Comprehensive Practice Part1

Comprehensive Practice Report taken: 8/28/2006 1:57:28 AM
Question 1 of 100
The nurse is caring for the mother of a newborn. The nurse recognizes that the mother
needs more teaching regarding cord care because she
1. Incorrect keeps the cord exposed to the air.
2. Incorrect washes her hands before sponge bathing her baby.
3. Correct washes the cord and surrounding area well with water at each diaper change.
4. Incorrect checks it daily for bleeding and drainage.
Answer Rationale:
1. Exposure to air helps dry the cord.
2. Good hand washing is the prime mechanism for preventing infection.
3. Washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to
infection.
4. It is important to check for complications of bleeding and drainage that might occur.
Client Need Category: Growth and Development Through the Life Span
Question 2 of 100
For a school nurse in a junior high school, it is important to check young teenage girls
for scoliosis. One way to assess this is to
1. Incorrect have each girl walk in a straight line.
2. Correct have each girl bend over and measure shoulder height.
3. Incorrect run fingers down the spine to feel for abnormalities.
4. Incorrect watch as each girl does physical education activities to see if any abnormality
is evident.
Answer Rationale:
1. Scoliosis is a lateral curvature. Girls with scoliosis may well be able to walk a straight line.
2. A quick assessment is to look for uneven shoulders. Ask the girl to bend over and look at bra
strap marks to see if one side is deeper.
3. The nurse is unlikely to detect scoliosis by running the fingers down the spine.
4. Watching the girls as they do physical education activities is unrealistic and not as likely to
pick up a potential problem as checking each girl individually.
Client Need Category: Prevention and Early Decection of Disease
Question 3 of 100
An adult with chronic renal failure is receiving peritoneal dialysis. His acid-base balance
and electrolyte levels are now within normal limits. His hemoglobin is 9.2 and his
hematocrit is 30. The most likely cause of his anemia is
1. Incorrect hemodilution secondary to fluid retention.
2. Incorrect eating insufficient protein due to taste changes that occur with dialysis.
3. Correct failure of his kidneys to produce the hormone necessary to stimulate bone
marrow to produce red blood cells.
4. Incorrect hemolysis of red blood cells as they move past the membrane containing the
dialysis solution.
Answer Rationale:
1. Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in
hematocrit were fluid retention, one would expect to find corresponding decreases in serum
sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the client would
retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not usually produce
such a drop in hemoglobin.
2. The cause of anemia in persons with chronic renal failure is lack of erythropoietin.
3. Erythropoietin produced by the kidneys is necessary to stimulate the bone marrow to produce
red blood cells. In chronic renal failure this hormone is not produced.
4. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move outside
the client's own blood vessels, so there are no mechanical forces to harm them.
Client Need Category: Physiological Adaptation
Question 4 of 100
Ms. E., 16 years old and 20 weeks pregnant, has attended a prenatal nutrition course at
her high school. The next day, the nurse knows she needs more instruction regarding
proper protein intake because she has chosen the following for lunch:
1. Incorrect roast chicken sandwich and ice cream cone.
2. Incorrect roast beef sandwich and vanilla pudding.
3. Incorrect fruit salad with cottage cheese and frozen yogurt.
4. Correct bacon, lettuce, and tomato sandwich and an apple.
Answer Rationale:
1. Poultry is a good source of protein as is ice cream.
2. Meat and puddings are recommended and good sources of protein.
3. Cheese and yogurt are good sources of protein.
4. There is very little protein in a bacon, lettuce, and tomato sandwich and an apple.
Client Need Category: Basic Care and Comfort
Question 5 of 100
Randy, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the
nurse that Randy needs to continue taking the salicylates he had received at home?
1. Incorrect Chorea.
2. Correct Polyarthritis.
3. Incorrect Subcutaneous nodules.
4. Incorrect Erythema marginatum.
Answer Rationale:
1. Chorea is the restless and sudden aimless and irregular movements of the extremities
suddenly seen in persons with rheumatic fever, especially girls.
2. Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates.
3. Subcutaneous nodules are nontender swellings over bony prominences sometimes seen in
persons with rheumatic fever.
4. Erythema marginatum is a skin condition characterized by nonpruritic rash, affecting trunk and
proximal extremities, seen in persons with rheumatic fever.
Client Need Category: Pharmacological and Parenteral Therapies
Question 6 of 100
A young woman is to undergo a Tensilon test. The nurse is explaining the test to the
client. Which statement the client makes indicates the best understanding of the test?
1. Correct "A positive test will be evident within 1 minute of the Tensilon injection.''
2. Incorrect "The test is of diagnostic value in only about 20% of persons with myasthenia
gravis.''
3. Incorrect "If the test is positive I will feel an immediate decrease in muscle strength.''
4. Incorrect "Tensilon acts by blocking the action of acetylcholine at the myoneural
junction.''
Answer Rationale:
1. A Tensilon test yields immediate results. If positive, the client almost immediately has an
increase in muscle strength.
2. The test is accurate in nearly all persons with myasthenia gravis.
3. Tensilon causes an increase in muscle strength.
4. Tensilon acts to increase the amount of acetylcholine available.
Client Need Category: Reduction of Risk Potential
Question 7 of 100
The nurse in an outpatient mental health clinic has identified marital discord as a
significant problem for one of the clients. A client with this type of problem would be
most likely to be dealing with issues in which developmental phase?
1. Incorrect Trust vs. mistrust.
2. Incorrect Identity vs. role confusion.
3. Correct Intimacy vs. isolation.
4. Incorrect Generativity vs. stagnation.
Answer Rationale:
1. Trust vs. mistrust is the developmental stage in which infants learn to trust the world by
having their basic needs met in a consistent manner.
2. Identity vs. role confusion is the developmental stage in which adolescents face the issues of
"who am I'' and "what am I going to do with my life.'' This stage does not target relationship
issues specifically.
3. According to Erickson's developmental stages intimacy vs. isolation is the stage that targets
intimate relationships.
4. Generativity vs. stagnation is the middle adult stage in which persons are concerned with
being productive and contributing to the greater society. This stage does not target
relationship issues specifically.
Client Need Category: Coping and Adaptation
Question 8 of 100
A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long
history of alcohol dependence. During the late evening following his admission, he
becomes increasingly disoriented and agitated. Which of the following would the client
be least likely to experience?
1. Incorrect Diaphoresis and tremors.
2. Incorrect Increased blood pressure and heart rate.
3. Incorrect Illusions.
4. Correct Delusions of grandeur.
Answer Rationale:
1. Diaphoresis and tremors occur in the first phase of alcohol withdrawal.
2. The blood pressure and heart rate increase in the first phase of alcohol withdrawal.
3. Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim
artificial lighting where the environment is not perceived accurately.
4. Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol.
The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal.
Client Need Category: Psychosocial Adaptation
Question 9 of 100
A young woman tells the nurse in the health clinic that her boyfriend has gonorrhea. He
told her about his disease after their last sexual experience three days ago. She wants to
know when she can expect symptoms. The nurse replies that the unusual time between
initial infection with Neisseria gonorrhoeae and the onset of symptoms is
1. Correct two to five days.
2. Incorrect five to seven days.
3. Incorrect one to two weeks.
4. Incorrect two to three weeks.
Answer Rationale:
1. The usual incubation period between infection with Neisseria gonorrhoeae and onset of
symptoms is two to five days.
2. The usual incubation period for Neisseria gonorrhoeae is two to five days.
Question 10 of 100
An adult woman is admitted to an isolation unit in the hospital after tuberculosis was
detected during a pre-employment physical. Although frightened about her diagnosis,
she is anxious to cooperate with the therapeutic regimen. The teaching plan includes
information regarding the most common means of transmitting the tubercle bacillus
from one individual to another. Which contamination is usually responsible?
1. Incorrect Hands.
2. Correct Droplet nuclei.
3. Incorrect Milk products.
4. Incorrect Eating utensils.
Answer Rationale:
1. Hands are the primary method of transmission of the common cold.
2. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The
bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by
an infected person.
3. The tubercle bacillus is not transmitted by means of contaminated food. Contact with
contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid,
or cholera.
4. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be
transmitted via reservoirs such as linens or eating utensils.
Client Need Category: Saftey and Infection Control
Question 11 of 100
Sandra, an R.N., reports to work looking unkempt. Nancy, another R.N., approaches
when she notices her using uncoordinated movements. Sandra's breath reeks of
peppermints and Nancy suspects Sandra may be intoxicated. What is the best initial
nursing action for Nancy to take?
1. Incorrect Call the supervisor and report Sandra.
2. Correct Confront Sandra, saying that she feels she is intoxicated, and relieve her of her
nursing duties immediately.
3. Incorrect Ignore the situation.
4. Incorrect Give Sandra a lecture about substance abuse and do nothing else.
Answer Rationale:
1. Calling the supervisor is a secondary measure after confronting the nurse and relieving the
nurse of her duties. You cannot always assume the supervisor will be immediately available,
and client safety should be addressed first.
2. When another nurse is unable to perform her nursing duties due to substance abuse, she
should not be allowed to continue them, as client safety is a primary concern.
3. Ignoring the situation is against the professional code of conduct for nurses.
4. Sandra needs to be relieved of her duties. She probably would not benefit from a lecture in her
condition.
Client Need Category: Management of Care
Question 12 of 100
An adult client has a comminuted fracture of the ulnar bone. He asks the nurse what
type of fracture this is. The nurse's response is based on which of these understandings?
1. Correct The ulnar bone has been crushed and broken in several places.
2. Incorrect The two ends of the fractured ulnar bone are pulled apart and separated from
each other.
3. Incorrect The ulnar bone has been broken in two and one end of the bone broke through
the skin.
4. Incorrect Only one side of the ulnar bone is broken.
Answer Rationale:
1. A comminuted fracture usually results from a crush injury and results in fractured and crushed
bones. The bone is broken in several places.
2. A displaced bone occurs when the two ends of the fractured bone are pulled apart and
separated from each other.
3. A compound or open fracture occurs when the bone has been broken in two and one end of
the bone breaks through the skin.
4. A greenstick or incomplete fracture is when only one side of the bone is broken. A greenstick
fracture happens in children whose bones are still soft.
Question 13 of 100
The nurse is assessing a six-month-old child. Which developmental skills are normal and
should be expected?
1. Incorrect Speaks in short sentences.
2. Correct Sits alone.
3. Incorrect Can feed self with a spoon.
4. Incorrect Pulling up to a standing position.
Answer Rationale:
1. The child develops language skills between the ages of one and three.
2. A six-month-old child is learning to sit alone.
3. The child begins to use a spoon at 12-15 months of age.
4. The baby pulls himself to a standing position about ten months of age.
Question 14 of 100
An adult is scheduled to undergo an exploratory laparotomy in one hour. The nurse has
just received the order to administer his preoperative medication. What assessment is
essential for the nurse before administering the medication?
1. Incorrect The client's ability to cough and deep breathe.
2. Correct Any drug hypersensitivity or allergy.
3. Incorrect The client's understanding of the surgical procedure.
4. Incorrect Whether the client's family is present and supportive.
Answer Rationale:
1. His ability to cough and deep breathe should be assessed earlier so that further teaching can
take place if needed. Once preoperative medications are administered, the client's ability to
retain information is impaired.
2. A complete drug history on every perioperative client is essential because of potential
reactions to drugs. Drug hypersensitivity and allergic reactions must be assessed before
preoperative medications are administered.
3. The client's understanding should be assessed earlier so the nurse can do further teaching if
indicated.
4. While it is optimal to have the family present, medication should be given as ordered so that
the timing of the peak action is most beneficial to the client.
Question 15 of 100
An elderly client requiring abdominal wound packing tid complains about his wound care
to the nurse making morning rounds. He states that "everyone does it differently and at
any time they feel like it.'' He is angry at being awakened at night for this procedure.
The best response for the nurse to make is
1. Incorrect "The wound care is being done as ordered by your doctor.''
2. Incorrect "I understand you're upset at losing sleep. You can have medication to help
you get back to sleep.''
3. Incorrect "Tell me what's really bothering you.''
4. Correct "After rounds I'll be back and we can plan your wound care.''
Answer Rationale:
1. This reply discounts the client's feelings and concerns.
2. This response only addresses part of the problem with suggestion of an inappropriate solution.
3. This response reflects a misunderstanding of the client's complaints as a symptom of another
problem.
4. The nurse arranges to plan wound care with the client, thereby allowing him to participate in
his own care and addressing the source of his anger.
Question 16 of 100
A 38-year-old woman asks the nurse why she should have a mammogram. The best
response for the nurse to make is
1. Incorrect "Mammograms can diagnose breast cancer with nearly 100% accuracy.''
2. Incorrect "Every sexually active woman needs to have a mammogram, since there is a
correlation between sexual intercourse and breast cancer.''
3. Correct "You are 38 years old. This is the appropriate time to have a baseline
mammogram done.''
4. Incorrect "The dye, or contrast medium, used when you have a mammogram helps the
radiologist see the difference between a tumor and a cyst.''
Answer Rationale:
1. Mammograms can detect tumors and other breast lesions when they are still too small to be
palpated (i.e., smaller than 1 cm). There is a documented false negative rate of 5-10%. A
client should not be promised nearly 100% accuracy.
2. There is no known correlation between sexual activity and breast cancer. A sexually active
woman under 35 would not need a mammogram unless there was a strong family history of
cancer or she had symptoms.
3. The schedule for mammogram testing recommended by the American Cancer Society is a
baseline between the ages of 35-40; once every 1-2 years between 40 and 50; and every year
after age 50.
4. Mammograms do not use contrast media.
Question 17 of 100
A two-year-old is to be admitted to the pediatric unit. His diagnosis is febrile seizures. In
preparing for his admission, which of the following is the most important nursing action?
1. Incorrect Order a stat admission CBC.
2. Incorrect Place a urine collection bag and specimen cup at the bedside.
3. Incorrect Place a cooling mattress on his bed.
4. Correct Pad the side rails of his bed.
Answer Rationale:
1. Preparing for routine laboratory studies is not as high a priority as preventing injury and
promoting safety.
2. Preparing for routine laboratory studies is not as high a priority as preventing injury and
promoting safety.
3. A cooling blanket must be ordered by the physician and is usually not used unless other
methods for the reduction of fever have not been successful.
4. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety
should take precedence.
Question 18 of 100
Mr. K. comes to the nurses' station complaining of shortness of breath, choking,
dizziness, and nausea. He says, "I think I'm going crazy or dying or something. I don't
know what happened. Help me, help me.'' When the nurse tries to ask about what
happened, Mr. K. can only say, "Help me, help me.'' The best interpretation for the nurse
to make regarding his level of anxiety is
1. Incorrect mild.
2. Incorrect moderate.
3. Incorrect severe.
4. Correct panic.
Answer Rationale:
1. Mild anxiety enhances reasoning ability.
2. Moderate anxiety may reduce the ability to focus attention but is manageable.
3. Severe anxiety impairs problem solving, but behavior focused on obtaining relief is possible.
4. Mr. K. has typical symptoms of a panic attack; especially indicative of panic is his inability to
focus on the nurse's questions or other current events.
Question 19 of 100
Mr. T., 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an
argument over Mr. T'staying up all night playing loud music. Mr. T. is hyperactive,
intrusive, and has rapid, pressured speech. He has not slept in three days and appears
thin and disheveled. Which of the following is the most essential nursing action at this
time?
1. Incorrect Providing a meal and beverage for Mr. T. to eat in the dining room.
2. Incorrect Providing linens and toiletries for Mr. T. to attend to his hygiene.
3. Incorrect Consulting with the psychiatrist to order a hypnotic to promote sleep.
4. Correct Providing for client safety by limiting his privileges.
Answer Rationale:
1. Food and fluids are necessary. However, Mr. T.'s hyperactivity does not allow him to sit quietly
to eat. Finger foods "on the run'' will provide needed nourishment.
2. When hyperactivity decreases, then approach Mr. T. regarding hygiene and grooming needs.
3. Medications will be ordered. However, a thorough evaluation must be done first.
4. Mr. T. has been assaultive with the landlord and it is reasonable to expect that he may be with
peers and staff. His mental illness produces a hyperactive state and poor judgment and
impulse control. External controls such as limiting of unit privileges will assist in feelings of
security and safety.
Question 20 of 100
The nurse is teaching an adult who has ulcerative colitis. In developing the teaching plan
which of the following foods should the nurse plan to instruct the client to avoid?
1. Incorrect Roast chicken and cooked spinach.
2. Incorrect Broiled liver and white rice.
3. Incorrect Cottage cheese and canned apricots.
4. Correct Pork chop and brown rice.
Answer Rationale:
1. Chicken is considered a mild meat and is acceptable as long as it does not have highly spiced
sauces. Cooked spinach is acceptable but a spinach salad would not be.
2. Broiled liver is acceptable as is white rice.
3. Cottage cheese is acceptable and canned apricots are allowed. Fresh apricots are not allowed
on a low-residue diet.
4. Persons with ulcerative colitis should be on a low-fiber (low- residue) diet. This diet will
provide the essential nutrients and is limited in high roughage content which stimulates
peristalsis and makes symptoms of ulcerative colitis worse. Foods to be avoided include whole
grains, nuts, raw fruits and vegetables, caffeine, alcohol, tough meats, pork, and highly spiced
meats.
Question 21 of 100
An order is written to start an IV on a 75-year-old client who is getting ready to go to
the operating room for a total hip replacement. What gauge of catheter would best meet
the needs of this client?
1. Correct 18
2. Incorrect 20
3. Incorrect 21 butterfly
4. Incorrect 25
Answer Rationale:
1. Clients going to the operating room ideally should have an 18- gauge catheter. This is large
enough to handle blood products safely and to allow rapid administration of large amounts of
fluid if indicated during the perioperative period.
2. An 18-gauge catheter is recommended. A 20-gauge catheter is a second choice.
3. A 21-gauge needle is too small and a butterfly too unstable for a client going to surgery.
4. A 25-gauge needle is too small.
Question 22 of 100
The nurse is assessing a client admitted in ketoacidosis. The nurse can expect the
client's skin to be
1. Incorrect clammy.
2. Correct flushed.
3. Incorrect diaphoretic.
4. Incorrect silky.
Answer Rationale:
1. Cool, clammy skin is seen in hypoglycemia.
2. Ketoacidosis causes dehydration that results in flushed, dry skin.
3. Diaphoresis is seen in hypoglycemia.
4. Silky skin is not seen in ketoacidosis.
Question 23 of 100
The nurse in the gynecology clinic is assessing a young woman. The client states that
she gets her menstrual period every 18 days. She states that her flow is very heavy and
lasts six days. The nurse identifies this pattern as
1. Incorrect dysmenorrhea.
2. Incorrect dyspareunia.
3. Correct menorrhagia.
4. Incorrect metrorrhagia.
Answer Rationale:
1. Dysmenorrhea is painful menstruation.
2. Dyspareunia is painful intercourse.
3. Menorrhagia is abnormally profuse or excessive menstrual flow.
4. Metrorrhagia is uterine bleeding other than that caused by menstruation.
Question 24 of 100
A client with an acute exacerbation of rheumatoid arthritis is admitted to the hospital for
treatment. Which drug, used to treat clients with rheumatoid arthritis, has both an anti-
inflammatory and immunosuppressive effect?
1. Incorrect Gold sodium thiomalate (Myochrysine)
2. Incorrect Azathioprine (Imuran)
3. Correct Prednisone (Deltasone)
4. Incorrect Naproxen (Naprosyn)
Answer Rationale:
1. Gold sodium thiomalate is usually used in combination with aspirin and nonsteroidal anti-
inflammatory drugs to relieve pain. Gold has an immunosuppressive affect.
2. Azathioprine is used for clients with life-threatening rheumatoid arthritis for its
immunosuppressive effects.
3. Prednisone is used to treat persons with acute exacerbations of rheumatoid arthritis. This
medication is given for its anti-inflammatory and immunosuppressive effects.
4. Naproxen is a nonsteroidal anti-inflammatory drug. Immunosuppression does not occur.
Question 25 of 100
Which of the following would best indicate to the nurse that a depressed client is
improving?
1. Incorrect Reduced levels of anxiety.
2. Correct Changes in vegetative signs.
3. Incorrect Compliance with medications.
4. Incorrect Requests to talk to the nurse.
Answer Rationale:
1. Reduced levels of anxiety do not indicate an improvement in depressive symptoms.
2. Vegetative signs such as insomnia, anorexia, psychomotor retardation, constipation,
diminished libido, and poor concentration are biological responses to depression. Improvement
in these signs indicate a lifting of the depression.
3. Compliance with medications does not indicate improvement in depression.
4. Requests to talk to the nurse vary. Requests may show trust in the nurse but are not a sign
that depression has diminished.
Question 26 of 100
The nurse is to irrigate a nasogastric tube every two hours. Which solution should the
nurse select to irrigate the tube?
1. Correct Normal saline.
2. Incorrect Tap water.
3. Incorrect Ringer's lactate.
4. Incorrect Half-strength peroxide.
Answer Rationale:
1. Normal saline is used to irrigate an NG tube since it will not cause a loss of sodium when it is
removed by suction. Saline is an isotonic solution which has the same osmotic pressure as that
found across the semi-permeable membrane within the cell.
2. Tap water is a hypotonic solution which has less osmotic pressure than blood serum, thus
causing the cells to swell. When the fluid is suctioned from the NG tube, the client will lose
sodium.
3. Ringer's lactate is an isotonic solution that contains sodium, potassium, chloride, calcium, and
lactate. This is not an appropriate solution to use for irrigation of an NG tube. Ringer's lactate
is a fluid and electrolyte replenisher that is prescribed for correction of extracellular volume
deficit.
4. Hydrogen peroxide is a solution used to cleanse open wounds. It is not indicated for internal
use.
Question 27 of 100
The school nurse is assisting a school teacher to understand the classroom capabilities
of a child with athetoid cerebral palsy. The nurse explains that the child most probably
will demonstrate
1. Incorrect exaggerated hyperactive reflexes.
2. Incorrect normal intelligence levels.
3. Correct slow, worm-like, writhing movements.
4. Incorrect unsteady gait and clumsy, uncoordinated upper extremity function.
Answer Rationale:
1. Hyperactive reflexes are seen in a child with spastic cerebral palsy.
2. The intellectual function of some children with cerebral palsy may be affected, but many
children with athetoid cerebral palsy have normal intelligence. Not enough information is given
to determine the intelligence level of this child.
3. Athetoid cerebral palsy is characterized by involuntary, purposeless, slow writhing motions.
4. Unsteady gait and clumsy, uncoordinated upper extremity function are seen in a child with
spastic cerebral palsy.
Question 28 of 100
A 25-year-old woman had surgery today. Her father, a physician but not her surgeon,
enters the nursing station and asks for her chart. The best action for the nurse to take is
1. Incorrect to give him the chart as requested.
2. Correct not to allow him to read the chart.
3. Incorrect to ask the attending surgeon if it is permissible for him to read the chart.
4. Incorrect to ask the client if she wants him to read her chart.
Answer Rationale:
1. The nurse must maintain the client's right of confidentiality. Since he is not the client's
physician and does not have a medical need to see her chart, he should not be allowed to read
the chart without written permission from the client, who is above the age of majority.
2. Since he is not the client's physician and does not have a medical need to see her chart, he
should not be allowed to read the chart without written permission from the client, who is
above the age of majority.
3. It is not the attending surgeon who can give permission for him to review the chart, it is the
client.
4. The client must give written permission for unauthorized persons to review her chart. This
client had surgery today and is probably not alert enough to give legal permission, which must
be written.
Question 29 of 100
The physician has ordered a Schilling's test for a client with possible pernicious anemia.
Implementation of the test will require the nurse to
1. Incorrect administer a mild laxative.
2. Correct initiate a 24-hour urine collection.
3. Incorrect administer an intramuscular dose of iron.
4. Incorrect insert an intravenous catheter.
Answer Rationale:
1. Laxatives should not be administered during the test, since increased gastrointestinal motility
may interfere with oral B12 absorption.
2. A Schilling's test measures the percent of vitamin B12 excreted in a 24-hour urine sample
following an intramuscular "loading'' dose of vitamin B12 and a radioactive oral dose of
vitamin B12.
3. An intramuscular dose of vitamin B12, not iron, is given. Iron is given to treat iron deficiency
anemia.
4. An intravenous catheter is not required for this test.
Question 30 of 100
When caring for an elderly client it is important to keep in mind the changes in color
vision that may occur. What colors are apt to be most difficult for the elderly to
distinguish?
1. Incorrect Red and blue.
2. Incorrect Blue and gold.
3. Incorrect Red and green.
4. Correct Blue and green.
Answer Rationale:
1. The elderly are better able to distinguish between red and blue because of the difference in
wavelengths.
2. The elderly are better able to distinguish between blue and gold because of the difference in
wavelengths.
3. The elderly are better able to distinguish between red and green because of the difference in
wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age.
4. The elderly have poor blue-green discrimination. The effects of age are greatest on short
wavelengths. These changes are related to the yellowing of the lens with age.
Question 31 of 100
A child has been brought to the emergency room with an asthma attack. What signs and
symptoms would the nurse expect to see?
1. Incorrect A prolonged inspiratory time and a short expiratory time.
2. Incorrect Frequent productive coughing of clear, frothy, thin mucus progressing to thick,
tenacious mucus heard only on auscultation.
3. Incorrect Hypoinflation of the alveoli with resulting poor gas exchange from increasingly
shallow inspirations.
4. Correct Swelling of the bronchial mucosa, with wheezes starting on expiration and
spreading to continuous.
Answer Rationale:
1. Bronchi normally expand and lengthen during inspiration and shorten during expiration.
Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an
even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an
effort to relieve hypoxia.
2. At the beginning of the attack, the cough is nonproductive and results from bronchial edema.
Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum.
3. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli
than can escape from them through the narrowed airways. Gas trapping also causes an
increased depth and rate of respirations.
4. The wheeze starts during the expiratory phase because of the extreme narrowing of the
bronchus on exhalation. As obstruction increases, wheezes become more high pitched and
continuous.
Question 32 of 100
The treatment of a client with chronic venous insufficiency and severe leg ulcers
includes the application of a gelatin bandage around the stasis ulcers. This is
1. Incorrect a Jobst stocking.
2. Correct An Unna's paste boot.
3. Incorrect a specialized ace bandage.
4. Incorrect a plaster of Paris bandage.
Answer Rationale:
1. A Jobst stocking is a custom-made support hose used to prevent venous stasis.
2. An Unna's paste boot is a gelatin-based bandage that is frequently used to treat the stasis
ulcers that occur in a client with venous insufficiency.
3. An ace bandage also provides support to the extremity.
4. A plaster of Paris bandage is a composition of a liquid and powder that hardens when it dries.
It is used in shaping a cast to support a fractured bone as it heals.
Question 33 of 100
An adult client is scheduled for a magnetic resonance imaging test. Before scheduling
the test it is most essential for the nurse to ask the client which question?
1. Incorrect Are you afraid of heights?
2. Correct Do you have any metal in your body?
3. Incorrect Are you allergic to shellfish?
4. Incorrect Are you pregnant?
Answer Rationale:
1. The client should be asked about claustrophobia--fear of small places. During the MRI the
client is placed in a cylinder, which can be frightening for persons with claustrophobia. There is
no reason to ask about fear of heights.
2. MRI testing is based on magnetic fields that are affected by and can affect metal in the body
such as pacemakers, hip prosthesis, skull plates, etc. It is essential to ask this question.
Depending on the type of metal and the part of the body being imaged the person with metal
may not be a candidate for MRI.
3. No contrast media is used with MRI and therefore no worry about allergy to iodine.
4. MRI does not use radiation. There are no known teratogenic effects of MRI.
Question 34 of 100
A middle-aged adult is being treated for second and third degree burns over 25% of his
body and is now ready for discharge. The nurse evaluates his understanding of discharge
instructions relating to wound care and is satisfied that he is prepared for home care
when he makes which statement?
1. Incorrect "I will need to take sponge baths at home to avoid exposing the wounds to
unsterile bath water.''
2. Correct "If any healed areas break open I should first cover them with a sterile
dressing and then report it.''
3. Incorrect "I must wear my Jobst elastic garment all day and can only remove it when I'm
going to bed.''
4. Incorrect "I can expect occasional periods of low-grade fever and can take Tylenol every
4 hours.''
Answer Rationale:
1. Bathing or showering in the usual manner is permitted, using a mild detergent soap such as
Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead
tissue.
2. The client is taught to report changes in wound healing such as blister formation, signs of
infection, and opening of a previously healed area. Sterile dressings are applied until the
wound is assessed and a plan of care developed.
3. The Jobst garment is designed to place constant pressure on the new healthy tissue that is
forming to promote adherence to the underlying structure in order to prevent hypertrophic
scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed
for wound assessment and wound care and to permit bathing.
4. The client must be aware that infection of the wound may occur; signs of infection, including
fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage
must be reported immediately.
Question 35 of 100
Jenny, age seven, has the chickenpox. Her mother calls a nurse friend to find out when
Jenny can return to school. What is the best response for the nurse to make?
1. Incorrect All the lesions must be completely gone before contact with others is resumed.
2. Incorrect Within two to three weeks, the itching should be under control and good hand
washing established so that contact with others can be started.
3. Correct Jenny can return six days after the first lesions appear, because the crusts will
be formed.
4. Incorrect Jenny must first learn to cough with her mouth covered, put tissues in the
trash, and wash her hands after touching her nose and mouth.
Answer Rationale:
1. Brownish lesions may remain on the skin for a while after the crusts have disappeared. It is
not necessary to wait that long before returning to school. Good hand washing will help to
prevent the spread of the disease to others, since it is carried through respiratory secretions.
2. The itching is very severe with chickenpox and can be the cause of secondary infections of the
skin and also scarring. It has no relationship to communicability.
3. Varicella zoster, the chickenpox virus, is found in the respiratory secretions of infected persons
and also in the skin lesions that are not scabbed over. Scabs are not infectious. By six days
after the rash first appears, all the lesions will be scabbed over.
4. Good respiratory hygiene is a good precaution with any disease spread by respiratory
secretions. To prevent transmission of the disease, her lesions must also be crusted over.
Question 36 of 100
An elderly man is admitted to the hospital. He was alert and oriented during the
admission interview. However, his family states that he becomes disruptive and
disoriented around dinnertime. One night he was shouting furiously and didn't know
where he was. He was sedated and the next morning he was fine. At dinnertime the
disruptive behavior returned. The client is diagnosed as having sundown syndrome. The
client's son asks the nurse what causes sundown syndrome. The nurse's best response is
that it is attributed to
1. Incorrect an underlying depression.
2. Incorrect inadequate cerebral flow.
3. Correct changes in the sensory environment.
4. Incorrect fluctuating levels of oxygen exchange.
Answer Rationale:
1. An underlying depression does not cause sundown syndrome.
2. There is not sufficient evidence to suggest he has inadequate cerebral blood flow. Because the
confusion occurs at sundown, the cause is probably changes in the sensory environment.
3. Sundown syndrome is related to environmental and sensory abnormalities that lead to acute
confusion.
4. Fluctuating levels of oxygen exchange do not cause sundown syndrome.
Question 37 of 100
Which of the following would best indicate to the nurse that a client is depressed?
1. Correct Feelings of worthlessness.
2. Incorrect Poor hygiene and grooming.
3. Incorrect Intense anxiety.
4. Incorrect Thought insertion.
Answer Rationale:
1. Depressive symptoms include exaggerated feelings of sadness, dejection, worthlessness,
hopelessness, and emptiness.
2. Poor grooming and hygiene are signs of mental decompensation in several mental illnesses
such as dementia, schizophrenia, and depression.
3. Intense anxiety alone is not a symptom of depression.
4. Thought insertion is a symptom of schizophrenia.
Question 38 of 100
The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long
it will be before she feels better. The nurse explains that the beneficial effects of ECT
usually occur within
1. Correct one week.
2. Incorrect three weeks.
3. Incorrect four weeks.
4. Incorrect six weeks.
Answer Rationale:
1. Beneficial effects of ECT usually are evident after the first several treatments. Since
treatments are administered at intervals of 48 hours, these effects are apparent after one
week of therapy.
2. Beneficial effects of ECT therapy are usually seen before three weeks. It takes three to four
weeks for tricyclic antidepressants to take effect.
3. Beneficial effects of ECT therapy are usually seen before four weeks. It takes three to four
weeks for tricyclic antidepressants to take effect.
4. Beneficial effects of ECT therapy are usually seen after the first few treatments.
Question 39 of 100
A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes for
eight hours and is 4 cm dilated. Since she is a candidate for infection, the nurse should
include which of the following in the care plan?
1. Incorrect Universal precautions.
2. Incorrect Oxytocin administration.
3. Correct Frequent temperature monitoring.
4. Incorrect More frequent vaginal examinations.
Answer Rationale:
1. Universal precautions are necessary for all clients but a specific assessment of the client's
temperature will give an indication the client is becoming infected.
2. Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially.
3. Temperature elevation will indicate beginning infection. This is the most important measure to
help assess the client for infections, since the lost mucous plug and the ruptured membranes
increase the potential for ascending bacteria from the reproductive tract. This will infect the
fetus, membranes, and uterine cavity.
4. More frequent vaginal examinations are not recommended, as frequent vaginal exams can
increase chances of infection.
Question 40 of 100
Ms. C. has had a CVA (cerebrovascular accident) and has severe right-sided weakness.
She has been taught to walk with a cane. The nurse is evaluating her use of the cane
prior to discharge. Which of the following reflects correct use of the cane?
1. Correct Holding the cane in her left hand, Ms. C. moves the cane forward first, then
her right leg, and finally her left leg.
2. Incorrect Holding the cane in her right hand, Ms. C. moves the cane forward first, then
her left leg, and finally her right leg.
3. Incorrect Holding the cane in her right hand, Ms. C. moves the cane and her right leg
forward, then moves her left leg forward.
4. Incorrect Holding the cane in her left hand, Ms. C. moves the cane and her left leg
forward, then moves her right leg forward.
Answer Rationale:
1. When a person with weakness on one side uses a cane, there should always be two points of
contact with the floor. When Ms. C. moves the cane forward, she has both feet on the floor,
providing stability. As she moves the weak leg, the cane and the strong leg provide support.
Finally, the cane, which is even with the weak leg, provides stability while she moves the
strong leg.
2. She should not hold the cane with her weak arm. The use of the cane requires arm strength to
ensure that the cane provides adequate stability when standing on the weak leg.
3. The cane should be held in the left hand, the hand opposite the affected leg.
4. If Ms. C. moved the cane and her strong foot at the same time, she would be left standing on
her weak leg at one point. This would be unstable at best; at worse, impossible.
Question 41 of 100
The nurse is to give medication to an infant. What is the best way to assess the identity of the infant?
1. Incorrect Ask the mother what the child's name is.
2. Incorrect Look at the sign above the bed that states the client's name.
3. Incorrect Compare the bed number with the bed number of the care plan.
4. Correct Compare the ankle band with the name on the care plan.
Answer Rationale:
1. Asking the parent could be appropriate if the identification band could not be found and the
medication had to be given immediately. Ask the parent to state the child's name, rather than
asking them whether a certain name is the name of the child. This eliminates
misunderstandings from hearing deficits. As soon as possible, a new identification band should
be put on the infant's ankle or wrist.
2. There should be a sign above the bed, but it could be from the last client who occupied the
bed. This is not as safe a method as asking the parent the child's name.
3. Mistakes in bed numbers can be made in admitting, on the unit, and in writing care plans or
medication card.
4. Making sure that the client's name is the same as the name on the medication plan is the only
safe way to administer medications.
Question 42 of 100
An 85-year-old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was
alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the
evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on
his bed. The most appropriate nursing intervention that will calm an agitated client is
1. Incorrect limit visits by staff.
2. Incorrect encourage family phone calls.
3. Incorrect position in a bright, busy area.
4. Correct speak soothingly and provide quiet music.
Answer Rationale:
1. The client needs frequent visits by the staff to orient him and to assess his safety.
2. Phone calls from his family will not help a client who is trying to climb over the side rails and
may even add to his danger.
3. Putting the client in a bright, busy area would probably add to his confusion.
4. The environment is an important factor in the prevention of injuries. Talking softly and
providing quiet music have a calming effect on the agitated client.
Question 43 of 100
The mother of a four-month-old who received his second DTP immunization yesterday calls the office
nurse to report he has a temperature of 104F and a hard red area as big as a quarter on his thigh. The
best interpretation of these data is that the child
1. Incorrect is reacting normally to the immunization.
2. Correct may be allergic to the vaccine.
3. Incorrect is developing symptoms of the disease.
4. Incorrect has developed a secondary infection.
Answer Rationale:
1. A high temperature and large local reaction are not a normal reaction to the vaccine.
2. The description sounds like an adverse reaction to the immunization. The child may be allergic
to the vaccine.
3. A high temperature and large local reaction are not symptoms of diphtheria, tetanus, or
pertussis (whooping cough). They are symptoms of an adverse reaction to the vaccine.
4. A secondary infection at the injection site would not occur the day after the injection. It would
take more time for a secondary infection to develop.
Question 44 of 100
Mr. T. was admitted to the psychiatric unit three days ago with a diagnosis of schizophrenia. Today the
nurse finds him facing the window, and he seems to be talking and listening. After validating that Mr. T.
is hallucinating, which is the best action by the nurse?
1. Incorrect Allow him to continue his conversation without interruption.
2. Incorrect Offer him a choice of IM or PO for his PRN medication.
3. Incorrect Tell him that his behavior is inappropriate and should stop.
4. Correct Involve him in some concrete game or other activity.
Answer Rationale:
1. The nurse needs to make an effort to help Mr. T. regain contact with reality, not continue with
his hallucination.
2. Medication is indicated only if the client becomes more agitated and poses a danger to himself
or others. Other interventions should be tried first.
3. A judgmental approach doesn't solve the problem and may increase Mr. T.'s hallucinations and
agitation. He needs involvement in a real world more pleasant than his hallucinations.
4. Involvement in reality may decrease Mr. T.'s preoccupation with his hallucinations.
Question 45 of 100
An adult has been receiving physical therapy following a cerebrovascular accident. His left leg is weak
and he is instructed in the use of a cane. The nurse evaluates the client's ability to use the cane and
documents that he uses the cane correctly when he
1. Incorrect holds the cane in his left hand.
2. Incorrect leans his body toward the cane when walking.
3. Correct advances the left leg and cane simultaneously.
4. Incorrect advances the right leg and cane simultaneously.
Answer Rationale:
1. A cane is used to help the client walk with greater balance and support. The cane should be
held in the hand opposite the involved leg (on the good side). In normal ambulation the
opposite arm and leg move forward together. Holding the cane on the opposite side reinforces
normal body mechanics, widens the base of support, and provides support to the weakened
leg.
2. The cane should be held fairly close to the body to prevent leaning. The client should maintain
an erect posture to reduce the chance of losing his balance and falling.
3. The cane should be held in the hand opposite the affected leg and should be advanced at the
same time the weak leg is advanced to maximize support.
4. The cane should be held in the hand opposite the affected leg and should be advanced at the
same time the weak leg is advanced to maximize support. The cane should be held in the hand
opposite the involved leg (on the good side). In normal ambulation the opposite arm and leg
move forward together.
Question 46 of 100
The nurse knows that which criteria is most important in determining whether a client is a good
candidate for PCA?
1. Correct He is alert.
2. Incorrect He is not overweight.
3. Incorrect His pain will be constant.
4. Incorrect His surgical procedure will be relatively short.
Answer Rationale:
1. PCA requires that the client be alert enough to activate the system. A client who is mentally
confused is not a good candidate for PCA.
2. The weight of the client has no relationship to ability to utilize PCA. Analgesic dosage can be
determined to accommodate various weights.
3. PCA is ideal for persons with intermittent pain because the person can activate the system and
be medicated when it is needed. Constant pain is not a criteria for use of PCA.
4. The length of the surgical procedure has no bearing on whether the client can use PCA.
Question 47 of 100
The nurse is assisting a child with congestive heart failure. Which of the following would the child be
least likely to manifest?
1. Incorrect Weakness and fatigue.
2. Incorrect Dyspnea.
3. Incorrect Tachycardia.
4. Correct Oliguria.
Answer Rationale:
1. Weakness and fatigue are common in congestive heart failure.
2. Dyspnea is common in congestive heart failure.
3. Tachycardia is common in congestive heart failure.
4. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in
congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea,
and tachycardia are clinical manifestations of congestive heart failure.
Question 48 of 100
A 43-year-old woman who has been experiencing vertigo and severe headaches for the past three weeks
is admitted to the hospital for control of hypertension. The physician has prescribed furosemide (Lasix)
and quinapril hydrochloride (Accupril) to augment treatment of the modifiable risk factors associated
with her secondary hypertension. What specific drug information should the nurse include in the
discharge plan for this client?
1. Incorrect Take Accupril only if not feeling well but take Lasix every day, reduce dietary
sodium intake, increase exercise level gradually, and take medications at
bedtime.
2. Correct Monitor blood pressure while taking medication, change positions slowly,
increase dietary potassium intake, take medications in the morning, and
increase fluid intake.
3. Incorrect Discontinue medication therapy once blood pressure is within normal range,
take medications in the early morning, decrease potassium intake, and
increase rest periods.
4. Incorrect Take both medications daily, expect some lightheadedness for the first week,
increase sodium intake, increase fluid intake, and monitor blood pressure only
monthly.
Answer Rationale:
1. The medications should be taken daily as ordered and should be taken in the morning.
2. Furosemide (Lasix) is a potent loop diuretic which can cause potassium depletion unless
dietary supplements are given. Early morning administration is recommended so that sleep is
not disturbed by nocturia. Both quinapril hydrochloride (Accupril) and furosemide (Lasix) may
cause lightheadedness and orthostatic hypotension because of vasodilation and decreased
vascular volume. Increased oral fluid intake often helps correct this and assists in flushing
excess sodium from the body. Blood pressure should be monitored daily at first and at least
weekly after the first follow-up visit to prevent syncopal episodes resulting from too-low blood
pressure.
3. The client should only discontinue medication upon the physician's order and should increase
potassium intake.
4. The client should not increase sodium intake and should monitor blood pressure daily at first
and weekly thereafter.
Question 49 of 100
An adult male is scheduled for exploratory surgery this morning. After he is premedicated for surgery
the nurse reviews his chart and discovers that he has not signed a consent form. The nurse's action is
based on which of the following understandings?
1. Incorrect Since the client came to the hospital consent is implied even if the consent for
the surgery has not been signed.
2. Correct All invasive procedures require a consent form.
3. Incorrect The nurse should have him sign a consent form immediately.
4. Incorrect The nurse should have the next of kin sign the necessary consent form.
Answer Rationale:
1. It cannot be legally assumed that the client consents to a procedure for which he has not
given consent. This is not legally defensible.
2. All invasive procedures require informed consent. The surgery is prescheduled and described
as exploratory and therefore is not an emergency. If the client is an adult and has not been
declared incompetent the client must sign the form. This client should not have surgery
performed without written consent. The nurse must notify the physician immediately.
3. The client has been premedicated for surgery and is not alert. He cannot give legal consent
when under the influence of mind-altering drugs.
4. The client is an adult and there is no evidence that he has been declared incompetent to make
his own decisions. The surgery is exploratory. There is no indication it is for an immediately
life-threatening condition. It is not appropriate to ask the next of kin to sign his consent form.
Question 50 of 100
Ms. R. is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands
the procedure when she makes which of the following remarks the night before the procedure?
1. Incorrect She says to her husband, "Please bring me a hamburger and french fries
tomorrow when you come. I hate hospital food.''
2. Correct "I told my daughter who is pregnant to either come to see me tonight or wait
until I go home from the hospital.''
3. Incorrect "I understand it will be several weeks before all the radiation leaves my body.''
4. Incorrect "I brought several craft projects to do while the radium is inserted.''
Answer Rationale:
1. The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are
not allowed.
2. People who are pregnant should not come in close contact with someone who has internal
radiation therapy. The radioactivity could possibly damage the fetus.
3. This statement is not true. As soon as the radiation source is removed (probably 36 to 72
hours after insertion), the client is no longer contaminated with radioactivity.
4. Craft projects usually require the client to sit. The client must remain flat with very little head
elevation during the time the rods are in place.
Question 51 of 100
A 27-year-old woman has Type I diabetes mellitus. She and her husband want to have a child so they
consulted her diabetologist, who gave her information on pregnancy and diabetes. Of primary
importance for the diabetic woman who is considering pregnancy should be
1. Incorrect a review of the dietary modifications that will be necessary.
2. Correct early prenatal medical care.
3. Incorrect adoption instead of conception.
4. Incorrect understanding that this is a major health risk to the mother.
Answer Rationale:
1. A review of dietary modifications is important once the woman is pregnant. However, it is not
of primary importance when considering pregnancy.
2. Pregnancy makes metabolic control of diabetes more difficult. It is essential that the client
start prenatal care early so that potential complications can be controlled or minimized by the
efforts of the client and health care team.
3. The alternative of adoption is not necessary just because the client is a diabetic. Many diabetic
women have pregnancies with successful outcomes if they receive good care.
4. While there is some risk to the pregnant diabetic woman, it is not considered a major health
risk. The greater risk is to the fetus.
Question 52 of 100
Ms. A. had a tuberculin skin test as part of an employment physical. A positive result is seen. The client
suggests to the nurse that the reason she has a positive skin test and a negative chest X-ray is that she
was born and raised in another country and received BCG vaccine as a child. The nurse's response is
based on the understanding that
1. Incorrect the only cause for a positive skin test and negative chest X-ray is exposure to
the tubercle bacillus without development of tuberculosis infection.
2. Incorrect the skin test is only a screening test.
3. Incorrect BCG vaccine is not effective against tuberculosis.
4. Correct BCG vaccine stimulates formation of antibodies against tuberculosis.
Answer Rationale:
1. A positive skin test and negative chest X-ray is seen in persons who have been immunized
against tuberculosis.
2. It is true that the skin test is only a screening test. However, this is not the key understanding
the nurse needs to respond to the client.
3. BCG vaccine is effective against tuberculosis.
4. BCG vaccine is given in many parts of the world to immunize against tuberculosis. It causes
formation of antibodies and consequently a positive reaction to a tuberculin skin test, which is
an antigen-antibody test. A positive skin test for tuberculosis in the person who has had BCG
vaccine indicates the vaccine is working and producing antibodies.
Question 53 of 100
Ms. J., 40, states, "That TV newsman is talking about me.'' The nurse recognizes this type of thought
process as
1. Incorrect thought broadcasting.
2. Correct delusion of reference.
3. Incorrect thought insertion.
4. Incorrect delusion of persecution.
Answer Rationale:
1. Thought broadcasting is a disturbance in thought pattern in which the individual thinks
everyone can hear his thoughts.
2. A delusion of reference is a fixed false belief that events or people are directly related to the
individual person.
3. Thought insertion is a disturbance in thought patterns in which the client thinks thoughts of
others are being placed in his mind.
4. A delusion of persecution is a fixed false belief that others are attempting to harm a person.
Question 54 of 100
The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the following food choices, if
selected by the client, indicate an understanding of a low-fat, high-fiber diet?
1. Incorrect Tuna salad sandwich on whole wheat bread.
2. Correct Vegetable soup made with vegetable stock, carrots, celery, and legumes
served with toasted oat bread.
3. Incorrect Chef's salad with hard boiled eggs and fat-free dressing.
4. Incorrect Broiled chicken stuffed with chopped apples and walnuts.
Answer Rationale:
1. Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber.
2. This choice shows a low-fat soup (which would have been higher in fat if made with chicken or
beef stock) and high-fiber bread and soup contents (both the vegetables and the legumes).
3. Salad is high in fiber, but hard boiled eggs are high in fat.
4. There is some fiber in the apples and walnuts. The walnuts are high in fat, as is the chicken.
Question 55 of 100
Which of the following is least likely to influence the potential for a client to comply with lithium
therapy after discharge?
1. Incorrect The impact of lithium on the client's energy level and life-style.
2. Incorrect The need for consistent blood level monitoring.
3. Incorrect The potential side effects of lithium.
4. Correct What the client's friends think of his need to take medication.
Answer Rationale:
1. The impact of lithium on the client's energy level and life style are great determinants to
compliance.
2. The frequent blood level monitoring required is difficult for clients to follow for a long period of
time.
3. Potential side effects such as fine tremor, drowsiness, diarrhea, polyuria, thirst, weight gain,
and fatigue can be disturbing to the client.
4. While the client's social network can influence the client in terms of compliance, the influence
is typically secondary to that of the other factors listed.
Question 56 of 100
A child who is two years and six months old has had one bout of nephrosis (nephrotic syndrome). His
mother suspected a recurrence when she observed swelling around his eyes. The nurse helps to confirm
this condition by recognizing what additional symptom?
1. Incorrect Blood pressure of 140/90.
2. Correct Marked proteinuria.
3. Incorrect Cola-colored urine.
4. Incorrect A history of positive streptococcal infection.
Answer Rationale:
1. Blood pressure is generally not elevated in nephrotic syndrome except in a child with severe
renal insufficiency. A normal blood pressure in a two-and-a-half-year-old should be between
80 and 85 systolic and 50 and 60 diastolic.
2. In nephrotic syndrome (nephrosis) plasma proteins are excreted in the urine due to an
abnormal permeability of the glomerular basement membrane of the kidney to protein
molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset
is two and a half years and it is more common in boys than girls.
3. Dark urine is not seen in nephrotic syndrome.
4. A history of a streptococcal infection is associated with glomerulonephritis.
Question 57 of 100
Zantac is ordered for an adult client. The nurse mistakenly administered Xanax. What is the most
appropriate action for the nurse to take?
1. Incorrect Notify the physician and document in the nurse's notes that the physician was
notified of the error.
2. Incorrect Notify the supervisor, complete a medication error incident report, and
document in the nurse's notes that an incident report was completed.
3. Incorrect Notify the house supervisor, assess client carefully, and document only if
adverse or untoward effects occur.
4. Correct Notify the physician, complete an incident report, and document the
notification of the physician and any assessments made.
Answer Rationale:
1. In addition to notifying the physician and documenting it, the nurse should complete an
incident report.
2. The physician must be notified. An incident report should be completed. However, no record of
the incident report should appear in the nurse's notes.
3. The physician must be notified. An incident report should be completed. However, no record of
the incident report should appear in the nurse's notes.
4. The physician must be notified of the medication error. An incident report should be
completed. However, no record of the incident report should appear in the nurse's notes. The
nurse should document that the physician was notified and any assessments completed.
Question 58 of 100
The nurse is evaluating the infection control procedures on the unit. Which finding indicates a break in
technique and the need for education of staff?
1. Incorrect The nurse aide is not wearing gloves when feeding an elderly client.
2. Incorrect A client with active tuberculosis is asked to wear a mask when he leaves his
room to go to another department for testing.
3. Correct A nurse with open, weeping lesions of the hands puts on gloves before giving
direct client care.
4. Incorrect The nurse puts on a mask, a gown, and gloves before entering the room of a
client on strict isolation.
Answer Rationale:
1. There is no need to wear gloves when feeding a client. However, universal precautions
(treating all blood and body fluids as if they are infectious) should be observed in all
situations.
2. A client with active tuberculosis should be on respiratory precautions. Having the client wear a
mask when leaving his private room is appropriate.
3. Persons with exudative lesions or weeping dermatitis should not give direct client care or
handle client-care equipment until the condition resolves.
4. Strict isolation requires the use of mask, gown, and gloves.
Question 59 of 100
The nurse in an infertility clinic is discussing the treatment routine. The nurse advises the couple that the
major stressor for couples being treated for infertility is usually
1. Incorrect having to tell their families.
2. Incorrect the cost of the interventions.
3. Incorrect the inconvenience of multiple tests.
4. Correct the right scheduling of sexual intercourse.
Answer Rationale:
1. Having to tell families may also be a factor contributing to stress but is not the major stressor.
2. Cost may also be a contributing factor to stress but is not usually the major factor.
3. The inconvenience of multiple tests may also be a factor contributing to stress but is not
usually the major factor.
4. Sexual activity "on demand'' is the major cause of stress for most infertile couples.
Question 60 of 100
An 80-year-old man has closed-angle glaucoma. He tells the nurse that he has heard that glaucoma may
be hereditary. He is concerned about his children, a son age 45 and a daughter age 38. The most
appropriate response by the nurse is to ask,
1. Incorrect "Are your children complaining of eye problems?''
2. Incorrect "There is no need for concern because glaucoma is not a hereditary disorder.''
3. Correct "There may be a genetic factor with glaucoma and your children should be
screened.''
4. Incorrect "Your son should be evaluated because he is over 40.''
Answer Rationale:
1. Chronic glaucoma is thought to be hereditary. Family members should be evaluated yearly
whether or not they have symptoms. Early glaucoma has few symptoms.
2. Chronic glaucoma is thought to be hereditary.
3. There is a strong hereditary factor in glaucoma. Therefore, family members should have
intraocular pressures measured yearly.
4. Family members of a client with glaucoma should be evaluated yearly at all ages.
Question 61 of 100
A delusional client is admitted to the hospital. The most appropriate action for the nurse to take is to
1. Incorrect attempt to disprove the client's delusion.
2. Correct focus on the reality aspects of the client's communication.
3. Incorrect place the client on room restriction to decrease stimuli.
4. Incorrect agree with the delusion until psychotropic medications take effect, then focus
on reality.
Answer Rationale:
1. Attempts to disprove the client's delusions often lead to tension. The client tends to defend
and hold onto his delusions when they are attacked.
2. Delusions are fixed false beliefs. The nurse focuses on reality aspects of communications in an
effort to promote health rather than focus on delusions, which could become further
entrenched.
3. Room restriction is not necessary for a delusional client, unless delusional behaviors prove
harmful to the client or others.
4. To agree with the delusional thinking reinforces the delusion. The nurse may also become part
of the client's delusional system.
Question 62 of 100
In completing an assessment of an elderly client who has been a victim of abuse, the nurse knows that
the elder who is at highest risk is
1. Correct a Caucasian female who is physically or cognitively impaired.
2. Incorrect a Caucasian male who has a physical disability.
3. Incorrect an African-American female whose physical or mental conditions cause
dependency on family members.
4. Incorrect an African-American male whose cognitive impairment causes behavioral
problems.
Answer Rationale:
1. According to Hirst and Miller (1986) as cited in Wilson, H., & Kneisl (1992), Psychiatric
Nursing, the elderly Caucasian female who has physical and/or cognitive impairment is at
greatest risk for elder abuse by a family member.
2. The elderly Caucasian female who has physical and/or cognitive impairment is at greatest risk
for elder abuse by a family member.
Question 63 of 100
The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After
carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the
dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for
cleaning and redressing the wound. The most appropriate action for the charge nurse is to
1. Incorrect interrupt the procedure to inform the staff nurse that sterile gloves are not
needed to remove the old dressing.
2. Incorrect congratulate the nurse on the use of good technique.
3. Incorrect discuss dressing change technique with the nurse at a later date.
4. Correct interrupt the procedure to inform the nurse of the need to wash her hands
after removal of the dirty dressing and gloves.
Answer Rationale:
1. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves
does not put the client in danger so discussion of this can wait until later.
2. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the
old dressing. The nurse should wash her hands after removing the soiled dressing and before
donning sterile gloves to clean and dress the wound.
3. The nurse should wash her hands after removing the soiled dressing and before donning the
sterile gloves to clean and dress the wound. Not doing this compromises client safety and
should be brought to the immediate attention of the nurse.
4. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the
old dressing. However, the use of sterile gloves does not put the client in danger so discussion
of this can wait until later. However, the nurse should wash her hands after removing the
soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this
compromises client safety and should be brought to the immediate attention of the nurse.
Question 64 of 100
An 84-year-old male patient has been bedridden for two weeks. Which of the following complaints by
the patient indicates to the nurse that he is developing a complication of immobility?
1. Correct Stiffness of the right ankle joint.
2. Incorrect Soreness of the gums.
3. Incorrect Short-term memory loss.
4. Incorrect Decreased appetite.
Answer Rationale:
1. Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy.
2. Soreness of the gums is not related to immobility.
3. Short-term memory loss is not related to immobility.
4. Decreased appetite is unlikely to be related to immobility.
Question 65 of 100
An adult client has been admitted to the psychiatric unit. She is convinced that a blemish on her face is a
malignant melanoma. By the end of the third day of hospitalization, her fear of dying from the
melanoma has reached psychotic proportions. The most adaptive way she might try to deal with this
would be to
1. Correct attempt thought-control methods to decrease pervasiveness of thoughts.
2. Incorrect request PRN medication whenever such thoughts intrude.
3. Incorrect share her concerns with another client whenever they arise.
4. Incorrect withdraw to her room whenever such thoughts arise.
Answer Rationale:
1. Thought-control methods are applicable to this situation and are the least restrictive method of
achieving symptom control.
2. Use of PRN medications is not the best way to reduce the frequency of such thoughts.
Medication may be helpful in the long run but will not work immediately.
3. Sharing her concerns with another client will not alleviate the fear of dying.
4. Being alone in her room is likely to increase her psychotic fears and have no beneficial effect.
Question 66 of 100
The nurse is caring for an elderly client who has been diagnosed as having sundown syndrome. He is
alert and oriented during the day but becomes disoriented and disruptive around dinnertime. He is
hospitalized for evaluation. The nurse asks the client and his family to list all of the medications,
prescription and nonprescription, he is currently taking. What is the primary reason for this action?
1. Correct Multiple medications can lead to dementia.
2. Incorrect The medications can provide clues regarding his medical background.
3. Incorrect Ability to recall medications is a good assessment of the client's level of
orientation.
4. Incorrect Medications taken by a client are part of every nursing assessment.
Answer Rationale:
1. Drugs commonly used by elderly people, especially in combination, can lead to dementia.
2. Assessment of the medication taken may or may not provide information on the client's
medical background. However, this is not the primary reason for assessing medications in a
client who is exhibiting sundown syndrome.
3. Ability to recall medications may indicate short-term memory and recall. However, that is not
the primary reason for assessing medications in a client with sundown syndrome.
4. Medication history should be a part of the nursing assessment. In this client there is an even
more important reason for evaluating the medications taken.
Question 67 of 100
The mother of a three-year-old child calls the clinic and states that her child has just swallowed an
unknown amount of baby aspirin. What is the best initial action for the nurse to take?
1. Incorrect Call the physician.
2. Incorrect Instruct the mother to bring the child to the emergency room as soon as
possible.
3. Incorrect Discuss with the mother observable changes for which she should watch the
child.
4. Correct Tell the mother to give ipecac to the child and then come to the emergency
room.
Answer Rationale:
1. The physician should be notified once the child is en route to the emergency room.
2. The mother should bring the child to the emergency room, but first should give ipecac.
3. Since the child took an unknown amount of aspirin, it would be inappropriate to have the child
remain at home. The child should be evaluated by a health care worker.
4. The first line of treatment is ipecac. The child should be seen as soon as possible after that.
The child has just swallowed the aspirin and is not described as being unconscious. Ipecac is
contraindicated if the child is unconscious.
Question 68 of 100
The nurse is evaluating a 70-year-old with respiratory disease. Which finding, if observed, indicates
compliance with breathing exercises?
1. Incorrect Decreased use of pursed lip breathing.
2. Incorrect Decreased coughing after exhalation when using resisted breathing exercises.
3. Correct Increased coughing after exhalation when using resisted breathing exercises.
4. Incorrect Inhaling through the mouth and exhaling through the nose.
Answer Rationale:
1. Clients with respiratory disease should use pursed lip breathing.
2. The client should have a cough after exhalation when using resisted breathing exercises.
3. Resisted breathing is one kind of breathing exercise that can be taught to clients with
respiratory disease. Noncompliance is common and is suspected when clients do not have
typical results. One of the expected results is a cough after the exhalation phase of resisted
breathing.
4. The client should inhale through the nose and exhale through the mouth.
Question 69 of 100
Mr. P. confides to the nurse that he is being pursued by the Federal Bureau of Investigation because he
has access to information that will prevent future wars. This behavior most likely represents which of
the following?
1. Incorrect Ideas of reference.
2. Correct Delusions.
3. Incorrect Hallucinations.
4. Incorrect Dissociation.
Answer Rationale:
1. Ideas of reference occur when the client assumes that events such as a news broadcast are
directly related to him. There is no evidence that this has occurred here, although it would not
be uncommon for a client such as Mr. P.
2. Delusions are fixed false beliefs. They occur when the client's unacceptable feelings are
projected and rationalized.
3. Hallucinations involve sensory perceptions without stimuli. There is no evidence that Mr. P. is
hallucinating.
4. Dissociation involves a change in the consciousness such as amnesia. There is no evidence
that Mr. P. has amnesia.
Question 70 of 100
A registered nurse (RN) is in charge of the care of eight clients, assisted by a nursing assistant (nurse
aide). The following clients need care that must be given at 10 a.m.: an adult with an infected decubitus
ulcer needs the wound cleaned and dressed; an adult needs to be ambulated for the first time following
an appendectomy; an adult who has returned from extensive shoulder surgery needs to have an ice bag
placed on the incision. How should the nurse proceed?
1. Correct Ask the nursing assistant to apply the ice bag and ambulate the client while
the RN performs the decubitus ulcer care.
2. Incorrect Ask the nursing assistant to perform decubitus care and ambulate the client
while the RN applies the ice bag.
3. Incorrect Ask the nursing assistant to ambulate the client while the RN performs
decubitus care and applies the ice bag.
4. Incorrect Ask the nursing assistant to perform decubitus care while the RN applies the
ice bag and ambulates the client.
Answer Rationale:
1. The RN should delegate routine care to nonprofessional staff. Complex wound care requires
the assessment and problem-solving skill possessed by the RN. The nursing assistant has the
knowledge and skill to ambulate a postoperative client for the first time. The least
comprehensive task is the application of an ice bag, which can be delegated to the nursing
assistant.
2. See rationale for choice #1.
Question 71 of 100
Ms. S. has just been admitted to the postpartum unit after delivery of a baby girl. The nurse brings her
baby in and prepares to assist her in breast feeding. Ms. S'says she doesn't want to try yet. She begins to
talk about her labor and delivery and how difficult it was. The nurse recognizes this behavior is
indicative of
1. Incorrect high risk for alteration in parenting related to the mother's lack of interest in
her baby's needs.
2. Incorrect fatigue from labor and delivery.
3. Incorrect inability to accept the reality of parenthood.
4. Correct normal developmental phase of taking-in during the early puerperium.
Answer Rationale:
1. Lack of interest in infant care and the need to talk about herself are perfectly normal at this
point in her puerperium.
2. Fatigue is not the best answer. Although she may be fatigued, the behavior does not indicate
this.
3. It is too soon after delivery to suggest the woman is unable to accept the reality of
parenthood. Her behavior is normal for this point in time.
4. Reva Rubin identified the phases of adjustment following delivery as taking-in, taking-hold,
and letting-go. Lack of interest in infant care and the need to talk about herself are perfectly
normal in this initial phase of taking-in.
Question 72 of 100
Which techniques are most important for a nurse to assess a 60-year-old client with a family history of
diabetes mellitus?
1. Correct Palpation of pedal pulses and auscultation for carotid bruit.
2. Incorrect Palpation of liver and observation of sclera.
3. Incorrect Palpation of spleen and pulse oximetry.
4. Incorrect Palpation of abdomen and auscultation of breath sounds.
Answer Rationale:
1. Type II diabetes is more frequent in persons with a family history of diabetes, especially as
they age. The vascular complications of diabetes may be present at the time of diagnosis,
since the symptoms of Type II diabetes mellitus may be so mild that detection of the disease
is delayed. Pedal pulses may be absent in the presence of peripheral vascular disease of the
lower limbs. The presence of a carotid bruit may indicate partial occlusion of the carotid artery
related to arteriosclerosis. Other organs typically affected in diabetes mellitus include the eye,
kidney, and nerves.
2. Liver complications are not common in diabetes. The eye changes in diabetes are on the
retina, not the sclera.
3. Palpation of the spleen and pulse oximetry are not screening tests for diabetes and do not pick
up common complications of diabetes.
4. Abdominal changes and respiratory complications are not indicative of diabetes.
Question 73 of 100
Karen is a 25-year-old who has had repeated psychiatric hospitalizations for exacerbation of psychotic
symptoms related to noncompliance with antipsychotic medications. She was brought to the hospital
today by the police, who found her intoxicated and wandering down the middle of the highway. The
admitting nurse on the psychiatric unit knows that Karen would be least apt to be at increased risk for
which of the following?
1. Incorrect Alcohol withdrawal symptoms.
2. Correct Cholinergic crisis.
3. Incorrect Sensory/perceptual symptoms.
4. Incorrect Suicidal crisis.
Answer Rationale:
1. Alcohol withdrawal is considered a risk as the client was intoxicated upon admission.
2. The client has a history of noncompliance with antipsychotic medications. Because of this a
cholinergic crisis is not a high risk for her. If she had been taking the prescribed antipsychotic
medications regularly there would be a risk of cholinergic crisis.
3. Sensory/perceptual symptoms are possible due to the alcohol use as well as the history of
psychotic symptoms.
4. Suicide is a risk due to withdrawal as well as sensory/perceptual alterations.
Question 74 of 100
An adult client has a fractured right ankle, which was casted in the emergency room. Before the client is
discharged, the nurse must teach crutch walking skills. Which is the correct technique?
1. Incorrect "Lift both crutches, advance a short distance and swing through with both
legs.''
2. Correct "Advance crutches and the right leg, then swing through and touch down with
the left leg.''
3. Incorrect "Advance left leg, then lift and advance crutches, and swing right leg.''
4. Incorrect "Hold both crutches under one arm, advance crutches up stairs. Hold onto rail,
lift body, and touch down one step with left leg.''
Answer Rationale:
1. Walking as described could only be achieved with a walker.
2. The three-point gait is used when one leg cannot bear weight. The body weight is supported
by the hands on the crutches and on the unaffected extremity (three points).
3. This is not a correct gait.
4. This describes the technique for stair climbing, which the client may need to know but is not
what the question asked.
Question 75 of 100
A 25-year-old woman is in her fifth month of pregnancy. She has been taking 20 units of NPH insulin
for diabetes mellitus daily for six years. Her diabetes has been well controlled with this dosage. She has
been coming for routine prenatal visits, during which diabetic teaching has been implemented. Which of
the following statements indicates that the woman understands the teaching regarding her insulin needs
during her pregnancy?
1. Incorrect "Are you sure all this insulin won't hurt my baby?''
2. Correct "I'll probably need my daily insulin dose raised.''
3. Incorrect "I will continue to take my regular dose of insulin.''
4. Incorrect "These finger sticks make my hand sore. Can I do them less frequently?''
Answer Rationale:
1. The client starts to need increased insulin in the second trimester. This statement indicates a
lack of understanding.
2. As a result of placental maturation and placental production of lactogen, insulin requirements
begin increasing in the second trimester and may double or quadruple by the end of
pregnancy.
3. The client starts to need increased insulin in the second trimester. This statement indicates a
lack of understanding.
4. Insulin doses depend on blood glucose levels. Finger sticks for glucose levels must be
continued.
Question 76 of 100
The nurse is monitoring an adult who is undergoing hemodialysis. The client suddenly becomes
cyanotic and complains of dyspnea and chest pain. His blood pressure is 70/40 and his pulse is weak and
rapid. The nurse calls the physician immediately because the signs and symptoms suggest which
complication of dialysis?
1. Incorrect Disequilibrium syndrome.
2. Correct Air embolism.
3. Incorrect Internal bleeding.
4. Incorrect Hemorrhage at the shunt.
Answer Rationale:
1. Symptoms of disequilibrium syndrome include headache, muscle twitching, backache, nausea,
vomiting, and seizures.
2. Air embolism is a potentially fatal complication characterized by sudden hypotension, dyspnea,
chest pain, cyanosis, and weak, rapid pulse.
3. Internal bleeding presents as apprehension; restlessness; pale, cold, clammy skin; excessive
thirst; hypotension; rapid, weak, thready pulse; and increased respirations. Sudden onset of
chest pain and dyspnea are not characteristic of internal bleeding.
4. Hemorrhage at the shunt has visible blood loss as well as apprehension; restlessness; pale,
cold, clammy skin; excessive thirst; hypotension; rapid, weak, thready pulse; and increased
respirations. Sudden onset of chest pain and dyspnea are not characteristic of bleeding at the
shunt.
Question 77 of 100
Mr. T. has been informed that he needs surgery for rectal cancer. His response is, "There's nothing
wrong with me. I just have hemorrhoids.'' The nurse knows this response to be which defense
mechanism?
1. Incorrect Projection.
2. Incorrect Repression.
3. Correct Denial.
4. Incorrect Displacement.
Answer Rationale:
1. Projection is blaming others for one's own shortcomings or unacceptable thoughts and feelings
about the self.
2. Repression is a forgotten memory that cannot be brought into awareness. Repressed thoughts
are anxiety producing and are often produced by trauma.
3. Denial is the blocking out of thoughts or feelings perceived as painful. Mr. T. is blocking the
news that he has rectal cancer and needs surgery.
4. Displacement is the expression of emotion onto someone or some object that is less
dangerous than the original person. Pent-up feelings are usually hostile ones expressed in a
safer environment, since to express it to the original person is unacceptable or too dangerous.
Question 78 of 100
A client with Guillain-Barr syndrome has been on a ventilator for three weeks, and can communicate
only with eye blinks because of quadriplegia. The intensive care nursing staff sometimes have no time
for this tedious communication process. The client's family comes infrequently since they run a family-
owned restaurant that does not close until visiting hours are over. How should the nurse respond to the
family's request for exemption from visiting hours?
1. Incorrect Arrange for a volunteer to stay with the client during the day to provide for
socialization needs and to facilitate communication with staff.
2. Incorrect Explain to the family that consistency in enforcing rules is important to prevent
complaints from the families of other clients.
3. Incorrect Suggest that the family visit in shifts during the normal visiting hours, since
the client needs to sleep at night.
4. Correct Make an exception to visiting regulations because of the long-term nature of
the client's recovery and the need for family support.
Answer Rationale:
1. The need for family support is vital to prevent discouragement and depression. A volunteer will
not take the place of family.
2. The need for family support is vital to prevent discouragement and depression, even at the
risk of offending the families of other patients.
3. Loss of a breadwinner during the lengthy recovery process may add financial problems for the
family.
4. Guillain-Barr syndrome is characterized by the onset of ascending paralysis, which may
include respiratory muscles. Persons with Guillain-Barr syndrome may remain ventilator-
dependent for weeks, but have full consciousness. The prognosis for recovery from Guillain-
Barr syndrome is good, but is very much dependent upon the level of supportive care during
the acute stage.
Question 79 of 100
The nurse is visiting a client at home and is assessing him for risk of a fall. The most important factor to
consider in this assessment is
1. Correct illumination of the environment.
2. Incorrect amount of regular exercise.
3. Incorrect the resting pulse rate.
4. Incorrect status of salt intake.
Answer Rationale:
1. To prevent falls, the environment should be well lighted. Night lights should be used if
necessary. Other factors to assess include removing loose scatter rugs, removing spills, and
installing handrails and grab bars as appropriate.
2. The amount of regular exercise is not the most important factor to assess. It is only indirectly
related.
3. The resting pulse rate is not related to preventing falls.
4. The salt intake is not directly related to preventing falls.
Question 80 of 100
The nurse is evaluating a new mother feeding her newborn. Which observation indicates the mother
understands proper feeding methods for her newborn?
1. Correct Holding the bottle so the nipple is always filled with formula.
2. Incorrect Allowing her seven - pound baby to sleep after taking 1 ounces from the
bottle.
3. Incorrect Burping the baby every ten minutes during the feeding.
4. Incorrect Warming the formula bottle in the microwave for 15 seconds and giving it
directly to the baby.
Answer Rationale:
1. Holding the bottle so the nipple is always filled with formula prevents the baby from sucking
air. Sucking air can cause gastric distention and intestinal gas pains.
2. A seven-pound baby should be getting 50 calories per pound: 350 calories per day.
Standardized formulas have 20 calories per ounce. This seven-pound baby needs 17.5 ounces
per day. 17.5 ounces per day divided by 6-8 feedings equals 2-3 ounces per feeding.
3. A normal newborn without feeding problems could be burped halfway through the feeding and
again at the end. If burping needs to be at intervals, it should be done by ounces or half
ounces, not minutes.
4. Microwaving is not recommended as a method of warming due to the uneven heating of the
formula. If used, the formula should be shaken after warming and the temperature then
checked with a drop on the wrist. The recommended method of warming is to place the bottle
in a pan of hot water to warm, and then check the temperature on the wrist before feeding.
Question 81 of 100
Ms. S. had a tuberculin skin test, which the nurse reads as positive. Which of the following is true about
the tuberculin skin test?
1. Correct The intradermal test does not differentiate active tuberculosis from dormant
infections.
2. Incorrect The induration is measured in cm.
3. Incorrect A positive test has a diameter of 5 mm.
4. Incorrect Results of a tuberculin skin test must be read within 24 hours.
Answer Rationale:
1. The tuberculin skin test measures the presence of antibodies against tuberculosis. Both
dormant and active infections will give a positive skin test.
2. The induration is measured in mm.
3. A positive test shows an induration of 10 mm or more.
4. Results of a tuberculin skin test are read in 48 to 72 hours.
Question 82 of 100
The nurse is assessing a 17-year-old female who is admitted to the eating disorders unit with a history of
weight fluctuation, abdominal pain, teeth erosion, receding gums, and bad breath. She states that her
health has been a problem but there are no other concerns in her life. Which of the following
assessments will be the least useful as the nurse develops the care plan?
1. Incorrect Information regarding recent mood changes.
2. Incorrect Family functioning using a genogram.
3. Incorrect Ability to socialize with peers.
4. Correct Whether she has a sexual relationship with a boyfriend.
Answer Rationale:
1. Information about mood changes is important to assess, as bulimia is often associated with
affective disorders.
2. Family functioning is the most essential point to assess, as it reveals if binge eating is
triggered by conflict within the family.
3. Information about ability to socialize with peers is important to assess, as it is possible the
problem initiated with peer relationships.
4. It is inappropriate to ask about her sexual relationships.
Question 83 of 100
The nurse is visiting an 80-year-old woman at home. She is mildly hypertensive, takes no medications,
ambulates with a cane, and lives by herself in her own home. The woman complains of constipation and
asks the nurse how to prevent it. Before making suggestions, the nurse assesses the client further. Which
of the following assessments will most help the nurse in devising a strategy to help this client?
1. Incorrect Determining the time and amount of the last bowel movement.
2. Correct Assessing the dietary habits of the client.
3. Incorrect Obtaining a drug history.
4. Incorrect Evaluating the mobility status of the client.
Answer Rationale:
1. The nurse may want to obtain this information. However, it is not the most important factor.
Diet has to take priority.
2. The nurse should assess this client for dietary habits. A diet that is high in fiber helps to
prevent constipation. It is not unusual for the elderly and those living by themselves not to eat
fresh fruits and vegetables.
3. The question states the client is hypertensive and takes no medications. A drug history may be
helpful, particularly if the client was taking narcotics, calcium, or iron, which tend to be
constipating. However, the question tells us she takes no medications.
4. Immobility may tend to cause constipation and activity helps to prevent constipation. The
question gives the information that the client ambulates with a cane and lives alone.
Therefore, further evaluation of mobility status will not be most helpful.
Question 84 of 100
Mrs. B.'s physician has prescribed tetracycline 500 mg po q6h. While assessing Mrs. B.'s nursing history
for allergies, the nurse notes that Mrs. B. is also taking oral contraceptives. What is the most appropriate
initial nursing intervention?
1. Incorrect Administer the dose of tetracycline.
2. Correct Notify the physician that Mrs. B. is taking oral contraceptives.
3. Incorrect Tell Mrs. B. she should stop taking oral contraceptives since they are
inactivated by tetracycline.
4. Incorrect Tell Mrs. B. to use another form of birth control for at least two months.
Answer Rationale:
1. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives.
The physician should be notified.
2. The physician should be notified. Tetracycline decreases the effectiveness of oral
contraceptives. There may be an equally effective antibiotic available that can be prescribed.
Note on the client's chart that the physician was notified.
The nurse should not tell the client to stop taking oral contraceptives unless the physician
orders this.
If the physician chooses to keep the client on tetracycline, the client should be encouraged to
use another form of birth control. The first intervention is to notify the physician.
Question 85 of 100
The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. The
nurse understands that the best explanation for development of esophageal varices is which of the
following?
1. Incorrect Chronic low serum protein levels result in inadequate tissue repair, allowing
the esophageal wall to weaken.
2. Incorrect The enlarged liver presses on the diaphragm, which in turn presses on the
esophageal wall, causing collapse of blood vessels into the esophageal lumen.
3. Correct Increased portal pressure causes some of the blood that normally circulates
through the liver to be shunted to the esophageal vessels, increasing their
pressure and causing varicosities.
4. Incorrect The enlarged liver displaces the esophagus toward the left, tearing the muscle
layer of the esophageal blood vessels, which allows small aneurysms to form
along the lower esophageal vessels.
Answer Rationale:
1. While low serum albumin is common with liver disease, it does not weaken the existing
structures of the body. Weakness of the esophageal wall is not the problem. Since the
esophageal vessels lie close to the surface, under the mucous membranes, the esophageal
wall does not support them at the inner surface.
2. The liver is located to the right of the esophagus. When it enlarges, it is more likely to
compromise expansion of the right lung than to affect the esophagus.
3. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood
circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts
some of the blood into the lower pressure veins around the lower esophagus. Since these
veins are not designed to handle the high-pressure portal blood flow, they develop varicosities,
which often rupture and bleed.
4. Enlargement of the liver does not displace the esophagus.
Question 86 of 100
An adult has continued slow bleeding from the graft after repair of an abdominal aortic aneurysm.
Because of the client's unstable condition, he is in the intensive care unit where visitors are limited to
the family. The client insists on having a visit from a medicine man whom the family visits regularly.
How should the nurse interpret this request?
1. Incorrect The principle of justice prohibits giving one client a privilege that other clients
are not permitted.
2. Incorrect Faith healers do not meet the standards for clergy exemption from visitation
rules.
3. Incorrect Medicine men are not approved by the hospital as legitimate health care
providers.
4. Correct Provision of holistic care requires that the client's belief system is honored.
Answer Rationale:
1. The client's spiritual needs must be met within the framework of his personal belief systems,
even if those beliefs differ from those of the nursing staff.
Question 87 of 100
Mrs. C. will have to change the dressing on her injured right leg twice a day. The dressing will be a
sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best
indicates that Mrs. C. understands the importance of maintaining asepsis?
1. Incorrect "If I drop the 4 X 4s on the floor, I can use them as long as they are not
soiled.''
2. Incorrect "If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile
normal saline.''
3. Correct "If I question the sterility of any dressing material, I should not use it.''
4. Incorrect "I should put on my sterile gloves, then open the bottle of saline to soak the 4
X 4s.''
Answer Rationale:
1. Anything dropped on the floor is no longer sterile and should not be used. The statement
indicates lack of understanding.
2. Anything dropped on the floor is no longer sterile and should not be used. The statement
indicates lack of understanding.
3. If there is ever any doubt about the sterility of an instrument or dressing, it should not be
used.
4. The 4 X 4s should be soaked prior to donning the sterile gloves. Once the sterile gloves touch
the bottle of normal saline they are no longer sterile. This statement indicates a need for
further instruction.
Question 88 of 100
The nurse is caring for a woman in the fourth stage of labor. The nursing care plan should include
monitoring the woman for
1. Incorrect uterine contractions.
2. Incorrect cervical dilation.
3. Incorrect birth of the baby and delivery of the placenta.
4. Correct readjustment to the nonpregnant state.
Answer Rationale:
1. Uterine contractions mark the beginning of the first stage of labor, not the fourth.
2. Cervical dilation is characteristic of the first and second stages of labor, not the fourth.
3. The third stage of labor is characterized by the delivery of the baby and the placenta.
4. The fourth stage of labor is the first hour or two after delivery and is a critical period for
maternal systems to stabilize after giving birth.
Question 89 of 100
A 50-year-old woman has been referred to the hypertension clinic because, in the past two months, her
blood pressure has ranged between 142/90 to 148/96. She is 55 pounds overweight for her height and
age. What life-style change should the nurse suggest for this woman?
1. Incorrect Lose weight as rapidly as possible.
2. Correct Plan a gradual exercise program.
3. Incorrect Begin vigorous exercise immediately.
4. Incorrect Avoid exercise until your blood pressure is within the normal range.
Answer Rationale:
1. Rapid weight loss is not healthy and if eating habits are not altered, all the weight lost and
more, will return when the client stops dieting.
2. An exercise program should be carefully planned and begun gradually.
3. The cardiovascular system might not be able to handle vigorous exercise right away. There
must be a gradual buildup to the level of exercise desired.
4. Moderate exercise may be begun before the blood pressure is within the normal range. The
client's blood pressure range listed is not that severe.
Question 90 of 100
A 35-year-old woman is admitted for treatment of depression. Which of these symptoms would the
nurse be least likely to find in the initial assessment?
1. Incorrect inability to make decisions.
2. Incorrect feelings of hopelessness.
3. Incorrect family history of depression.
4. Correct increased interest in sex.
Answer Rationale:
1. Indecisiveness and fear of being wrong are common in depression.
2. Depression creates feelings that nothing will ever improve.
3. The risk of depression is increased when there is a family history.
4. Interest in sex is markedly decreased in depression.
Question 91 of 100
A fifteen-year-old is treated in the emergency room for a fractured right ankle. A plaster walking cast is
applied and the client is instructed to walk with the aid of crutches once the cast has dried. While
instructing the client to ambulate with crutches the nurse most appropriately teaches the client to
1. Incorrect place the crutches under the arms, bear weight on the axilla, and position both
crutches 8-10 inches in front of the body.
2. Incorrect move crutches and feet in the following sequence: right crutch, left foot, left
crutch, right foot.
3. Correct move both crutches and the right foot forward simultaneously followed by the
left foot.
4. Incorrect move the right foot and left foot forward together followed by the left foot and
right crutch.
Answer Rationale:
1. Weight should be borne by the hands; weight borne by the axilla can cause damage to the
brachial plexus nerves and can cause crutch paralysis.
2. This is the four-point gait and it is taught when the client can move each leg separately and
can bear considerable weight on each of them.
3. This is the three-point gait, which is used when one leg is injured or weak and the other leg is
capable of supporting the client's full body weight. Most of the body weight is placed on the
crutches when the fractured leg is moved forward.
4. This is a two-point gait and is used by persons capable of bearing weight on both legs. It
permits faster ambulation than the four-point gait, which could also be used.
Question 92 of 100
An adult client's insulin dosage is 10 units of regular insulin and 15 units of NPH insulin in the morning.
The client should be taught to expect the first insulin peak
1. Incorrect as soon as food is ingested.
2. Correct in two to four hours.
3. Incorrect in six hours.
4. Incorrect in ten to twelve hours.
Answer Rationale:
1. The first insulin peak will occur two to four hours after administration of regular insulin.
2. Regular insulin is classified as rapid acting and will peak two to four hours after administration.
The second peak will be eight to twelve hours after the administration of NPH insulin. This is
why a snack must be eaten mid-morning and also three to four hours after the evening meal.
3. The first insulin peak will occur two to four hours after administration of regular insulin.
4. The first insulin peak will occur two to four hours after administration of regular insulin. The
second peak will occur eight to twelve hours after the administration of NPH insulin.
Question 93 of 100
A client has a closed head injury. Vital signs are T 103F rectally; pulse 100; respirations 24; B.P.
110/84. Hourly urine output is 200 ml/hr. What is the best understanding of the cause of these findings?
1. Correct Damage to the hypothalamus resulting in decreased hormone production.
2. Incorrect Movement of fluid from the tissue into the intravascular space, resulting from
sepsis.
3. Incorrect An increase in antidiuretic hormone (ADH) as a result of injury to the
hypothalamus.
4. Incorrect Fluid shifts from the tissue into the intravascular space due to administration of
normal saline used during fluid resuscitation.
Answer Rationale:
1. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone
(ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus
also controls temperature. Injury causes a very high temperature.
2. Sepsis is unlikely with a closed head injury. The assessments are classic for hypothalamus
injury.
3. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone
(ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus
also controls temperature. Injury causes a very high temperature.
4. Normal saline is isotonic and would not cause these fluid shifts.
Question 94 of 100
Miss R. is an 88-year-old client at a long-term care facility. Prior to administering any medication or
treatment to this client the nurse must confirm identity by
1. Incorrect asking the client if she is Miss R.
2. Correct reading the client's identification bracelet.
3. Incorrect reading the client's medical record.
4. Incorrect asking the roommate to state the client's name.
Answer Rationale:
1. An alert, oriented client should be asked to state her full name so that there is no confusion in
identity. The ID bracelet will confirm identity when the client is not alert or oriented to person.
2. Reading the name on the client's ID bracelet is the most accurate way to confirm identity.
3. Reading the client's medical record will not confirm identity.
4. The roommate is not an accurate source for client identification.
Question 95 of 100
A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel
in the correct procedures. Which statement by the nursing assistant indicates the best understanding of
the correct protocol for blood and body fluid isolation?
1. Incorrect Masks should be worn with all client contact.
2. Correct Gloves should be worn for contact with nonintact skin, mucous membranes, or
soiled items.
3. Incorrect Isolation gowns are not needed.
4. Incorrect A private room is always indicated.
Answer Rationale:
1. Masks should only be worn during procedures that are likely to cause splashes of blood or
body fluid.
2. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous
membranes; for handling soiled items; and for performing venipuncture.
3. Gowns should be worn during procedures that are likely to cause splashes of blood or body
fluids.
4. A private room is only indicated if the client's hygiene is poor.
Question 96 of 100
The nurse is caring for a mother and her newborn son. Which statement the mother makes indicates
understanding of newborn care?
1. Incorrect "The face and neck are washed first, then the eyes, going from the outer
corners inward.''
2. Incorrect "As soon as the cord looks dried, my baby can sit in a tub bath instead of being
sponged.''
3. Incorrect "After applying alcohol to the cord once a day with the bath, the diaper is
applied over the umbilicus to keep it dry.''
4. Correct "The yellow-white covering over the end of the penis is part of the healing
process and should not be removed, but washed gently with water.''
Answer Rationale:
1. The face and neck are washed after the eyes, so that a completely clean washcloth can be
used for the eyes. The eyes are washed from the inner canthus outward, to prevent blockage
of the tear ducts with exudate and transference of organisms into the nasal passages from the
eyes.
2. The cord must not only look dry, but must have fallen off and the area underneath completely
healed before it can safely be soaked with water containing fecal organisms, etc.
3. Alcohol, or another drying agent prescribed, should be applied several times a day. The diaper
should never cover the unhealed cord because of the urinary and fecal organisms that could
come in contact with the cord.
4. The yellow-white covering over the end of the penis is part of the healing process and should
not be removed, but washed gently with water. Rubbing or the use of soap on the area will
cause irritation. Any bleeding or other exudate needs to be reported to the physician.
Question 97 of 100
The nurse is performing an ophthalmologic examination on an elderly client. The client states, "my
peripheral vision is decreased.'' The nurse's best response to this client during the exam is
1. Incorrect "You should be grateful you are not blind.''
2. Correct "As one ages, peripheral vision decreases. This is normal.''
3. Incorrect "You should rest your eyes frequently.''
4. Incorrect "You may be able to improve your vision if you move slowly.''
Answer Rationale:
1. This is poor communication.
2. As one ages, the eyes undergo changes including a decreased ability to focus on near objects,
increased difficulty with color discrimination and a lessened field of peripheral vision.
3. Resting the eyes will not increase peripheral vision.
4. Moving slowly will not increase peripheral vision. Moving slowly might be relevant if the client
had a detached retina.
Question 98 of 100
The nurse evaluates a delusional client for improvement. Which of the following statements indicates a
positive outcome for a delusional client?
1. Incorrect Client states he/she hears voices, but only when alone.
2. Correct Client states people are observing him but are not talking about him.
3. Incorrect Client expresses less fear in using the public phone on the hospital unit.
4. Incorrect Client states he/she can now use the unit shower room because he/she
realizes the shoe left by another client is not a rat.
Answer Rationale:
1. Hearing voices refers to auditory hallucinations, not the delusions the client is exhibiting.
2. The intensity of the ideas of reference has diminished, showing improvement in the client's
delusional thinking.
3. Less fear in using the public phone is evidence of improvement in a phobic client, not a
delusional client.
4. Correctly interpreting environmental stimuli reflects improvements in a client who experiences
illusions.
Question 99 of 100
The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators.
Which goal would need to be accomplished first? The client
1. Correct demonstrates the relaxation response when asked.
2. Incorrect verbalizes the underlying cause of the disorder.
3. Incorrect rides the elevator in the company of the nurse.
4. Incorrect role plays the use of an elevator.
Answer Rationale:
1. The ability to use relaxation is basic to treatment of phobia.
2. Clients with phobias are resistant to insight therapy.
3. Riding the elevator accompanied by the nurse is an appropriate long-term goal.
4. Role playing may be appropriate after the client has learned relaxation.
Question 100 of 100

A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen.
Which factor indicates further information is needed by the nurse?
1. Incorrect The client's dietary habits include foods high in bulk.
2. Incorrect The client's fluid intake is between 2500-3000 ml per day.
3. Incorrect The client engages in moderate exercise each day.
4. Correct The client's bowel habits were not discussed.
Answer Rationale:
1. Foods high in bulk are appropriate.
2. 2500-3000 ml fluid intake is appropriate.
3. Exercise should be a part of a bowel training regimen.
4. To assess the client for a bowel training program the factors causing the bowel alteration
should be assessed. A routine for bowel elimination should be based on the client's previous
bowel habits and alterations in bowel habits that have occurred because of illness or trauma.
The client and the family should assist in the planning of the program which should include
foods high in bulk, adequate exercise, and fluid intake of 2500-3000 ml.

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Comprehensive Practice Report taken: 8/28/2006 1:57:28 AM

Question 100 of 100

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