QB 4

1. The nursing assistant reports to the nurse that four of the patients are vomiting. Which
of the following patients should the nurse see FIRST?
A client 2 days postop after abdominal surgery with a nasogastric tube attached to low
suction.
A client diagnosed with cirrhosis of the liver with extensive ascites.
A client diagnosed with lung cancer undergoing chemotherapy.
An elderly client diagnosed with irritable bowel syndrome (IBS).

Strategy: “FIRST” indicates priority

1) CORRECT— assess for patency of the NG tube; muscle spasms associated with vomiting
causes severe pain and can threaten the integrity of the wound

2) at risk for dehydration; integrity of wound more important

3) at risk for electrolyte imbalance and dehydration; determine if NG tube is patent

4) due to age, at significant risk for fluid and electrolyte imbalance, potential problem

2. The nurse determines which client is at highest risk of developing colorectal cancer?
A 33-year-old African American female elementary-school teacher diagnosed with
endometriosis.
A 47-year-old Chinese male who owns a restaurant and has a history of a ruptured
appendix.
A 50-year-old Caucasian male cattle farmer diagnosed with ulcerative colitis.
A 70-year-old Caucasian female who is a retired bus driver and has an inguinal hernia.

Strategy: Think about each answer.

1) no risk factors for colorectal cancer

2) no risk factors

3) CORRECT— risk factors include age over 50 and history of ulcerative colitis; diet for
ulcerative colitis is high protein, high calorie and low residue; diet high in fat, high in
protein, and low in residue is a risk factor for colorectal cancer

4) age is a risk factor

3. A client with a 20-year history of asthma experiences acute respiratory distress. Which
breath sound does the nurse consider as ominous for this client?
Absence of wheezing.
 Presence of crackles.
Absence of bilateral rales.
Presence of coarse rhonchi.

1) CORRECT— In a client with asthma, the absence of wheezing indicates acute respiratory
distress. The small airways are completely constricted. This client needs immediate
intervention.

2) Crackles or rales are abnormal breath sounds caused by air moving through fluid. This
breath sound is not associated with asthma.

3) Bilateral rales are not expected with asthma. Symptoms of asthma include dyspnea,
wheezing, nonproductive cough, tachycardia, and tachypnea.

4) Coarse rhonchi are continuous grating sounds. This sound indicates a disease of the
bronchi and is not associated with asthma.

4. The nurse provides care to a primipara client who asks the nurse when she is going to
deliver. The medical record at 0800 indicates the client's cervix is 5 cm dilated, 100%
effaced, and the head is at +1 station. The client is having regular contractions and labor
has progressed without incident. Which response by the nurse is most appropriate?
"If your labor continues to progress as it has, you might deliver between 2:00 and 4:00
p.m."
"Because you are a first-time mom, your progress should be at 1 to 1.2 cm per hour
and up to 3 hours of pushing."
"You are making nice progress in your labor. It should be within the next few hours."
"Every labor is different. It is impossible to predict when you will deliver."

1) It is impossible to predict the exact time of delivery.

2) While this statement is clinically correct, it does not answer the client's question.

3) It is impossible to predict the exact time of delivery.

4) CORRECT— This is the best response from the nurse. Every labor is different and it is
impossible to predict when the client will deliver the newborn.

5. The psychiatric inpatient unit has four new admissions. Which client does the nurse
see first?
A salesperson diagnosed with depression after the baby was born with Down syndrome
and the spouse threatened to file for divorce.
A police officer with a history of posttraumatic stress disorder (PTSD) who was
admitted with agoraphobia after two of his co-officers were killed.
 A computer programmer admitted with a diagnosis of generalized anxiety disorder who
has extensive debt and just filed for bankruptcy.
A college student admitted for depression and anxiety after a sibling committed suicide
and a parent was recently diagnosed with lung cancer.

1) This client has experienced two losses—one actual loss in terms of not having the
anticipated well child and one potential loss in terms of the spouse leaving. While depressed
and probably anxious, this client is likely to benefit from clarification of issues and sharing of
support and referral options.

2) CORRECT – This client has a high potential for violence to self and/or others. There is
easy access to weapons, and knowledge of how to use them. Agorophobia particularly
causes this client to be uneasy in the new surroundings and potentiates acting out in fear.

3) Unemployment or financial problems are particular risk factors for suicide, but the
scenario does not point to any particular sign of suicide lethality potential.

4) Siblings of a person who committed suicide (especially if prior to adulthood) often feel
despair and survivor guilt, putting themselves at risk for suicide. This client has experienced
two serious losses—one actual and one potential.

6. The nurse cares for clients at the student health clinic. Which signs and symptoms should
cause the nurse to suspect cocaine abuse in the college student?
Frequent sneezing, reports of a sore throat, and a temperature of 100°F (37.8°C).
Diarrhea, vomiting, and abdominal pain.
Fatigue, dilated pupils, and anorexia.
Reports of insomnia, rhinorrhea, and facial pain.

Strategy: Determine how each answer choice relates to cocaine abuse.

(1) suggests viral infection or allergic rhinitis

(2) could indicate gastrointestinal problem or substance withdrawal

(3) could indicate any type of substance abuse or other illness

(4) correct—associated with cocaine use by inhalation; nose is most common route for
administration

7. The nurse makes patient assignments after making patient rounds. The nurse should
assign which of the following clients to a nursing assistant?
A client immediately postop after an abdominal hysterectomy complaining of nausea.
A client with a spinal cord injury at the level of C-6 complaining of a pounding
headache.
 A client diagnosed with an abdominal wound that requires a sterile dressing change.
A client diagnosed with a left-sided cerebrovascular accident complaining of
incontinence.

Strategy: Assign the nursing assistant clients with standard, unchanging procedures.

1) requires the assessment skills of an RN

2) symptoms of autonomic dysreflexia; requires care of RN

3) assign to the LPN/LVN

4) CORRECT— assign clients with standard, unchanging procedures

8. The nurse cares for clients in the emergency department (ED). A newly married woman is
brought to the ED by her parents, who relate that their son-in-law was killed 3 days ago in a
boating accident. The parents report their daughter has been uncontrollably screaming and
crying since the boating accident. Which of the following actions should the nurse take
FIRST?
Administer diazepam (Valium).
Ask the parents to leave the room.
Refer the client and her parents to family therapy.
Silently sitting with the wife maintaining eye contact.

Strategy: “FIRST” indicates priority.

1) may be appropriate at some point, but more important to convey to client that the nurse
understands her loss and will be with the client

2) may be appropriate at some point, but not the nurse’s first action

3) may be appropriate at some point, but not the nurse’s first action

4) correct— important that nurse convey warmth, caring, and empathy with the client;
nurse should structure environment so client can express feelings about her loss; allowing
the sharing painful feelings while the nurse is silent and maintaining eye contact is healing
and conveys concern

9. The nurse is caring for a client with metastatic cancer and who had a peripherally inserted
central catheter (PICC) placed four days ago. Which assessment findings does the nurse
expect? Select all that apply.
The nurse feels no resistance when flushing the PICC with saline.

The PICC insertion site has dried blood under the transparent dressing.
 The PICC insertion site is on the client's left chest.
The exposed (non-tunneled) portion of the PICC measured 18 cm yesterday and
today.
The client is receiving a vesicant chemotherapy medication through the PICC.

The client reports taking a shower early this morning.

Strategy: “Which findings does the nurse expect to observe” indicates an expected
outcome. Determine the outcome of each answer. Is it desired?

1) CORRECT — this is a normal finding

2) the sterile dressing should be changed weekly and as needed if it becomes loose, soiled,
or damp

3) PICCs are inserted through a vein in the arm, usually the antecubital fossa

4) CORRECT — PICCs are up to 60 cm in length, including the tunneled portion; RN

measures the exposed length each shift to ensure the catheter has not migrated

5) CORRECT — irritating and vesicant medications may be infused via a PICC

6) CORRECT — the site and dressing may be covered with a transparent semipermeable
dressing during bathing; if the sterile dressing becomes loose or damp during the shower,
apply a new sterile dressing

10. The client is diagnosed with myasthenia gravis. The nurse instructs the client about the
disease. Which statement, if made by the client to the nurse, indicates the need for further
teaching?
"I should not drink alcoholic beverages."
"I should not go places that are crowded."
"I should try to stay calm."
"I should use my hot tub daily."

Strategy: "Need for further teaching" indicates you are looking for an incorrect statement.

(1) should be avoided

(2) may cause infection

(3) emotional extremes can cause exacerbations

(4) correct—should avoid heat (sauna, hot tubs, sunbathing)

11. A 6-month-old infant is brought to the wellness clinic by parents for a routine visit.
Which observation requires follow up by the nurse for evaluation of a possible
developmental delay?
The infant cries and clings to the parent when the nurse is present.
The infant's weight has increased from 8 lb (3.6 kg) to 16 lb (7.3 kg) since birth.
The infant requires support from the parent in order to sit upright.
The infant abducts the extremities and fans the fingers when there is a noise.

1) Crying in the presence of strangers and clinging to a parent or caregiver, which are
reflective of stranger anxiety, are normal findings at 5–6 months. Stranger anxiety and
associated behaviors peak at approximately 7–8 months. No follow up is needed.

2) The infant's weight typically doubles by 5–6 months. This observation is a normal finding.
No follow up is indicated.

3) To sit upright, the infant typically will require support until 7–8 months of age. Because
this observation is a normal finding, follow up is not needed.

4) CORRECT— The Moro reflex, which is an involuntary startle response, is strongest during
first 2 months after birth. This reflex should disappear after approximately 4 months of age.
Follow up is indicated, as a persistent Moro reflex may be indicative of altered neurological
development.

12. The nurse cares for clients in the senior citizens facility. The client relates to the nurse
that, "I had pneumonia once, and I don't want to get it again." To develop an effective
teaching plan for this client, it is most important for the nurse to obtain an answer to which
question?
“How often do you cough and deep breathe?”
“Have you received a flu shot this year?”
“Do you avoid crowds?”
“How much sleep do you receive each night?”

Strategy: “MOST important” indicates discrimination is required to answer the question.

1) activity, coughing, and deep breathing helps prevent pneumonia; community-acquired

pneumonia often follows viral infections or influenza

2) CORRECT— community-acquired pneumonia (most common form of pneumonia) often

follows viral infections or influenza; also ask client status of pneumococcal vaccine

3) avoid crowds during periods of flu outbreak; priority is obtaining the flu vaccine
4) encourage client to get enough rest and sleep and eat balanced meals; primary
prevention is priority

13. The nurse conducts a neurologic assessment on a new patient in the neurology clinic.
Assessment of the biceps and patellar deep tendon reflexes does not readily elicit a
response. It is MOST important for the nurse to take which of the following actions?
Record the reflexes as either 0 or 1+ and proceed to assess the pulses of all four
extremities with a Doppler ultrasound device.
Test again using the opposite side of the reflex (percussion) hammer and strike more
firmly.
Retest the biceps while the patient clenches the teeth, and retest the patellar while the
patient interlaces the fingers and pulls them against each other.
Tap the patient’s face just below and in front of the ear and leave a blood pressure cuff
inflated on patient’s arm for 3 minutes.

Strategy: "MOST important" indicates discrimination is required to answer the question.

(1.) not sufficient to simply record reflexes; reflexes are graded on a 0 to 4+ scale, so 0 or
1 would be appropriate if they were very diminished or absent; no need to check all pulses
with Doppler; no particular relationship with pulses and reflexes

(2.) no reason; to prevent pain, pointed end of triangular hammer should be used to strike
over small areas, e.g., biceps; the flat end should be used to strike over larger areas, e.g.,
Achilles; striking should be done with a brisk, rapid wrist movement

(3.) CORRECT—these are known as reinforcement techniques; isometric contraction of

other muscles can increase the generalized reflex response/activity of the body; distraction
may also be a reason for this effectiveness, as tension can inhibit a reflex being elicited

(4.) tests to assess for hypocalcemia or tetany (Chvostek’s sign and Trousseau’s sign); it is
hypercalcemia, not hypocalcemia, that could cause decreased deep tendon reflexes (DTRs)

14. Which of the following statements if made by the client BEST indicates to the nurse the
client understands teaching to prevent hypokalemia?
“I should take the potassium supplements on an empty stomach.”
“I should crush the potassium tablets if I can’t swallow them.”
“I should eat more bananas as well as take the potassium supplement.”
“I should avoid salt substitutes while taking the potassium supplement.”

Strategy: “BEST” indicates discrimination is required to answer the question. read answers
first before answering question; topic is client education about potassium supplementation

1) potassium supplements should be taken with meals

2) do not crush, may affect the potency or action of the drug

3) bananas are a good source of potassium; increasing natural potassium intake while on a
potassium supplement may result in hyperkalemia

4) CORRECT— many salt substitutes are potassium-based, which combined with the
prescribed potassium supplement may result in hyperkalemia

15. The home health nurse visits the home of a client with a history of kidney stones. Which
instruction is most important for the nurse to include in the teaching?
"Drink at least 2000–3000 mL water per day."
"Avoid drugs that cause elevated calcium levels."
"Avoid foods that contain calcium."
"Participate in a regular exercise program."

1) CORRECT— High urine output dilutes the concentration of minerals and flushes them
from the body.

2) The priority for the client is diluting the urine to facilitate the passage of minerals.

3) It is more important to avoid foods that are high in oxalates, such as spinach, asparagus,
and cabbage.

4) Exercise is a good health promotion habit. A client will need to increase fluids to prevent
dehydration and to facilitate the flushing of minerals that can increase kidney stones.

16. The nurse makes client care assignments for the day. Which client does the nurse assign
to the LPN/LVN? (Select all that apply.)
Client taking ferrous sulfate who reports black stools.

Client with jugular vein distention and muffled heart sounds.

Client with bronchitis who requires a sputum sample collection.

Client with new onset hemianopsia and aphasia.

Client receiving oral nitrofurantoin for cystitis.

Client with a new onset left bundle branch block.

1) CORRECT — Black stools are expected while taking ferrous sulfate. This is a stable client
and an appropriate client to assign to the LPN/LVN.

2) Jugular vein distention and muffled heart sounds are indicative of cardiac
tamponade. This client is unstable and should not be assigned to the LPN/LVN.
3) CORRECT — This is a stable client. There is no indication the client is in respiratory
distress. An LPN/LVN can collect a sputum sample.

4) New onset hemianopsia and aphasia indicate possible stroke. This client is unstable and
should not be assigned to the LPN/LVN.

5) CORRECT — This is a stable client. An LPN/LVN can administer the antibiotic

(nitrofurantoin). Cystitis does not typically result in an unstable condition.

6) A new onset left bundle branch block indicates possible myocardial infarction. This client
is potentially unstable and should not be assigned to the LPN/LVN.

17. The nurse cares for a client diagnosed with a myocardial infarction 12 hours ago. The
client is on bed rest, is prescribed 100 mg metoprolol oral BID, has oxygen by nasal cannula
at 2 liters per minute (LPM), and has intravenous 5% dextrose in water at 20 mL/hour. The
nurse notes sudden onset of this cardiac rhythm:

Which action should the nurse take first?

Increase nasal cannula flow to 4 LPM.
Obtain an oxygen saturation level.
Notify the health care provider.
Obtain a 12-lead electrocardiogram.

determine if the outcome of #1 or #3 would help the client

1) implementation; may not correct the underlying cause of PVCs; can keep for
consideration

2) assessment: there is enough information provided; eliminate; client at risk for ventricular
dysrhythmias

3) CORRECT — implementation, client at high risk for ventricular tachycardia or fibrillation;

pharmacologic intervention needed

4) assessment, not needed; eliminate; continuous monitoring indicates frequent PVCs

18. The nurse performs a physical assessment on an 80-year-old female. The nurse expects
to find which of the following findings?

Select all that apply:

The client has increased flexibility

The client’s height has decreased by 1 inch.

The client has increased range of motion.

The client has increased endurance.

The client has diminished muscle tone.

The client has joint stiffness.

Strategy: Think about each answer.

1) will have decreased flexibility due progressive deterioration of cartilage

2) CORRECT— caused by decreased bone density in vertebrae

3) has diminished range of motion due to progressive deterioration of cartilage

4) has decreased endurance due to atrophy of muscles

5) CORRECT— due to diminished size of muscles

6) CORRECT— due to changes in cartilage

19. The community health nurse obtains laboratory test results for four clients. After
evaluating the lab results, the nurse determines that which of the clients should be
contacted FIRST?
Urine culture and sensitivity with colonization of E. coli .
Urinalysis with leukocytes.
Elevated serum antistreptolysin O (ASO) titer.
Cystourethrogram reveals vesicoureteral reflux.

Strategy: “FIRST” indicates priority.

1) validates urinary tract infection; not as threatening to health as glomerulonephritis

2) reflects urinary tract infection or contamination during specimen collection; no immediate

significant threat to health
3) CORRECT— indicates glomerulonephritis, damage to glomerulus caused by an
immunological reaction that results in proliferative and inflammatory changes within the
glomerular structure

4) X-ray study of bladder and urethra; radiopaque dye injected, patient voids, x-rays taken
during voiding

20. The nurse cares for a 4-year-old child diagnosed with epiglottitis. It is MOST important
for the nurse to take which of the following actions?
Instruct a nursing assistant to take the child to the x-ray department.
Use a padded tongue blade to assess the child’s gag reflex.
Obtain a blood culture and arterial blood gases (ABGs) as ordered.
Apply a pulse oximeter and start an IV.

Strategy: “MOST important” indicates priority.

1) epiglottitis is inflammation of the epiglottis and can be life-threatening; a professional

should be with the child at all times

2) Never insert a tongue blade into the mouth of a child diagnosed with epiglottitis; gag
reflex can cause complete obstruction of the airway

3) crying can cause obstruction of airway

4) CORRECT— treatment includes moist air and IV antibiotics to decrease epiglottal

swelling; pulse oximeter measures oxygen saturation to determine the need for
supplemental oxygen

21. A client experiences a pulmonary embolism after abdominal surgery. Which information
in the client's history will contraindicate the use of thrombolytic therapy?
Has type 2 diabetes mellitus.
Takes medications as needed for angina pectoris.
Is recovering from a concussion that occurred 3 weeks ago.
Uses an inhaler for treatment of asthma.

1) Diabetes is not a contraindication for thrombolytic therapy. Side effects of tissue

plasminogen activor (t-PA) include anaphylaxis, spontaneous cerebral, gastrointestinal and
genitourinary bleeding, in addition to dysrhythmias.

2) Medications for angina pectoris are not a contraindication for thrombolytic therapy.

3) CORRECT— Thrombolytic therapy is contraindicated in a client who experienced a

trauma within the past 2 months. Other contraindications include active internal bleeding,
history of hemorrhagic stroke, intracranial or intraspinal surgery, intracranial neoplasm,
atriovenous malformation, aneurysm, and severe uncontrolled hypertension.

4) An inhaler to treat asthma is not a contraindication for thrombolytic therapy.

22. The nurse receives hand-off communication from the previous shift. Which client will the
nurse see first?
Client with chronic renal failure reporting swollen fingers and ankle edema.
Client 1 day postoperative after abdominal surgery with dried blood on the abdominal
dressing.
Client with type 1 diabetes mellitus who states, "I have this quivering feeling in my
abdomen."
Client on high doses of antibiotics for a resistant infection reporting diarrhea.

1) Swollen fingers and ankle edema indicates peripheral edema, which occurs in the client
with chronic renal failure. Treatment includes fluid and sodium restrictions.

2) Dried blood on a postoperative wound dressing is not life-threatening. This is a stable

client.

3) CORRECT – A quivering feeling indicates hypoglycemia. Additional symptoms include

tachycardia, cold and clammy skin, weakness, and pallor. The client's capillary blood
glucose level should be assessed, and a carbohydrate source provided.

4) Diarrhea commonly occurs with antibiotic therapy. The nurse should monitor fluid and
electrolytes, and check for skin breakdown.

23. The home care nurse visits a client diagnosed with AIDS. The nurse instructs the client’s
caregiver about how to prevent infection. What is the MOST important instruction the nurse
should give to the client’s caregiver?
“Cover your nose and mouth when you sneeze or cough.”
“Get rid of all pets in the home.”
“Wash your hands frequently.”
“Wash the client’s dishes separately.”

Strategy: “MOST important” indicates priority.

1) appropriate action because client is susceptible to illness; priority is washing hands

2) not necessary; client should not touch litter boxes, feces, bird droppings, or water in the
fish tank; encourage client to wash hands with soap and water after handling the family pet
3) CORRECT— single best way to kill germs; caretaker should wash hands after going to
the bathroom and before and after fixing food; should also wash hands before and after
caring for the client

4) not necessary; wash all dishes together

24. The nurse plans care for a one-week-old child with tetralogy of Fallot. It is MOST
important for the nurse to take which of the following actions?
Offer the infant water every four hours.
Enlarge the hole in the nipple of the formula bottle.
Position the infant on his stomach after bottle-feeding.
Gradually increase the time between bottle feedings.

1) should offer formula to meet nutritional needs; has increased calorie needs due to
increased metabolic rate

2) CORRECT— allows the child to obtain nourishment easily; feed on a 3-hour schedule
and feed soon after awakening so infant doesn’t cry

3) support infant and feed in a semi-upright position

should offer feeding every 3 hours; stroke infant’s jaw and cheek to encourage sucking;
complete feeding in half an hour

25. The nurse is contacted by a client diagnosed with a chronic idiopathic seizure disorder
currently controlled with anticonvulsant medication. The client is getting married in five
weeks, and she is concerned about having a seizure during the ceremony. Which of the
following actions by the nurse is BEST?
Ask physician to increase the client’s medication dosage for the wedding day.
Ask a nurse to attend the wedding and assist as needed.
Teach the bride-to-be how to perform relaxation exercises.
Tell the bride-to-be to make a medication and seizure chart.

Strategy: “BEST” indicates discrimination is required to answer the question.

1) physician cannot know how much medication will be required to overcome the stress
associated with the wedding day; client does not want to have side effects of drowsiness
and dizziness

2) more important to try to prevent seizure

3) might be helpful if assessment determined precipitators are stress related

4) CORRECT— may help identify seizure triggers such as alcohol, stress, caffeine,
constipation; may be increase in seizure activity during menses

26. The nurse teaches a client who experiences persistent tachycardia. Which instruction
does the nurse include in teaching the client about tachycardia? (Select all that apply.)
Avoid becoming overheated while outdoors.

Regular propranolol use causes bradycardia.

Seek counseling as needed for anxiety management.

Use prescribed medications to control asthma.

Rest as much as possible and avoid strenuous work.

1) CORRECT – The body responds to hyperthermia by increasing the heart rate to meet
metabolic demand to cool off. The client should drink cool liquids, limit time in the sun, and
take other reasonable measures to avoid becoming too hot.

2) Propranolol, a beta blocker, causes decrease in heart rate, but should not result in
bradycardia. Propranolol, taken as prescribed, should result in a normal heart rate.

3) CORRECT – Anxiety causes increase in heart rate, and should be managed to prevent
this. If the client needs counseling or medication to accomplish this, then they should seek
that treatment.

4) CORRECT – An asthma exacerbation causes an increase in heart rate and should be

prevented with daily medications as prescribed. Medications such as albuterol may be
avoided in this client with an abnormal rhythm. However, even this treatment is preferable
to the cardiac strain of an asthma attack.

5) Walking or other mild to moderate physical activity performed on a regular basis is

beneficial to reducing tachycardia. Resting as much as possible and avoiding strenuous work
is not a reasonable suggestion. The client should rest when needed, balanced with activity.

27. The nurse leads a family therapy session for the family of an adolescent diagnosed with
depression. During the first session, the teen’s mother dominates the discussion. Which of
the following responses by the nurse is MOST appropriate?
“Please let some of the other family members speak.”
“You appear to be frustrated about dealing with your teen.”
“You and I will speak privately after the session is over.”
“How do the rest of you feel about what your Mother is saying.”

Strategy: Remember therapeutic communication.

1) nontherapeutic response
2) is therapeutic; one purpose of family therapy is to help members develop their own
sense of identity

3) important to give every member in the group a chance to talk as a group

4) CORRECT— allows every member of group to offer feedback about the effect the
mother’s monopoly of the session has on each person

28. The nurse prepares a client for left total hip replacement. Which of the following
statements, if made by the client to the nurse, indicates an emotional readiness for
surgery?
“I know the physician isn’t telling me everything, but there is nothing I can do about
it.”
“I’ve never heard of this specialist before. Does he do much work here?”
“I’m glad the trapeze is here so I can start working on my exercises as soon as I wake
up.”
“Can you please check my chart? I’m not sure that other nurse recorded that I am a
diabetic.”

Strategy: Think about each answer

1) indicates fear and helplessness

2) indicates fear and lack of trust

3) CORRECT— indicates acceptance and a readiness to participate in postoperative care

4) indicates fear that something is going to be missed and a lack of trust of the nursing staff

29. The nurse, preparing medication for a client, has a 20 mL multidose vial of heparin
labeled 10,000 units per mL. The prescribed concentration is to mix 25,000 units of heparin
per 250 mL of normal saline. Which amount of heparin, in mLs, will the nurse add to the
250 mL bag of normal saline? (Record your answer using one decimal place.)
Your Response:
Correct Response:2.5
mL

30. The nurse observes a nursing assistive personnel

(NAP) transfer a client with right-sided paralysis
using a hydraulic lift. For which action will the nurse intervene?
Lowers the bed before the transfer is initiated.
 Positions a canvas sling under the center of the body.
Folds client's arms over the chest.
Pumps the hydraulic handle using long, slow strokes.

1) CORRECT— The bed should be raised so the NAP uses proper body mechanics during the
transfer. A lowered bed increases the NAP's risk for injury.

2) The client should be centered in the sling. This provides support for the client's body
during the transfer.

3) Folding the arms over the chest prevents injury to the arms, especially the paralyzed
side, and provides for client safety.

4) Pumping the handle using long, slow strokes ensures safe support of the client during the
elevation of the sling.

31. The nurse observes a nursing assistive personnel (NAP) transfer a client with right-sided
paralysis using a hydraulic lift. For which action will the nurse intervene?
Lowers the bed before the transfer is initiated.
Positions a canvas sling under the center of the body.
Folds client's arms over the chest.
Pumps the hydraulic handle using long, slow strokes.

1) CORRECT— The bed should be raised so the NAP uses proper body mechanics during the
transfer. A lowered bed increases the NAP's risk for injury.

2) The client should be centered in the sling. This provides support for the client's body
during the transfer.

3) Folding the arms over the chest prevents injury to the arms, especially the paralyzed
side, and provides for client safety.

4) Pumping the handle using long, slow strokes ensures safe support of the client during the
elevation of the sling.

32. The nurse performs teaching for a patient receiving amitriptyline hydrochloride (Elavil).
The nurse should intervene if the patient makes which of the following statements?

Select all that apply:

“I will take Elavil at bedtime.”

“I always forget to wear sunscreen.”

“I will stop eating cheese and yogurt.”

 “It may be 3 to 4 weeks before I feel better.”

“When I start to feel better, I can adjust the dosage of Elavil.”

“I can exercise as soon as I wake up in the morning.”

Strategy: Determine the outcome of each answer. Is it desired?

1) appropriate action; has a sedative effect; other side effects include blurred vision, dry
mouth, diaphoresis, postural hypotension, palpitations, constipation, urinary retention,
increased appetite

2) CORRECT— sunblock required

3) CORRECT— true of MAO inhibitors (Nardil, Marplan); foods containing tyramine may
cause hypertension

4) true statement; takes 3-4 weeks to achieve therapeutic level and see changes in mood

5) CORRECT— patient should never adjust dosage of medication without consulting a

physician

6) CORRECT— may cause orthostatic hypotension; instruct client to sit on side of bed
before arising in the morning

33. The nurse receives a phone call from a pediatric client's caregiver. The caregiver reports
a pin is stuck in the child's eye. Which statement by the caregiver concerns the
nurse? (Select all that apply.)
"The tears will probably push out the pin."

"I washed the eye with my allergy eye drops."

"How do I sterilize tweezers to pull the pin out?"

"We're on the way to the emergency department."

"I covered the child's eyes with a scarf."

1) CORRECT – To prevent further damage, the pin should be left in place until the client is
evaluated by a health care provider.

2) CORRECT – Irrigating the eye may cause movement of the pin, leading to more tissue
damage.

3) CORRECT – No attempt at removing the pin should be made. Moving the foreign body
may cause more damage to the eye tissue and even lead to vision loss.
4) The client should be immediately evaluated by a health care provider.

5) Covering the eyes is an appropriate intervention to help reduce eye movement and
prevent further tissue damage.

34. The nurse cares for the client 2 hours after placement of a cuffed tracheostomy tube.
When the nurse enters the client's room, the tracheostomy tube is 90% displaced out of the
stoma. Which action should the nurse take first?
Place oxygen at 6 LPM over the stoma opening.
Auscultate bilateral breath sounds.
Check the client's pulse oxygenation reading.
Use a hemostat to dilate the opening of the stoma.

step 5: what is the outcome of the action

1) implementation, physical, breathing; eliminate; will not be effective unless airway is

open; new stoma will not have well-formed tract

2) assessment, not needed at this time; eliminate; a closed stoma on a tracheostomy client
indicates a closed airway and is the priority

3) assessment, not needed at this time; eliminate; reestablishing a patent airway is a

priority over assessing oxygenation

4) CORRECT — implementation, airway; first action is to open airway; some stoma swelling
expected due to recent surgical procedure

35. The nurse oversees care provided by an LPN/LVN and the nursing assistive personnel
(NAP). Which task is most appropriate to delegate to the NAP?
Monitor a client during the first 15 minutes after the nurse begins a blood transfusion.
Determine the patency of a chest tube drainage system for a client with a
pneumothorax.
Teach a client newly diagnosed with type 1 diabetes mellitus how to fill out the menu.
Implement bladder training measures for a client with urinary incontinence.

1) Monitoring a client receiving a blood transfusion is the responsibility of the nurse.

2) Determining the patency of a chest tube drainage system is the responsibility of the
nurse. The NAP can measure and record chest tube drainage.

3) Client teaching is the responsibility of the nurse.

4) CORRECT –The NAP can be delegated activities related to bladder training. Establishing
the bladder training program is the responsibility of the nurse.
36. A client is prescribed to receive 1000 mL of dextrose 5% and water with 30,000 units of
heparin to infuse at 50 mL/hr. Which amount of heparin does the client receive each
hour? (Record your answer using a whole number. Do not round.)
units/hour

Ratio/Proportion:

Dimensional Analysis:

37. A nurse plans care for a patient diagnosed with Graves’ disease. When planning the
patient’s care, the nurse should include which of the following?
Serve the client 2 meals per day.
Provide frequent rest periods.
Provide extra clothes for warmth.
Offer coffee and tea with meals.

Strategy: Determine the outcome of each answer. Is it desired?

1) hyperthyroidism; symptoms include hyperactivity, sensitivity to heat, weight loss,

tachycardia, frequent mood swings; offer six meals a day that are high in calories due to the
high metabolic rate

2) CORRECT— provide an environment that is free of stress and activity due to the high
metabolic rate; restrict visitors and control choice of roommates

3) suffer from heat intolerance and need a cool environment

4) avoid stimulants

38. The home care nurse receives a phone call from the wife of a client recovering from a
left above-the-knee amputation. The client awakened screaming with pain in the amputated
portion of the limb. The wife relates to the nurse that she is worried about her husband’s
mental health. Which of the following responses by the nurse is BEST?
 “Did you have him turn on his abdomen?”
“Please try to calm down. There is nothing to be upset about.”
“Is the residual limb bleeding or does it have an unusual odor?”
“That kind of pain is common after an amputation. Does he have something he can
take for the pain?”

Strategy: “BEST” indicates discrimination is required to answer the question.

1) flexor spasms may cause pain in residual part of limb; is not related to pain in the absent
portion of the limb

2) negates the wife’s experience; offer specific information; not likely to calm down until
she understands the process

3) assessment of the residual limb is relevant to determine source of pain, can be relevant
under different circumstances; does not address the fact he’s having pain in the absent
portion of the limb

4) CORRECT— nerve endings often become pinched in the scar tissue; brain still has image
of the missing limb

39. A client is prescribed digoxin 0.425 mg IV. The available medication supply is digoxin
500 mcg/2 mL. Calculate the amount of medication the nurse will administer to deliver one
dose of medication to the client. (Record your answer using one decimal place. Follow
appropriate rounding rules.)
Your Response:
Correct Response:1.7
mL

Conversion: 1 mg = 1000 mcg

Ratio/Proportion: Dimensional Analysis:

40. A client must follow a high protein, low sodium,

and low potassium diet. Which menu selections require follow-up teaching by the
nurse? Select all that apply.
Roast beef sandwich, coleslaw, and baked beans.

Broiled chicken breast, spinach salad, and green beans.

 Poached salmon fillet, broiled cabbage, and lemonade.

Steel cut oatmeal with brown sugar, fresh blueberries, and black coffee.

Grilled chicken Caesar salad and whole grain roll with iced tea.

Strategy: "Requires follow-up teaching" indicates incorrect information. Determine the

outcome of each answer. Is it an incorrect food?

1) CORRECT — coleslaw and baked beans are high in sodium

2) CORRECT — spinach is high in potassium

3) CORRECT — salmon is high in potassium

4) appropriate for dietary restrictions

5) CORRECT — Caesar salad high in sodium and potassium

41. The nurse notes that a child has nonorganic failure to thrive (FTT). Which action will the
nurse take when caring for the child?
Feed the child in the presence of other children.
Assign a consistent core group of staff to care for the child.
Place the child in a room near the nurse's station.
Rotate the staff so that the parents can see a variety of feeding approaches.

1) The feeding environment should be quiet and non-stimulating. Feeding in the presence of
other children may be too distracting for the child.

2) CORRECT – A consistent team of nurses helps build trust. The cycle of dissatisfaction
and frustration causes difficulty between the parent and the child. Feeding techniques are
best taught to parents by example and demonstration.

3) The child with FTT often requires an environment without interruption, especially during
meal time. Placing the child in a room close to the nurse's station may be distracting and
should be avoided.

4) Consistency of the staff is important to gain the trust of the child and the parents.

42. Four clients enter the emergency department at one time for triage. Prioritize the order
in which the nurse assesses the clients starting with the first priority client. All options
must be used.

Correct Answer
  A client who is dyspneic and has swollen lips after being stung by a bee.
 A client who is diaphoretic and is feeling chest pressure.
 A client diagnosed with an open fracture and chest contusions from a motor vehicle accident.
 A client diagnosed with COPD with shortness of breath has an oxygen saturation of 88 percent.


Strategy: Utilize the ABCs, real vs. potential, and stable vs unstable. When determining
the order of the nurse's actions, determine the outcomes and make the decision based on
outcomes.

1) indicates potential anaphylaxis which may involve airway compromise; immediate, real
problem; airway issue takes first priority

2) indicates possible cardiac ischemia; immediate, real problem; circulatory issue takes high
priority

3) potential airway/circulation problem with contusions and fracture; real issues higher
priority than potential

4) potential problem; acute issues higher priority than chronic issues; relatively normal
assessment for a client diagnosed with emphysema

43. A client is scheduled for magnetic resonance imaging (MRI) of the upper abdomen.
Which information about the client is most important for the nurse to communicate to the
technician prior to the test?
Allergic to penicillin.
Treated for aortic stenosis.
History of gastric ulcers.
Right metal hip prosthesis.

1) An MRI is not contraindicated for an allergy to penicillin.

2) An MRI is not contraindicated for aortic stenosis, which is a malfunction of the aortic
valve between the left atria and ventricles. This disease process results in ventricular
hypertrophy, pulmonary congestion, and reduced cardiac output.

3) An MRI is not contraindicated for gastric ulcers. People with this disorder develop
symptoms at age 45 years and older. Symptoms include pain occurring one hour after a
meal or when fasting that is relieved by vomiting.

4) CORRECT— An MRI is contraindicated for clients with metal implanted objects. All
jewelry and other metal objects are removed before the test in those who are able to
undergo an MRI.

44. The nurse cares for a client receiving sulfasalazine (Azulfidine). The nurse should include
which of the following in the client’s teaching plan?
Restrict fluids to 1,500 cc per day.
 Explain to the client that the stools may become clay-colored.
The medication should be continued, even after symptoms subside.
If diarrhea occurs, the client should discontinue the medication.

Strategy: Determine the outcome of each answer. Is it desired?

1) sulfonamides used to treat inflammatory bowel disease; increase fluids to prevent

crystallization in the kidney tubules

2) may turn the urine an orange-red color temporarily; does not discolor stool

3) CORRECT— decreases bowel inflammation; administer after meals or with food

4) diarrhea is symptom of ulcerative colitis; should continue taking the medication

45. The nurse provides postpartum care to a client who is bottle-feeding her newborn
infant. Which client statement requires follow up by the nurse?
"It feels so good to stand in a warm shower."
"I'll wear a tight-fitting bra."
"I'll take the pain medication prescribed by the doctor."
"Ice packs will help my breasts feel better."

1) CORRECT— Application of warm or hot water to the breasts may stimulate milk
production and cause breast engorgement. To help suppress lactation, the client should be
instructed to avoid running warm water over the breasts, especially the nipples.

2) To help suppress lactation, the client should wear a well-fitted bra (even while sleeping)
until softening of the breasts occurs. This statement is reflective of an appropriate action
and requires no follow up by the nurse.

3) Mild analgesics may be prescribed to help reduce pain related to breast engorgement.
The client's statement indicates correct understanding of the plan of care and requires no
follow up.

4) Application of ice packs to the breasts will help relieve engorgement. This statement
indicates an appropriate action and requires no follow up by the nurse.

46. A client reports perineal irritation from frequent urination. Which action will the nurse
suggest for prevention of this condition?
Apply povidone iodine ointment to the perineum.
Cleanse the perineum gently with warm water two to three times a day.
Use extra-large incontinence briefs during the day.
Expose the perineum to the air for 20 minutes each day.
1) Povidone iodine ointment is not the best treatment for perineal irritation. A topical
antibacterial medication would be a better suggestion.

2) CORRECT— Warm water cleanses the skin and prevents the development of an
infection. Washing two or three times a day promotes good hygiene. A barrier cream may
also be used.

3) Wearing incontinence briefs is not the best suggestion as this may increase perineal
irritation.

4) Exposing the perineum to air for 20 minutes each day is the best suggestion for healing
the irritation. The area should be kept clean and dry.

47. A client comes to the clinic reporting muscle weakness, breathlessness, and bone pain.
The nurse notes that the client takes phenytoin 100 mg three times a day. When providing
nutritional counseling, which food grouping best meets this client's needs?
Bananas, mushrooms, yams.
Oranges, broccoli, papayas.
Milk, cantaloupe, kale.
Soybeans, spinach, pumpkin seeds.

1) Bananas, mushrooms, and yams includes some folate, but no vitamin D.

2) These foods are high in vitamin C and potassium. Broccoli is a minor source of calcium.
Oranges are a good source of folic acid. The papaya does supply some folic acid. None of
these are sources of vitamin D.

3) CORRECT – Anticonvulsants can cause folate and vitamin D deficiencies. The client has
symptoms reflective of anemia and bone resorption. Folate deficiency can cause anemia.
Good sources of folate are green leafy vegetables, legumes, tomatoes, and various fruits
such as oranges and cantaloupe. Good sources of vitamin D include milk. Kale is also a good
source of calcium to work with the vitamin D.

4) The spinach, soybeans, and pumpkin seeds are a good source of folate, but this does not
address the client's vitamin D level.

48. The nurse in the outpatient clinic prepares to perform a venipuncture on a client with a
diagnosis of Crohn’s disease. The patient suddenly becomes upset and asks, “What are you
really going to be injecting into my veins?” Which of the following responses by the nurse is
BEST?
“Nothing. I’m just going to draw some blood.”
“What makes you think I’m going to inject anything into your vein?”
“Have you had a bad experience with venipunctures before?”
 “You sound frightened. What are your specific concerns?”

Strategy: Remember therapeutic communication.

1) giving true information, but doesn’t allow client to verbalize feelings

2) nontherapeutic; defensive response

3) yes/no question; nontherapeutic

4) CORRECT— reflects feelings and allows client to verbalize feelings and concerns

49. The nurse manager of the oncology unit is planning an inservice to address
confidentiality issues. Which of the following measures should the nurse manager stress as
being BEST to prevent confidentiality violations?
Keep ambulatory patients and visitors away from the nursing station as much as
possible.
Call patients and one another by first names only.
Answer the telephone by saying the type of unit, but not the floor number.
Accompany the physicians doing walking rounds at the bedside.

Strategy: Determine the outcome of each answer. Is it desired?

(1.) CORRECT—much activity goes on at the nursing station in terms of in-person and
telephone conversations, paperwork, computer screens, etc., and multiple disciplines
participate there; ambulatory patients, or visitors waiting for their needs to be addressed or
just standing nearby, can easily be exposed to information about other patients

(2.) does not prevent confidentiality violations and may be disrespectful; some patients may
prefer to be addressed by their surname

(3.) this is more likely to violate confidentiality by conveying patient’s diagnosis to the caller
(e.g., answering with "Oncology" = cancer) than if the phone were answered simply with
the floor number, which is the usual procedure

(4.) very useful in interdisciplinary collaboration and, if done correctly, in terms of involving
the patient; however, in terms of confidentiality, it can be a problem if there is more than
one patient in a room and also if discussions are held outside patient rooms in hallways
before and/or after seeing patient, as they often are

50. The health care provider orders a heparin drip for a client with cardiac disease. The
order reads "2,000 units of heparin per hour." The IV solution contains 20,000 units of
heparin in 500 mL of 5% dextrose in water. The nurse should regulate the client's IV to
deliver how many mL per hour?
Your Response:
Correct Response:50

Strategy: Perform the math.

Correct answer: 50

51. The nurse provides care for four clients on a medical surgical unit. The nurse knows that
which client is most at risk for wound dehiscence and evisceration?
A client diagnosed with Parkinson disease who is 5 feet 8 inches tall, weighs 150 lb, and
had a stereotactic pallidotomy 2 days ago.
A client diagnosed with diabetes mellitus type 2 who is 5 feet 5 inches tall, weighs 195
lb, and had an appendectomy 1 day ago.
A client with history of mitral stenosis who is 5 feet 2 inches tall, weighs 130 lb, and
had open-heart surgery for mitral valve reconstruction 3 days ago.
A client with a fractured femur who is 6 feet 1 inch tall, weighs 170 lb, and had open
reduction and internal fixation surgery 4 days ago.

1) This client is not at high risk for dehiscence, and the wound cannot eviscerate as the
incision was made in the skull.

2) CORRECT— The client has three risk factors: being overweight, having diabetes (which
impairs wound healing), and being post-abdominal surgery. Abdominal surgery is the most
frequent type of surgery in which wound dehiscence and evisceration appear.

3) The client has no major risk factors for wound dehiscence or evisceration.

4) The client has no major risk factors for wound dehiscence or evisceration.

52. The nurse provides care to a client with a cuffed endotracheal tube inserted after a drug
overdose. Which observation most concerns the nurse?
The pilot balloon does not fill when air is injected.
Food-like material is present in the endotracheal tube.
The inner cannula is lying on the chest of the patient.
There is condensation in the endotracheal tube on exhalation.
1) The balloon not functioning correctly is a cause for concern, but is not the priority since
there is still an airway via the tube. The pilot balloon indicates presence or absence of air in
cuff, and lack of balloon filling indicates cuff leak, which may have been caused by a tear or
rupture in the cuff or pilot system. The tube needs to be replaced

2) CORRECT – Food in the endotracheal tube indicates esophageal intubation. Therefore,

there is no airway and the tube needs to be immediately removed. The client should be
hyperventilated to prevent hypoxia before attempting another intubation with a new sterile
tube.

3) There is no inner cannula in an endotracheal tube. Inner cannulas are present in most
tracheostomy tubes.

4) Condensation indicates correct positioning of the tube in the trachea.

53. Caring for clients in the pediatric clinic, the nurse performs an assessment of a 9-
month-old infant. The nurse expects which of the following findings?

Select all that apply:

The infant sits unsupported.

The infant pulls himself to a standing position.

The infant attempts to build a two-block tower.

The infant responds to simple verbal commands.

The infant can say three to five words.

The infant hugs his mother on request.

Strategy: Picture a 9-month-old infant.

1) CORRECT— can sit without support for prolonged period of time

2) CORRECT— can also stand while holding onto furniture

3) appropriate for a 12-month-old; a 9-month-old compares two cubes

4) CORRECT— comprehends “no-no”

5) appropriate for a 12-month-old

6) does show interest in pleasing parents; hugging parent on request more appropriate for a
12-month-old
54. The nurse observes an LPN/LVN prepare a sterile field for a sterile dressing change.
Which action by the LPN/LVN is most important for the nurse to intervene?
Includes extra 4 × 4 gauze pads to wipe up any spills on the sterile field.
Sets up the sterile field in front of an open window.
Sets up the sterile field on a waist-level table.
Sets up the sterile field immediately in front of the nurse.

1) Any spills on a sterile field causes contamination. Should this occur, all items and
supplies are to be discarded and a new sterile field is established. Although this is a
potential problem, it does not require the nurse to immediately intervene.

2) CORRECT – Air from an open open window can cause microorganisms in the air current,
contaminating the sterile field. The windows and doors should be closed and another sterile
field should be set up.

3) The sterile field should be set up on a waist-level table. This is appropriate behavior.

4) Setting up the sterile field is appropriate behavior. The LPN/LVN faces the sterile field
and should not reach across the field.

55. The nurse provides care to clients in the postanesthesia care unit (PACU). Which client
requires immediate attention by the nurse?
Client with a new tracheotomy with a small amount of serosanguineous drainage on the
dressing.
Client who is responsive with a moderate amount of clear fluid draining from the
nasogastric tube.
Client with a chest tube and dark red drainage in the collection chamber.
Client who is unresponsive to verbal stimuli with the oral airway out of place.

1) A small amount of serosanguineous drainage on the dressing of a new tracheostomy is

an expected finding. The client is stable and does not require immediate attention by the
nurse.

2) Clear fluid draining from a nasogastric tube does not indicate a complication. The client is
stable and does not require immediate attention by the nurse.

3) Dark red drainage in a chest tube collection chamber is an important finding but does not
require immediate attention. The nurse may need to gently "milk" the tubing in the direction
of the drainage if necessary.

4) CORRECT - The client who is unresponsive and missing an oral airway needs to have the
airway reinserted to maintain a patent airway.

56. The nurse monitors a client who is recovering from coronary artery bypass graft surgery
(CABG). Which finding most concerns the nurse?
 The jugular veins are distended, but the lung sounds are clear.
The client reports sharp localized pain over the sternum.
Lab values of potassium 4.6 mEq/L, calcium 9.4 mg/dL (2.4 mmol/L), and magnesium
1.6 mg/dL (0.7 mmol/L).
The core body temperature is 97.2°F (36.2°C).

1) CORRECT — Jugular vein distention is a symptom of cardiac tamponade. Cardiac

tamponade is a potential complication after a CABG caused by blood accumulating around
the heart (from bleeding and nonpatent mediastinal tubes) and compressing the
myocardium, atria, and ventricles.

2) This is an expected finding after a CABG since the heart has been accessed through the
sternum. The client will be treated with pain medication.

3) All these laboratory values are within normal limits. The normal range for potassium is
3.5 to 5 mEq/L. For calcium it is 8.6 to 10.2 mg/dL (2.2 to 2.5 mmol/L), and for magnesium
it is 1.3 to 2.3 mg/dL (0.53 to 0.95 mmol/L).

4) Mild hypothermia is expected after a CABG because of induced hypothermia during

surgery and heat loss from the open chest. The nurse will provide the client with warm
blankets.

57. A client newly diagnosed with Ménière disease is counseled about important dietary
modifications. Which comment by the client best indicates to the nurse that teaching is
successful?
"I have seen a lot of dietetic foods in the store. I will focus on buying them."
"I will avoid Chinese restaurants and fast-food places when I go out to eat."
"I will buy one of those commercial salt substitutes to use when I want salt."
"I can have corned beef and smoked fish, but not pickles or creamed sauces."

1) Not all dietetic foods are low in sodium. The client must read each label.

2) CORRECT – Clients with Ménière disease require a low-sodium diet to decrease fluid
retention (endolymphatic fluid, which is clear, intracellular fluid located in the labyrinth of
the inner ear). Many Chinese restaurants use MSG and soy sauce, both of which are high in
sodium. Fast-food places and products also have a tendency to be high in sodium.

3) Spices and herbs are better substances for flavor enhancement. This is not an incorrect
understanding, it just is not the best example of understanding the teaching.

4) Meat and fish products that are canned, smoked, pickled, or cured should be avoided
because they are high in sodium, as are pickles and, often, creamed sauces.
58. The fire alarm sounds in the hospital that houses a locked inpatient psychiatric unit. The
alarm code indicates that the fire is on another medical unit. Which priorityaction does the
nurse on the psychiatric unit take?
Ensure that all clients are in the day room.
Assign a staff member to each of the unit's locked doors.
Explore with clients their past experiences with fire.
Prepare for evacuation of the unit using the stairs.

1) CORRECT – The priority is direct client care (think RACE, even though fire is not on this
unit). Psychiatric clients are usually mobile, versus confined to bed, and the unit usually has
a central gathering area such as a day room. Staff should be assigned to check all rooms
and direct patients to leave their rooms and go to the day room.

2) The priority is locating and centralizing patients. Fire alarms in a large institution often
automatically unlock all locked doors in the building, anyway. If the clients are in a central
location, there is no need to worry about the doors.

3) The priority is safety of clients. It is not an appropriate time to discuss feelings and
thoughts during a potential emergency, unless one of the clients exhibits anxiety that must
be contained. Even then, exploring feelings as a group is not the best way to handle an
individual issue. If anything, distraction techniques may be utilized while waiting for the fire
to be either cleared or to require further action.

4) If evacuation is necessary, use of stairs (versus elevators) is the correct method, but the
fire is on a different unit and may be contained without affecting the psychiatric unit.

59. The nurse provides care to a hospitalized client who has just begun receiving low-dose
radiation (LDR) via seed implants for treatment of prostate cancer. To ensure safety of the
client's visitors and health care team members, the nurse implements which intervention?
Limiting visitors to spending no more than 60 minutes per visit with the client.
Requiring pregnant staff members to wear a lead apron when providing client care.
Planning the client's care to minimize staff members' exposure to radiation.
Ensuring visitors remain at least 2 feet from the radiation source.

1) Visitors should be limited to spending no more than 30 minutes per visit with the client.
Children and individuals who are pregnant should not be permitted to visit the client who is
undergoing brachytherapy.

2) Pregnant staff members should not be assigned to provide care to a client who is
undergoing internal radiation (brachytherapy).

3) CORRECT— To minimize the health care team's exposure to radiation, client care should
be planned to allow the least amount of exposure to the client.

4) Visitors should maintain a minimum distance of 6 feet from the radiation source.
60. The nurse cares for a client 24 hours after a right pneumonectomy due to cancer. The
client’s wife reports that the client drinks a fifth of vodka daily. The nurse reports to the
physician the client is restless, agitated, and irritable. The physician orders chlorpromazine
(Thorazine), 25 mg IM now. Which of the following actions should the nurse take FIRST?
Administer the medication as ordered.
Contact the physician.
Continue to monitor the client.
Ensure that the lights are on in the client’s room.

Strategy: Think about the outcome of each answer.

1) Thorazine is an antipsychotic/antiemetic; client has symptoms of alcohol withdrawal,

contact the physician

2) CORRECT— client has symptoms of alcohol withdrawal; other symptoms include

tremors, insomnia, alcoholic hallucinations; administer sedation as needed, monitor vital
signs, seizure precautions; place client in a quiet, well-lit room

3) contact the physician regarding the order; usually administer benzodiazepines

4) appropriate action; priority is to question the order

61. The nurse instructs a client diagnosed with COPD about how to perform pursed lip
breathing. Which of the following statements by the client to the nurse indicates further
teaching is necessary?
“I will tighten my stomach muscles as I finish breathing out.”
“I will take twice as long to breathe out as I did to breathe in.”
“I will breathe in deeply through my nose, hold it, and then breathe out.”
“I will pretend I am whistling when I breathe out.”

Strategy: “Further teaching is necessary” indicates incorrect information.

1) using abdominal muscles helps to squeeze out all of the air

2) appropriate action; exhalation should be at least twice as long as inhalation; mild

resistance of partially opposed lips prolongs exhalation and increases airway pressure

3) CORRECT— incorrect action; breath should never be held during pursed lips breathing

4) ensures slow, soft, and steady exhalation

62. The nurse provides care to a client receiving an epinephrine infusion following a cardiac
arrest. Which assessment finding demonstrates that treatment is effective?(Select all that
apply.)
 Blood pressure 130/67 mm Hg on the right arm.

Apical heart rate 99 beats/min.

Pedal pulses +1 and weak bilaterally.

Pupils constricted and equal bilaterally.

Capillary refill less than 2 seconds.

1) CORRECT – Epinephrine is a vasopressor and is used off-label to help maintain an

adequate blood pressure. A BP within normal limits indicates the treatment is effective.

2) CORRECT – Epinephrine is a vasopressor and is used off-label to help maintain an

adequate heart rate and rhythm. An apical pulse within normal limits indicates the
treatment is effective.

3) Pedal pulses that are +1 and weak bilaterally indicates inadequate perfusion and that
treatment is not effective. Epinephrine is a vasopressor used to maintain adequate heart
rate and rhythm.

4) Intravenous epinephrine has little to no effect on the pupils and does not indicate
effectiveness of the treatment.

5) CORRECT – A capillary refill of less than 2 seconds indicates normal tissue perfusion and
adequate cardiac output.

63. The nurse provides care to a client who is comatose. Which observation requires
intervention by the nurse?
Feet rest against a board at the foot of the bed.
Pillow under the calves, elevating the legs.
Capillary refill time of the great toe is 3 seconds.
Skin over the ischial tuberosities appears blanched.

1) Resting the feet against a board at the foot of the bed prevents footdrop. The plantar
surface of the feet should be against the board to maintain dorsiflexion of the ankle joint.

2) Placing a pillow under the lower legs increases venous return and reduces lower
extremity edema.

3) A capillary refill time of 3 seconds indicates the rate of peripheral blood flow. A normal
rate is 1 to 3 seconds. A longer rate or sluggish return of color indicates slow peripheral
blood flow.
4) CORRECT— The absence of normal red tones in the skin indicates tissue ischemia due to
reduction of blood flow. This area should not be massaged; however, the client does need to
be repositioned to take the body weight off of this area.

64. The nurse educates a client who was recently diagnosed with pyelonephritis. Which
client statements indicate to the nurse that further teaching is required? Select all that
apply.
"I could have avoided this if I had kept my blood pressure under better control."
"I don't enjoy drinking water, but if I notice my urine has an odor, I'll try to drink
more."
"Since I'm allergic to sulfa medications, the health care provider will give me IV
antibiotics."
"When I have a fever, I will take acetaminophen as prescribed."

"I can tell I'm getting better when the pain in my back goes away."

"After the antibiotics are finished, I will need to schedule a visit to the clinic."

Strategy: "Further teaching is required" indicates incorrect information. Answers are

quotations, so think about what the words mean. Determine the outcome of each
answer. Is it incorrect information?

1) CORRECT — no correlation between pyelonephritis and hypertension

2) CORRECT — the client needs to be instructed to drink six to eight 8-ounce glasses of
fluid, not necessarily water; client's urine may or may not have odor

3) CORRECT — although trimethoprim/sulfamethoxazole is a common treatment for

pyelonephritis, there are other oral antibiotics that may be prescribed

4) true statement, no need for the nurse to follow up

5) true statement, clients with pyelonephritis often have flank pain

6) true statement, the client will need a follow-up culture

65. The home care nurse makes an initial visit to a client with heart failure. The client takes
digoxin 0.25 mg and furosemide 40 mg daily. It is most important for the nurse to
intervene if the client makes which statement?
"I take my digoxin either in the morning or midday."
"I eat a dish of ice cream for dessert every night."
"I take herbal licorice to control my stomach ulcer."
"I take the furosemide after supper each day."
1) It is better to take the cardiac glycoside at the same time each day, but this is not the
priority.

2) The client should avoid foods that are high in fat, but it is not a priority for nurse to
intervene.

3) CORRECT – Licorice can increase potassium loss and may cause digoxin toxicity and
arrhythmias.

4) Diuretics should be taken in the morning, or at least 6 to 8 hours prior to going to bed, to
prevent diuresis from interfering with sleep and causing falls in the night. The nurse needs
to assess and teach, but this is not the priority.

66. The nurse provides care for a 24-year-old client with a family history of hyperlipidemia.
The client reports that the client's parents take atorvastatin and states, "I'm going to ask
my health care provider to prescribe it for me." Which responses by the nurse are
appropriate? Select all that apply.
"It is important to use contraception while taking statin medications."

"Most people taking statin medications experience few adverse effects."

"Statins have not been found to be effective in women."

"Follow a fat-free diet and you will not have to worry about having a stroke."

"Plan to have blood work done at least yearly if you take atorvastatin."
"Since your cholesterol level is only 220 mg/dL (5.7 mmol/L), you are not a candidate
for a statin medication."

1) CORRECT — statin medications are classified as pregnancy risk category X and should
not be taken during pregnancy

2) CORRECT — statin medications are well-tolerated by most people

3) statin medications are effective for everyone

4) although a low fat diet may reduce the risk for a stroke, a fat-free diet is unhealthy and
difficult to follow

5) CORRECT — when taking a statin medication the client will need to have liver function
tests monitored to make sure no adverse effects are occurring

6) optimal total cholesterol is less than 200 mg/dL (5.2 mmol/L)

67. The home health nurse visits the home of a mother, father, and their 5-year-old child.
The mother’s 84-year-old mother has been living with them for 2 months, and the nurse
visits to assess the grandmother’s health status after hospitalization for a fall and broken
arm. Which of the following statements by the 5-year-old boy MOST concerns the nurse?
 "My grandma’s cat got a cut on his stomach and won’t come out of the corner. Can
you fix it?"
"Sometimes when I drink milk, I throw up."
"We never go anywhere any more since Grandma moved in with us."
"I want to be a doctor when I grow up and take care of hurt children and animals all
over the world."

Strategy: Think about what the child’s words mean.

(1.) CORRECT—these injuries and behaviors may indicate pet abuse, which can be a sign of
other abuse going on in the home; this home has three categories of often-abused people:
child, spouse, elder; the 84-year-old was hospitalized for injuries that might have been
related to abuse; in this family situation, it is difficult to say who might have been abused,
but there are grounds for suspicion and further investigation

(2.) concerning, but not the priority; may indicate a cow’s-milk allergy; eliminating all dairy
products is usual management

(3.) may indicate sadness and/or anger on part of child

(4.) not priority

68. A client newly diagnosed with emphysema is being discharged to home. Which client
statement indicates to the nurse an understanding of the discharge instructions? (Select all
that apply.)
"I need to get my annual influenza vaccine."

"I need to decrease my smoking to half a pack a day."

"I will sit while watching my grandson's soccer games."

"I should limit my fluid intake to 4 cups of water a day."

"I am signing up for tai chi at my local community center."

"I should eat three large meals each day."

1) CORRECT — It is important to limit the risk for infection. Clients with emphysema are at
high risk of infection and develop influenza-related complications, such as pneumonia, more
easily.

2) The client needs to quit smoking completely.

3) CORRECT — It is important for this client to conserve energy when possible.

4) Fluid intake should be increased to liquefy secretions. Four cups of liquid per day is not
adequate. This client needs to drink more than the recommended daily intake of 8 cups.

5) CORRECT — It is important to practice relaxation and stress reduction techniques.

Exercise also will help this client gain control of respiratory effort.

6) The client should eat small, frequent meals. This helps prevent pressure on the
diaphragm, which increases the work of breathing.

69. The nurse instructs a client diagnosed with diverticulosis. Which client statement
indicates that further teaching is needed?
"I will eat fruits and vegetables with every meal."
"I will select meats that are low in fat."
"I will start weight lifting for strength."
"I will work on losing some weight."

Strategy: "Further teaching is needed" indicates incorrect information.

1) adding fiber to the diet will increase bulk in the stool; fiber is avoided if diverticulitis
develops

2) this is a good health habit to eat no more than 30% of the daily calories from fat

3) CORRECT— weight lifting or excessive bending should be avoided due to the stress
placed on the abdomen

4) losing weight will benefit a client by placing less pressure in the abdomen area

70. A nursing assistive personnel (NAP) was injured in an automobile accident. After
rehabilitation, the NAP walks with a limp and a slow, unstable gate. The NAP returns to work
on an acute care surgical unit. Which action by the nurse manager is best?
Survey other units for more suitable positions for the NAP.
Recommend the NAP apply for disability benefits.
Transfer the NAP to a less demanding shift on the unit.
Transfer a portion of the NAP's duties to other staff.

1) CORRECT – The American Disability Act (ADA) recommends that the NAP be offered a
position that is appropriate. The manager could first evaluate the care the NAP is able to
provide before offering reassignment.

2) The ADA requires reasonable accommodations. The injuries may impede speed of work,
but not the ability to perform the job. To apply for disability, the NAP has to meet certain
standards of decreased ability and performance.
3) Regardless of the shift, the NAP has to be able to perform the care required. A shift
change would not necessarily be helpful.

4) Redistributing the workload may jeopardize client safety and reduce staff morale.

71. The nurse evaluates care given by a nursing assistant. The nursing assistant ambulates
a client to the bathroom, and the nurse overhears the nursing assistant ask a family
member to stand with a client while the nursing assistant cares for another client. Which of
the following responses by the nurse is BEST?
“Why did you ask the family member to stay with the client?”
“Please stay with the client and call me if the client becomes dizzy.”
“Do not ask a family member to do your job.”
“Did the client ask you to leave?”

Strategy: “BEST” indicates discrimination is required to answer the question.

1) do not ask “why” questions; priority is client safety

2) CORRECT— priority at this time is client safety; after client is safely back in bed, nurse
should review proper procedure with the nursing assistant

3) priority is to ensure the client is safe

4) yes/no question; address client safety first before determining why the incident occurred

72. The nursing assistive person on an acute urology unit gives the nurse the intake and
output sheet for a client diagnosed with chronic kidney disease. The client’s output was
measured on the day shift but not recorded on the evening shift. Which action should the
charge nurse take first?
Call the nurse assigned to the evening shift and request the information.
Complete an agency incident report.
Ask the client to give the output for last evening.
Notify immediate supervisor of the incident.

Strategy: “FIRST” indicates priority.

1) CORRECT— the goal is to make every effort to retrieve the data; knowledge of output
used to support decision making about most appropriate interventions; nurses often carry
notes home with them or store their work sheets in their lockers; this method seeks a
possible resource

2) last step; information may be available; quality client care is first priority; don’t have
problem yet
3) some clients notice the volume and some do not; is a possible resource, but is not the
best resource; is nurse’s job to record output

4) focus is not maintaining system at this point; focus is on collection of prime data for
management of client health needs

73. The client reports, "I can't get warm. I'm cold all the time" to the nurse. The client's
spouse reports recent behavior changes and forgetfulness. The client is unsure when daily
medications were taken last. The nurse notes the client has periorbital edema and a flat
affect. Vital signs reveal T 95.6°F (35.3°C); BP 100/60 mm Hg; pulse 58 beats/min;
respirations 26 breaths/min. Laboratory data reveal serum pH 7.25; PaCO2 50 mm Hg;
HCO3 23 mEq/L; serum T4 is 4.2 mcg/dL; serum TSH 6.3 mcg/dL. Which action does the
nurse take when providing client care? (Select all that apply.)
Reorient client every 15 minutes.

Administer oral levothyroxine sodium.

Administer intravenous (IV) hydrocortisone.

Obtain a stat 12-lead electrocardiogram (ECG).

Place client on continuous cardiopulmonary monitoring.

1) The client is conscious and alert, so reorienting doesn't apply at this time.

2) CORRECT — The client has advanced hypothyroidism. The initial and least invasive
treatment to prevent myxedema coma is oral T4 replacement therapy.

3) IV hydrocortisone is administered when a client is unconscious or unable to swallow. This

client is conscious.

4) A stat 12-lead ECG is obtained immediately after acute cardiac changes or symptoms of
acute coronary syndrome are identified (e.g., ST elevation, reports of chest pain), and then
typically after pharmacologic treatment is initiated.

5) CORRECT — The client is at risk for acute cardiopulmonary changes. The continuous
monitoring captures acute changes in cardiac rhythm and oxygenation (O2 sat). Blood
pressure can be monitored in time intervals, usually every 5 to 15 minutes, and provides
real-time data for emergent response.

74. A group of clients are identified as at risk for pressure injury. For which client does the
nurse initiate pressure injury prevention measures? (Select all that apply.)
A client in skeletal traction who is diaphoretic.

A client with reddened areas that blanch on both elbows.

A premature neonate with nasogastric feedings.

An infant who had surgical repair of an umbilical hernia.

 A client who has a temperature of 103°F (39.44 oC).

A client with urinary retention who self-catheterizes.

1) CORRECT — The immobility imposed by skeletal traction combined with moist skin from
diaphoresis puts this client at risk for a pressure injury.

2) Skin that blanches does not indicate an ongoing problem with pressure.

3) CORRECT — A preterm neonate does not have sufficient subcutaneous fat stores and is
at risk for skin breakdown. The presence of an NG tube increases the neonate's risk, due to
pressure from the tube and tape on delicate skin.

4) After an umbilical hernia repair, this infant should be mobile and not at risk for pressure
injuries.

5) Fever alone does not increase a client's risk of developing a pressure injury.

6) Intermittent catheterization does not increase a client's risk of developing a pressure

injury.

75. A sequential compression device (SCD) is ordered for a patient recovering from a
retropubic prostatectomy. It will be the first time for the nurse to apply such a device.
Which of the following statements by the nurse to the nursing manager best reflects correct
understanding of the proper procedure?
"I will wrap the sleeves snugly, but I will be certain I can fit one finger between each
one and the leg."
"I will put the antiembolism stockings on before I wrap and secure the sleeves."
"I will start by positioning each sleeve under the leg so that the opening is at the
ankle."
"I will measure the circumference of the midcalf and the midthigh to ensure that the
sleeves are the correct size."

Strategy: Determine the outcome of each answer. Is it desired?

(1.) incorrect action; need to be able to fit two fingers, not just one, between the sleeve and
the leg; correct fit prevents irritation to the leg; it also allows for the device to reach
adequate inflation pressure and prevents slipping out of position when deflation occurs; the
fit can be checked by inserting two fingers in the knee opening
(2.) CORRECT—correct action; it is acceptable, though not essential, to apply antiembolism
stockings prior to applying the sequential compression device sleeves; the stockings can
decrease the itching, sweating, and heat that can build up under the plastic sleeves and
thereby cause discomfort and skin irritation
(3.) incorrect action; the opening should be at the knee (in front) and at the popliteal pulse
point (in back)
(4.) incorrect action for sequential compression device; circumference of the thigh is
measured at the gluteal fold; correct sleeve size ensures proper fit and function