication IVP.
l 4. Prop the client on the side with pillows.
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ANSWERS
37. Correct answer 2: The nurse should reapply the

ostomy bag. A loose bag allows fecal material to get
on the abdominal skin and can cause excoriation. A
pink moist stoma is desired. Brown drainage (feces)
is normal. The client not wanting to look at the
stoma is a normal psychological reaction. Content
LevelAnalysis.
38. Correct answer 4: The chest pain may or may not

be cardiac in nature, but the nurse must assume it is
a life-threatening pain until proved otherwise. This
client must be seen first. A client with postoperative
pain of 5 and vomiting are not priority over chest
pain. ContentSurgical; Category of Health Alteration
Postoperative; Integrated ProcessAssessment; Client
694
39. Correct answer 1: The RN should perform the shift

assessments. There are IVP medications that only
an RN should administer. The UAP can perform
the morning care. The RN should monitor lab
values. ContentSurgical; Category of Health
40. Correct answer 4: The client is at risk for aspiration

of stomach secretions. The nurse should prop the
client on the side so that if the client vomits, the
vomitus can be expelled from the mouth. Oxygen
will not treat nausea. The surgeon will have an order
on the chart for nausea medication. Pain medication
could make the client more nauseated. Content
SECTION SIXTEEN
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695
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Pharmacology
SECTION SIXTEEN
697
Pharmacology
1. The client with a head injury is experiencing increased
intracranial pressure (ICP). The neurosurgeon prescribes
the osmotic diuretic mannitol (Osmitrol). Which
intervention should the nurse implement when
l 1. Cover the tubing with aluminum foil.
l 2. Assess the clients neurological status.
l 3. Monitor the clients central venous pressure (CVP).
l 4. Use Y-tubing when administering the medication.
the following clients. Which medication would the nurse
l 1. The loop-diuretic furosemide (Lasix) to the client
with a potassium level of 3.7 mEq/L.
l 2. The oral anticoagulant warfarin (Coumadin) to the
client with an International Normalized Ratio
(INR) of 2.8.
3. The cardiac glycoside digoxin (Lanoxin) to the
4. The anticonvulsant phenytoin (Dilantin) to the
client with a digoxin level of 1.8 mg/dL.

client with a Dilantin level of 24 mcg/mL.
3. The male client newly diagnosed with epilepsy is

prescribed the anticonvulsant medication phenytoin
(Dilantin). Which information should the nurse discuss
with the client?
l 1. Explain the importance of regular dental hygiene.
l 2. Tell the client it is normal for his urine to turn
orange.
l 3. Instruct the client to monitor the Dilantin level
weekly.
l 4. Inform the client he can drive as long as he takes
the medication.
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ANSWERS
1. Correct answer 2: The medication is being administered to decrease the clients ICP; therefore, monitoring the neurological status would be an appropriate
intervention. The medication is not affected by light,
CVP is monitored for heart function, and Y-tubing is
used for administering blood. ContentPharmacology;
2. Correct answer 4: The therapeutic serum level of

Dilantin is 1020 mcg/mL; therefore, the nurse
should question administering this medication. The
normal serum potassium level is 3.54.5 mEq/L; the
therapeutic INR is 23; and normal digoxin level is
0.82.0 mg/dL; therefore, the nurse would administer
these medications. ContentPharmacology; Category
698
3. Correct answer 1: A side effect of Dilantin therapy

is gingival hyperplasia, which can be managed with
regular flossing, brushing, cleanings, and regular
dental care. The clients urine does not turn orange;
the Dilantin level is checked at the health-care
providers office; and the medication causes drowsiness
and therefore the client should not drive a car.
ContentPharmacology; Category of Health Alteration
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SECTION SIXTEEN
4. The nurse in the intensive care unit (ICU) is caring for

a client diagnosed with a left cerebral arterial thrombotic
stroke who received thrombolytic medication. Which
l 1. Administer 81-mg aspirin, an antiplatelet.
l 2. Check the clients hemoglobin/hematocrit (H&H).
l 3. Monitor the clients partial thromboplastin time
(PTT) level frequently.
l 4. Refer the client to the physical therapist.
5. The elderly client diagnosed with Parkinson disease
(PD) has been prescribed levodopa/carbidopa (Sinemet).
Which data indicate the medication has been effective?
l 1. The client has a normal arm swing when
ambulating.
l 2. The client has a flat affect when talking to the
nurse.
l 3. The client walks with a forward shuffling gait.
l 4. The client rotates the thumb and forefinger together.
Pharmacology
699
6. The nurse is caring for a male client taking donepezil

(Aricept), a cholinesterase inhibitor. Which finding would
indicate the medication is ineffective?
l 1. The client is able to state his name and birth date.
l 2. The client is discussing an upcoming event with
the family.
l 3. The client thinks his daughter is his deceased wife.
l 4. The client is talking on the telephone with his son.
7. The nurse on a medical unit is administering
medications at 0900. Which medication should the nurse
l 1. Acetylcysteine (Mucomyst), a mucolytic, to a client
who is coughing forcefully.
l 2. Cefazolin (Ancef ), an antibiotic, intravenous
piggyback (IVPB) to a client diagnosed with
the flu.
l 3. Diphenhydramine (Benadryl), an antihistamine, to
a client who is congested.
l 4. Dextromethorphan (Robitussin), an antitussive, to
a client who has pneumonia.
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ANSWERS
4. Correct answer 3: The anticoagulant heparin is
700
6. Correct answer 3: Aricept is administered for stage 12
administered to prevent clot reformation after lysis of

the clot by the thrombolytic; therefore; monitoring
the clients PTT would be appropriate. Aspirin is not
administered; H&H are not affected by thrombolytic
therapy; and the physical therapist would not see the
client until transferred out of the ICU. Content
Alzheimer disease. Inability to identify a loved one appropriately indicates the clients medication is not effective.
The client knowing his name, talking about upcoming
events, and talking on the phone indicate the clients
cognitive level is intact, which means the medication is
effective. ContentPharmacology; Category of Health
Pharmacology; Category of Health AlterationDrug


Assessment; Client NeedsPhysiological Integrity, Pharmacological and Parenteral Therapies; Cognitive LevelAnalysis.
5. Correct answer 1: Jerky abnormal swinging of the

arms is a symptom of PD; normal arm swinging
indicates the medication is effective. A flat affect, a
forward shuffling gait, and pin-rolling motion
(cogwheel) indicate the medication is not effective.
Drug Administration; Integrated ProcessEvaluation;
7. Correct answer 1: An adverse effect of Mucomyst is

bronchospasm; therefore, the nurses questioning this
medication is appropriate. Antibiotics are often administered for viral infections to prevent secondary bacterial
infections. Antihistamines are prescribed for congestion
and a nonproductive cough that is associated with pneumonia; there is no reason to question these medications.
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SECTION SIXTEEN
8. The nurse is administering medications at 1600 to

clients on a medical unit. Which medication should the
l 1. Humalog insulin for a client with a blood glucose
level of 200 mg/dL.
l 2. Acetamineophen (Tylenol), a non-narcotic
analgesic, for a client with a headache.
l 3. Pantoprazole (Protonix), a proton-pump inhibitor,
to a client with a stress ulcer.
l 4. Promethazine (Phenergan), an antiemetic, to a
client who is vomiting.
9. The nurse is preparing to administer a nitroglycerin
(a coronary vasodilator) transdermal patch to the
client diagnosed with a myocardial infarction. Which
l 1. Cleanse the site of the old nitroglycerin patch.
l 2. Remove the previously applied nitroglycerin patch.
l 3. Use non-sterile gloves when applying the transdermal
patch.
l 4. Date and time transdermal patch prior to applying
to clients skin.
Pharmacology
701
10. The client diagnosed with coronary artery disease is

prescribed atorvastatin (Lipitor), an HMG-CoA reductase
inhibitor. Which statement by the client indicates the
l 1. I really havent changed my diet, but I am taking
my medication every day.
l 2. I am feeling pretty good, except I am having
muscle pain all over my body.
l 3. I will take the medication in the evening so I will
get better results.
l 4. I am taking this medication first thing in the
morning with a bowl of oatmeal.
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ANSWERS
8. Correct answer 4: This client is in physiological

distress; this client should receive medication to stop
the vomiting first. A 200 mg/dL blood glucose, a
headache, and a stress ulcer would not be priority
over a client who is vomiting. ContentPharmacology;
9. Correct answer 2: The nurse must first remove the

old patch and then cleanse the skin so medication
will not be absorbed. The nurse should then date and
time the new patch and use gloves when applying the
patch. Nitroglycerin causes hypotension, and the nurse
should question administering a transdermal patch
if the clients blood pressure is less than 90/60.
702
10. Correct answer 3: Lipitor is administered in the

evening to increase its effectiveness. This statement
indicates the teaching is effective. The client needs
to adhere to a low-fat, lowcholesterol diet on this
medication. Statins can cause muscle injury, which
can lead to myositis or fatal rhabdomyolysis, and
medication should be administered in the evening.
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SECTION SIXTEEN
11. The client is dizzy and lightheaded when getting

up out of the chair. Which medication should the nurse
prepare to administer for the client exhibiting the
following telemetry strip?
l
l
l
l
1. Atropine
2. Cordarone
3. Lanoxin
4. Intropin
Page 703
Pharmacology
703
12. The nurse is preparing to administer warfarin

(Coumadin), an anticoagulant. The clients current
laboratory values are:
Prothrombin time (PT) 12; control 12.9
Partial thromboplastin time (PTT) 39; control 36
INR 2.9
l 1. Discontinue the intravenous bag immediately.
l 2. Prepare to administer AquaMephyton
(vitamin K).
l 3. Notify the healthcare provider (HCP) so he/she
can increase the dose.
l 4. Administer the medication as ordered.
13. The client is receiving an intravenous infusion of
heparin. The bag hanging has 20,000 units of heparin in
500 mL of D5W. The HCP has ordered the medication
to be delivered at 2000 units/hr. At what rate would the
nurse set the intravenous pump?
Answer: ____________________
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ANSWERS
11. Correct answer 1: The client is in complete heart

block, and the medication of choice is atropine,
which decreases vagal stimulation and increases
pulse rate. Cordarone treats ventricular dysrhythmias; Lanoxin would further slow the heart; and
Intropin increases blood pressure. Content
12. Correct answer 4: A therapeutic INR is 23;

therefore, the nurse should administer the medication. AquaMephyton is the antidote for Coumadin
toxicity. ContentPharmacology; Category of Health
LevelAnalysis.
704
13. Correct answer 50 mL/hr: When setting the

intravenous pump the nurse must first determine
the number of units per mL.
20,000 units = 40 units/mL
500 mL
2000 units/hr = 50 mL
40 units/mL
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Pharmacology
SECTION SIXTEEN
14. The client diagnosed with iron-deficiency anemia

is being discharged on oral iron preparation. Which
teaching?
l 1. I will bring a stool specimen every week to the
doctor.
l 2. I should take my iron tablet with vitamin D
capsules.
l 3. It would be best if I took my medication with
meals only.
l 4. I may notice my stools turning a greenish black
color.
15. The nurse is preparing to administer medication to
the following clients. Which medication should the nurse
question?
l 1. The biguanide metformin (Glucophage) to the
client with type 1 diabetes who is scheduled for an
intravenous pyelogram (IVP).
l 2. The loop-diuretic bumetanide (Bumex) to a client
diagnosed with congestive heart failure.
705
3. The biological response modifier erythropoietin
(Procrit) to a client diagnosed with end-stage renal

failure.
4. The central-acting alpha agonist clonidine
(Catapres) to a client diagnosed with essential
hypertension.
16. The nurse on a medical unit has received the

morning report. Which medication should the nurse
administer first?
l 1. The proton pump inhibitor pantoprazole
(Protonix) to a client who is nothing by mouth
(NPO).
l 2. The mucosal barrier agent sulcralfate (Carafate) to
a client with peptic ulcer disease.
l 3. The antacid calcium carbonate (TUMS) to a client
complaining of indigestion.
l 4. The antibiotic bismuth (Pepto Bismol) to a client
diagnosed with a peptic ulcer.
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ANSWERS
14. Correct answer 4: Iron causes the clients stool
706
16. Correct answer 2: Carafate must be administered
to turn greenish-black; this indicates the client

understands the discharge teaching. The clients stool
is not checked weekly, and oral iron should be taken
with vitamin C and on an empty stomach for best
absorption. ContentPharmacology; Category of
on an empty stomach before a meal to coat the

stomach; therefore, this medication should be
administered first. The other medications are routine
medications and do not need to be administered
before breakfast for effectiveness. Content


15. Correct answer 1: Glucophage is a large molecule;

the kidneys have difficulty excreting Glucophage and
contrast dye (used in intravenous pyelogram) simultaneously. This could result in kidney damage and
lactic acidosis. All the other medications would be
appropriate for the client. ContentPharmacology;
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SECTION SIXTEEN
17. The client with inflammatory bowel disease is

prescribed sulfasalazine (Azulfidine), a sulfonamide
antibiotic. Which intervention should the nurse
implement when administering this medication?
l 1. Notify the HCP if any bruising or bleeding is
noted.
l 2. Limit oral fluid intake to 1000 mL/day.
l 3. Administer the medication once a day with
breakfast.
l 4. Assess the clients stool for steatorrhea and mucus.
18. The client is diagnosed with a peptic ulcer disease
(PUD) secondary to Helicobacter pylori bacteria. Which
discharge instructions should the nurse teach?
l 1. Discuss placing the head of the bed on blocks to
prevent reflux.
l 2. Teach the client to take acetylsalicylic acid (aspirin)
for pain.
l 3. Take the prescribed medications exactly as prescribed
and it will cure the ulcer.
l 4. Instruct the client to eat a bland diet with six small
feedings a day.
Pharmacology
707
19. The nurse is transcribing the admitting HCPs orders

for an elderly client diagnosed with acute diverticulitis.
Which order would the nurse question?
l 1. Administer the intravenous antibiotic cefazolin
(Ancef ).
l 2. Administer acetaminophen (Tylenol) rectally for
temperature >102F.
l 3. Administer a concurrent intravenous antibiotic.
l 4. Administer a narcotic analgesic for the clients pain.
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ANSWERS
17. Correct answer 1: Instruct the client to report any

bruising or bleeding because it could be a sign of the
drug-induced blood disorder agranulocytosis. The
client increases fluid intake to prevent crystalluria.
The medication is administered every 68 hours, not
once a day, and it will not cause fat, frothy stools so
the nurse does not need to assess the stool. Content
18. Correct answer 3: H. pylori is a bacterial infection

cured by a combination of medications. The client
has PUD, not gastroesophageal reflux disease (GERD),
so there is no reason to elevate the head of the bed
to prevent reflux. The client should not take aspirin
because it decreases the production of protective
prostaglandins, and the client is prescribed a regular
diet. ContentPharmacology; Category of Health
AlterationDrug Administration; Integrated
708

LevelSynthesis.
19. Correct answer 2: The client should not have

anything inserted into the inflamed and irritated
rectum because, under those conditions, there is a
high risk of colon perforation. Antibiotics and pain
medication would not be questioned. Often, clients
receive more than one antibiotic in an effort to
cover all potential bacterial infections. Content
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20. The client is diagnosed with end-stage liver failure

and is experiencing hepatic encephalopathy. The HCP
prescribes lactulose (Cephulac), a laxative. Which data
would indicate to the nurse the medication is not
effective?
l 1. The clients handwriting is legible.
l 2. The client has a decreased ammonia level.
l 3. The client has two to three soft stools a day.
l 4. The client is oriented to person only.
21. The client with chronic hepatitis C is prescribed
interferon alfa-2a (Roferon-A), an antiviral medication.
Which information should the nurse discuss with the
client?
l 1. Demonstrate the correct way to administer
subcutaneous injections.
l 2. Explain the importance of wearing a mask when
around children.
l 3. Instruct the client to report flu-like symptoms to
the HCP.
l 4. Teach the client to take the medication daily and
sit up for 30 minutes.
Page 709
Pharmacology
709
22. Which statement indicates to the nurse the client understands the scientific rationale for taking acidophilus
capsules?
l 1. Acidophilus will help me not get diarrhea when
I take antibiotics.
l 2. The medication will help treat the viral infection
in my intestines.
l 3. If I take this medication every day I will not get a
bacterial infection.
l 4. This medication will help me prevent Lyme
disease when I am camping.
23. The client taking orlistat (Xenical), a lipase inhibitor,
reports copious frothy diarrheal stools. Which action
l 1. Explain this is expected because the client ate a
fatty diet.
l 2. Tell the client to take over-the-counter antidiarrheal
medication.
l 3. Instruct the client to eat foods high in dietary fiber.
l 4. Recommend the client decrease fluid intake for
24 hours.
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ANSWERS
20. Correct answer 4: Hepatic encephalopathy can be

caused by high levels of ammonia. Lactulose is administered to decrease the ammonia level. Altered neurological functioning (oriented to person only) indicates
the medication is not effective. Handwriting legibility
gets worse with increasing ammonia level. A decrease
in ammonia level and two to three soft stools indicate
the medication is effective. ContentPharmacology;
21. Correct answer 1: This medication is administered

subcutaneously three times a week. It does cause
flu-like symptoms, but the medication does not
cause the client to be contagious or immunosuppressed, so there is no reason to wear a mask around
children. Hepatitis C is transmitted through blood
and body fluids. ContentPharmacology; Category
710

LevelSynthesis.
22. Correct answer 1: Acidophilus, a robotic, is a

bacterium that replaces the normal intestinal flora
and helps to prevent suprainfections, including
thrush, diarrhea, or a yeast infection, in clients
taking antibiotics. It does not help prevent or treat
viral infections, bacterial infections, or Lyme disease.
23. Correct answer 1: If a client consumes more than

30% of the calories in fats while taking Xenical, the
fats will not be absorbed by the gastrointestinal tract,
and the result is foul-smelling frothy diarrhea stools.
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SECTION SIXTEEN
24. The elderly female client calls the clinic and complains
of loose watery stools. Which interventions should the
l 1. Instruct the client to take an antiemetic
medication.
l 2. Tell the client to check her chest for skin turgor.
l 3. Ask the client how many stools she has had in the
last 24 hours.
l 4. Tell the client to go to the emergency department.
l 5. Ask the client what other medications she has
taken.
25. The client who had abdominal surgery returned
from the post-anesthesia care unit (PACU) with a
patient-controlled analgesia (PCA) pump. Which
l 1. Observe the client administering a bolus.
l 2. Check the PCA setting with another nurse.
l 3. Instruct the family not to push the button.
l 4. Document the PCA medication on the chart.
Pharmacology
711
26. The nurse is preparing to administer promethazine

(Phenergan) 12.5 mg intravenous push (IVP) via a
peripheral IV line infusing normal saline at 100 mL/hr.
l 1. Flush the peripheral IV line with 10 mL of normal
saline.
l 2. Question administering the Phenergan IVP.
l 3. Dilute the Phenergan with normal saline, and
administer slowly.
l 4. Administer the medication, and elevate the
clients arm.
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ANSWERS
24. Correct answer 3, 5: The nurse should determine

the number of stools to help determine if the client
may be becoming dehydrated, especially because she
is elderly. Many medications cause diarrhea, so this
should be assessed. The client cannot check herself
for skin turgor; an antiemetic is for vomiting, not
diarrhea; and at this time the client does not need
to go to the emergency department. Content
25. Correct answer 2: For safety the nurse should

double-check PCA settings with another nurse. This
ensures that the correct dosage is being administered
when the client pushes the PCA button. The nurse
should ensure the client knows how to use the PCA
pump, tell the family not to give the client pain
medication, and document the PCA medication on
the chart. ContentPharmacology; Category of Health
712

26. Correct answer 3: Phenergan is caustic to peripheral

veins, resulting in a chemical phlebitis, and it is
painful when being administered peripherally.
Diluting the medication and pushing slowly
prevents pain and sclerosing of the vein. Normal
saline is compatible with Phenergan so the nurse
does not need to flush the line. Elevating the arm
is done in codes after administering IV medication.
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SECTION SIXTEEN
27. The nurse administered Humulin R via sliding

scale to a client with type 1 diabetes at 1600. Which
l 1. Assess the client for hyperglycemia around 1800.
l 2. Ensure the client eats a night-time snack.
l 3. Monitor how much food is consumed at the
evening meal.
l 4. Check the clients serum blood glucose level.
28. The client diagnosed with type 1 diabetes is
diaphoretic and unconscious. Which action should
l 1. Prepare to administer intravenous regular insulin.
l 2. Inject Humulin N subcutaneously in the abdomen.
l 3. Hang an intravenous infusion of D5W at a
keep-open rate.
l 4. Administer 1 amp of intravenous 50% glucose.
Pharmacology
713
29. The nurse is caring for the client diagnosed with type
2 diabetes complaining of being thirsty and urinating
every hour. Which action should the nurse implement
first?
l 1. Check the clients serum blood glucose level.
l 2. Give the client a glass of orange juice.
l 3. Determine when the last antidiabetic medication
was administered.
l 4. Assess the clients blood pressure and apical pulse.
30. The school nurse is teaching a class about type 2
diabetes mellitus (DM) to elementary school teachers.
Which information is most important for the nurse to
discuss with the teachers?
l 1. Instruct the teachers how to administer
subcutaneous insulin.
l 2. Explain that type 2 diabetes can lead to long-term
chronic complications.
l 3. Teach signs/symptoms of hypoglycemia and the
immediate treatment.
l 4. Tell the teachers that medication is usually not
prescribed for type 2 DM.
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ANSWERS
27. Correct answer 3: Humulin R peaks in 24 hours;

therefore, the client should eat supper to prevent
hypoglycemia. The nighttime snack would cover
Humulin N administered at 1630. Content
28. Correct answer 4: One amp of 50% glucose

would be used to treat a severe hypoglycemic
reaction, which is what the client is experiencing.
Insulin would further lower the clients blood
glucose level, and D5W is not enough dextrose
to correct the clients hypoglycemia. Content
714
29. Correct answer 1: The clients serum blood glucose

level should be checked because the type 2 diabetic
glucose level can be extremely high. The glucometer
registers only 400600, and an accurate blood glucose level is needed. ContentPharmacology; Category
LevelApplication.
30. Correct answer 2: Type 2 DM in children is an

epidemic that must be addressed in schools. Teachers
need to know that even if a child does not feel bad,
long-term complications are occurring. Insulin is
not prescribed for type 2 DM in children, but
oral hypoglycemics are. Children are more likely
to be hyperglycemic than hypoglycemic. Content
LevelSynthesis.
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SECTION SIXTEEN
31. Which medication would the nurse question

administering?
l 1. Meperidine (Demerol), an opioid, to a client
diagnosed with pancreatitis.
l 2. Epinephrine, a beta-adrenergic agonist, to a client
with an allergic reaction.
l 3. Methylprednisolone (Solu-Medrol), a glucocorticoid,
to a client with Cushing disease.
l 4. Vasopressin (ADH), a hormone, to a client
diagnosed with diabetes insipidus (DI).
32. The client had a bilateral adrenalectomy for Cushing
disease and is prescribed the glucocorticoid prednisone.
Which statement indicates to the nurse the client
l 1. When I quit taking my medication I will have to
taper it off.
l 2. I should stop taking the medication if I develop a
round face.
l 3. I should wear a Medic-Alert bracelet in case
something happens.
l 4. I must wear SPF 30 sunscreen while taking my
medication.
Pharmacology
715
33. The emergency department nurse is caring for a

female client in an addisonian crisis. Which intervention
l 1. Monitor the clients potassium and sodium level.
l 2. Administer methylprednisolone (Solu-Medrol)
intravenous (IV).
l 3. Monitor the clients intravenous infusion site.
l 4. Ask the client what medications she is currently
taking.
34. The female client has been taking levothyroxine
(Synthroid), a thyroid hormone, for a year. Which data
would indicate to the nurse the medication is effective?
l 1. The client has lost 10 lb in the last year.
l 2. The client is complaining of being nervous.
l 3. The clients oral temperature is 96.3F.
l 4. The client denies having hot flashes.
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ANSWERS
31. Correct answer 3: Cushing disease is a hyperfunction of the adrenal gland resulting in excess steroids,
so the nurse should question administering this
medication. Demerol is the drug of choice for
pancreatitis; epinephrine is administered for
allergic reactions; and vasopressin is administered
for DI. ContentPharmacology; Category of Health
LevelAnalysis.
32. Correct answer 3: All clients with a chronic

medical condition should wear Medic-Alert
bracelets or necklaces. The medication cannot be
discontinued; a bilateral adrenalectomy means all the
hormones produced must be replaced. Content
716
33. Correct answer 2: Addisonian crisis is a state of no

glucocorticoids or mineral corticoids; therefore, the
nurse should first administer glucocorticoids IV.
Monitoring electrolytes, interviewing the client, and
monitoring the site are appropriate but not before
preventing shock by administering the medication.
34. Correct answer 1: Synthroid is administered to clients

diagnosed with hypothyroidism. If the client has signs
of hypo- or hyperthyroidism, the medication is not
effective; the client needs to be in the euthyroid state.
Clients who are hypothyroid gain weight, so a loss of
weight over an extended period indicates her metabolism has improved and the medication is effective.
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SECTION SIXTEEN
35. The client diagnosed with hyperthyroidism is

prescribed an antithyroid medication and is being seen
in the clinic. Which question should the nurse ask the
client?
l 1. Do you have any trouble urinating since taking
this medication?
l 2. Have you developed any stretch marks on your
abdomen?
l 3. Have you experienced any burping after eating a
large meal?
l 4. Do you ever see people or things other people do
not see?
36. The client in end-stage renal disease (ERSD) is
taking calcitriol, a vitamin D analogue. Which client
assessment data would warrant intervention by the nurse
concerning this medication?
l 1. Increased visual acuity.
l 2. Hematuria.
l 3. Increased bone density.
l 4. Steatorrhea.
Pharmacology
717
37. The nurse observes the unlicensed assistive personnel

(UAP) performing delegated tasks. Which action by the
UAP requires immediate intervention?
l 1. The UAP tells the client whose urine is green that
the nurse said this was normal because of one of
the medications.
l 2. The UAP tells the client to talk to the primary
nurse about a medication concern.
l 3. The UAP provides a bedside commode for a client
receiving a loop diuretic.
l 4. The UAP increases the continuous bladder
irrigation (CBI) for the client with a transurethral
resection of the prostate.
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ANSWERS
35. Correct answer 4: Clients with hyperthyroidism
718
37. Correct answer 4: A CBI should be treated as a
experience hallucinations because of the increased

metabolism; therefore, asking this question is appropriate because the nurse has to determine if the
medication is effective. Urinary tract infections,
striae, and burping are not side effects of the
medication. ContentPharmacology; Category of
medication because it helps decrease bladder spasms

and bleeding; therefore, the UAP should not do
this. The UAP telling the client what the nurse said,
referring medication questions to the nurse, and
providing a bedside commode are appropriate and
therefore would not warrant intervention. Content

LevelAnalysis.

36. Correct answer 2: Hematuria is an adverse effect of

calcitriol, and the nurse should notify the health-care
provider to ask about discontinuing the medication.
Vitamin D does not increase visual acuity and does
not affect the stool. Increased bone density indicates
the medication is effective. ContentPharmacology;
Therapies; Cognitive LevelSynthesis.
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SECTION SIXTEEN
38. The male client diagnosed with complaints of urinary

frequency, terminal dribbling, and nocturia tells the nurse
he is taking the herbal supplement saw palmetto. Which
l 1. Recommend the client talk to his HCP to change
his medication.
l 2. Teach the client to drink lots of fluid when taking
this herb.
l 3. Take no action because this herb helps shrink the
prostrate tissue.
l 4. Ask the client why he started taking the herb saw
palmetto.
39. The client with renal calculi was prescribed allopurinol
(Zyloprim) for uric acid stones. Which statement indicates
the client understands the teaching?
l 1. I should have at least 8 ounces of milk with
my pill.
l 2. I drink at least eight glasses of water a day.
l 3. My joints ache so I take a couple of aspirins.
l 4. I really enjoy a glass of wine with my evening meal.
Pharmacology
40. The client diagnosed with rule-out renal calculi is
scheduled for an intravenous dye pyelogram (IVP).
l 1. Determine if the client has allergies to iodine.
l 2. Check the clients liver function studies.
l 3. Keep the client NPO after midnight.
719
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ANSWERS
38. Correct answer 3: Research has proved the efficacy

of the use of saw palmetto to benign prostate
hypertrophy (BPH) because it shrinks prostate tissue,
resulting in relief of urinary obstructive symptoms.
Therefore, the nurse should not take any action.
The client does not need to increase fluid intake for
this herb. ContentPharmacology; Category of Health
AlterationComplementary Alternative Medicine;
39. Correct answer 2: The client should increase fluid

intake to prevent drug accumulation and toxic
effects and to minimize the risk of kidney stone
formation. The medication does not need to be
taken with milk; aspirin increases the acidity of the
urine; and the client should avoid high-purine foods
and wine to help keep the urine alkaline. Content
720

40. Correct answer 1: The dye is iodine-based, and if

the client is allergic to iodine, an allergic reaction
to the dye can occur. The nurse should check renal
status, not liver function studies. The client is not
NPO and does not have an indwelling urinary
catheter. ContentPharmacology; Category of Health
LevelApplication.
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SECTION SIXTEEN
41. The client is receiving an intravenous infusion of

heparin. The hanging bag has 20,000 units of heparin in
500 mL of D5W at 25 mL/hr. How much heparin has
infused during the 12-hour shift?
Answer: _________________________
42. The nurse is teaching the client the correct use of a

metered dose inhaler. Which intervention should the
nurse implement?
l 1. Instruct the client to push the top of the medication
canister while exhaling.
l 2. Explain the need to wait 1 minute before taking a
second puff of medication.
l 3. Teach the client to rinse the mouth with an
alcohol-based mouthwash.
l 4. Tell the client to take two quick puffs of the
inhaler, then exhale.
Pharmacology
721
43. The primary nurse is at the bedside and is preparing

to administer 3 mL of medication into the ventrogluteal
muscle. Which action should the charge nurse take?
l 1. Take no action as this is acceptable standard of
practice.
l 2. Ask the primary nurse to come to the nurses
station.
l 3. Tell the nurse to inject the medication into the
deltoid muscle.
l 4. Complete an occurrence report documenting the
behavior.
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ANSWERS
41. Correct answer 12,000 units of heparin over

12 hours: When determining the units, the nurse must
first determine how many units are in each milliliter:
120,000 units = 40 units/mL
500 mL
40 units/mL 25 mL = 1000 mL/hr
1000 mL 12 hours = 12,000 units of heparin over
12 hours
42. Correct answer 2: The client needs to wait at least

1 minute between puffs to allow for absorption of the
medication. The client should push the top of the
medication canister when inhaling, and the client
should rinse with water. ContentPharmacology;
722
43. Correct answer 1: The ventrogluteal muscle is the

injection site of choice for 3 mL because it is a large
muscle mass that is free of major nerves. The deltoid
muscle should not be used to administer more than
1 or 2 mL because the muscle is small and can only
accommodate small doses of medication. Content
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Pharmacology
SECTION SIXTEEN
44. Which action by the primary nurse warrants

intervention by the charge nurse?
l 1. The charge nurse observes the primary nurse
disposing of a used needle at the clients bedside.
l 2. The charge nurse observes the primary nurse using
two methods to identify the client who is receiving
medications.
wasting narcotic medications without a second
nurse verifying the waste.
documenting the removal of morphine from the
narcotic box.
45. The male client tells the nurse he is starting to itch,
and the nurse notes a red rash over the clients body, and
he is scratching himself. Which action should the nurse
implement first?
l 1. Assess the clients fingernails for length.
723
3. Prepare to administer diphenhydramine (Benadryl),
4. Check the clients medication administration
an antihistamine.
record (MAR) for medication taken.
46. Which interventions should the nurse implement

when administering a tablet to the male client? List in the
order in which the tasks should be completed.
l 1. Ask the client if he is allergic to any medication.
l 2. Place the client in the high-Fowler position.
l 3. Open the medication and place in the
medication cup.
l 4. Check the medication against the clients medication
administration record (MAR).
l 5. Remain with the client until all medication is
swallowed.
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ANSWERS
44. Correct answer 3: The nurse must always have

another nurse verify narcotic wastage. The other three
actions would not warrant immediate intervention by
the charge nurse. ContentPharmacology; Category of
ProcessEvaluation; Client NeedsSafe Effective Care
LevelSynthesis.
45. Correct answer 4: Because the client appears to be

having an allergic reaction, the first intervention
would be to determine what medications the client
has received. The nurse does not want the client to
cause bleeding from scratching. Notifying the HCP
and administering medication would not be implemented prior to checking for the cause. Content
724
46. Correct answer 4, 1, 2, 3, 5: The nurse must make

sure the right medication is being administered at
the right time by checking the clients MAR and
then determine if the client is allergic to the medication. Then, to prevent choking, the client should
be in a sitting position. Finally, the nurse should
administer medication and wait until the medication
is swallowed. ContentPharmacology; Category of
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SECTION SIXTEEN
47. The nurse is preparing to administer medication via

a nasogastric tube. Which intervention should the nurse
implement first?
l 1. Assess and verify tube placement.
l 2. Check the clients residual volume.
l 3. Flush the tubing with water.
l 4. Pour medication into the syringe barrel.
48. The nurse is preparing to administer dopamine, a
beta and alpha agonist, to the client in cardiogenic shock.
l 1. Administer in the distal port of the central line only.
l 2. Assess the blood pressure (BP) every 4 hours.
l 3. Evaluate the intake and output every hour.
Pharmacology
725
49. The Department of Homeland Security has issued a

warning of suspected biological warfare using the anthrax
bacillus to the skin. Which sign and symptoms would
support the initial diagnosis of anthrax?
l 1. Pruritus, ulcerative macules, and edema.
l 2. Fever, chills, headache, and malaise.
l 3. Nausea, vomiting, diarrhea, and fatigue.
l 4. Petechiae, ecchymosis, and dyspnea.
50. The client in a code has the following arterial blood
gases (ABGs): pH 7.31, PaO2 60, PaCO2 58, HCO3 19.
Which medication should the nurse prepare to administer
to the client?
l 1. Dopamine, a vasopressor medication.
l 2. Oxygen via nasal cannula at 2 L/min.
l 3. Calcium gluconate, an electrolyte replacement.
l 4. Sodium bicarbonate, an alkalinizing agent.
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ANSWERS
47. Correct answer 1: Assessment is the first intervention,

and verifying the tube is in the stomach is priority
when administering medications via the nasogastric
tube. If the residual is greater than 100 mL in an adult,
the medication should not be administered because
this indicates the client is not digesting the feedings.
Flushing the tubing ensures it is patent. Content
48. Correct answer 3: Dopamine is administered to

prevent shock and to ensure perfusion to the renal
arteries, which prevents acute renal failure. Therefore, evaluating the output every hour is appropriate.
Dopamine can be administered peripherally; the
BP should be checked more frequently; and the
pulse oximeter reading does not affect the medication. ContentPharmacology; Category of Health
726

LevelApplication.
49. Correct answer 1: Anthrax exposure via the skin

results in lesions that cause edema, ulcerative macules, and itching. Option 2 lists signs of tularemia;
option 3 lists signs of initial radiation exposure; and
option 4 lists signs that are not those of anthrax
exposure. ContentPharmacology; Category of Health
AlterationBioterrorism; Integrated ProcessAssessment;
50. Correct answer 4: The ABGs indicate the client

is in metabolic acidosis, and the drug of choice is
sodium bicarbonate. Oxygen in a code is given
initially via an ambu-bag and then by intubation.
Dopamine and calcium gluconate do not affect
ABGs. ContentPharmacology; Category of Health
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SECTION SIXTEEN
51. The occupational health nurse of a chemical

manufacturing plant is called to the scene where a
worker has passed out in an enclosed garage while
mixing some chemicals. Which action should the nurse
implement first?
l 1. Have the supervisor ventilate the area.
l 2. Assess the client for breathing.
l 3. Call the poison control hotline.
l 4. Activate the emergency response system, 911.
52. Which medication should the nurse administer first
to the client experiencing a cardiac arrest?
l 1. Amiodarone (Cordarone).
l 2. Epinephrine, a sympathomimetic.
l 3. Lidocaine, an antidysrhythmic.
l 4. Atropine, an antidysrhythmic.
Page 727
Pharmacology
727
53. The client who was raped is offered the medications

mifepristone (RU 486), a birth control pill, and
misoprostol (Cytotec), a prostaglandin. Which statement
indicates to the emergency department nurse the client
understands the reason for taking this medication?
l 1. I am so glad I wont get AIDS if I take this
medication for 2 weeks.
l 2. I hope these medications will help me calm down
and deal with the rape.
l 3. These medications will keep me from getting
pregnant by that awful man.
l 4. Taking these medications will help the soreness in
my vaginal area.
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ANSWERS
51. Correct answer 1: Because the client passed out in

the enclosed garage, the first action would be to
aerate the garage and then call 911 to notify poison
control. Another person should not be in the
garage until ventilation has been established. The
National Poison Control Hotline (1-800-222-1222)
is the equivalent of dialing 911 locally. Content
Client NeedsSafe Effective Management of Care;
52. Correct answer 2: Epinephrine is the first medication

administered intravenously or via an endotracheal
tube because it constricts the periphery and shunts
blood to the heart and brain. The other medications
are administered in a code but are not the first medication to be given. ContentPharmacology; Category
728
53. Correct answer 3: The medications will cause the

client to abort any potential fetus. The medications
must be taken within 35 days after the rape.
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Pharmacology
SECTION SIXTEEN
54. The male client is diagnosed with low back pain and
is prescribed the muscle relaxant carisoprodol (Soma).
Which priority intervention should the occupational
health nurse implement with the client?
l 1. Determine if the client is taking the medication
while working.
l 2. Ensure the client does not operate heavy machinery
while on duty.
l 3. Tell the client to have someone drive him to work
if he is taking the medication.
l 4. Inform the supervisor that the client is taking this
medication.
55. The nurse is administering medications to clients on
an orthopedic unit. Which medication should the nurse
question?
l 1. Ibuprofen (Motrin), a nonsteroidal anti-inflammatory
drug (NSAID), to a client with back pain and a
history of asthma.
l 2. Morphine, an opioid analgesic, to a client with a
back pain of 2 on the 110 pain scale.
729
3. Methocarbamol (Robaxin), a muscle relaxant, to a
4. Propoxyphene (Darvon N), a narcotic agonist, to a
client with chronic back pain.

client with knee surgery.
56. The client diagnosed with arterial hypertension

develops a cold. Which statement indicates the client
l 1. I need to be careful when purchasing cold
medications over the counter.
l 2. I must get a prescription from the HCP when
I get a cold.
l 3. I can take any cold medication as long as I check
my blood pressure.
l 4. I should limit my fluid intake when taking cold
medications.
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ANSWERS
54. Correct answer 1: The first intervention is to

determine if the client is taking the medication.
Then, all the other interventions should be implemented. ContentPharmacology; Category of Health
LevelAnalysis.
55. Correct answer 2: A client with a pain level of 2

should not receive a narcotic opioid medication;
therefore; this medication should be questioned by
the nurse. NSAIDs, such as ibuprofen, should be
questioned in clients diagnosed with peptic ulcer
disease. The other medications would be appropriate
for the clients. ContentPharmacology; Category of
730
56. Correct answer 1: The client should be informed

about the dangers of self-medicating with over-thecounter (OTC) cold medications that work by
causing vasoconstriction that will increase the clients
hypertension. The client does not need a prescription for a cold medication. The client should rest
in bed and drink plenty of liquids. Content
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Page 731
SECTION SIXTEEN
57. The client diagnosed with chronic obstructive

pulmonary disease (COPD) is prescribed methylprednisolone
(Solu-Medrol), a glucocorticoid, IVP. Which assessment
data would warrant immediate intervention?
l 1. The client has a moon face.
l 2. The clients glucose level is 168 mg/dL.
l 3. The client has rusty-colored sputum.
l 4. The clients creatinine level 0.8 nmol/L.
58. The client admitted for an acute exacerbation of
reactive airway disease is receiving intravenous
aminophylline. The clients serum theophylline level is
10 mcg/mL. Which action should the nurse implement?
l 1. Assess the client for nausea and restlessness.
l 2. Continue to monitor the aminophylline drip.
l 3. Discontinue the aminophylline drip.
Pharmacology
731
59. The client with chronic reactive airway disease is

taking the leukotriene receptor inhibitor montelukast
(Singulair). Which statement indicates the client
l 1. I will take two puffs of my Singulair every
4 hours.
l 2. I will notify my HCP if I get any type of
headache.
l 3. I should take a drug holiday every 2 weeks and
skip a dose.
l 4. This medication will not help me when I have an
asthma attack.
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ANSWERS
57. Correct answer 3: Rusty-colored sputum indicates

the client has a respiratory infection, which could
be masked by the steroid; therefore; this datum
warrants intervention. Steroid therapy interferes with
glucose metabolism, which causes an elevated
glucose level. A moon face is a side effect of steroid
therapy, and the creatinine level is within normal
limits (WNL). ContentPharmacology; Category of
58. Correct answer 2: The therapeutic level for

theophylline is 1020 mcg/mL; therefore, the nurse
should continue to monitor the aminophylline drip.
As the serum theophylline level rises above 20 mcg/mL,
the client will experience nausea, vomiting, diarrhea,
insomnia, and restlessness. ContentPharmacology;
732

59. Correct answer 4: Singulair is a prophylactic

medication taken to prevent asthma attacks; it will
not be effective during an acute asthma attack. The
client must take the pill daily and not skip doses to
maintain therapeutic effectiveness. The most common side effect is a headache and would not warrant
notifying the HCP. ContentPharmacology; Category
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Page 733
SECTION SIXTEEN
60. The nurse is preparing to administer the following

medications. Which client would the nurse question
receiving the medication?
l 1. The client receiving digoxin (Lanoxin) who has a
digoxin level of 1.2 ng/mL.
l 2. The client receiving intravenous heparin who has a
partial prothrombin time (PTT) of 82 seconds.
l 3. The client receiving phenytoin (Dilantin) who has
a Dilantin level of 18 mg/dL.
l 4. The client receiving valproic acid (Depakote) who
has a Depakote level of 75 mg/dL.
61. The nurse admitted a client diagnosed with
pneumonia 4 hours ago. The admission orders read
cefazolin (Ancef ) IVPB every 6 hours. Which data
would warrant notifying the HCP?
l 1. The client is unable to provide a sputum specimen.
l 2. The client is allergic to the antibiotic penicillin.
l 3. The clients fragile veins warranted placing a
22-gauge IV catheter.
l 4. The clients white blood cell count is 18,000/mm3.
Pharmacology
733
62. The client who is a Jehovahs Witness is prescribed

erythropoietin (Procrit), a biological response modifier.
Prior to administering the first dose of medication, which
l 1. Question the order on religious grounds.
l 2. Have the client sign an informed consent.
l 3. Check the clients white blood cell count.
l 4. Assess the clients blood pressure.
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ANSWERS
60. Correct answer 2: The therapeutic PTT for a

client on intravenous heparin, an anticoagulant,
is 1.52 times the control (normal value); a level
greater than 78 seconds warrants questioning.
Therapeutic level of Lanoxin is 0.82.0 ng/mL, of
Dilantin 1020 mg/dL, and Depakote 50100 mg/dL.
61. Correct answer 1: Intravenous antibiotics should

be initiated within 1 hour of the order when at all
possible. A delay could place the client at risk for
gram-negative shock. The nurse should notify the
HCP that no sputum has been obtained. Ancef is a
cephalosporin, not a penicillin; a 22-gauge catheter
is appropriate for IVPB; and an elevated white blood
cell count would be expected. ContentPharmacology;
734

62. Correct answer 4: The nurse should check the

blood pressure because rapidly increasing the volume
of blood in the vascular tree can increase the blood
pressure. Members of the Jehovah Witness church
refuse to accept blood and blood products, but
Procrit is not a blood product, and it does not
require an additional consent form. Procrit stimulates red blood cell (RBC), not white blood cell
(WBC), production. ContentPharmacology; Category
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Page 735
SECTION SIXTEEN
63. The oncology nurse is preparing to administer the

morning medications. Which biological response modifier
would the nurse question?
l 1. Oprelvekin (Neumega) to the client with a platelet
count of 50,000 mm3.
l 2. Filgrastim (Neupogen) to a client with a white
blood cell count of 1000 mm3.
l 3. Pegfilgrastim (Neulasta) to a client with a white
blood cell count of 9,000 mm3.
l 4. Darbepoetin (Aranesp) to a client with a red blood
cell count of 6,000,000 mm3.
64. The client has received chemotherapy every other
day every 3 weeks for the last 8 months. The clients
current lab values are hemoglobin and hematocrit
(H&H) 12 g/dL and 39%, WBC 2200/mm3,
neutrophils 50, and platelet count 100,000/mm3.
Which information should the nurse teach the client?
l 1. Avoid individuals with colds or other infections.
l 2. Maintain nutritional status with supplements.
l 3. Plan for periods of rest to prevent fatigue.
l 4. Use a soft-bristle toothbrush and electric razor.
Pharmacology
735
65. The client diagnosed with cancer has an implanted

port for chemotherapy administration. Which statement
indicates the client understands the teaching concerning
care of the port?
l 1. I must flush my port every day with 10 mL of
normal saline.
l 2. I must carry a clamp with me at all times in case
my catheter breaks.
l 3. My nurse will flush my port after every
chemotherapy treatment.
l 4. My HCP will change my implanted port every
month using a J-wire.
66. The 37-year-old client diagnosed with breast cancer
is prescribed the anti-estrogen hormone tamoxifen
(Nolvadex). Which statement indicates the client
l 1. I should take this medication at night to reduce
the side effects.
l 2. I will have less chance of developing osteoporosis.
l 3. I must see my gynecologist at least every 2 years.
l 4. I may begin having hot flashes and difficulty
sleeping.
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ANSWERS
63. Correct answer 3: Neulasta is administered to
736
65. Correct answer 3: Implanted ports are surgically
increase the white blood cell (WBC) production,

and this clients WBC is within normal limits;
therefore; the nurse should question administering
the medication. Neumega stimulates platelet
production; Neupogen stimulates WBC production;
and Aranesp stimulates red blood cell production.
placed under the skin and are accessed by the HCPs

when needed; therefore the nurse will maintain the
patency of the device. There is no external catheter
to be flushed or broken, and the implanted device
can stay in place for years as long it does not get
infected and remains patent. ContentPharmacology;


Evaluation.
64. Correct answer 1: The clients low WBC count and

absolute neutrophil count makes the client at risk for
infection because the client lacks mature WBCs to
fight infection. The clients H&H and platelet count
are within normal limits and would not require supplements, rest, or bleeding precautions. Content
66. Correct answer 4: Tamoxifen suppresses estrogen

and causes symptoms of early menopause. It also
increases the clients risk of developing endometrial
cancer and osteoporosis. Taking it at night does not
reduce the side effects. ContentPharmacology;
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Page 737
SECTION SIXTEEN
67. The oncology nurse is administering continuous

infusion of doxorubicin (Adriamycin) over 24 hours. The
medication is mixed in 1000 mL of normal saline. Which
rate should the nurse set the infusion pump?
Answer: __________________
68. The female client with major depressive disorder

who is taking the selective serotonin reuptake inhibitor
(SSRI) sertraline (Zoloft) calls the psychiatric clinic and
reports feeling confused and restless. She also has an
elevated temperature. Which intervention should the
psychiatric nurse implement?
l 1. Instruct the client to stop taking the SSRI.
l 2. Ask the client if she received the flu vaccine
recently.
l 3. Tell the client to take acetaminophen (Tylenol).
l 4. Explain that these are expected side effects.
Pharmacology
737
69. The client was prescribed an antidepressant 4 weeks

ago. Which statement by the client indicates to the nurse
the medication is effective?
l 1. I went on a shopping spree last week and spent
$1000.
l 2. I am getting out of bed every day and working in
the yard.
l 3. I just dont have the energy to fix supper at night
for my family.
l 4. My doctor told me my drug level is within the
therapeutic range.
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ANSWERS
67. Correct answer 41 mL/hr: The nurse should divide

1000 mL by 24 to get the answer 41.2; 0.2 is less than
.05 so the problem is rounded down, not up. Content
68. Correct answer 1: Serotonin syndrome (SES) is a

serious complication of SSRIs, which produces
mental changes (confusion, anxiety, and restlessness),
hypertension, tremors, sweating, hyperpyrexia
(elevated temperature), and ataxia. Conservative
treatment includes stopping SSRI and supportive
treatment. If untreated, SES can lead to death.
ContentPharmacology; Category of Health
LevelAnalysis.
738
69. Correct answer 2: The effectiveness of the antidepressant medication is determined by the clients
change in behavior. A shopping spree in manic
behavior, fatigue, and decreased energy indicate
depression; there is no therapeutic drug level for
antidepressants. ContentPharmacology; Category
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SECTION SIXTEEN
70. The male client diagnosed with bipolar disorder for

1 year has a level of 0.4 mEq/L of the anti-mania drug
lithium (Eskalith).Which action should the nurse
implement first?
l 1. Instruct the client to continue taking the
medication.
l 2. Tell the client to continue to increase fluid intake.
l 4. Ask the client when and how he takes his
medication.
71. The nurse is admitting a client who reports taking
valproic acid (Depakote), an anticonvulsant medication.
Which question would be most important for the nurse
to ask the client?
l 1. Have you ever had a migraine headache?
l 2. When was the last time you had a seizure?
l 3. Why are you taking Depakote?
l 4. How long ago did you have a manic episode?
Page 739
Pharmacology
739
72. The client diagnosed with schizophrenia is prescribed

risperidone (Risperdal), an atypical antipsychotic. Which
medication teaching should the nurse discuss with the
client?
l 1. Tell the client to avoid wine and yeast products.
l 2. Instruct the client to change positions slowly.
l 3. Encourage the client to drink eight glasses of water
a day.
l 4. Discuss the importance of decreasing salt in the diet.
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Page 740
ANSWERS
70. Correct answer 4: The therapeutic serum level is

0.61.5 mEq/L, and the nurse should first assess
why the lithium level is below therapeutic range.
Then the nurse should instruct the client to
continue to take the medication and increase fluids.
Why the client is not taking the medication or any
other reason why the therapeutic level is not attained
would determine if the HCP should be notified.
71. Correct answer 3: The most important question is

to determine why the client is taking Depakote; it
can be prescribed for seizures or for bipolar disorder.
The nurse should not assume why the client is
taking the medication; therefore, options 2 and
4 would not be most important. ContentPharmacology;
740

72. Correct answer 2: A side effect of all types of

antipsychotics is orthostatic hypotension (lightheadedness and dizziness when rising), which can be
minimized by moving slowly when assuming an
erect posture. Foods high in tyramine should be
avoided by clients taking monoamine oxidase
inhibitors, and increasing fluid and decreasing salt
are instructions for clients taking lithium. Content
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Pharmacology
SECTION SIXTEEN
73. The client with paranoid schizophrenia is prescribed

the atypical antipsychotic quetiapine (Seroquel). Which
statement best describes the scientific rationale for
l 1. This medication helps to stabilize the chemical
imbalance in the brain.
l 2. This medication increases the dopamine secretion
in the brain tissue to improve speech.
l 3. Seroquel will help decrease the clients anxiety due
to the paranoia.
l 4. This medication affects the cholinergic receptor
sites in the diseased brain tissue.
74. The client diagnosed with schizophrenia has been
taking the conventional antipsychotic medication
chlorpromazine (Thorazine) for 5 years. Which
assessment data would warrant discontinuing the
medication?
l 1. The clients significant other reports the client has
no hallucinations or delusions.
l 2. The client has a score of 30 on the Mini-Mental
Status Examination (MMSE).
741
3. The client complains of having a dry mouth and
4. The client has as score of 27 on the Abnormal
the sun hurting the eyes.

Involuntary Movement Scale (AIMS).
75. The unconscious client was admitted to the

emergency department with an overdose of the anxiolytic
alprazolam (Xanax). Which intervention should the nurse
implement first?
l 1. Prepare to administer an emetic with activated
charcoal.
l 2. Request a mental health consultation for the client.
l 3. Prepare to administer the antidote flumazenil
(Romazicon) IV.
l 4. Determine why the client had an overdose of
medication.
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ANSWERS
73. Correct answer 1: Schizophrenia is caused by a

chemical imbalance in the brain, and antipsychotic
medications help prevent the hallucinations and
delusions. ContentPharmacology; Category of Health
LevelAnalysis.
74. Correct answer 4: The AIMS (ranging 030, with

30 being the worst) is a tool used to evaluate for
tardive dyskinesia, which is an adverse effect that
may develop after months or years of continuous
therapy. No hallucinations/delusions indicate the
medication is effective; a score of 30 on the MMSE
means the client is cognitively intact; and dry mouth
and photophobia are expected. ContentPharmacology;
742
75. Correct answer 3: Because the client is unconscious,

the antidote flumazenil (Romazicon) IV should be
administered. It is a benzodiazepine antagonist that
reverses the sedative effects. Encouraging vomiting
would be appropriate if the client were conscious,
and determining why the client took the overdose
and arranging a mental health consult would
be appropriate but only after the antidote is
administered and the client regains consciousness.
ContentPharmacology; Category of Health
LevelSynthesis.
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SECTION SIXTEEN
76. The client is receiving the anxiolytic lorazepam

(Ativan) for a generalized anxiety disorder. Which
assessment data best indicate the medication is effective?
l 1. The client reports feeling less anxious.
l 2. The clients pulse is not greater than 110.
l 3. The clients respiratory rate is not greater than 26.
l 4. The client reports a 2 on a 110 anxiety scale.
77. The client who is a chronic alcoholic is admitted
to the medical unit for pneumonia. Which priority
l 1. Administer chlordiazepoxide (Librium), a
benzodiazepine, every 4 hours.
l 2. Monitor the intravenous thiamine (vitamin B1).
l 3. Check the clients intravenous site.
l 4. Obtain the clients chest x-ray.
Page 743
Pharmacology
743
78. The client tells the psychiatric clinic nurse, I am

addicted to heroin, and I really want to stop this time.
l 1. Ask the client how much heroin is used daily.
l 2. Refer the client to a methadone clinic.
l 3. Determine if the client has financial resources.
l 4. Assess the clients support system.
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ANSWERS
76. Correct answer 4: The best indicator of the medications effectiveness is the clients objective report
of the anxiety level. Rating anxiety on a scale helps
the nurse to quantify the clients response to
the medication. Words like less or more are
subjective, not objective. Physical assessment data
do not evaluate the psychosocial effectiveness of the
77. Correct answer 1: Delirium tremens (DT) is the

worst-case scenario for someone undergoing alcohol
withdrawal; therefore, administering Librium, which
provides safe withdrawal from alcohol, is priority.
Thiamine is a vitamin prescribed to prevent
Wernicke encephalopathy, but DT prevention is
priority. Because the client is already diagnosed with
pneumonia, the chest x-ray will have already been
taken. ContentPharmacology; Category of Health
744

78. Correct answer 2: A methadone clinic will provide

the client with medication and support to successfully
stop taking heroin. It does not matter how much
heroin the client uses. Many clinics are free or
based on ability to pay, and the clients support
system may or may not be helpful to the client.
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Pharmacology
SECTION SIXTEEN
79. The client with a staggering gait is brought to the

emergency department by a friend. The client is restless
and hallucinating and is having a panic attack. Which
question should the nurse ask the clients friend?
l 1. How many alcoholic drinks has your friend had
today?
l 2. When is the last time your friend took
amphetamines?
l 3. Has your friend smoked any marijuana today?
l 4. Which route and what time did your friend use
cocaine?
80. The 13-year-old adolescent with attention
deficithyperactivity disorder (ADHD) is taking
methylphenidate (Ritalin), a central nervous system
stimulant. Which statement indicates to the nurse the
adolescent understands the medication teaching?
l 1. I can carry my medication in a personal pill
container with me at school.
l 2. I should take my medication before breakfast,
lunch, and supper.
745
3. I must take all my medication before 1:00 in the
4. I just take my medication on days that I have
afternoon.
important tests.
81. The client with a full-thickness burn over 48% of

the body is admitted to the burn unit 3 hours after a fire.
The HCP writes an order for Ringer lactate 550 mL/hr.
l 1. Question the HCPs orders.
l 2. Administer the intravenous fluid on a pump.
l 3. Do not administer more than 150 mL/hr.
l 4. Contact the pharmacy to discuss the order.
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ANSWERS
79. Correct answer 2: These are signs/symptoms of

an amphetamine overdose; therefore; this is an
appropriate question. The nurse would not suspect
alcohol overdose with these signs/symptoms.
Marijuana produces apathy and increased appetite.
Cocaine overdose is exhibited by tachycardia,
pupillary dilation, and cardiac arrhythmias. Content
80. Correct answer 3: Ritalin should be taken before

1:00 in the afternoon so the client will be able to
sleep at night. Medication should be kept in the
prescription bottle, should be given during or after
meals to minimize appetite suppression, and should
not be taken on test days only. ContentPharmacology;
746
81. Correct answer 2: Fluid resuscitation formulas

specify that the total amount of fluid must be
infused in 24 hours: 50% in the first 8 hours,
followed by the other 50% over the other 16 hours.
This is a large amount of fluid, but administering
that much is not uncommon in clients with fullthickness burns covering more than 20% of total
body surface area. ContentPharmacology; Category
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Pharmacology
SECTION SIXTEEN
82. The client diagnosed with multiple sclerosis requests

pain medication. When the nurse enters the room with
the narcotic medication, the nurse finds the client
laughing and talking with visitors. Which action should
l 1. Do not administer the narcotic pain medication at
this time.
l 2. Notify the HCP of the clients narcotic-seeking
behavior.
l 3. Administer the clients prescribed pain medication.
l 4. Check the MAR to see if there is a non-narcotic
medication ordered.
83. The client who is 1 day postoperative abdominal
surgery is complaining of pain of 8 on a 110 pain scale.
l 1. Check the MAR to determine when the last pain
medication was administered.
l 2. Reposition the client in the bed with the head of
the bed elevated to 30.
3. Administer the clients as-needed (prn) narcotic
4. Assess the clients abdomen for tenderness and
747
pain medication intravenously over 5 minutes.

check the abdominal dressing.
84. The nurse administered naloxone (Narcan), a

narcotic antagonist, to the client who received an
overdose of an opioid medication. Which interventions
l 1. Turn and position the client on the side.
l 2. Monitor the clients blood pressure and pulse
every hour.
l 3. Assess the clients respirations every 15 minutes.
l 4. Maintain the clients intravenous site.
l 5. Administer repeated doses every 23 minutes.
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ANSWERS
82. Correct answer 3: This is a classic picture of chronic

pain. Pain is whatever the client says it is and occurs
whenever the client says it does. The nurse should
not judge the client and should administer the pain
83. Correct answer 4: The nurses first intervention is

to determine if the client is experiencing routine
postoperative pain or a complication of the surgical
procedure. ContentSurgical; Category of Health
748
84. Correct answer 1, 3, 4, 5: The client should be

placed on the side to prevent aspiration. Narcans
half-life is very short, and the effects wear off
quickly, so the IV site should be kept patent for
administering needed medications. Repeated
doses are administered every 23 minutes until an
adequate response is achieved. The respiratory rate
is monitored, not blood pressure and pulse. Content
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SECTION SIXTEEN
85. The clinic nurse administers the antibiotic ceftriaxone

(Rocephin) intramuscularly into the clients ventrogluteal
muscle. Which action should the nurse implement?
l 1. Massage the injection site with an alcohol swab.
l 2. Inject lidocaine (Xylocaine) around the injection
site.
l 3. Instruct the client to remain in the clinic for
30 minutes.
l 4. Apply a cold compress to the clients injection site.
86. The nurse is working in the emergency department.
Which client should the nurse care for first?
l 1. The 2-year-old client who has the croup and is
crying vigorously.
l 2. The 6-year-old client who has a rash after taking an
antibiotic.
l 3. The 10-year-old client who has a fracture of the
right ulna.
l 4. The 12-year-old client who has lower abdominal
cramping.
Pharmacology
749
87. The client with rheumatoid arthritis is prescribed

hydroxychloroquine sulfate (Plaquenil), a disease-modifying
antirheumatic drug (DMARD). Which statement
indicates the client understands the teaching?
l 1. I will get my eyes checked every 6 months.
l 2. I can have a glass of wine with my evening meal.
l 3. It is important to take the medication on an
empty stomach.
l 4. I will call my HCP if the pain is not relieved in
2 weeks.
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ANSWERS
85. Correct answer 3: The client is at risk for an allergic

reaction; therefore, the client should remain at the
clinic for at least 30 minutes. Rocephin is painful,
and the area should not be massaged. Lidocaine is
administered with the Rocephin in the same syringe,
not around the area, and a warm compress would be
helpful, not a cold compress. ContentPharmacology;
86. Correct answer 2: A client experiencing a potential

allergic reaction (rash) should be assessed first to
determine if the allergic reaction is life-threatening.
If the client is crying, the client is breathing.
A fractured extremity and abdominal cramping are
not life-threatening. ContentEmergency; Category
LevelAnalysis.
750
87. Correct answer 1: Plaquenil can cause pigmentary

retinitis and vision loss; therefore, the client should
have a vision examination every 6 months. Plaquenil
may increase the risk of liver toxicity when administered with hepatotoxic agents such as alcohol. The
medication should be taken with milk to decrease
gastrointestinal upset, and it takes 36 months to
achieve the desired effect. ContentPharmacology;
Integrated ProcessEvaluation; Client Needs
Therapies; Cognitive LevelEvaluation.
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SECTION SIXTEEN
88. The client is taking a nonsteroidal anti-inflammatory

drug (NSAID). Which medication information should
the nurse discuss with the client?
l 1. Sit up for 30 minutes after every dose.
l 2. Take the medication with food or milk.
l 3. Do not take vitamin supplements with NSAIDs.
l 4. Expect the urine and body fluids to turn orange.
89. The clinic nurse has administered the recommended
vaccinations to a 2-month-old infant. Which discharge
instructions should the nurse discuss with the parents?
l 1. Notify the HCP if the infant develops fever
>102F.
l 2. Instruct the parents to keep the childs legs
restrained.
l 3. Give the infant the acetylsalicylic acid for comfort.
l 4. Keep the infant in the parents room at night for a
few days.
Pharmacology
751
90. The client diagnosed with multiple sclerosis is

prescribed baclofen (Lioresal), an antispasmodic. Which
intervention should the nurse discuss with the client?
l 1. Recommend that the client check the serum
baclofen levels daily.
l 2. Instruct the client not to take baclofen if having
muscle spasms.
l 3. Tell the client not to abruptly stop taking the
medication.
l 4. Explain to the client that a decrease in muscle
strength will occur.
91. The female client tells the clinic nurse she is taking
St. Johns wort for her depression. Which statement
indicates the client understands the medication teaching?
l 1. I will make sure I use sunscreen when I am
outside.
l 2. I will use artificial tears when taking this herb.
l 3. I will not take birth control pills when taking
St. Johns wort.
l 4. I will take my herb with at least two glasses of
water.
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ANSWERS
752
88. Correct answer 2: NSAIDs interfere with prostaglandin
90. Correct answer 3: The medication is administered
production in the stomach and increase the risk for

peptic ulcer disease; therefore, the medication should
be taken with food or milk. Sitting up will not prevent
gastrointestinal distress. The client can take vitamins,
and the urine and body fluids will not turn orange.
for muscle spasms and, if abruptly discontinued,

may result in rebound seizures. The medication
must be tapered, and serum baclophen levels are
not routinely monitored. Baclofen has no muscle
relaxant action, and it does not decrease muscle
strength. ContentPharmacology; Category of Health

89. Correct answer 1: If high fever, a shrill cry, or

seizures develop, the parents should notify the HCP.
The parents should bicycle (move) the legs with
every diaper change to decrease soreness. Aspirin
products should not be given to children due to
Reye syndrome. There is no reason for the child to
stay in the parents room. ContentPharmacology;
LevelSynthesis.

LevelSynthesis.
91. Correct answer 1: St. Johns wort can cause

photosensitization dermatitis; therefore, the client
should use sunscreen when outside. This herb does
not cause dry eyes, does not interact with birth
control pills, and does not need to be taken with two
glasses of water. ContentPharmacology; Category
of Health AlterationComplementary Alternative Medicine; Integrated ProcessEvaluation; Client Needs
Therapies; Cognitive LevelEvaluation.
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SECTION SIXTEEN
92. The client newly diagnosed with tuberculosis is

prescribed the antitubercular medications isoniazid (INH)
and rifampin (Rifadin). Which information should the
nurse discuss with the client? Select all that apply.
l 1. Instruct the client to decrease the amount of dark,
green leafy vegetables.
l 2. Explain that the clients urine and other body fluids
will turn orange.
l 3. Tell the client to remain in isolation until there are
three negative sputum cultures.
l 4. Inform the client a public health staffer will observe
the client taking the medication.
l 5. Discuss the need to take the medication for 1 month
before stopping the medications.
prior to administering the beta blocker metoprolol
(Lopressor)?
l 1. Check the clients serum potassium level.
l 2. Ensure the client has had something to eat.
l 3. Take the clients apical pulse and blood pressure.
l 4. Ask the client if he/she has had a cough.
Pharmacology
753
94. The nurse is caring for a client diagnosed with HIV

infection. Which data suggest the need for prophylaxis
with trimethoprim sulfa (Bactrim)?
l 1. The client has a positive HIV viron count.
l 2. The clients blood urea nitrogen (BUN) level is
41 mg/dL.
l 3. The client has four Kaposi sarcoma lesions.
l 4. The clients CD4 count is less than 300/mm3.
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ANSWERS
92. Correct answer 2, 3, 4: Rifampin turns the urine

and body secretions orange and can discolor contact
lenses, but it is not harmful to the client. The
client is considered communicable until three
early-morning negative sputum tests are obtained.
The client will be on antitubercular medication for
up to 1 year and will be observed when taking the
medication by a public health official as tuberculosis
is a communicable disease and a threat to the
community. Dark, green leafy vegetables will not
affect this medication. ContentPharmacology;
93. Correct answer 3: Beta blockers decrease the

sympathetic stimulation to the heart; therefore, the
nurse would question administering the medication
if the apical pulse is less than 60 and blood pressure
is less than 90/60. The potassium level is not affected
by this medication; the client does not have to take
754
the medication on a full stomach; and the cough

is pertinent to an angiotensin-converting enzyme
inhibitor, not a beta blocker. ContentPharmacology;
94. Correct answer 4: The client with a CD4 count of

less than 300/mm3 (normal is 4501400/mm3) is at
risk for developing Pneumocystis carnii pneumonia
(PCP), and Bactrim should be prescribed. A client
with HIV would have a positive viron count; the
BUN is high (821 mg/dL) but is not a reason
for Bactrim and Kaposi sarcoma indicates an
opportunistic cancer. ContentPharmacology;
LevelAnalysis.
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SECTION SIXTEEN
95. The 34-year-old client who is diagnosed with AIDS

and is prescribed highly active antiretroviral therapy
(HAART) tells the nurse, I am not working so I dont
have insurance. Which priority intervention should the
nurse implement?
l 1. Discuss the side effects and adverse effects of the
HAART medications.
l 2. Refer the client to the hospital social worker.
l 3. Explain discontinuing HAART will cause rebound
HIV replication.
l 4. Tell the client to have regular lab work drawn.
96. The school nurse is talking to the mother of a child
with head lice. Which information should the nurse
discuss with the mother?
l 1. Shampoo the childs head with permethrin (Nix),
an ectoparasiticide.
l 2. Scrub the childs hair and scalp with lindane
(Kwell), a scabicide.
l 3. Blow-dry the childs hair on hot immediately after
shampooing.
l 4. Use a wide-toothed comb after shampooing the
childs hair.
Pharmacology
755
97. The male client is prescribed metronidazole (Flagyl)

for inflammatory bowel disease. Which information
l 1. Explain the clients significant other must take
Flagyl concurrently.
l 2. Tell the client he cannot drink alcohol while taking
this medication.
l 3. Instruct the client not to take the medication with
grapefruit.
l 4. Encourage the client to wear sunglasses when
outside while taking the medication.
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Page 756
ANSWERS
95. Correct answer 2: HAART involves three or four
756
97. Correct answer 2: If the client drinks alcohol while
expensive medications that must be purchased

monthly; without insurance the client will need
financial assistance, which is the role of the social
worker. Once the client can afford the medications,
then implementing medication teaching is appropriate. ContentPharmacology; Category of Health
taking Flagyl, the client will have an acute reaction

and vomit excessively. Having the significant other
take Flagyl concurrently is appropriate if the client is
taking medication for a vaginal infection. Grapefruit
does interact with some medications but not with
Flagyl, and Flagyl does not cause photosensitivity.

LevelSynthesis.

96. Correct answer 1: Nix kills adult lice and their

ova and is the drug of choice for lice. Kwell is not
recommended for children because of the risk for
convulsions. The hair should be combed while wet
with a fine-tooth comb. ContentPharmacology;
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Pharmacology
SECTION SIXTEEN
98. The nurse is administering the antifungal medication

ketoconazole (Nizoral) to a client with oral candidiasis
(thrush). Which instruction should the nurse provide the
client?
l 1. Tell the client to chew the medication thoroughly
before swallowing.
l 2. Demonstrate to the client how to apply the cream
with a sterile tongue blade.
l 3. Instruct the client to swish the medication in the
mouth and then to swallow.
l 4. Recommend the client apply elixir to sores and
then spit out the medication.
99. The client with a stage 4 pressure ulcer on the coccyx
area is being treated with an autolytic medication for
dbridement and an occlusive dressing. The unlicensed
assistive personnel (UAP) reports to the nurse that the
clients wound has a foul odor. Which intervention
l 1. Tell the UAP to check the clients oral temperature.
l 2. Notify the wound ostomy continence nurse
(WOCN).
l
l
757
3. Assess the clients pressure ulcer immediately.

4. Explain to the UAP the smell is expected due to
the treatment.
100. The female client tells the clinic nurse her eyes are
l
l
l
l
dry and irritated. Which intervention should the

nurse implement?
1. Recommend the client use artificial tears in both eyes.
2. Notify the ophthalmologist for prescription
eyedrops.
3. Check the clients eyes using the ophthalmoscope.
4. Instruct the client to wear eye shields at night.
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Page 758
ANSWERS
758
98. Correct answer 3: Thrush is a yeast infection in
100. Correct answer 1: If there is no redness or inflam-
the mouth; swishing the medication will apply it

topically to the oral lesions, and swallowing will
have a systemic effect on the thrush. Content
mation or signs of an infection, then the nurse

could recommend using artificial tears, which is
an over-the-counter medication. If the artificial
tears is ineffective, then the client may need a prescription. The ophthalmoscope is used to look at
the retina, and eye shields will not help dry
eyes. ContentPharmacology; Category of Health

99. Correct answer 4: This is an expected reaction

of this wound care treatment. The foul odor is
produced by the breakdown of cellular debris and
does not indicate that the wound is infected; therefore, the nurse would not ask the UAP to take the
clients temperature. ContentPharmacology; Category
LevelSynthesis.

LevelApplication.
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Page 759
INDEX
A
Abdomen
hard, rigid, 203204, 229230
in peptic ulcer disease, 193-194
Abdominal aortic aneurysm,
99-104, 117
Abdominal cramping, 219220
Abdominal hysterectomy, total,
439440
Abdominal pain, 685686
Abdominal-peritoneal resection,
693694
Above-the-knee amputation,
305306
Absence seizures, 517518
Abuse, 457464
Acanthosis nigricans, 410
Acetaminophen, 213214
Acetylcysteine, 699700
Acidophilus, 709710
Acquired immunodeficiency
syndrome, 3536, 253254,
411412, 587592, 631632,
655656, 755756
Activities of daily living, 281282
Acute bacterial prostatitis,
327328
Acute diverticulitis, 199202
Acute epiglottitis, 515516

Acute gastroenteritis, 221222
Acute glomerulonephritis, 335336
Acute myeloid leukemia,
535536
Acute otitis media, 4344
Acute pain, 683693
Acute pancreatitis, 263264,
267268, 275276
Acute renal failure, 321322
Acute sinusitis, 139140
Acyanotic cardiovascular defect,
507508
Addison disease, 253254
Addisonian crisis, 715716
Adolescents, 445446. See also
Pediatrics/pediatric disorders
Adrenal disorders, 253258
Adrenalectomy, 271272,
715716
Adrenocorticotropic hormone,
253254
Adriamycin. See Doxorubicin
Adult respiratory distress
syndrome, 155162
Advance directive, 367368,
583584
AIDS. See Acquired

immunodeficiency syndrome
Airway management, 1516
Airway obstruction, 574
Alcohol, 265266, 415416
Alcoholism, 413414, 743744
Allergic dermatitis, 627628
Allergies, 623630, 724
Allopurinol, 719720
Alprazolam, 395396, 741742
Alzheimer disease, 403404,
407408
American Cancer Society,
195196
American Diabetic Association,
239240
American Spinal Injury
Association, 1314
Aminophylline, 731732
Amniocentesis, 475476
Amphetamines, 419420,
539540, 745746
Amputation, 301306
Amsler grids, 46
Amylase, serum, 264
Anemia, 109114, 535538, 596,
705706
Anesthesia, 681682
Aneurysm, abdominal aortic,

99104, 117
Angina, 5761
Angiocatheter, 301302
Angiotensin-converting enzyme
inhibitors, 9394
Ankle fracture, 533534
Anorexia nervosa, 411414
Anthrax, 565568, 725726
Antibiotics, 201202, 513514,
531532, 733734
Anticholinergic effects, 387388
Anticholinesterase medications,
617618, 623624
Anticipatory grieving, 2728,
145146, 607608
Anticoagulants, 6970, 107108,
163164, 294, 310
Anticonvulsants, 1718
Antidepressants
selective serotonin reuptake
inhibitors, 375376,
737738
tricyclic, 373374
Antiembolism hose, 107108
Antihistamines, 629630
Anti-inflammatory medication,
507508
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Page 760
INDEX
Antipsychotic medications,
383386, 739742
Antisocial personality, 391392
Antiviral medication, 659660
Anxiety disorders, 395402,
741744
Aortic murmur, 7374
Aortic stenosis, 7172
APGAR score, 479480
Appendectomy, 525526
Appendicitis, 687688
AquaMEPHYTON, 109110
Aricept. See Donepezil
Arterial blood gases, 157158,
182, 725726
Arterial hypertension, 8788,
729730
Arterial occlusive disease,
95100
Arteriovenous fistula, 355356
Arthritis
osteoarthritis, 4546,
279284
rheumatoid, 593598,
749750
Ascites, 211212
Aseptic meningitis, 3334
Aspiration pneumonia, 135136
760
Aspirin, 4546, 118, 507508,
523524, 597598
Asthma, 127134
Atherosclerosis, 6168, 100,
102, 104
Ativan. See Lorazepam
Atorvastatin, 6566, 701702
Atrial fibrillation, 25, 7778
Atropine, 78
Attention deficithyperactivity
disorder, 539542, 745746
Aura, 4950
Autism, 543544
Autonomic dysreflexia, 4, 12
Avoidant personality, 389390
Azulfidine. See Sulfasalazine
B
Babbling, 500
Baclofen, 751752
Bacterial meningitis, 3136,
519520
Bacterial prostatitis, 327328
Barlow maneuver, 487488,
530
Barrett esophagitis, 188
Basal cell carcinoma, 653654
Bee-sting allergy, 623624
Below-the-knee amputation,
301302
Beneficence, 153154
Benign prostatic hypertrophy,
325332, 720
Benzodiazepines, 395396
Beta blockers, 119120,
753754
Bile, 199200
Biological response modifier,
735736
Biopsy, sentinel node breast,
455456
Bioterrorism, 563568, 725726
Bipolar disorder, 377384,
543544, 739740
Birth control, 445452
Black lung, 127128
Bladder
cancer of, 341346
overactive, 433434
Blood pressure, 1112, 8990,
499500
Blood screening, 215216
Blood transfusion, 111112,
114
Blood urea nitrogen, 335336
Borborygmi, 222
Borderline personality, 389390,

393394
Bottle caries, 501502
Botulism, 563564
Bowel sounds, 199200
Braden scale, 645646
Brain attack. See Cerebrovascular
accident
Brain natriuretic peptide,
115116
Brain tumors, 2531, 5152
Breast cancer, 453454, 463464,
735736
Breast disorders, 451458
Breast reconstruction surgery,
453454
Breastfeeding, 447448
Bronchoscopy, 147148
Bruit, 100
Buck traction, 311312
Bulimia nervosa, 409410
BUN, 335336
Burns, 639644, 663664,
745746
C
Calcitriol, 717718
Calcium, 287288, 323324
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Page 761
INDEX
Calcium channel blockers, 8788,
633634
Calcium EDTA, 577578
Calculi
renal, 335342, 633634,
719720
ureteral, 339342
Caldwell-Luc procedure, 141142
Cancer
bladder, 341346
breast, 453454, 463464,
735736
colorectal, 193198
laryngeal, 149154, 173174,
689690
lung, 143150, 175176
ovarian, 437438
prostate, 347349
skin, 649656, 669671
testicular, 349352
uterine, 439440
Candidiasis, 231232, 588,
757758
Capillary refill, 509510
Car seats, 499500
Carafate. See Sucralfate
Carbamazepine, 381382
Carbon monoxide poisoning,
575576
761
Carcinoembryonic antigen, 196
Cardiac arrest/codes, 553556,
727728
Cardiac catheterization, 509510
Cardiac compressions, 553554
Cardiac dysrhythmias, 5960
Cardiac inflammatory disorders,
7984
Cardiogenic shock, 725726
Cardiopulmonary resuscitation,
555556
Cardiovascular disorders
abdominal aortic aneurysm,
99104, 117
anemia, 109114, 535538,
596, 705706
angina, 5761
atherosclerosis, 6168
cardiac inflammatory disorders,
7984
congestive heart failure, 8994
deep vein thrombosis, 105110
dysrhythmias, 7379
essential hypertension, 8590
management of, 115120
myocardial infarction, 5761
pediatric, 505510
peripheral vascular disease,
9599
valve disorders, 6973

Caries, 501502
Carisoprodol, 729730
Case manager, 229230
Cast, 529530
Catapres, 414
Cataracts, 4546
Cathartics, 223224, 233234
Ceftriaxone, 39, 749750
Cellulitis, 657658, 668
Cerebrovascular accident, 2125,
5354
Cervical neck injury, 293294
Chancres, 359360, 364
Change-of-shift report, 1314
Chemical burns, 643644
Chemical spill, 579580
Chemotherapy
administration of, 735736
intravesical, 343344
ovarian cancer treated with,
439440
Chest pain. See Angina
Chest physiotherapy, 134
Chest trauma, 165172
Chest tubes, 167170
Cheyne-Stokes respirations,
175176
Childbirth, 479480
Children. See also

febrile seizures, 1920
in psychiatric unit, 421422
type 2 diabetes mellitus in,
713714
Chlamydia, 361364
Chlorine, 567568
Chlorpromazine, 383384,
741742
Cholecystectomy
laparoscopic, 203206
open, 203208
Cholelithiasis, 207208
Cholesterol, 6364
Cholinergics, 4748
Cholinesterase inhibitor, 699700
Chondroitin, 283284
Chronic kidney disease,
351354
Chronic obstructive pulmonary
disease, 123128, 255256,
273274, 731732
Chronic pain, 747748
Chronic pancreatitis, 265270
Chronic pyelonephritis, 333334
Chvostek sign, 324, 561562
Circumcision, 487488
Claustrophobia, 2728, 399400
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INDEX
Cleft lip and palate, 489490,
523524
Client safety, 427428
Clinic manager, 465466
Clomiphene (Clomid), 441442
Closed head injury, 34, 78,
263264
Clostridium botulinum, 219220
Clozapine (Clozaril), 387388
Clubfeet, 529530
Cocaine, crack, 417418
Cochlear implant, 677678
Coffee-ground emesis, 191192
Cognitive disorders, 401408
Cognitive impairments, 4142
Colonoscopy, 197198, 203204
Colorectal disease, 193198
Colostomy, 195198, 527528,
650, 693694
Coma, 243244, 251252,
583584
Common cold, 139140
Community-acquired
pneumonia, 135136
Compartment syndrome, 297298
Complementary and alternative
medicine
multiple sclerosis treated with,
609610
762
osteoarthritis treated with,
283284
respiratory disorders treated
with, 143144
St. Johns wort, 441442
Condoms, 357358, 445446,
448449
Conduct disorder, 541542,
545546
Confabulation, 403404
Confusion, 405406
Congenital aganglionic
megacolon, 525526
Congenital diaphragmatic hernia,
523524
Congestive heart failure, 8994,
509510
Constipation, 201202, 206,
223228
Continent urinary diversion,
345346
Continuous bladder irrigation,
326, 329330, 718
Coronary artery disease, 115119
Corrosives, 573574
Corticosteroids, 601602
Cortisol, 253254
Coumadin, 109110
Coup/contrecoup head injury,

519520
Crack cocaine, 417418
Crackles, 243244
Craniotomy, 2930
Creatinine, 355356
Cred maneuver, 289290
Critical incident stress
management, 571572
Crohn disease, 179182
Crutchfield tongs, 910
Cullen sign, 266
Cushing syndrome, 253256,
271272, 715716
Cutaneous lupus erythematosus,
601602
Cyanide gas, 566
Cyclophosphamide, 607608
Cyst, ovarian, 439440
Cystic fibrosis, 511512
Cystitis, 333334
D
Date rape drugs, 417418
DDAVP, 262
D-dimer test, 161162
Decadron. See Dexamethasone
Decerebrate posturing, 572,
581582
Decorticate posturing, 56, 2728,

520
Deep vein thrombosis, 14,
105110, 119120, 311312,
482
Defibrillation, 7576
Dehydration, 234, 323324, 538
Delirium, 401402
Delirium tremens, 744
Dementia, vascular, 405406
Democratic leadership style,
369370
Depakote. See Valproic acid
Dependent personality, 391392
Depression, major, 373378,
421424, 543544
Dermatitis, allergic, 627628
Detrol. See Tolterodine
Developmental dysplasia of the
hip, 529530, 533534
Dexamethasone, 3132, 5152
Dextran, 561562
Diabetes insipidus, 5354,
259262
Diabetes mellitus
type 1, 237242, 713714
type 2, 241248, 713714
Diabetic ketoacidosis, 237242,
581582
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INDEX
Diagnostic and Statistical Manual
of Mental Disorders, 393396
Dialysis
hemodialysis, 357358, 382
peritoneal, 353354
Diaphragm (contraception), 450
Diarrhea, 223228, 525526
Diet
for calcium phosphate renal
calculi prevention, 335336
for essential hypertension, 8586
for heart valve disease, 7172
for lower esophageal sphincter
dysfunction, 185186
low-fat, low-cholesterol,
6768
for osteoporosis, 287288
pediatric, 507508, 525526
Diethylstilbestrol, 348
Digoxin
in adults, 8992, 115116
in children, 505506, 510,
547548
Dilantin. See Phenytoin
Dilutional hyponatremia, 258
Diphenhydramine, 629630
Disaster nursing, 567574
Discharge teaching and
instructions
763
abdominal aortic aneurysm,
103104
allergies, 627628
angina, 5758
bipolar disorder, 381382
cathartic abuse, 223224
chronic kidney disease,
355356
colonoscopy, 203204
congestive heart failure, 9394
coronary artery disease,
115119
Cushing disease, 255256
deep vein thrombosis,
103104
diverticulosis, 201202
essential hypertension, 8586
head injury, 78
inflammatory bowel disease,
179180
laser in situ keratomileusis,
681682
low back pain, 289290
lung cancer, 147148
myasthenia gravis, 617618,
621622
pancreatitis, 265266
pneumonia, 515516
psoriasis, 661662
pulmonary embolus, 163164

renal calculi, 335336
rheumatic fever, 8384
supratentorial brain surgery,
521522
systemic lupus erythematosus,
599600
total hip replacement,
307311
uterine prolapse, 433434
valve disorders, 7172
wedge resection for breast
cancer, 453454
Disciplining of employees,
465466
Disease-modifying antirheumatic
drugs, 593596, 749750
Diverticulosis/diverticulitis,
199204, 707708
Do Not Resuscitate order,
175176
Domestic abuse, 459460
Donepezil, 699700
Dopamine, 559560, 725726
Dorsalis pedis pulse, 99100
Down syndrome, 521522
Doxorubicin, 737738
Drooling, 515516
Drug overdose, 575578
Drug rehabilitation program,

415416
DSM-IV-TR. See Diagnostic and
Statistical Manual of Mental
Disorders
Dual-energy x-ray absorptiometry,
285286
Duchenne muscular dystrophy,
533534
Dyskinesia, 42
Dyspareunia, 439440
Dysphagia, 2324, 604
Dysrhythmias, 7379
E
Eating disorders, 407414
Echinacea, 144
Echocardiogram, 7172
Echolalia, 385386
Ectopic pregnancy, 473474
Edrophonium chloride, 617618
Elder abuse, 461462
Electrocardiogram, 505506
Electrolytes, 321326
Emaciation, 417418
Embolus, pulmonary, 161165
Emergency nursing
bioterrorism, 563568
cardiac arrest codes, 553556
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INDEX
disaster/triage nursing,
567574, 583584
poisoning, 573578
shock, 557564
Emergency operations plan,
571572
Employee discipline, 465466
Endarterectomy, 2122
Endocarditis
infective, 8384
subacute bacterial, 8182
Endocrine disorders
adrenal disorders, 253258
pancreatitis, 263270,
275276
pituitary disorders, 257264
thyroid disorders, 247252
type 1 diabetes, 237242,
713714
type 2 diabetes, 241248,
713714
Endoscopic retrograde
cholangiopancreatography,
207208, 267268
Endotracheal tube, 160
End-stage chronic obstructive
pulmonary disease, 127128
764
End-stage liver disease, 209212,
709710
End-stage renal disease, 353354,
357358, 717718
Epiglottitis, 515516
Epilepsy, 1516, 521522
Epinephrine, 555556, 728
Epi-pen, 623624
Erythropoietin-1, 351352
Eskalith. See Lithium
Esophagogastroduodenoscopy,
185186, 189190
Essential hypertension, 8590, 104
Ethical principles
beneficence, 153154
fidelity, 231232, 271272
veracity, 491492, 541542
Exercise
Kegel, 431432
osteoporosis and, 287288
in type 1 diabetes, 239240
Exploratory laparotomy, 673674
Extracorporeal membrane
oxygenation, 523524
Extrahepatic biliary atresia,
527528
Extrapyramidal side effects, 384,
388
Eyedrops, 4748
F
Faces pain scale, 687688
Fat embolism, 298299
Febrile seizures, 1920
Fecal diversion, 649650
Fecal impaction, 223224
Female condom, 445446
Femoral cardiac catheterization,
509510
Femoral fracture, 297298
Fertilization, in vitro, 441442
Fetal monitoring, 477478
Fexofenadine, 625626
Fibroid tumors, uterine,
437438
Fibular fracture, 297298
Fidelity, 231232, 271272
Filter needle, 78
Finasteride, 330
Flaccid posturing, 56
Flagyl. See Metronidazole
Fluid and electrolytes, 321326
Fluid deprivation test, 259260
Fluid resuscitation formulas, 746
Flumazenil, 742
Fluticasone, 131132
Folic acid deficiency anemia,
111114
Foreign objects, 517518
Fractures, 295300, 531532

Friction rub, 80
Frontal lobe brain tumor, 2728
Full-thickness burns, 639640,
745746
Fundal displacement, 483484
Furosemide, 9394
G
Gait, 291292
Gait belts, 2324, 289290,
368
Gallbladder disease, 203208,
233234
Gamma knife stereotactic
surgery, 31
Gardasil, 435436
Gastric lavage, 577578
Gastric reflux, 130
Gastritis, 223224
Gastroenteritis, 219224,
323324, 525526
Gastroesophageal reflux disease,
183188
Gastrointestinal disorders
colorectal disease, 193198
constipation, 201202, 206,
223228
diarrhea, 223228, 525526
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INDEX
diverticulosis/diverticulitis,
199204, 707708
gallbladder disease, 203208,
233234
gastroenteritis, 219224
gastroesophageal reflux disease,
183188
hepatitis, 213218, 231232,
709710
inflammatory bowel disease,
179184, 527528,
707708, 755756
liver disease, 209214
pediatric, 523528
peptic ulcer disease, 189194,
231232, 707708
Gastrostomy feedings,
percutaneous, 133134,
227228
General anesthesia, 681682
Generalized anxiety disorder,
395396, 743744
Genitourinary disorders
benign prostatic hypertrophy,
325332
bladder cancer, 341346
fluid and electrolytes, 321326
765
male cancers, 347352
prostate cancer, 347349
renal calculi, 335342,
633634, 719720
renal failure, 351358
sexually transmitted diseases,
357364, 436, 450
urinary tract infection,
331336
Gingival hyperplasia, 522, 698
Glasgow Coma Scale, 34, 584,
612
Glaucoma, 4748
Globulin, 217218
Glomerulonephritis, 335336
Glucocorticoids, 609610
Glucosamine, 283284
Gonorrhea, 359362
Gowers maneuver, 534
Graduate nurse, 6162, 113114,
173174, 187188, 365366,
547548, 579580
Graves disease, 247248
Grey-Turner sign, 266
Grieving, 607608
Group A beta-hemolytic
streptococcal infection, 507508
Guillain-Barr syndrome,
105106, 611618, 630
H
Hallucinations, 40, 385386
Haloperidol (Haldol), 387388
Hand washing, 664
Head injury
adult, 38, 581582
pediatric, 519520
Headache, 1112, 517518,
549550
Health Insurance Portability and
Accountability Act, 52, 460,
667668
Health promotion, 499506
Heart block, 7778
Heart murmurs, 6970, 7374,
117118
Heart sounds, 5758, 7980, 115
Heartburn, 183184, 188
Helicobacter pylori, 707708
Hemarthrosis, 539540
Hematological disorders,
535540
Hemiparesis, 2526
Hemodialysis, 357358, 382
Hemophilia A, 539540
Hemothorax, 169170
Heparin, 107108, 119120,
163164, 295296, 699700,
703704, 721722
Hepatic encephalopathy, 709710
Hepatitis, 213218, 231232,
709710
Hepatoportoenterostomy, 528
Hernia, congenital diaphragmatic,
523524
Herniated disc disease, 289296
Herpes zoster, 661662
Hiatal hernia, 188
Highly active antiretroviral
therapy, 755756
Hip
developmental dysplasia of,
529530, 533534
fracture of, 297298
total replacement of, 307314
Hirschsprung disease, 525526
Histamine-2 blockers, 189190
Histrionic personality, 393394
HMG-CoA reductase inhibitors,
6566, 701702
Homan sign, 109110
Homograft, 641642
Hospice care, 592
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INDEX
Hospital ethics committee,
495496, 669670
Human chorionic gonadotropin,
443444
Human immunodeficiency virus,
587588, 753754
Human papillomavirus, 359360
Humeral fracture, 297300
Hydrocephalus, 517518
Hydrochlorothiazide, 8586
Hydrocortisone, 627628
Hydroxychloroquine sulfate,
749750
Hyperglycemic, hyperosmolar
nonketotic coma, 243244
Hyperinsulinemia, 269270, 410
Hyperkalemia, 326
Hyperlipidemia, 507508
Hypernatremia, 321322
Hyperparathyroidism, 269270
Hypertension
arterial, 729730
after erythropoietin
administration, 352
essential, 8590, 104
pregnancy-induced, 472,
475476
Hypertensive crisis, 8586
766
Hyperthyroidism, 249250, 274,
717718
Hypoactive bowel sounds, 199200
Hypoglycemia, 18, 486
Hypoglycemics, 241242
Hypokalemia, 92
Hypophysectomy,
transsphenoidal, 259260
Hyporeflexia, 612
Hypothyroidism, 249252
Hypovolemia, 104, 620, 680
Hypovolemic shock, 210, 558,
561562
Hypoxemia, 162
Hysterectomy, 439440, 494
I
Iatrogenic, 255256
Ileal conduit, 343346
Ileostomy, 179180
Immobilizer, 295296
Immune inflammatory disorders
acquired immunodeficiency
syndrome, 3536, 253254,
411412, 587592,
631632, 655656,
755756
allergies, 623630, 724
Guillain-Barr syndrome,
105106, 611618, 630
multiple sclerosis, 603610,
747748, 751752
myasthenia gravis, 617624,
631632
rheumatoid arthritis, 593598,
749750
599604
Immunizations, 501502,
751752
Immunosuppressives, 597598
Immunotherapy, 625626
Impaired gas exchange, 133134
Impaired mobility, 3940
Impetigo, 657658
In vitro fertilization, 441442
Incentive spirometer, 125126,
204
Incontinence, stress, 431434
Increased intracranial pressure,
697698
Indwelling urinary catheter,
331332, 364
Infant. See also Children;
care of, 499502

maternal child health, 485492
Infectious diarrhea, 227228
Infective endocarditis, 8384
Infertility disorders, 441446
Inflammatory bowel disease,
179184, 527528, 707708,
755756
Influenza type A, 143144
Informed consent, 673674
Infratentorial craniotomy, 2930
Infusion pump, 557558,
665666
Inhaled steroids, 131132
Insulin, 237238, 713714
Integumentary system
burns, 639644, 663664
pressure ulcers, 643650,
663664, 757758
skin cancer, 649656, 669671
skin infections, 655662
Intention tremors, 3738
Interferon alfa-2a, 709710
Intermediate-acting insulin,
237238
Intermittent claudication, 6566
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INDEX
International Normalized Ratio,
163164
Intracranial pressure, increased,
78
Intrapartum care, 475482
Intrauterine device, 449450
Intravenous piggyback, 489490,
527528
Intravenous pump, 40, 535536,
681682
Intravenous pyelogram, 337338,
633634, 719720
Intravesical chemotherapy,
343344
Iodine 131, 249250
Iron deficiency anemia, 111112,
705706
Iron overdose, 577578
Isoniazid, 753754
IUD. See Intrauterine device
J
Jehovahs Witnesses, 481482,
733734
Jock itch. See Tinea cruris
Joint replacements, 307312
Juvenile arthritis, 531532
767
K
Kayexalate, 367368
Kegel exercises, 431432
Ketoconazole, 757758
Ketones, 239240
Kidneys
acute failure of, 321322. See
also Renal failure
chronic disease of, 351354
end-stage renal disease,
353354, 357358,
717718
Klebsiella, 125126
Kussmaul breathing, 241242
L
Lactulose, 209210, 709710
Laminectomy, 293294, 316
Laparoscopic cholecystectomy,
203206
Laparotomy, exploratory,
673674
Laryngeal cancer, 149154,
173174, 689690
Laryngeal edema, 247248
Laryngectomy, 149154,
173174
Laser in situ keratomileusis,

677678, 681682
Latex allergy, 449450, 467468,
623624
Laxatives, 209210, 233234,
409410
Lead poisoning, 577578
Lesions, 651652
Leukemia, 535536
Leuprolide, 443444
Levodopa, 4142
Levodopa/carbidopa, 699700
Levothyroxine, 249252, 715716
Librium, 414
Lice, 661662, 755756
Licensed practical nurse, 3940,
4950, 6162, 225226,
303304, 425426, 483484,
547548, 631632
Lidocaine, 7374, 557558
Lift pad, 645646
Lioresal. See Baclofen
Lipitor. See Atorvastatin
Lithium, 379382, 424, 426,
739740
Lithotripsy, 339340
Liver disease, 209214
Long-term care facility, 281282,

285286, 289290, 661662
Lopressor. See Metoprolol
Lorazepam, 743744
Low back pain, 102, 289296,
369370
Low-density lipoprotein, 6566
Lower esophageal sphincter
dysfunction, 185186
Lower respiratory infections,
133138
Low-fat, low-cholesterol diet,
6768
Lumbar puncture, 613616
Lung cancer, 143150, 175176
Lung expansion, 512
Lyme disease, 655656
M
Macular degeneration, 4546
Mafenide acetate, 641642
Magnesium sulfate, 475476
Magnetic resonance imaging, 56,
2728, 605606
Major depression, 373378,
421424, 543544
Male infertility, 441446
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INDEX
Malignant hyperthermia, 680
Malignant melanoma, 653656
Mania, 377384
Mannitol, 78, 697698
Marijuana, 419420
Mastectomy, modified radical,
451452, 455458
Mastitis, 494
Material safety data sheet,
569570
Maternal child health
antepartum, 471476
infant, 485492
newborn, 485492
Mechanical heart valves, 6970
Mechanical ventilation, 157160,
613614
Medical/surgical nurse, 493494
Medication. See Pharmacology;
specific medication
Medication administration
record, 5152
Medication errors, 495496
Medroxyprogesterone, 451
Megestrol (Megace), 411412
Melanin, 652
768
Melena, 112
Mnire disease, 4344
Meningitis, 3136, 142
Meningococcal meningitis, 3132
Menorrhagia, 109110
Mental health disorders
anxiety disorders, 395402,
741744
bipolar disorder, 377384,
543544, 739740
cognitive disorders, 401408
depression, 373378, 421424
eating disorders, 407414
mania, 377384
personality disorders, 389396
schizophrenia, 383388
substance abuse disorders,
413420
Mestinon. See Pyridostigmine
Metabolic acidosis, 182
Metastases, 145146
Metered dose inhaler, 131132,
721722
Metformin, 245246, 705706
Methadone, 415416, 743744
Methotrexate, 593596
Methylphenidate, 539540,
745746
Methylprednisolone, 609610,
731732
Metoprolol, 753754
Metronidazole, 755756
Mid-epigastric pain, 685686
Misoprostol, 193194
Mitral valve
regurgitation of, 117118
stenosis of, 7374
Modifiable risk factors
angina, 5960
female infertility, 445446
osteoporosis, 285286
pressure ulcers, 645646
Modified radical mastectomy,
451452, 455458
Montelukast, 127128, 731732
Morphine sulfate, 581582,
687688
Mucomyst. See Acetylcysteine
Mucosal barrier agents, 185186
Multiple sclerosis, 603610,
747748, 751752
Murmurs, heart, 6970, 7374,

117118
Muscular dystrophy, 533534
Musculoskeletal disorders
amputation, 301306
fractures, 295300, 531534
herniated disc disease,
289296
joint replacements, 307312
low back pain, 289296
osteoarthritis, 279284
pediatric, 529534
Myasthenia gravis, 617624,
631632
Myasthenic crisis, 621622
Myelomeningocele, 517518
Myocardial infarction, 5761,
117118, 417418
Myxedema coma, 251252
N
Naloxone (Narcan), 575576,
747748
Narcissistic personality, 391392
Nasogastric tube, 269270, 725
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INDEX
Nausea and vomiting, 475476.
See also Vomiting
Neck dissection, radical, 153154,
689690
Neck stiffness, 140
Needlestick injuries, 589590
Negligence, 463464
Neostigmine, 621622
Nerve agents, 567568
Neurogenic shock, 559560
Neuroleptic malignant syndrome,
387388
Neurological disorders
brain tumors, 2531, 5152
cerebrovascular accident,
2125, 5354
head injury, 38
management issues, 4954
meningitis, 3136
Parkinson disease, 3742
pediatric, 517524
seizures, 1520
sensory deficits, 4348
spinal cord injury, 914
Newborn, 485492
Nicotine, 6364
Nitroglycerin, 5758, 6162,
701702
769
Nits, 661662
Nizoral. See Ketoconazole
Nolvadex. See Tamoxifen
Nonsteroidal anti-inflammatory
drugs, 8182, 186, 281282,
531532, 595596, 751752
Norton scale, 645646
Nosocomial-acquired urinary
tract infection, 335336
Nuchal rigidity, 3132, 140
O
Oat cell carcinoma, 149150
Obesity, 279280, 411412
Obsessive-compulsive disorder,
397400
Oil retention enemas, 224
Open cholecystectomy, 203208
Operative care
acute pain, 683693
postoperative nursing, 679684
preoperative care, 673678
Oppositional defiant disorder,
541542
Oral contraceptive pills,
447450
Orchiectomy, bilateral, 349350
Orlistat, 411412, 709710

Orthostatic hypotension, 740
Ortolani maneuver, 488, 530
Osmitrol. See Mannitol
Osteoarthritis, 4546, 279284
Osteomyelitis, 531532
Osteoporosis, 285290
Otic drops, 4344
Otitis media, acute, 4344
Outpatient mental health clinic,
423424
Ovarian cyst, 439440
Ovarian disorders, 435440
Ovarian overstimulation
syndrome, 443444
Overactive bladder, 433434
Over-the-counter medications,
137138
P
Pain
abdominal, 685686
acute, 683693
low back, 102, 289296,
369370
mid-epigastric, 685686
osteoarthritis, 283284
patient-controlled analgesia for,

349350, 689690
postoperative, 683684,
747748
right upper quadrant, 233234
Pain medications, 313314,
691692
Pancreatitis, 263270, 275276
Pancytopenia, 114
Panic attacks, 397398
Paracentesis, 209210
Paralysis, 2324
Paranoid personality, 389390
Parkinson disease, 3742, 699700
Paroxetine, 375376, 399400
Partial laryngectomy, 149150
Partial seizure, 1718
Patient-controlled analgesia,
349350, 689690, 711712
Pavlik harness, 534
Pediatrics/pediatric disorders. See
also Children; Infant; Newborn
cardiovascular system, 505510
gastrointestinal system,
523528
health promotion, 499506
hematological system, 535540
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INDEX
musculoskeletal system,
529534
neurological system, 517524
pain assessments, 687688
psychiatric, 539546
respiratory system, 511518
type 2 diabetes mellitus,
713714
Pelvic floor dysfunction, 431436
Pelvic fracture, 299300
Pelvic inflammatory disease,
361362
Peptic ulcer disease, 189194,
231232, 707708
Percutaneous gastrostomy
feedings, 133134, 227228
Pericardial effusion, 80
Pericardiocentesis, 8284
Pericarditis, 7982
Peri-pad, 431432
Peripheral edema, 257258
Peripheral vascular disease, 6364,
9599
Peritoneal dialysis, 353354
Peritonitis, 203204
Personal protective equipment,
557558, 563564
Personality disorders, 389396
770
Pertussis, 511512
Pessary, 435436
Phantom pain, 303304
Pharmacology, 697758
Phenergan. See Promethazine
Phenylbutazone, 595596
Phenytoin, 1720, 521522,
697698
Pheochromocytoma, 271272
Photophobia, 40
Pituitary disorders, 257264
Pituitary tumor, 2930
Placenta previa, 478
Plantar reflexes, 1112
Plaquenil. See
Hydroxychloroquine sulfate
Plasmapheresis, 619620
Platelet count, 484
PLEUROvac, 169170
Pneumocystis carinii pneumonia,
589590, 754
Pneumonectomy, 147148,
171172
Pneumonia, 3940, 135136,
173174, 204, 515516,
733734
Pneumothorax, 157158,
165168
Poisoning, 501502, 573578,

727728
Polydipsia, 473474
Polyphagia, 241242
Polyuria, 473474
Postanesthesia care unit,
679680, 693694, 711712
Postoperative nursing,
679684
Postpartum care, 481486
Post-traumatic stress disorder,
397400
Posture, 291292
Potassium, 321322, 325326
Prednisone, 255256
Pre-eclampsia, 472, 475476
Pregnancy
antepartum care, 471476
ectopic, 473474
intrapartum care, 475482
postpartum care, 481486
Pregnancy-induced hypertension,
472, 475476
Premature ventricular
contractions, 5960, 554
Preoperative care, 673678
Pressure ulcers, 643650,
663664, 757758
Primary progressive multiple

sclerosis, 607608
Prolapsed umbilical cord,
477478
Promethazine, 711712
Prostate gland
benign hypertrophy of,
325332, 720
cancer of, 347349
transurethral resection of,
325330, 365366
Prostate-specific antigen,
329332
Prostatitis, 327328
Prostigmin. See Neostigmine
Psoriasis, 661662
Psychiatric disorders, 539546.
See also Mental health disorders
Pulmonary embolus, 107108,
161165
Pulse oximeter, 134, 643644,
666
Pulsus paradoxus, 80
Purse-lip breathing, 151152
Pyelogram, intravenous,
337338, 633634, 719720
Pyelonephritis, chronic, 333334
Pyloric stenosis, 527528
2133_Index_759-774.qxd
11/7/09
6:53 PM
Page 771
INDEX
Pyridostigmine, 623624
Pyrosis, 188
Q
Quetiapine, 741742
R
Radiation therapy, 149150, 536
Radical mastectomy, modified,
451452, 455458
Radical neck dissection, 153154,
689690
Radioactive iodine, 249250
Ranitidine, 189190
Rape, 457460, 463464
Reactive airway disease, 127134,
731732
Rectocele, 433434
Reflexes, 487488
Regional enteritis, 179182
Registered nurse, 141142,
467468, 547548
Renal calculi, 335342, 633634,
719720
Renal failure, 269270, 351358
Reperfusion dysrhythmias, 5960
Respiratory disorders
adult respiratory distress
syndrome, 155162
771
asthma, 127134
chest trauma, 165172
chronic obstructive pulmonary
disease, 123128
laryngeal cancer, 149154,
173174
lower respiratory infections,
133138
lung cancer, 143150,
175176
pediatric, 511518
pulmonary embolus, 161165
reactive airway disease,
127134
upper respiratory infections,
137144
Respiratory failure, 616
Respite care, 407408
Restoril, 482
Restraint of client, 315316
Retinal detachment, 4950,
677678
Retroviruses, 587588
Reye syndrome, 523524
Rheumatic fever, 6970, 8184
Rheumatoid arthritis, 593598,
749750
Rhinitis, allergic, 630, 635636
RhoGAM, 481482
Rifampin, 135136, 753754
Right upper quadrant pain,
233234
Risk factors
angina, 5960
female infertility, 445446
ovarian cancer, 437438
pressure ulcers, 645646
Risperidone (Risperdal),
387388, 739740
Rocephin. See Ceftriaxone
Roferon-A. See Interferon
alfa-2a
Rohypnol, 417418
Romazicon. See Flumazenil
RU-486, 461462, 727728
Rubella, 503504
S
Safety
adolescent, 545546
client, 427428, 590
newborn, 491492
Salmonellosis, 219220
Sarin, 567568
Saw palmetto, 6162, 328330,

719720
Scabies, 659660
Schizophrenia, 383388,
739740
Seizures, 1520, 517518
Selective serotonin reuptake
inhibitors, 375376, 737738
Semi-Fowler position, 194
Sensory deficits, 4348
Sentinel node breast biopsy,
455456
Septic meningitis, 3336
Septic shock, 559562
Septicemia, 559560
Seroquel. See Quetiapine
Serotonin syndrome, 376,
737738
Sexual abuse, 459460
Sexual assault nurse examiner,
457458
Sexual harassment, 175176
Sexuality, 503504
Sexually transmitted diseases,
357364, 436, 450
Shaken baby syndrome, 520
Sharps container, 365366
Shock, 509510, 557564
Shunt, 517518
2133_Index_759-774.qxd
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6:53 PM
Page 772
INDEX
Sickle cell anemia, 537538
Sickle cell crisis, 537538,
549550
Sigmoid colostomy, 195198,
693694
Singulair. See Montelukast
Sinus bradycardia, 7576
Sinusitis, 139140
Skin cancer, 649656, 669671
Skin infections, 655662
Small-cell carcinoma, 143144
Smoking, 676
cessation of, 415416
lung cancer and, 143146
osteoporosis and, 285286
Snakebite, 575576
Sniffing, 419420
Soma. See Carisoprodol
Speech therapy, 678
Sperm banking, 350
Spermicide, 447448
Spica cast, 534
Spinal anesthesia, 681682
Spinal cord injury, 914, 5354
Spinal shock, 910
Spiral fracture, 531532
Spontaneous pneumothorax,
169170
772
Sputum, 123128
Squamous cell carcinoma,
653654
St. Johns wort, 441442,
751752
Standard precautions, 564, 588
Staphylococcal food poisoning,
221222
Status asthmaticus, 129130
Status epilepticus, 1718
Stimulant laxatives, 409410
Stoma, 343344
Streptococcal infection, 507508
Stress incontinence, 431434
Stroke. See Cerebrovascular
accident
Subacute bacterial endocarditis,
8182
Substance abuse disorders,
413420
Sucralfate, 706
Sudden cardiac death, 553554
Sudden infant death syndrome,
513514
Suicide, 377378, 422424
Sulfamylon. See Mafenide
acetate
Sulfasalazine, 707708
Sunburn, 639640
Sunscreen, 649650
Supratentorial brain surgery,
521522
Surfactant therapy, 160
Surgery
acute pain, 683693
postoperative nursing,
679684
preoperative care, 673678
Swan-neck fingers, 593594
Synchronized cardioversion,
117118
Syndrome of inappropriate
antidiuretic hormone, 30,
257258, 261264
Synthroid. See Levothyroxine
Syphilis, 361364
Systemic lupus erythematosus,
599604
T
Tacrine, 405406
Tamoxifen, 735736
TBI Act, 78
Tegretol. See Carbamazepine
Telemetry, 7380
Tension pneumothorax, 167168
Testicular cancer, 349352

Testicular self-examination,
349350
Testosterone, 445446
Tetralogy of Fallot, 505506
Thiamine, 413414
Thiazide diuretics, 8586
Third heart sound, 116
Thorazine. See Chlorpromazine
Thrombolytic therapy, 5960
Thrombolytics, 699700
Thrush, 201202, 231232
Thyroid disorders, 247252
Thyroid hormones, 273274
Thyroid storm, 249250
Thyroidectomy, bilateral,
247250, 323324
Tibia fracture, 297298
Tinea cruris, 657658
Tissue plasminogen activator,
2122
Tobacco, 6364
Tolterodine, 433434
Tonic-clonic seizure, 1518
Tonsillectomy, 513514
Tonsillitis, 141142
Total abdominal hysterectomy,
439440
2133_Index_759-774.qxd
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Page 773
INDEX
Total hip replacement, 307314
Total knee replacement, 307310
Total parenteral nutrition,
179180, 183184, 195196,
323324
TRAM flap, 454
Transient ischemic attacks, 2122
Transsphenoidal hypophysectomy,
2930, 259260
Transurethral resection of the
prostate, 325330, 365366
Traumatic brain injury, 36
Traumatic Brain Injury Act, 78
Travelers diarrhea, 219220
Tremors, 3738
Trendelenburg position, 293294,
302
Triage nursing, 567574,
583584
Tricyclic antidepressants,
373374
Trimethoprim-sulfamethoxazole,
753754
Trisomy 21, 521522
Trousseau sign, 324
Tuberculin skin testing, 135136
Tuberculosis, 135138,
753754
773
Tularemia, 563564
Tympanic membrane rupture,
4344
Tympanoplasty, 4546
Type 1 diabetes mellitus,
237242, 713714
Type 2 diabetes mellitus,
241248, 713714
U
Ulcerative colitis, 179184
Ulnar fracture, 531532
Umbilicus, 265266
Unlicensed assistive personnel
Alzheimer disease, 407408
anorexia-bulimia, 411412
breast disorders, 455456
cardiac compressions by,
553554
cardiovascular disorders,
6768, 8788, 125126
eating disorders, 411412
emergency nursing, 579580,
583584
endocrine disorders, 271272
gastrointestinal disorders,
181182, 211212
genitourinary disorders,
325326, 351352,
365368
immune inflammatory
disorders, 601604,
631632
integumentary disorders,
647650, 653654,
659660, 663666
maternal child health,
487488, 493494
mental health disorders,
373374, 387388,
407408, 425426
musculoskeletal disorders,
279280, 293294,
305306, 315318
neurological disorders, 1314,
1718, 2324, 5354
newborn, 487488, 493494
operative care, 675676,
685686
pediatric care, 547548
pharmacology, 717718
respiratory disorders, 143144
scabies, 659660
skin cancer, 653654

601602
womens health, 437438
Upper gastrointestinal series,
205206
Upper respiratory infections,
137144
Ureteral calculi, 339342
Urinary catheter, indwelling,
331332, 364
Urinary diversion, 341346
Urinary incontinence, 431432
Urinary tract infection, 331336
Urine output, 331332
Uterus
disorders of, 435440
fibroid tumors in, 437438
prolapse of, 431436, 467468
V
Vaginal contraceptive ring,
449450
Valproic acid, 387388, 739740
Valve disorders, 6973
Vascular dementia, 405406
Vegan diet, 471472
Venous insufficiency, 9598
2133_Index_759-774.qxd
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Page 774
INDEX
Ventilation, mechanical,
157160, 613614
Ventilators, 157158
Ventricular fibrillation, 7576
Ventriculoperitoneal shunt,
517518
Ventrogluteal muscle, 721722,
749750
Veracity, 491492, 541542
Viral hepatitis, 215216
Vitamin D, 285286
Vitamin K, 489490
774
Vomiting, 78, 191192,
475476
W
Warfarin, 26, 78, 109110,
163164, 703704
Wernicke encephalopathy, 414,
426
Wheezing, 511512
Whole bowel irrigation, 578
Whooping cough, 511512
Womens health
abuse, 457464
birth control, 445452
breast disorders, 451458
infertility disorders, 441446
ovarian disorders, 435440
pelvic floor dysfunction,
431436
uterine disorders, 435440
Wound dbridement, 666
X
Xanax. See Alprazolam
Xenical. See Orlistat
Z
Zyloprim. See Allopurinol

NCLEX-RN Q&A Flash Cards by Ray A. Hargrove-Huttel, Kathryn Cadenhead Colgro

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2133_FM_i-xviii.

Kathryn Cadenhead Colgrove

West Coast University

Trinity Valley Community College

Kathryn Cadenhead Colgrove

Tammy Blatnick, RN, MS

Ruth Gladen, MSN

Cheri Goit, MSN

Cheryl DeGraw, RN, MSN, CNE, CRNP

Susan Golden, MSN, RN

Valerie Edwards, RN, MSN

Annie Ruth Grant, BSN, MSN

Joyce Arlene Ennis, RN, MSN, ANP, BC

Rhonda Renea Hendricks, RN, MSN, BA

Julia Hooley, RN, BSN

Linda Ann Kucher, MSN, RN, CMSRN

Martha Horst, MSN, RN

Christy Madore, FNP-C, MSN

Cheryl Jackson, RN, BSN

Donna Maheady, ARNP, EdD

Peggy Kelly, RN, BSN

Nadine Mason, CEN, MSN, CRNP

Kim Kocur, MSN, RNC

Susan A. Moore, RN, PhD

Kathy OConnor, MSN, APRN-BC, FNP,

Diane Peters, RN, MSN

Kowanda O. Robinson, RN, BSN

Brigitte Thiele, RN, BSN

Jean Rodgers, RN, MSN

Kathy Thornton, RN, PhD

Nancy Rogers, RN, BSN, MA

Joan Ulloth, RN, PhD

Patsy M. Spratling, RN, MSN

10. Maternal Child Health ____________ 469

11. Pediatric Disorders _______________ 497

2. Cardiovascular Disorders __________ 55

12. Emergency Nursing ______________ 551

3. Respiratory Disorders _____________ 121

13. Immune Inflammatory

1. Neurological Disorders ____________

4. Gastrointestinal Disorders _________ 177

14. Integumentary ___________________ 637

Introduction to F.A. Davis Card Questions Features the Latest

Using a Nursing Standard to Make a Decision

Maslows Hierarchy of Needs

3. The rehabilitation nurse is caring for the client with a

1. Correct answer 1: Signs/symptoms of TBI include

2. Correct answer 2: A 15 on the Glasgow Coma Scale

3. Correct answer 4: Cognitive is mental functioning;

4. The intensive care nurse is caring for a client diagnosed

4. Correct answer 1: Flaccid posturing is the worst-case

5. Correct answer 3: The nurse should first determine

Copyright 2010 F.A. Davis Company

6. Correct answer 1, 4, 5: The client is enclosed in an

7. The client with increased intracranial pressure is

9. The nurse is discussing the TBI Act at a support

7. Correct answer 4: The nurse must use a filter needle

8. Correct answer 4: Vomiting indicates an increase in

Copyright 2010 F.A. Davis Company

9. Correct answer 1: The TBI Act is part of the

10. Correct answer 3: For 710 days post head injury,

Spinal Cord Injury

13. The rehabilitation nurse caring for the young client