Nclex Final Coaching.docx

1. A client with chronic renal failure plans to receive a kidney transplant. Recently, the physician told the client that he is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, “I want to go off dialysis. I’d rather not live than be on this treatment for the rest of my life.” Which responses are appropriate? Select all that apply. 1. Take a seat next to the client and sit quietly. 2. Say to the client, “We all have days when we don’t feel Ike going on.” 3. Leave the room to allow the client to collect his thoughts. 4. Say to the client, “You’re feeling upset about the news you got about the transplant.” 5. Say to the client, “The treatments are only 3 days a week. You can live with that.” 2. Which signs and symptoms might a nurse observe in a client having an adverse reaction to a loop diuretic? Select all that apply. 1. Weakness 2. Irregular pulse 3. Hyperactive bowel sounds 4. Decreased muscle tone 5. Potassium level of 3.1 mEq/L 6. Ventricular arrhythmias 3. A nurse is caring for a client with advanced cancer. Based on the nursing progress notes below, what should be the nurse’s next intervention?

5. A client is ordered heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/ml. How many milliliters of heparin should the nurse administer? Record your answer using one decimal place. Answer: 0.6ml 6. A nurse is caring for a client with a hiatal hernia. The client complains of abdominal pain and sternal pain after eating. The pain makes it difficult for him to sleep. Which instructions should the nurse recommend when teaching this client? Select all that apply. 1. Avoid constrictive clothing. 2. Lie down for 30 minutes after eating. 3. Decrease intake of caffeine and spicy foods. 4. Eat three meals per day. 5. Sleep in semi-Fowler’s position. 6. Maintain a normal body weight. 7. A nurse is performing cardiac assessment. Identify where the nurse places the stethoscope to best auscultate the pulmonic valve.

1. Reread the Patient’s Bill of Rights to the client. 2. Call the client’s spouse to discuss the client’s statements. 3. Tell the client that he can receive adequate pain relief only in the hospital. 4. Explain that an advance directive can express the client’s wishes. RATIONALE: The nurse should explain how an advance directive can be used to express the client’s wishes. An advance directive is a legal document that’s used as a guideline for life-sustaining medical care of the client with an advanced disease or disability who can no longer indicate his own wishes. This document can include a living will, which instructs the physician not to administer life-sustaining treatment, and a health care power of attorney, which names another person to act on the client’s behalf for medical decisions in the event that the client can’t act for himself. The Patient’s Bill of Rights doesn’t specifically address the client’s wishes regarding future care. Calling the spouse is a breach of the client’s right to confidentiality. Stating that only a hospital can provide adequate pain relief in a terminal situation demonstrates inadequate knowledge on the nurse’s part of the resources available through collaboration with hospice 4. While assessing a client’s spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.

8. A nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. Which interventions should the nurse perform? Select all that apply. 1. Place the client in a prone position. 2. Approach the client from the left side. 3. Encourage deep breathing and coughing. 4. Discourage bending down. 5. Orient the client to his environment. 6. Administer a stool softener. 9. A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation below, which laboratory result is the priority for the nurse to report to the physician?

13. A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of ineffective tissue perfusion (peripheral)? Select all that apply. 1. Edema 2. Skin pink in color 3. Strong, bounding pulses 4. Normal sensation 5. Skin discoloration 6. Skin temperature changes

1. Rheumatoid factor 2. Blood culture 3. Alkaline Phosphatase 4. ESR

14. While examining the hands of a client with osteoarthritis, a nurse notes heberden’s node on the second (pointer) finger. Identify the area on the finger where the nurse observed the node.

10. A nurse is caring for dlent5 with diabetes insipidus and must be aware of the disorder’s pathophysiology. Place the following events in chronological sequence to show the pathophysiologic process. Use all of the options.

15. 1. A client with sepsis and hypotension is being treated with dopamine hydrochloride. A nurse asks a colleague to double-check the dosage that the client is receiving. The 250-ml bag contains 400 mg of dopamine, the infusion pump ¡s running at 23 mI/hour, and the clent weighs 80 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using one decimal point. Answer: 7.7 mg/kg/min 11. The nurse is admitting a client with newly diagnosed diabetes mellitus and left-sided heart failure. Assessment reveals low blood pressure, increased respiratory rate and depth, drowsiness, and confusion. The client complains of headache and nausea. Based on the serum laboratory results below, how would the nurse interpret the client’s acid—base balance?

16. The nurse is evaluating an electrocardiogram (ECG) tracing. Which graphic shows the QT interval?

1. Metabolic Alkalosis 2. Metabolic Acidosis 3. Respiratory Alkalosis 4. Respiratory Acidosis 12. An elderly client has a history of aortic stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur.

17. A client with a bicuspid aortic valve has severe stenosis and is scheduled for valve replacement. While teaching the client about the condition and upcoming surgery, the nurse shows a heart illustration. Which valve should the nurse indicate as needing replacement?

21. A nurse observes the following pattern when monitoring the electrocardiogram (ECG) of a stable client. What should the nurse do?

1. Continue to observe for deterioration of the heart rhythm. 2. Administer 0.5 mg of atropine sulfate by I.V. push as ordered. 3. Prepare for transvenous pacemaker insertion as ordered. 4. Administer amiodarone (Cordarone) 150 mg I.V. as ordered. 22. A nurse is caring for a client with pulmonary edema. The physician writes the following orders. Which order should the nurse clarify?

18. A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member, the monitor exhibits the following. Which interventions should the nurse do first?

1. Place the client on oxygen 2. Confirm the rhythm with a 12-lead ECG 3. Administer amiodarone I.V. as prescribed 4. Assess the client’s airway, breathing, and circulation. 19. Following coronary artery bypass graft surgery, a client is admitted to the surgical intensive care unit and connected to a cardiac monitor. The nurse can’t detect a pulse or blood pressure and observes the following pattern on the electrocardiogram (ECG) monitor. What does this pattern show?

1. Morphine LV. 2 mg every 2 hours P.R.N. for shortness of breath 2. Furosemide I.V. 40 mg every 6 hours 3. 0.9% normal saline solution I.V. at 150 ml/hour 4. Dobutamine 5 mcg/kg/minute I.V 23. A client who is receiving procainamide has the following electrocardiogram (ECG) tracing. The nurse anticipates that the physician will order which drug?

1. Artifact 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Pulseless electrical activity 20. A nurse determines that a hockey player hospitalized with bilateral leg fractures is hemodynamically stable, She observes the following pattern on the electrocardiogram (ECG) monitor. Which nursing intervention is most appropriate at this time?

1. None; this arrhythmia is benign 2. Administering atropine sulfate, 0.5 mg, as ordered to increase heart rate. 3. Continuing to monitor if lengthening PR intervals 4. Evaluating the client’s serum electrolyte studies

1. Quinidine sulfate 2. Lidocaine (Xylocaine) 3. A higher dose of procainamide (Pronestyl) 4. Magnesium sulfate RATIONALE: This ECG shows torsades de pointes. In this variant form of ventricular tachycardia, QRS complexes rotate about the baseline, their amplitude decreasing and increasing gradually as the rhythm progresses. To shorten the QT interval and prevent this arrhythmia from recurring, the physician is likely to order magnesium sulfate. Because torsades de pointes is precipitated by a long QT interval, drugs that prolong the QT interval, such as quinidine and procainamide, are contraindicated. The most effective treatment is overdrive pacing with an electronic pacemaker until the offending drug is excreted. Typically, such drugs as lidocaine — normally

effective in suppressing ventricular activity — fail to convert torsades de pointes to a normal sinus rhythm. 24. A client is admitted with acute coronary syndrome. The nurse measures the client’s blood pressure at 97/66 mm Hg, obtains a palpable femoral pulse, notes that the client is awake and coherent, and observes the following pattern on the electrocardiogram (ECG) monitor. Based on these findings, the nurse should take which action?

1. Defibrillate at 200 jouIes as ordered. 2. Administer a precordial thump as ordered. 3. Administer amiodarone (Cordarone) 150 mg I.V. 4. Continue to defibrillate at increasing joules, as ordered, until a stable heart rhythm is restored. 25. The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as:

1. Administer the medications. 2. Call the physician. 3. Withhold the captopril. 4. Question the metoprolol dose. 28. The nurse observes the cardiac rhythm (see below) for a client who is being admitted with a myocardial infarction. What should the nurse do first?

1. Prepare for immediate cardioversion. 2. Begin cardiopulmonary resuscitation (CPR). 3. Check for a pulse. 4. Prepare for immediate defibrillation. 29. The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which of the following changes on the client's chart to the physician?

1. Atrial fibrillation. 2. Ventricular tachycardia. 3. Premature ventricular contractions. 4. Sinus tachycardia. 26. The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram strip below). The nurse should:

1. Urine output. 2. Heart rate. 3. Blood pressure. 4. Respiratory rate. 30. An 85-year-old client is admitted to the emergency department (ED) at 8 PM with syncope, shortness of breath, and reported palpitations (See nurse's notes below). At 8:15 PM, the nurse places the client on the ECG monitor and identifies the following rhythm (see below). The nurse should do which of the following? Select all that apply.

1. Notify the physician. 2. Call the rapid response team. 3. Assess the client for changes in the rhythm. 4. Administer lidocaine as prescribed. 27. Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 AM, the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?

1. Apply oxygen. 2. Prepare to defibrillate the client. 3. Monitor vital signs. 4. Have the client sign consent for cardioversion as prescribed. 5. Teach the client about warfarin (Coumadin) treatment and the need for frequent blood testing. 6. Draw blood for a CBC count and thyroid function study. 31. Twenty-four hours after a client undergoes aortic valve replacement surgery, the following pattern appears on the electrocardiogram (ECG) monitor. How should the nurse interpret this pattern?

1. Atrial fibrillation 2. Normal Sinus tachycardia 3. Atrial Flutter 4. Multifocal atrial tachycardia

1. Stage 1, latent phase 2. Stage 2 3. Stage 1, active phase 4. Stage 1, transition phase RATIONALE: During the active phase of stage 1 labor, membranes may rupture spontaneously. Contractions last about 40 to 60 seconds and recur every 3 to 5 minutes, and the cervix dilates from about 3 cm to 7 cm. During the latent phase of stage 1, contractions last 20 to 40 seconds and occur every 5 to 30 minutes and the cervix dilates from O to 3 cm. During stage 2 labor, the cervix is fully dilated and effaced and the neonate is born. During the transition phase of stage 1, contractions last 60 to 90 seconds and occur every 2 to 3 minutes and the cervix dilates from 7 cm to 10 cm. 34. A nurse is evaluating an external fetal monitoring strip. Identify the are on this strip that causes her to be concerned about uteroplacental insufficiency.

32. A client is admitted to the surgical intensive care unit following small-bowel resection. The ECG monitor shows the pattern below. What does this pattern indicate?

1. Ventricular tachycardia 2. Atrial Flutter 3. Atrial fibrillation 4. Normal sinus rhythm 33. On the waveform below, identify the area that indicates possible umbilical cord compression.

33. While waiting to receive report at shift change, a nurse reads the entry below in a client’s chart. After reading this note, the nurse knows her client is in which stage of labor?

35. The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance. 1. Administer the medication over 5 minutes. 2. Dilute the medication with normal saline. 3. Draw up the medication in a tuberculin syringe. 4. Check the client’s identification band. 5. Clamp the primary tubing distal to the port. 11. Correct Answer: 3, 2, 4, 5, 1 3. Because this is less than 1 mL, the nurse should draw this medication up in a 1-mL tuberculin syringe to ensure accuracy of dosage. 2. The nurse should dilute the medication with normal saline to a 5- to 10-mL bolus to help decrease pain during administration and maintain the IV site longer. 3. Administering 0.25 mg of digoxin in 0.5 mL is very difficult, if not impossible, to push over 5 full minutes, which is the manufacturer’s recommended administration rate. If the medication is diluted to a 5- to 10-mL bolus, it is easier for the nurse to administer the medication over

5 minutes. 4. The nurse must check two identifiers according to the Joint Commission safety guidelines. 5. The nurse should clamp the tubing between the port and the primary IV line so that the medication will enter the vein, not ascend up the IV tubing. 1. Cardiovascular and narcotic medications are administered over 5 minutes. 36. The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first? 1. Discontinue the client’s vasoconstrictor, dopamine. 2. Notify the client’s healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client’s neurological status. 12. 1. The nurse should first discontinue the medication that is causing the increase in the client’s blood pressure prior to doing anything else. 2. The nurse should notify the HCP but not prior to taking care of the client’s elevated blood pressure. 3. The client may need a medication to decrease the blood pressure but the nurse should first discontinue the medication causing the elevated blood pressure. 4. The nurse must first decrease the client’s blood pressure prior to assessing the client. MAKING NURSING DECISIONS: The test taker should remember that when the client is in distress, do not assess. The nurse must intervene and take care of the client. If any of the options is assessment data the HCP will need or an intervention that will help the client, then the test taker should not select the option to notify the HCP. 37. The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with acute rheumatic fever carditis who does not want to stay on bed rest. 2. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; CO3, 22. 3. The client who is showing multifocal premature ventricular contractions (PVCs). 4. The client diagnosed with angina who is scheduled for a cardiac catheterization. 13. 1. The client with rheumatic heart fever is expected to have carditis and should be on bed rest. The nurse needs to talk to the client about the importance of being on bed rest but this client is not in a life-threatening situation and does not need the most experienced nurse. 2. These ABG values are within normal limits; therefore, a less experienced nurse could care for this client. 3. Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client. 4. A cardiac catheterization is a routine procedure and would not require the most experienced nurse. 38. The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? 1. The UAP is instructed to bathe the client who is on telemetry.

2. The UAP is requested to obtain a bedside glucometer reading. 3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic. 14. 1. All clients in the ICU are on telemetry, and the UAP could bathe the client. This would not warrant intervention by the charge nurse. 2. The UAP can perform glucometer checks at the bedside, and there is nothing that indicates the client is unstable. This would not warrant intervention by the charge nurse. 3. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. 4. This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client. 39. The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice. 2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min. 3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8. 15. 1. The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice. 2. The apical heart rate should be greater than 60 beats/minute before administering the medication; therefore, the nurse would not question administering this medication. 3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be taken with foods to prevent gastric upset; therefore, the nurse would not question administering this medication. 4. The INR therapeutic level for warfarin (Coumadin), an anticoagulant, is 2 to 3; therefore, the nurse would not question administering this medication. 40. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D)55 year-old Hispanic teacher The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising. 41. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

42. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. 43. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain. 44. What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height. 45. At a community health fair the blood pressure of a 62 yearold client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long. 46. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with StevensJohnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home. 47. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth.

As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia 48. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status The correct answer is D: Notify the health care provider of the child''s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction. 49. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents 50. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. 51. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future. 52. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize

A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day The correct answer is C: Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. 53. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container. 54. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation. 55. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli D) Emotional lability The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA. 56. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough D) Meconium ileus The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF. 57. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should

A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient D) Instruct the client's wife to call the doctor if his symptoms become worse The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest. 58. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination. 59. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk." The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers. 60. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling. 61. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls." B) "I will set limits on exploring the house." C) "I understand the need to use those new skills." D) "I intend to keep control over our child." The correct answer is C: "I understand the need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

62. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube B) Check that the feeding solution matches the dietary order C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) Ensure that feeding solution is at room temperature The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration. 63. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication. 64. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) All striated muscles B) The cerebellum C) The kidneys D) The leg bones The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle. 65. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to A) Achieve harmony B) Maintain a balance of energy C) Respect life D) Restore yin and yang The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. 66. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein B) Restrict fluids C) Force fluids and reassess blood pressure D) Limit fluids to non-caffeine beverages The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. 67. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Rightsided heart function is

assessed through the evaluation of the central venous pressures (CVP). 68. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airway D) Obtain the crash cart The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest. 69. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 C) Urine output 50 ml/hour D) Respiratory rate 16 The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications. 70. While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant. 71. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A) Excessive fetal weight B) Low blood sugar levels C) Depletion of subcutaneous fat D) Progressive placental insufficiency The correct answer is D: Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia. 72. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity. B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today." The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger." The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

73. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? A) Weight gain of 5 pounds B) Edema of the ankles C) Gastric irritability D) Decreased appetite The correct answer is D: Decreased appetite Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias. 74. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 yearold twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? A) Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida 3 para 1 D) Gravida 3 para 2 The correct answer is C: Gravida 3 para 1 Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins). 75. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A) Apply dressing using sterile technique B) Improve the client's nutrition status C) Initiate limb compression therapy D) Begin proteolytic debridement The correct answer is B: Improve the client''s nutrition status The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help. 76. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder The correct answer is D: Have the client empty bladder The first step in the process is to have the client void prior to administering the preoperative medication. The other actions follow this initial step in this sequence: 4 3 1 2 77. Which of these statements best describes the characteristic of an effective reward-feedback system? A) Specific feedback is given as close to the event as possible B) Staff are given feedback in equal amounts over time C) Positive statements are to precede a negative statement D) Performance goals should be higher than what is attainable The correct answer is A: Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood. 78. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) Increase the heart rate B) Lead to dehydration C) Are considered aerobic

D) May be competitive The correct answer is B: Lead to dehydration The client must take in adequate fluids before and during exercise periods. 79. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? A) At least 2 full meals a day is eaten. B) We go to a group discussion every week at our community center. C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors. D) The medication is not a problem to have it taken 3 times a day. The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce. 80. Scenario #1 Mr. O is 63 years old. He was dizzy and lightheaded at home and almost fell. His wife brought him by car to the ER. Mr. O was admitted to KP DMC with syncope. This is not his first time being admitted to the hospital. He has been treated in the past for congestive heart failure and acute myocardial infarction. He feels like he is pretty healthy as he only takes NSAIDs at home for chronic back pain. Mr. O got to KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him and found his blood pressure 138/84, pulse 76 and regular, and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs were normal, but his IV infiltrated during transport. Betsy, RN started a new IV and put a warm compress on the old site. Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA found Ben, RN and told him that he had just helped get Mr. O off the bedpan. Mr. O had a large, black tarry stool and was complaining of not feeling well. Ben, RN asked him how he was feeling. Mr. O said he just didn’t feel well and could not get comfortable. He asked if he could have something for his belly, he states “it’s really hurting!”. Ben, RN assessed his abdomen and found that it was distended and Mr. O had diffuse abdominal pain. He rated his pain a 6 on a scale of 110. For Scenario #1, which of the following statements is the best example of "situation"? A. This is Nurse Joe from 6 East. This is in regards to Mr. O in Room 6322. I am concerned about his distended abdomen and associated pain. B. Hi doctor, my patient here on 6 East says his stomach hurts really bad. C. Hello, Mr. O said his belly is "really hurting" . He got here sometime yesterday I think and I believe he's here for syncope. D. Hello, my patient's stomach is really distended and he says it hurts a lot. 81. Scenario #1 Mr. O is 63 years old. He was dizzy and lightheaded at home and almost fell. His wife brought him by car to the ER. Mr. O was admitted to KP DMC with syncope. This is not his first time being admitted to the hospital. He has been treated in the past for congestive heart failure and acute myocardial infarction. He feels like he is pretty healthy as he only takes NSAIDs at home for chronic back pain. Mr. O got to KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him and found his blood pressure 138/84, pulse 76 and regular, and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs were normal, but his IV infiltrated during transport. Betsy, RN started a new IV and put a warm compress on the old site. Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA found Ben, RN and told him that he had just helped get Mr. O off the bedpan. Mr. O had a large, black tarry stool and was complaining of not feeling well. Ben, RN asked him how he was feeling. Mr. O said he just didn’t feel well and could not get comfortable. He asked if he could have something for his belly, he states “it’s really hurting!”. Ben, RN assessed his abdomen and found that it was distended and Mr. O had

diffuse abdominal pain. He rated his pain a 6 on a scale of 110. For Scenario #1, which of the following statements is the best example of what's included in "background"? A. The patient has a history of CHF and MI. The patient also fell at home and was having black stool here at the hospital. B. The patient is in the hospital because of syncope. His abdomen is distended and he had large black tarry stool. C. He had a large black stool, his IV was infiltrated in the ED, and he fell at home. D. Mr. O has CHF and MI in the past, he also fell at home and his BP is 94/66 82. Scenario #1 Mr. O is 63 years old. He was dizzy and lightheaded at home and almost fell. His wife brought him by car to the ER. Mr. O was admitted to KP DMC with syncope. This is not his first time being admitted to the hospital. He has been treated in the past for congestive heart failure and acute myocardial infarction. He feels like he is pretty healthy as he only takes NSAIDs at home for chronic back pain. Mr. O got to KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him and found his blood pressure 138/84, pulse 76 and regular, and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs were normal, but his IV infiltrated during transport. Betsy, RN started a new IV and put a warm compress on the old site. Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA found Ben, RN and told him that he had just helped get Mr. O off the bedpan. Mr. O had a large, black tarry stool and was complaining of not feeling well. Ben, RN asked him how he was feeling. Mr. O said he just didn’t feel well and could not get comfortable. He asked if he could have something for his belly, he states “it’s really hurting!”. Ben, RN assessed his abdomen and found that it was distended and Mr. O had diffuse abdominal pain. He rated his pain a 6 on a scale of 110. For Scenario #1, which of the following statements is the best example of what's included in "assessment"? A. My assessment of the situation is that the patient may have a GI bleed as a result of his use of NSAIDs for chronic back pain. B. The patient isn't feeling good so what should we do. C. This isn't the first time the patient has been in the hospital. He takes NSAIDS at home. D. I guess if you want to come see the patient to assess him you can. 83. Scenario #1 Mr. O is 63 years old. He was dizzy and lightheaded at home and almost fell. His wife brought him by car to the ER. Mr. O was admitted to KP DMC with syncope. This is not his first time being admitted to the hospital. He has been treated in the past for congestive heart failure and acute myocardial infarction. He feels like he is pretty healthy as he only takes NSAIDs at home for chronic back pain. Mr. O got to KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him and found his blood pressure 138/84, pulse 76 and regular, and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs were normal, but his IV infiltrated during transport. Betsy, RN started a new IV and put a warm compress on the old site. Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA found Ben, RN and told him that he had just helped get Mr. O off the bedpan. Mr. O had a large, black tarry stool and was complaining of not feeling well. Ben, RN asked him how he was feeling. Mr. O said he just didn’t feel well and could not get comfortable. He asked if he could have something for his belly, he states “it’s really hurting!”. Ben, RN assessed his abdomen and found that it was distended and Mr. O had diffuse abdominal pain. He rated his pain a 6 on a scale of 110. For Scenario #1, which of the following statements is the best example of what's included in "recommendation"? A. I think we need to draw an H/H for the patient and keep the patient NPO. B. What should we do? C. What do you think is going on with the patient? D. I guess the patient is really sick, so what did you want me to do?