Silvestri1701-1800
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PN~CD~Questions~1701-1800 -
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Comprehensive Review CD Questions 1701-1800
{COMP: questions: 1738-1742, 1746, 1748, 1776, 1778; formulas: 1738, 1741, 1742, 1746, 1748.} 1701. A nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which of the following first? 1. Temperature 2. Urine output 3. Respiratory status 4. PCA pump Answer: 3 Rationale: Morphine sulfate depresses respirations. The nurse monitors the client’s respiratory status closely. Although the incorrect options may be a component of the data collection process, option 3 identifies the priority nursing action. Test-Taking Strategy: Note the key word first. Use the ABCs—airway, breathing, and circulation—to guide you to the correct option. Review the priority nursing interventions when caring for a client receiving morphine sulfate if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 734. 1702. A nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which action? 1. Check the placement of the tube 2. Check the last time that medications were given 3. Check the client’s temperature 4. Warm the feeding to 103° F Answer: 1 Rationale: To prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or place the head of the bed elevated at least 30 degrees. Before the feeding, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Formulas are administered at room temperature. Options 2 and 3 are not directly related to the issue of the question. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. To prevent the complication of aspiration when feeding a client with an NG tube, the nurse would first
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assess accurate placement of the tube. Review the principles related to NG tube feedings, if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1403, 1408. 1703. A client receiving total parenteral nutrition (TPN) is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position? 1. Supine 2. Prone 3. High-Fowler’s 4. Left side in Trendelenburg’s Answer: 4 Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg’s position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. Options 1, 2, and 3 identify incorrect positions. Test-Taking Strategy: Use the process of elimination and note the key word immediately. Eliminate options 1 and 2 first because they are both flat positions. From the remaining options, think about the principles of gravity and the anatomy of the cardiopulmonary system to direct you to option 4. Review the priority nursing actions when an air embolism occurs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1315. 1704. A nurse is checking a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the site. The nurse should do which of the following first? 1. Check for a blood return 2. Remove the IV 3. Apply a warm compress 4. Measure the area of infiltration Answer: 2 Rationale: Blanching, coolness, and edema of the IV site are all classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the first action by the nurse is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if
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the infiltrated solution is not damaging to the surrounding tissue. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed. Test-Taking Strategy: Note the key word first. Although all of the options may be appropriate, it is necessary to prioritize. The signs presented in the question identify infiltration. Infiltration indicates that the IV needs to be removed. Review the signs of infiltration and the appropriate initial interventions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1189. 1705. A client has just been treated with cardioversion. The nurse should assess which of the following first? 1. Status of airway 2. Oxygen flow rate 3. Level of consciousness 4. Blood pressure Answer: 1 Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority. Test-Taking Strategy: Note the key word first. Use the ABCs—airway, breathing, and circulation—to direct you to option 1. Review the priority nursing responsibilities following cardioversion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 577. 1706. A nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which of the following? 1. Stimulate the perioral cavity with a finger 2. Clap the hand or slap on the mattress 3. Stimulate the pads of the hands by firm pressure 4. Stimulate the ball of the foot by firm pressure Answer: 2 Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar reflex is elicited by
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stimulating the palm of the hand by firm pressure, and the plantar reflex is elicited by stimulating the ball of the foot by firm pressure. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 are similar and should be eliminated first. From the remaining options, focusing on the issue of the question, the Moro reflex, will assist in directing you to option 2. Review assessment of neonatal reflexes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 700. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 523, 524. 1707. A nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which of the following first? 1. Peripheral pulses 2. Temperature 3. Heart rate 4. Blood pressure (BP) Answer: 1 Rationale: The client who receives circumferential burns to the extremities is at risk for impaired peripheral circulation. The priority assessment would be to check for peripheral pulses to ensure that adequate circulation is present. Although the temperature, heart rate, and BP would also be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses. Test-Taking Strategy: Use the process of elimination. Focus on the key words first and circumferential burns of both legs to assist in directing you to the correct option. If you had difficulty with this question or are unfamiliar with the priority assessment in a client who sustained a circumferential burn of an extremity, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing References: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1629. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 525. 1708. A nurse is preparing to get a quadriplegic client out of bed into a chair. The nurse places which of the following items on the seat of the chair as the best device for pressure relief? 1. Water pad 2. Plastic lined absorbent pad 3. Pillow
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4. Air ring Answer: 1 Rationale: The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client’s weight on the device. These include foam, water, gel, or alternating air pads. A plastic lined pad absorbs moisture, but provides no pressure relief. A pillow provides cushion, but does not redistribute weight equally. An air ring relieves pressure in some spots, but causes pressure in others by its design. Test-Taking Strategy: The key words in the question are pressure relief and quadriplegic. Eliminate option 2 first because it does not provide any protection against pressure. Eliminate option 4 next because it redistributes weight unequally under this client. Choose correctly from the remaining options by recalling that the water pad will redistribute weight, and the pillow will not. Review the devices that provide pressure relief to prevent skin breakdown if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 279. 1709. A nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse if the procedure will be painful. The nurse should make which response to the client? 1. “No it is not painful.” 2. “You will receive a general anesthetic.” 3. “A local anesthetic will be given.” 4. “You will be heavily medicated before the procedure.” Answer: 3 Rationale: A local anesthetic is used to anesthetize the skin and subcutaneous tissue to minimize tissue discomfort with needle insertion. The client will feel some pain briefly when the sample is aspirated out of the marrow. Options 1, 2, and 4 are incorrect statements. Test-Taking Strategy: Focus on the diagnostic test and how this test is performed. Knowing that the procedure may be performed at the bedside will assist in eliminating options 2 and 4. Knowing that the procedure is invasive will assist in eliminating option 1. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 176. 1710. A nurse is administering intramuscular iron to an assigned client. The nurse
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should do which of the following to prevent skin staining around the injection site? 1. Use a Z-track method for administration 2. Administer the injection in the nondominant arm 3. Administer the injection in the thigh 4. Massage the site well after injection Answer: 1 Rationale: Proper technique for administering iron by the intramuscular route includes using a Z-track technique and changing the needle after drawing it up, but before the medication is given. The medication should be given in the upper outer quadrant of the buttock and not in exposed areas, such as the arms or thighs. The site should not be massaged after injection. Test-Taking Strategy: Use the process of elimination. Focusing on the issue, to prevent skin staining, will assist in eliminating options 2 and 3. Use principles of medication administration by the intramuscular route and focus on the medication being administered to direct you to option 1. Review the procedure for the administration of iron if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 711. 1711. A nurse has conducted dietary teaching with the client who has iron deficiency anemia. The nurse determines that the client understood the information if the client states to increase intake of which of the following foods? 1. Refined white bread 2. Egg whites 3. Pineapple 4. Kidney beans Answer: 4 Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver, and other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots. Test-Taking Strategy: Focus on the client’s diagnosis. Recalling the foods high in iron will direct you to option 4. Review foods high in iron if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Nix, S. (2005). Williams’ basic nutrition & diet therapy (11th ed.). St. Louis: Mosby, pp. 142-143.
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1712. A nurse is checking the skin on a client who is immobile and notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as a: 1. Stage 1 pressure ulcer 2. Stage 2 pressure ulcer 3. Stage 3 pressure ulcer 4. Stage 4 pressure ulcer Answer: 2 Rationale: In a stage 2 pressure ulcer, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and may characterize as an abrasion, blister, or shallow crater. The skin is intact in stage 1. A deep craterlike appearance occurs in stage 3, and sinus tracts develop in stage 4. Test-Taking Strategy: Use the process of elimination and knowledge of the characteristics associated with each stage of pressure ulcers. Focusing on the description in the question, partial-thickness skin loss of the upper layer of the skin, will direct you to option 2. If you had difficulty with this question, review the characteristics associated with each stage of pressure ulcers. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 273. 1713. A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder? 1. Drowsiness, headache, and tachypnea 2. Decreased respiratory depth and rate and dysrhythmias 3. Disorientation and dyspnea 4. Tachypnea, dizziness, and paresthesias Answer: 2 Rationale: The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth, nausea, vomiting, diarrhea, restlessness, numbness and tingling in the extremities, twitching in the extremities, hypokalemia, hypocalcemia, and dysrhythmias. Options 1, 2, and 4 are not associated with metabolic alkalosis. Test-Taking Strategy: Knowledge about the clinical manifestations of metabolic alkalosis will direct you to option 2. Remember that in this disorder the respiratory rate and depth decrease. Review the clinical manifestations of metabolic alkalosis if this question was difficult. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 165.
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1714. A nurse is assisting in monitoring a client who may be started on total parenteral nutrition (TPN). The nurse reviews the client’s laboratory results and determines that the client is at risk for severe malnutrition if the albumin level report indicates which critical level? 1. 5.0 g/dl 2. 4.5 g/dl 3. 3.9 g/dl 4. 2.8 g/dl Answer: 4 Rationale: The serum albumin level is a critical indicator of the need for TPN. The client whose albumin level is 2.8 g/dl is at severe risk for malnutrition. The normal serum albumin level in the adult is 3.4 to 5 g/dl. Options 1, 2, and 3 identify normal albumin levels. Test-Taking Strategy: Note the key words critical level. Knowing that the normal albumin level is 3.4 to 5 g/dl will direct you to option 4. Review this laboratory test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 148. 1715. One unit of packed red blood cells has been prescribed for a client postoperatively because the client’s hemoglobin level is low. The physician prescribes diphenhydramine (Benadryl) to be administered before the administration of the transfusion. The nurse determines that this medication has been prescribed to: 1. Prevent a rash and pruritus 2. Prevent a fever 3. Promote sedation 4. Promote bone marrow absorption Answer: 1 Rationale: An urticaria reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine. Options 2, 3, and 4 are incorrect statements. Acetaminophen (Tylenol), however, may be prescribed before the administration to assist in preventing an elevated temperature. Test-Taking Strategy: Focus on the medication. Recalling the classification of diphenhydramine and that it is an antihistamine will assist in directing you to option 1. Review blood transfusion reactions and their management if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills
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Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 333. 1716. A nurse is providing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure? 1. “I should douche just before I collect the specimen.” 2. “I should cleanse the perineum from back to front.” 3. “I need to collect the urine in the cup just after I start to urinate.” 4. “I need to bring the specimen to the laboratory within 48 hours after I collect it.” Answer: 3 Rationale: As part of correct procedure, the client should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results. It is not normal procedure to douche before collecting the specimen. Test-Taking Strategy: Use the process of elimination. Use basic principles related to hygiene to eliminate option 2. Recalling that the specimen should be brought to the laboratory after collection will assist in eliminating option 4. From the remaining options, noting the name of the type of sample “midstream” will direct you to option 3. If this question was difficult, review this procedure. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 701-702. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 1151. 1717. A physician has written an order for a preoperative client to have “enemas until clear.” The nurse has administered three enemas, and the client is still passing brown liquid stool. Which of the following actions should the nurse take next? 1. Wait 30 minutes, check the client’s electrolyte levels, and then administer another enema 2. Continue to administer the enemas until the stool is clear 3. Encourage the client to drink clear liquids and administer another enema in 1 hour 4. Notify the registered nurse (RN) Answer: 4 Rationale: Up to three enemas may be given when there is an order for enemas until clear. If more than three are necessary, the nurse notifies the RN who will then call the physician (or act based on agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1, 2, and 3 are incorrect for these reasons. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are similar. Also, use knowledge of basic bowel elimination procedures and
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consider the physiological effects that can occur with enema administration. This will assist in directing you to the correct option. Review the procedure for administering enemas if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A, (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 681. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 751. 1718. A client comes to the emergency room with lethargy; has deep, regular respirations; and a fruity odor to the breath. The client’s arterial blood gases (ABG) −
results are: pH of 7.25, PCO2 of 34 mm Hg, PO2 86 of mm Hg, HCO 3 of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Answer: 1 Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the PCO2 is greater than 45, whereas respiratory alkalosis is present when the PCO2 is less than 35. Metabolic −
acidosis is present when the pH is less than 7.35, and the HCO 3 is less than 22 mEq/L, −
whereas metabolic alkalosis is present when the pH is greater than 7.45, and the HCO 3 is greater than 27 mEq/L. This client’s ABG are consistent with metabolic acidosis. Test-Taking Strategy: Remember that in a metabolic imbalance you will find that the pH −
and the HCO 3 move in the same direction. Therefore options 3 and 4 are eliminated first. Next, remember that the pH is elevated with alkalosis and low in acidosis. Option 1 reflects a metabolic acidotic condition and describes the blood gas values as indicated in the question. Review the steps related to reading blood gas values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 165. Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 245. 1719. A client wishes to donate blood for a family member and asks the nurse about the
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procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility? 1. Eosinophil count 2. Monocyte count 3. Red blood cell count 4. Indirect Coombs’ test Answer: 4 Rationale: The indirect Coombs’ test detects circulating antibodies against red blood cells (RBCs), and is the “screening” component of the order to “type and screen” a client’s blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The direct Coombs’ test is used to detect idiopathic hemolytic anemia, by detecting the presence of autoantibodies against the client’s RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematological screening test. A red blood cell count is also part of a complete blood count and determines the number of circulating red blood cells, but does not determine compatibility. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are part of routine lab work, a complete blood count. Review the tests identified in the options if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 412. 1720. A nurse is monitoring a client for bradypnea. Which of the following is characteristic of this respiratory pattern? 1. Labored and increased in depth and rate 2. Regular but interspersed with periods of apnea 3. Abnormally deep, regular, with increased rate 4. Regular but abnormally slow Answer: 4 Rationale: Bradypnea is characterized by respirations that are regular but abnormally slow. Kussmaul’s respirations are abnormally deep, regular, and increased in rate. Hyperpnea is characterized as respirations that are labored and increased in depth and rate. Respirations that cease for a number of seconds are identified as apnea. Test-Taking Strategy: Note the relation of the word “bradypnea” in the question and the words “abnormally slow” in option 4. Review the characteristics of these types of respirations if this question was difficult. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 472.
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1721. A nurse has assisted with obtaining a set of arterial blood gases (ABG). The nurse avoids doing which of the following to properly obtain and send the specimen? 1. Records the client’s temperature on the requisition 2. Records the percent of oxygen on the requisition 3. Obtains a 3-mL syringe from the medication supply area 4. Places the specimen on ice Answer: 3 Rationale: The specimen is drawn into a heparinized syringe to prevent clotting of the blood. A 3-mL syringe taken from the medication supply area is not used. The other options are correct. The specimen should be placed on ice after it is obtained. The requisition is fully completed identifying pertinent client information, such as body temperature and amount of oxygen in use. Test-Taking Strategy: Note the key word avoids. This word indicates a false-response question and that you need to select the incorrect action. Recalling that a heparinized syringe is used to prevent clotting of the blood will direct you to the correct option. Review the procedure for obtaining ABG if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 249. 1722. A nurse is caring for a client whose magnesium level is 4.0 mg/dl, and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if the client has relief from which sign or symptom? 1. Muscular excitability 2. Loss of deep tendon reflexes 3. Twitches 4. Tetany Answer: 2 Rationale: The normal magnesium level is 1.6 to 2.6 mg/dl. A client with a magnesium level of 4.0 mEq/L is experiencing hypermagnesemia. Signs include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, tachycardia, hypotension, and loss of consciousness. Tetany, muscular excitability, and twitches are seen in a client with hypomagnesemia. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are similar in that they all reflect neurological excitability. If you had difficulty with this question, review the signs found in magnesium imbalances. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 244.
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1723. A nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gases results indicate that the client is experiencing respiratory alkalosis. The nurse would then evaluate the results of serum electrolytes to see if which electrolyte imbalance is present? 1. Hyponatremia 2. Hypokalemia 3. Hypercalcemia 4. Hyperchloremia Answer: 2 Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth; headache; light-headedness; vertigo; mental status changes; paresthesia, such as tingling of the fingers and toes; hypokalemia; hypocalcemia; tetany; and convulsions. Clinical manifestations do not include hyponatremia, hypercalcemia, or hyperchloremia. Test-Taking Strategy: Use the process of elimination and knowledge of the signs and symptoms of respiratory alkalosis to answer the question. Remember that hypokalemia occurs in respiratory alkalosis. If this question was difficult, review the clinical manifestations associated with respiratory alkalosis. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 162. 1724. A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Answer: 1 Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions, such as diarrhea or the creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for developing the acid-base disorders identified in options 2, 3, and 4. Test-Taking Strategy: Begin to answer this question by recalling that intestinal fluids are alkaline. With this in mind, you may eliminate options 2 and 4 first because alkaline secretions are lost in a client with an ileostomy. Note that the client condition described in the question is a client with a gastrointestinal disorder. This will direct you to choose the metabolic acidosis over the respiratory acidosis. If you had difficulty with this question, review the causes of metabolic acidosis. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 165. 1725. A nurse enters a laundry room to empty a bag of dirty linens and discovers that there is a fire in the laundry room. The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher to extinguish the fire. The nurse prepares to use the fire extinguisher by first: 1. Squeezing the handle on the extinguisher 2. Pulling the pin on the fire extinguisher 3. Obtaining a pair of gloves and putting them on before touching the extinguisher 4. Obtaining a mask and putting it on before using the extinguisher Answer: 2 Rationale: A fire can be extinguished by smothering it with a blanket or by the use of a fire extinguisher. To use the extinguisher, the pin is pulled first. The extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is then squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly. Although the nurse needs to be cautious when using an extinguisher, it is not necessary to don gloves or a mask. Additionally, these actions would delay the process of extinguishing the fire. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because these actions would delay the process of extinguishing the fire. Remember the mnemonic PASS to prioritize in the use of a fire extinguisher. P = Pull the pin; A =Aim at the base of the fire; S = Squeeze the handle; S = Sweep from side to side to coat the area evenly. If you had difficulty with this question, review the appropriate use of a fire extinguisher. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 991. 1726. A nurse is caring for a client with liver disease. Laboratory studies are performed, and the client’s serum calcium level is 13.0 mg/dl. The nurse checks to see that which of the following medications is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance? 1. Calcitonin (Calcimar) 2. Vitamin D 3. Calcium gluconate 4. Calcium chloride Answer: 1 Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dl. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are used to treat
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tetany that results from acute hypocalcemia. In hypercalcemia, large doses of vitamin D should be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. Test-Taking Strategy: Begin to answer this question by determining that the client is experiencing hypercalcemia. With this knowledge, you can eliminate options 3 and 4 because you would not administer medication that would further increase the calcium level. From the remaining options, remember that excessive vitamin D is a causative factor of hypercalcemia. If you had difficulty with this question, review the treatment for hypercalcemia. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 783. 1727. A nurse is assigned to care for a client on contact precautions. On review of the client’s record, the nurse notes that the client has a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client’s room and obtains which of the following necessary protective items? 1. Gloves, gown, and goggles 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves and a gown Answer: 1 Rationale: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves and a gown to be worn if direct client contact is anticipated. Shoe protectors are not necessary. Test-Taking Strategy: Note the key words contact precautions, irrigation, and frequent suctioning. Use the process of elimination in determining the necessary items required to care for this client. If you had difficulty with this question, review Transmission Based Precautions. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 930, 941. 1728. A nurse is doing discharge teaching with a client who has sickle cell disease. The nurse instructs the client to avoid which of the following factors that could precipitate a sickle cell crisis? 1. Mild exercise
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2. Fluid overload 3. Warm weather 4. Infection Answer: 4 Rationale: The client should avoid infections, which can increase metabolic demand and cause dehydration, precipitating a sickle cell crisis. The client should also avoid dehydration from other causes. Warm weather and mild exercise does not need to be avoided, but the client should take measures to prevent dehydration during these conditions. Fluids are important to prevent dehydration. Finally the client should avoid being in areas of high altitude or flying in nonpressurized aircraft because of lesser oxygen tension in these areas. Test-Taking Strategy: Use the process of elimination noting the key word avoid. Recalling the precipitating factors of sickle cell crisis will direct you to option 4. Review these precipitating factors if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 524. 1729. A client is admitted to the hospital with sickle cell crisis. The nurse checks this client for which frequent symptom of the disorder? 1. Bradycardia 2. Pain 3. Diarrhea 4. Blurred vision Answer: 2 Rationale: Sickling crisis often causes pain in the bones and joints, accompanied by joint swelling. Pain is a classic symptom of the disease and may require large doses of narcotic analgesics when it is severe. The symptoms listed in the other options are not part of the clinical picture. Test-Taking Strategy: To answer this question correctly, you must be familiar with the signs and symptoms of sickle cell crisis. Recalling that the primary treatment of sickle cell crisis focuses on the administration of fluids and on management of pain will enable you to eliminate the incorrect options. If this question was difficult, review the clinical manifestations associated with sickle cell crisis. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 525. 1730. A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted in the client?
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1. Increased blood pressure 2. Increased heart rate 3. Positive Trousseau’s sign 4. Hypoactive bowel sounds Answer: 3 Rationale: Signs of hypocalcemia include paresthesias, hyperactive reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include a decreased heart rate, hypotension, hyperactive bowel sounds, increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Options 1, 2, and 4 are signs of hypercalcemia. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are similar in that they both reflect an increase in relation to cardiovascular function. From the remaining options, it is necessary to know that a positive Trousseau’s sign is an indication of hypocalcemia. Review the findings noted in hypocalcemia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 470. 1731. A nurse has instructed a client in safety measures while using oxygen in the home. The nurse determines that the client needs additional instructions if the client verbalized to: 1. Keep the oxygen concentrator as close to the room wall as possible 2. Use a straight razor to shave while wearing the oxygen 3. Follow the oxygen prescription exactly 4. Forbid smoking or open flames within 10 feet of the oxygen source Answer: 1 Rationale: The oxygen concentrator is kept slightly away from the walls and corners to permit adequate airflow. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use. This could result in fire and injury to the client. Therefore a straight razor is used for shaving. The client should follow the oxygen prescription exactly. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include keeping the source out of direct sunlight; having telephone numbers for the physician, nurse, and oxygen vendor available; and teaching the client signs and symptoms requiring emergency care. Test-Taking Strategy: Note the key words needs additional instructions. These words indicate a false-response question and that you need to select the incorrect client statement. General principles regarding prescriptions will assist in eliminating option 3. From the remaining option, recall that the major hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. This will assist in eliminating options 2 and 4. Review oxygen safety measures if you had difficulty with this question. Level of Cognitive Ability: Comprehension
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Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills References: Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3rd ed). St. Louis: Mosby, p. 750. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 318. 1732. A nurse has completed diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that further teaching is necessary when the client makes which of these statements? 1. “This diet will help to lower my blood pressure.” 2. “The reason I need lower salt intake is to reduce fluid retention.” 3. “This diet is not a replacement for my antihypertensive medications.” 4. “Canned foods are inexpensive and are good to use on a low-sodium diet.” Answer: 4 Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Canned foods use salt as a preservative and should not be encouraged as part of a low-sodium diet. Lifelong medication is necessary in the treatment of hypertension. Test-Taking Strategy: Use the process of elimination noting the key words further teaching is necessary. These words indicate a false-response question and that you need to select the incorrect client statement. Focusing on the issue, a low-sodium diet, will direct you to option 4. Review the components of a low-sodium diet if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. Saunders, pp. 156, 241, 243. 1733. A physician orders an intravenous fat emulsion solution for a client who will be receiving total parenteral nutrition (TPN). The nurse explains to the client that the fat emulsion solution is administered: 1. To increase the amount of fluid intake 2. To add bulk to the client’s system 3. To prevent fluid volume deficit 4. To provide essential fatty acids and additional calories Answer: 4 Rationale: Clients receiving their total nutrition parenterally for a prolonged period of time are at risk for developing essential fatty acid deficiency. Fat emulsions are given to meet client nonprotein caloric needs and provide essential fatty acids, which cannot be met by TPN administration alone. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Note the relation between “fat
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emulsion” in the question and “fatty acids” in the correct option. If you had difficulty with this question, review the purpose of administering fat emulsion during TPN therapy. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 532. 1734. A nurse teaches a client how to administer enoxaparin (Lovenox) subcutaneously. The nurse determines that the client understands the correct procedure if the client does which of the following on a return demonstration? 1. Bunches the skin before injection 2. Uses a 1-inch needle 3. Aspirates before injection 4. Massages after injection Answer: 1 Rationale: With subcutaneous injection of enoxaparin, the administration technique is the same as for heparin. The smallest gauge needle available (25 to 27 gauge) is used to prevent injection site hematoma. A “bunching” technique or Z-track technique is used, and the medication is injected deep into fatty abdominal tissue. Aspiration before injecting is not done, and the injection site is not massaged. The needle is withdrawn gently to minimize bleeding, and injection sites are rotated systematically. Test-Taking Strategy: Use the process of elimination. Recall that enoxaparin is a subcutaneously administered anticoagulant medication. Knowing this, select the option that is a standard subcutaneous injection technique. Review the subcutaneous procedure for injections if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: McKenry, L., & Salerno, E. (2001). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 91. 1735. A nurse is caring for a client with a nasogastric tube who has orders to have the tube irrigated once every 8 hours. The nurse ensures that which of the following solutions is placed in the client’s room to be used for the irrigation when the client’s serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L? 1. Sterile water 2. Normal saline 3. Tap water 4. 5% dextrose solution Answer: 2 Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, normal
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(isotonic) saline should be used rather that sterile water (hypotonic) for gastrointestinal or urinary tract irrigations. It is not ordinary clinical practice to irrigate with 5% dextrose solution. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 1 and 3 because they involve water. Select from the remaining options by knowing that the client’s condition (hyponatremia) requires use of an isotonic irrigating solution. Review the tonicity of fluids and the normal potassium and sodium serum levels if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 345. 1736. A client has a serum sodium level of 151 mEq/L, and the nurse conducts dietary teaching with the client about the types of foods to avoid. The nurse determines that the client needs further information if the client later states that which of the following is a good food choice? 1. American cheese 2. Rhubarb 3. Spinach 4. Fish Answer: 1 Rationale: The client’s laboratory value reflects hypernatremia since the normal serum sodium level is 135 to 145 mEq/L. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. These would include foods from animal sources, which contain physiological saline and highly processed meats and other foods that often have sodium added as a preservative. Spinach and rhubarb are good food sources of calcium. Fish is high in phosphorus. Test-Taking Strategy: Note the key words needs further information. These words indicate a false-response question and that you need to select the incorrect food item. Note that the client’s laboratory value reflects hypernatremia. Eliminate options 2 and 3 first because they are fruits and vegetables and are lower in sodium. Select from the remaining options by recalling that cheese is a dairy product and is higher in sodium. Review the food items high in sodium content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. Saunders, pp. 156, 241. 1737. A nurse suspects that a co-worker is substance impaired and is self-administering narcotic medications rather than administering them to clients as prescribed. Which of
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the following actions will the nurse take? 1. Confront the co-worker about the suspicion 2. Report the information to a supervisor 3. Call the impaired nurse organization and report the co-worker 4. Report the information to the police Answer: 2 Rationale: An impaired nurse is one who is unable to function effectively because of some type of substance abuse. Nurse practice acts require reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor who will then report to the Board of Nursing. Options 1, 3, and 4 are incorrect. Confronting the nurse may cause a conflict. The supervisor will report the substance abuse situation as necessary. Test-Taking Strategy: Follow the channel of organizational structure to report situations such as this one. By reporting the information, the nurse alerts the institution to the potential problem and sets the stage for further investigation and appropriate action. Review this content if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 25. Zerwekh, J., & Claborn, J. (2003). Nursing today: Transitions and trends (4th ed.). Philadelphia: W.B. Saunders, p. 437.1738. A physician prescribes meperidine hydrochloride (Demerol) 15 mg intramuscularly for a client in pain. The medication label states meperidine hydrochloride (Demerol) 25 mg/mL. How many milliliters will the nurse administer to the client? Answer: 0.6 Rationale: Use the formula for calculating medication doses. Formula: Desired 15 mg _______ × mL = mL per dose ______ × 1 mL = 0.6 mL Available 25 mg Test-Taking Strategy: Follow the formula for the calculation of the correct dose. It is not necessary to perform a conversion with this problem. Recheck your work using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, pp. 80-81.
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1739. A physician prescribes phenytoin (Dilantin) 0.2 g orally twice daily. The medication label states 100-mg capsules. How many capsule(s) will the nurse prepare to administer the dose? Answer: 2 Rationale: Convert 0.2 g to mg. In the metric system, to convert larger to smaller multiply by 1000 or move the decimal three places to the right. Therefore 0.2 g = 200 mg. The nurse will administer two capsules. Test-Taking Strategy: In this medication calculation problem, it is necessary to first convert grams to milligrams. Once you have done the conversion and reread the medication calculation problem, you will know that two capsules is the correct answer. Follow the formula for the calculation of the correct dose. Recheck your work with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, pp. 80-81. 1740. A physician prescribes atenolol (Tenormin) 0.05 g orally daily. The label on the medication bottle states atenolol (Tenormin) 50-mg tablets. How many tablets will the nurse administer to the client? Answer: 1 Rationale: Convert 0.05 g to mg. In the metric system, to convert larger to smaller multiply by 1000 or move the decimal three places to the right. Therefore 0.05 g = 50 mg. The nurse will administer one tablet. Test-Taking Strategy: In this medication calculation problem, it is necessary to first convert grams to milligrams. Once you have done the conversion and reread the medication calculation problem, you will know that one tablet is the correct answer. Follow the formula for the calculation of the correct dose. Recheck your work with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, pp. 80-81. 1741. A physician prescribes digoxin (Lanoxin) 0.5 mg PO daily for a client with congestive heart failure. The medication label states 0.25 mg/tablet. How many tablet(s) will the nurse administer to the client? Answer: 2 Rationale: Follow the formula for the calculation of the correct dose. Formula: Desired 0.5 mg
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_______ × 1 tablet = tablet per dose ______ × 1 tablet = 2 tablets Available 0.25 mg Test-Taking Strategy: Follow the formula for the calculation of the correct dose. It is not necessary to perform a conversion with this problem. Label each figure including the answer. Recheck your work with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, pp. 80-81.1742. A physician prescribes levothyroxine (Synthroid) 150 mcg orally daily for a client with hypothyroidism. The medication label states 0.1 mg/tablet. The home care nurse will instruct the client to take how many tablet(s)? Answer: 1.5 Rationale: Convert 150 mcg to mg. In the metric system, to convert smaller to larger divide by 1000 or move the decimal three places to the left. Therefore 150 mcg = 0.15 mg. Next, use the formula for determining the correct dose. Formula: Desired 0.15 mg _______ × 1 tablet = tablet per dose ______ × 1 tablet = 1.5 tablet Available 0.1 mg Test-Taking Strategy: In this medication calculation problem, it is necessary to first convert micrograms to milligrams. Next, follow the formula for the calculation of the correct dose. Label each figure including the answer. Recheck your work using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, pp. 80-81. 1743. A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of the tuberculosis and tells the client that: 1. Medication will not be started until after delivery of the fetus 2. Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months 3. The newborn infant must receive medication therapy immediately following birth. 4. The need for therapeutic abortion is required Answer: 2 Rationale: More than one medication may be used to prevent growth of resistant
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organisms in the pregnant woman with tuberculosis. Treatment must continue for a prolonged period of time. The preferred treatment for pregnant woman is daily isoniazid plus rifampin for a total of 9 months. Ethambutol is also added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing should be repeated at 3 months on the infant, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid would be given. Test-Taking Strategy: Knowledge regarding the therapeutic management for the mother with tuberculosis and for the newborn infant is required to answer this question. Eliminate options 1, 3, and 4 because of the absolute words “not,” “must,” and “required,” respectively. If you had difficulty with this question, review treatment measures for the mother with tuberculosis. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 1069-1070. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 730. 1744. A nurse is reinforcing information about health care to a pregnant client that is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to: 1. Prevent further stress on the maternal immune system 2. Reduce the risks of anemia during pregnancy 3. Minimize the possibility of preterm labor 4. Minimize the risk of premature rupture of the membranes Answer: 1 Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client and not getting appropriate rest can compromise the maternal immune system. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Although options 2, 3, and 4 are goals of care, option 1 represents the primary management issue for the HIV-infected client. Test-Taking Strategy: Use the process of elimination and focus on the diagnosis of the client. Note the key words primarily in the question and immune in the correct option. Although all of the options are important, the option that specifically relates to the client with HIV is option 1. Review care measures for the pregnant client with HIV if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 124, 430.
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Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 728. 1745. A pregnant client who is anemic tells the nurse that she is concerned about her baby’s condition following delivery. Which nursing response would best support the client? 1. “You will not have any problems if you follow all the advice the physician has given you.” 2. “Your baby will need to spend a few days in the neonatal intensive care unit following delivery.” 3. “Don’t worry about your baby. Complications are rare.” 4. “The effects of anemia on your baby are difficult to predict, but let’s review your plan of care to ensure that you are providing the best nutrition and growth potential.” Answer: 4 Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options 1 and 3 provide a false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client’s plan of care to clarify information and reassure the mother. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Eliminate options 1 and 3 because these options provide a false reassurance to the client. Eliminate option 2 next because this response will cause further concern in the client. If you had difficulty with this question, review therapeutic communication techniques and the effects of maternal anemia on the fetus. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 918-919. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 717-718.1746. A client is to receive 1000 mL of 5% dextrose in water over a time period of 125 mL/hr. The gtt factor is 10 gtt/mL. The nurse sets the flow rate at how many gtt per minute? (Round answer to the nearest whole number.) Answer: 21 Rationale: The first step is to determine how many hours the IV will last. This requires simple division of the total volume of milliliters to be infused (1000 mL) by the total milliliters per hour (125 mL). This calculates to 8 hours and is then converted to minutes, which is 480 minutes (8 hours × 60 minutes). Next, use the formula to calculate the flow rate. Formula: Total volume in mL × gtt factor ____________________________ = Flow rate in gtt per minute
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Time in minutes 1000 mL × 10 gtt 10000 _________________ = _________ = 20.8 or 21 gtt/min 480 minutes 480 Test-Taking Strategy: Use the formula for IV infusion rates when calculating these IV problems. Remember that you need to convert hours to minutes. Be careful with the multiplication and division. Remember to round the answer to the nearest whole number. Review the formula for calculating IV infusion rates if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, p. 212. 1747. A client with a fractured femur is placed in skeletal traction. The nurse should do which of the following to monitor for nerve injury? 1. Check the blood pressure 2. Check the neurovascular status of the affected extremity 3. Monitor the client’s ability to perform active range of motion (ROM) exercises to the affected extremity 4. Check the pin sites for drainage Answer: 2 Rationale: Bone fragments and tissue edema associated with a fracture can cause nerve damage. The nurse would assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active ROM exercises with an extremity that is fractured and in traction. Test-Taking Strategy: Focus on the issue, monitoring for nerve injury. Note the relation between the issue and option 2. Review the signs and symptoms of nerve injury following a fracture if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 150.1748. A physician prescribes 1000 mL of normal saline to be infused over a period of 12 hours. The gtt factor is 15 gtt/mL. The nurse sets the flow rate at how many gtt per minute? (Round answer to the nearest whole number.)
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Answer: 21 Rationale: Use the formula for calculating IV infusion rates. Convert 12 hours to minutes (12 hours × 60 minutes = 720 minutes). Formula: Total volume in mL × gtt factor ____________________________ = Flow rate in gtt per minute Time in minutes 1000 mL X 15 gtt 15000 _________________ = _________ = 20.8 or 21 gtt/min 720 minutes 720 Test-Taking Strategy: Use the formula for IV infusion rates when calculating these IV problems. Remember to convert hours to minutes. Be careful with the multiplication and division and use a calculator to check your answer. Review the formula for calculating IV infusion rates if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, p. 212. 1749. A nurse is assigned to care for a client that is Asian. The nurse enters the room and following a greeting and introduction to the client, the nurse begins to discuss the plan of care for the day. During the discussion, the client turns away from the nurse. The nurse should take which action? 1. Continue with the discussion 2. Ask the client if he or she can hear the nurse 3. Return later to continue with the discussion 4. Leave the room and ask for another nurse to be assigned to the client Answer: 1 Rationale: In Asian cultures, direct eye contact is often viewed as being rude. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Asking the client if he or she can hear the nurse or leaving the room and returning later to continue with the discussion may be viewed as a rude gesture by the client. Test-Taking Strategy: Knowledge of the characteristics of this cultural group and therapeutic communication techniques will assist in answering this question. Eliminate options 2, 3, and 4 because these are nontherapeutic actions. If you had difficulty with this question, review the communication practices of this cultural group. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 53.
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1750. A nurse reviews an assigned client’s laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse would determine that this is an expected finding if the client had which of the following health problems? 1. Ulcerative colitis 2. Diarrhea 3. Severe burn injury 4. Cushing’s syndrome Answer: 3 Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia. This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic ketoacidosis). The client with Cushing’s syndrome, ulcerative colitis, or the client with diarrhea is at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 1 and 2 first because they both reflect gastrointestinal losses. From the remaining options recalling that cell destruction causes potassium shifts will direct you to the correct option. Also, remember that Cushing’s syndrome presents a risk for hypokalemia, whereas Addison’s disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 783. 1751. A nursing student prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client, and the registered nurse asks the nursing student how the medication works. The student correctly responds that the medication works in the gastrointestinal tract by releasing: 1. Sodium ions in exchange for primarily bicarbonate ions 2. Sodium ions in exchange for primarily potassium ions 3. Bicarbonate in exchange for primarily sodium ions 4. Potassium ions in exchange for primarily sodium ions Answer: 2 Rationale: Sodium polystyrene sulfonate (Kayexalate) is a cation exchange resin used in the treatment of hyperkalemia. The resin either passes through the intestine or is retained in the colon. It releases sodium ions in exchange for primarily potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. Test-Taking Strategy: Focus on the name of the medication, Kayexalate, which indicates potassium excretion. This will assist in directing you to option 2. If you had difficulty with this question, review the action of this medication.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 980. 1752. A nurse is providing instructions to the nursing assistant who will be caring for a client with hand restraints. The nurse instructs the nursing assistant to check the client’s skin and circulation under the restraints: 1. Every 30 minutes 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours Answer: 1 Rationale: The nurse should instruct the nursing assistant to assess restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints should always be followed. Test-Taking Strategy: Focus on the issue, checking the client’s skin and circulation under the restraints. Since circulatory status is a primary concern with the use of restraints, it is best to select option 1. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 512. 1753. A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is: 1. 1 inch below the iliac crest 2. One fingerbreadth below the symphysis pubis 3. 1 inch below the coccyx 4. 1 cm above the ischial spines Answer: 4 Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Test-Taking Strategy: Knowledge that station is measured in centimeters and uses the ischial spines as a reference point will assist in answering this question. Note that options 1, 2, and 3 are similar in the use of “below,” which would be represented by a positive measurement in determining station. Review station if you had difficulty with this question.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 470, 472. 1754. A pediatric nurse arrives at work and is told to report (float) to the emergency room for the day because the emergency room is expecting numerous victims to arrive following a train accident. The nurse has never worked in the emergency room and is anxious about floating to this area. Which of the following is the appropriate nursing action? 1. Tell the nursing supervisor that she is feeling sick and needs to go home 2. Refuse to float to the emergency room 3. Discuss her anxieties and concerns about floating with the nursing supervisor. 4. Ask another pediatric nurse to float to the emergency room Answer: 3 Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, nurses discuss any anxieties and concerns about floating with the nursing supervisor. Options 1 and 2 may be interpreted as client abandonment. Although option 4 may be an alternative option at some point, it is not the appropriate action. Test-Taking Strategy: Note the key word appropriate. Eliminate options 1 and 2 because these actions may be interpreted as client abandonment. Next, eliminate option 4 because it is not within the realm of the nurse’s responsibilities to ask another nurse to float. Review nursing responsibilities related to “floating” if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 418-419. 1755. A 22-year-old client who was struck by a car while jogging is brought to the emergency room by the ambulance team. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted, but are unsuccessful. The client’s fiancée is with the client and tells the nurse that the client is an organ donor. In anticipation that the client’s eyes will be donated, which of the following should the nurse implement initially? 1. Call the National Eye Bank to confirm that the client is a donor 2. Position the deceased client supine and place dry sterile dressings over the eyes 3. Close the deceased client’s eyes and place a small ice pack on the eyes
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4. Ask the fiancée to obtain the client’s will from the lawyer Answer: 3 Rationale: When a corneal donation is anticipated, the client’s eyes are closed, and gauze pads with a small ice pack are placed on the client’s eyes. The head of the bed should also be elevated. Antibiotic eyedrops may also be prescribed. These actions will assist in preventing infection and edema. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Option 2 is incorrect, and option 4 is unnecessary. Calling the National Eye Bank to confirm that the client is a donor will delay necessary and immediate intervention. Test-Taking Strategy: Note the key word initially. This indicates that the nurse needs to take an action that will preserve the integrity of the deceased client’s eyes. Noting the words “close the deceased client’s eyes” in option 3 will direct you to this option. Review this procedure if you had difficulty with the question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1092. 1756. A nurse is collecting data from a pregnant client and is preparing to take the client’s blood pressure. The nurse positions the client: 1. Lying down 2. In a sitting position 3. On the right side 4. On the left side Answer: 2 Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client in the sitting position with the arm supported in a horizontal position at heart level. Options 1, 3, and 4 are incorrect, and these positions may cause physiological stress that will affect the blood pressure. Test-Taking Strategy: Use the process of elimination noting that options 1, 3, and 4 are similar. If you are unfamiliar with the procedure of performing a blood pressure on a pregnant client, review this procedure. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 840. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 143. 1757. A nurse is assisting in performing an assessment on a client that is 32 weeks’ gestation. The nurse measures the fundal height in centimeters and expects the findings
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to be which of the following? 1. 22 cm 2. 28 cm 3. 32 cm 4. 40 cm Answer: 3 Rationale: From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks’ gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect, and the pregnancy is further advanced than previously thought. If the estimated date of delivery is correct, it may be possible that more than one fetus is present. Test-Taking Strategy: Knowledge regarding the expected findings in fundal height in a pregnant client from 22 weeks’ gestation until term is required to answer this question. Recalling that in this client the fundal height measured in centimeters will be roughly plus or minus 2 cm of the gestational age of the fetus in weeks will direct you to option 3. If you are unfamiliar with this assessment technique, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 416. 1758. A nurse is reviewing the record of a client who has just been told that a pregnancy test result is positive. The physician has documented the presence of Goodell’s sign, and the nurse determines that this sign is indicative of: 1. A softening of the cervix 2. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus 3. The presence of human chorionic gonadotropin (hCG) in the urine 4. The presence of fetal movement Answer: 1 Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell’s sign. Cervical softening will be noted during pelvic examination by the examiner. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is due to blood circulation through the placenta. Human chorionic gonadotropin is noted in maternal urine in a urine pregnancy test. Goodell’s sign does not indicate the presence of fetal movement. Test-Taking Strategy: Knowledge regarding physiological findings in Goodell’s sign is required to answer this question. Remember that in the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell’s sign. If you had difficulty with this question, review the changes in the cervix that occur during pregnancy. Level of Cognitive Ability: Comprehension
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Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 352. 1759. A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse that the IV site is swollen. The nurse checks the IV site and notes that it is also cool and pale and that the IV has stopped running. The nurse documents that which of the following has probably occurred? 1. Infiltration 2. Phlebitis 3. Thrombosis 4. Infection Answer: 1 Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissue exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line. The other three options are likely to be accompanied by warmth at the site, not coolness. Test-Taking Strategy: To answer this question accurately, it is necessary to be familiar with the signs and symptoms that accompany complications of IV therapy. Focusing on the findings in the question will direct you to option 1. If this question was difficult, review the signs of infiltration. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 576. 1760. A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term? 1. “It is irregular, painless contractions that occur throughout pregnancy.” 2. “It is the soft blowing sound that can be heard when the uterus is auscultated.” 3. “It is the fetal movement that is felt by the mother.” 4. “It is the thinning of the lower uterine segment.” Answer: 3 Rationale: Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks’ gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, and this in known as uterine souffle. This sound is due to the blood circulation to the placenta and corresponds to the maternal pulse. Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the
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third trimester. A thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegar’s sign. Test-Taking Strategy: Knowledge regarding the term “quickening” is required to answer this question. Recalling that quickening is fetal movement will direct you to option 3. If you are unfamiliar with the signs associated with pregnancy, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 354, 398. 1761. A nurse is collecting data on a pregnant client and is preparing to auscultate the fetal heart sounds. The nurse prepares to use a fetoscope knowing that fetal heart sounds can be heard with a fetoscope by which week of gestation? 1. 8 to 10 weeks 2. 10 to 12 weeks 3. 14 to 16 weeks 4. 18 to 20 weeks Answer: 4 Rationale: Fetal heart sounds can be heard with a fetoscope by 18 to 20 weeks’ gestation. Options 1, 2, and 3 are incorrect because the fetal heart sounds cannot be heard with a fetoscope at these gestational times. Test-Taking Strategy: Knowledge regarding auscultation of fetal heart sounds is required to answer this question. Noting the key word fetoscope in the question will assist in directing you to option 4. If you are unfamiliar with the assessment of and auscultation of fetal heart sounds, review this procedure. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 418. 1762. A nurse-midwife is performing an assessment on a pregnant client and is assessing the client for the presence of ballottement. The nurse who is assisting understands that the nurse-midwife will implement which of the following to test for the presence of ballottement? 1. Auscultate for fetal heart sounds 2. Palpate the abdomen for fetal movement 3. Assess the cervix for thinning 4. Initiate a sudden tap on the cervix Answer: 4 Rationale: Near midpregnancy, a sudden tap on the cervix during a vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position. When the cervix is tapped, the fetus floats upward in the amniotic fluid. The examiner
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feels a rebound when the fetus falls down. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Knowledge regarding assessment of ballottement in the pregnant client is required to answer this question. Remember that ballottement relates to a rebound of the fetus. If you are unfamiliar with this assessment technique, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 583. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 136-137. 1763. A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBC) on a client. The licensed practical nurse who is assisting in caring for the client plans to remain with the client for how many minutes following the start of the infusion? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 60 minutes Answer: 2 Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most frequent period during which a transfusion reaction may occur. This enables the nurse to quickly detect a reaction and intervene quickly. Option 1 is not ample time to remain with the client. The time frames in options 3 and 4 are unnecessary. Test-Taking Strategy: Specific knowledge related to blood transfusion procedures is needed to answer this question accurately. Remember that the client needs to be directly monitored for the first 15 minutes of the transfusion. Review the procedure for administering blood transfusions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 623-624. 1764. A client is complaining of pain at the site of the intravenous (IV) infusion device. The nurse checks the IV site and determines that the client has phlebitis. Which of the following actions should the nurse take? 1. Slow the rate of the IV infusion 2. Notify the registered nurse (RN) 3. Apply ice packs to the site 4. Plan to assist with starting a new line in a proximal portion of the same vein Answer: 2 Rationale: Since phlebitis has occurred, the nurse notifies the RN who will notify the
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physician about the IV complication. The nurse should plan to remove the IV and apply warm moist compresses to the area to speed resolution of the inflammation. The nurse should plan to assist in restarting the IV in a different vein from the one with the phlebitis. Test-Taking Strategy: Focus on the issue, phlebitis at an IV site. Thinking about the physiological effect of each of the actions identified in the options will assist in directing you to option 2. Review nursing interventions related to phlebitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 576-577. 1765. A nurse caring for a Chinese-American client plans care considering the client’s view of illness. Which of the following most appropriately describes the ChineseAmerican’s view of illness? 1. Illness is caused by supernatural forces 2. Illness is a punishment for sins 3. Illness is a disharmonious state that may be caused by demons and spirits 4. Illness is due to an imbalance between yin and yang Answer: 4 Rationale: Chinese Americans believe that illness is due to an imbalance between yin and yang, which they believe is caused by prolonged sitting or lying or overexertion. In the African-American culture, illness is viewed as a disharmonious state that may be caused by demons and spirits. Hispanic Americans believe that illness occurs as a result of punishment for sins. Native Americans believe that illness is caused by supernatural forces. Test-Taking Strategy: Use the process of elimination and focus on the health beliefs of the Chinese-American culture. If you had difficulty with the question, review these various beliefs. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 54. 1766. A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client places a sign above the bed stating that the client should remain on bed rest: 1. With the foot of bed elevated as much as tolerated by client 2. In the high-Fowler’s position 3. With the head of bed elevated at least 60 degrees
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4. With the head of bed elevated no more than 30 degrees Answer: 4 Rationale: Following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The affected leg is kept straight, and the head is elevated no more than 30 degrees until hemostasis is adequately achieved. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are similar. From the remaining options, remembering that the affected leg is kept straight will assist in eliminating option 1. If you had difficulty with this question, review postcardiac catheterization care. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 292. 1767. A pregnant client asks a nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between: 1. 6 to 8 weeks’ gestation 2. 8 to 10 weeks’ gestation 3. 12 to 14 weeks’ gestation 4. 16 to 20 weeks’ gestation Answer: 4 Rationale: Fetal movement, called quickening, is not perceived until the second trimester. Between 16 to 20 weeks’ gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. Test-Taking Strategy: Knowledge regarding quickening and the detection of fetal movement by the mother are required to answer this question. Use the process of elimination, and in this situation it is best to select the option that indicates the greatest length of gestational time. If you are unfamiliar with the process of quickening, review this assessment finding. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 354. 1768. A client with an indwelling intravenous (IV) catheter has an order for an IV solution to be changed to 1000 mL of 0.9% sodium chloride to infuse at 100 mL/hr. When determining the rationale for the change in fluid, the nurse interprets that the client probably needs this type of solution because it: 1. Will increase the plasma osmolarity
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2. Will decrease the plasma osmolarity 3. Is isotonic with the plasma and other body fluids 4. Is hypotonic with the plasma and other body fluids Answer: 3 Rationale: Sodium chloride 0.9% is isotonic and is frequently used for intravenous infusion because it does not affect the plasma osmolarity. Options 1, 2, and 4 are incorrect regarding this type of solution. Test-Taking Strategy: Use the process of elimination and knowledge regarding the concepts related to body fluids. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 2 and 4. Remembering that the normal concentration of saline in the body is 0.9% will direct you to option 3. Review the various types of IV solutions if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1137. 1769. A physician is discussing the fluid balance of a postoperative client. The physician states that the client’s insensible fluid loss is approximately 600 mL daily. The nurse interprets that the physician is referring to fluid loss that is occurring thorough the: 1. Wound drain and skin 2. Skin and lungs 3. Nasogastric tube and wound drain 4. Foley catheter and nasogastric tube Answer: 2 Rationale: Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis without the client’s awareness. Sensible losses are those that are measurable and include wound drainage, gastrointestinal tract losses, and urine output. Test-Taking Strategy: Note the key words insensible fluid loss. Recalling that insensible losses cannot be measured will direct you to option 2. Review sensible and insensible fluid losses if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 48. 1770. A nurse is assigned to care for a group of clients on the clinical nursing unit. The nurse determines that third-spacing of fluids is least likely to develop in the client with: 1. Major burn 2. Renal failure 3. Laënnec’s cirrhosis 4. Hypertension
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Answer: 4 Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and the pericardial sac. Risk factors include the older client and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, and gastrointestinal malabsorption and malnutrition. Test-Taking Strategy: Use the process of elimination recalling the concepts of thirdspacing of fluids. Noting the key words least likely will direct you to option 4. If you had difficulty with this question, review these concepts and the causes of third-spacing. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 213, 218-219. 1771. A nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume in which of the following clients that is most at risk for this fluid imbalance? 1. A client with congestive heart failure 2. A client with acute renal failure 3. A client with an ileostomy 4. A client with major trauma Answer: 3 Rationale: The client with an ileostomy is at risk for deficient fluid volume because of increased gastrointestinal tract losses. Other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, or the presence of an ileostomy or colostomy. Clients who have heart failure, renal failure, or major trauma are at risk for excess fluid volume. Test-Taking Strategy: Read the question carefully noting that it asks for the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. Clients who have the disorders presented in options 1, 2, and 4 would be likely to retain fluid rather than lose it. If you had difficulty with this question, review the causes of deficient fluid volume. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 158-159,349-350. 1772. A nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which of the following assigned clients is most at risk for excess fluid
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volume? 1. The client with a draining abdominal wound 2. The client with a nasogastric tube to low suction 3. The client with renal failure 4. The client with an ileostomy Answer: 3 Rationale: The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. Other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. The client with an ileostomy, a draining abdominal wound, or a nasogastric tube is at risk for deficient fluid volume. Test-Taking Strategy: Use the process of elimination. Read the question carefully noting that it asks for the client at risk for an excess. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options 1, 2, and 4 lose fluid. The only condition that can cause an excess is the condition noted in option 3. If you had difficulty with this question, review the causes of excess fluid volume. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 159, 782. 1773. A nurse is caring for a client with cirrhosis who has a nursing diagnosis of excess fluid volume. The nurse would determine that the diagnosis is resolving if which of the following data is obtained by the nurse? 1. Increasing central venous pressure 2. Increasing pulse 3. Decreasing body weight 4. Decreasing urine output Answer: 3 Rationale: A sign that excess fluid volume is resolving is loss of body weight. The other options listed indicate that the client is retaining additional fluid. Assessment findings associated with excess fluid volume include cough, dyspnea, rales, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, elevated central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. These symptoms must reverse if the excess fluid volume is to be resolved. Test-Taking Strategy: Use the process of elimination and note the key word resolving. Recalling the effects of fluid on various physical assessment findings will direct you to option 3. If you had difficulty with this question, review the assessment signs noted in excess fluid volume. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation
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Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 159. 1774. A nurse is collecting data from a client with hypertension who is being treated with diuretic therapy. The nurse would monitor the client for hypokalemia if the client is receiving which of the following diuretics? 1. Triamterene (Dyrenium) 2. Amiloride HCL (Midamor) 3. Spironolactone (Aldactone) 4. Bumetanide (Bumex) Answer: 4 Rationale: Bumetanide (Bumex) is a loop diuretic, which places this client at risk for hypokalemia. The nurse assesses this client carefully for signs of hypokalemia, monitors serum potassium levels, and encourages intake of potassium sources in the diet. Spironolactone, triamterene, and amiloride HCL are potassium-sparing diuretics. Test-Taking Strategy: Use the process of elimination recalling the classifications of the various diuretics identified in the options. Remember that spironolactone, triamterene, and amiloride HCL are potassium-sparing diuretics. Review the classifications of these diuretics if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 143. 1775. A blood glucose measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother? 1. Administration of an oral hypoglycemic agent 2. Administration of NPH insulin on a daily basis 3. A 3-hour oral glucose tolerance test 4. A sliding scale regular insulin dose Answer: 3 Rationale: A maternal glucose is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour oral glucose tolerance test is recommended to determine the presence of gestational diabetes. Options 1, 2, and 4 would not be prescribed based solely on the maternal glucose levels. Further follow-up would be implemented. Test-Taking Strategy: Use the steps of the nursing process remembering that data collection is the first step. Eliminate options 1, 2, and 4 because they are similar in that they all identify the administration of medication to treat the elevated blood glucose. Option 3 is the only option that identifies further assessment of the client. Review measures to evaluate and treat elevated blood glucose levels in a pregnant client if you had difficulty with this question. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 359, 892. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 145.1776. A nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the physician. Select the warning signs that the nurse places on the list. ___ The presence of irregular painless contractions ___Visual disturbances ___ Rapid weight gain ___ Generalized or facial edema ___Nausea on arising in the morning Answer: Visual disturbances Rapid weight gain Generalized or facial edema Rationale: Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, regular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection. Nausea on arising in the morning is a normal and expected occurrence in pregnany. Test-Taking Strategy: Focus on the issue, the warning signs in pregnancy. Select the signs that are not a normal and expected occurrence in pregnancy. If you had difficulty with this question, review the warning signs in pregnancy. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 351-352, 863. 1777. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client needs further instruction if the client states that which of the following foods is high in potassium? 1. Raisins 2. Eggs 3. Beef 4. Pork
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Answer: 2 Rationale: One large egg provides 66 mg of potassium. One half cup of raisins contains 700 mg of potassium. Four ounces of beef contain 420 mg, and 4 oz of pork contain 525 mg of potassium. Test-Taking Strategy: Note the key words needs further instruction. These words indicate a false-response question and that you need to select the item lowest in potassium. Learn the foods that are high and low in potassium content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 162.1778. A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse provides a list of instructions for the client regarding management of care. Select the instructions that the nurse places on the list. ___ To maintain strict bed rest throughout the remainder of the pregnancy ___ To count the number of perineal pads used on a daily basis ___ To note the quantity and color of blood on each perineal pad ___ To watch for the evidence of the passage of tissue ___ To avoid any sexual activity for the remainder of the pregnancy Answer: To count the number of perineal pads used on a daily basis To note the quantity and color of blood on each perineal pad To watch for the evidence of the passage of tissue Rationale: The preference of the individual woman should be the deciding factor as to whether they rest in bed. Some woman may wish to rest, and they should be encouraged to do whatever feels best for them. Strict bed rest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased and for 2 weeks following the last evidence of bleeding or as recommended by the physician or nurse-midwife. The woman is instructed to count the number of perineal pads used on a daily basis and to note the quantity and color of blood on the pad. The woman should also watch for the evidence of the passage of tissue. Test-Taking Strategy: Note the client’s diagnosis. Select the instructions that relate to the diagnosis. Also, note that the incorrect instructions contains the absolute words “strict” and “avoid,” respectively. Review therapeutic management for a threatened abortion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 862.
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Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 663. 1779. A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is most important? 1. Recording that the count was incorrect 2. Informing the surgeon of the situation 3. Looking on the instrument table for the sponge 4. Asking the circulating nurse to look for the sponge Answer: 2 Rationale: The surgeon has the ultimate responsibility for the safety of the client and can stop the surgery until the sponge is found. Although documenting is necessary, this is not the most important action. Although options 3 and 4 may be appropriate, the physician needs to be informed about the missing sponge. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, a surgical sponge is missing. Noting the key words most important and recalling that the surgeon is ultimately responsible for the client will direct you to option 2. Review care to the intraoperative client if you had difficulty with this question. Phase of the Nursing Process: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 414. 1780. A client is brought to the emergency room and is unconscious. From the viewpoint of informed consent, a nurse determines that emergency treatment can be initiated to the unconscious client: 1. Only if the client’s family has given consent 2. Because emergency treatment can be provided under the emergency doctrine 3. Because the nurse is covered under liability insurance 4. As long as the nurse documents the care given accurately Answer: 2 Rationale: Emergency treatment can be provided under the “emergency doctrine.” This doctrine implies that the client would have consented to treatment if able because the alternative would have been death or disability. The emergency doctrine removes the need for obtaining informed consent before emergency treatment and care is initiated. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Option 1 is an unrealistic option because the client’s family may not be present. Additionally, this option contains the absolute word “only.” Options 3 and 4 are unrelated to the issue of informed consent. Additionally, option 4 is standard nursing procedure regardless of the situation. If you had difficulty with this question, review care to the client in emergency situations and the issues surrounding informed consent.
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Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Mosby’s medical, nursing, & allied health dictionary (2002). (6th ed.). St. Louis: Mosby, p. 588. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 417. 1781. A nurse positions a client for a surgical procedure. Which position can most likely lead to the potential for decreased lung expansion in the client? 1. Lithotomy 2. Supine 3. Lateral 4. Side lying Answer: 1 Rationale: The thoracic cage normally expands in all directions except posteriorly. In the lithotomy position, the expansion of the lungs is restricted at the ribs or sternum, and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Respiratory function is impaired because of this interference with normal movements. The volume of air that can be inspired is reduced. The positions in options 2, 3, and 4 would not interfere with the expansion of the lungs. Test-Taking Strategy: Use the process of elimination and visualize each position and its effect on lung expansion. The supine position in option 2 would not interfere with the expansion of the lungs; therefore eliminate this option. Eliminate options 3 and 4 because they are similar positions. The lithotomy position is the one that will most likely interfere with the expansion of the lungs. If you had difficulty with this question, review these positions. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 132. 1782. A nurse is caring for a home-bound older postoperative cardiovascular client. The caregiver’s daughter states to the nurse, “My mother has fallen out of bed three times.” Which observation by the nurse would indicate the need for intervention to ensure safety? 1. Client is oriented to person, place, and time 2. Caregiver leaves one side rail down while the client is in bed 3. Client’s bed is in a low position 4. Caregiver uses the overbed table for feedings Answer: 2 Rationale: Leaving a side rail down on the bed of an older client increases the risk of falling. The aging process also increases this client’s potential for falls; evaluating the safety of the environment is a necessity. Options 1, 3, and 4 identify observations that
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provide safety to the client. Test-Taking Strategy: Use the process of elimination focusing on the issue, an unsafe observation, and note the key words need for intervention to ensure safety. Option 1 indicates that the client is oriented, which would reduce the risk of falling. Options 3 and 4 also identify a safe and appropriate environment. Review the causes of falls in an older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 490-491, 499. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 964-965. 1783. A nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is most likely to react to a disagreement with this fellow employee by: l. Slamming cupboards in the office 2. Telling a friend that this employee hates her or him 3. Getting angry at the supervisor 4. Apologizing and offering to go out to lunch together Answer: 2 Rationale: The defense mechanism of projection is an unconscious process that projects emotionally unacceptable feelings to other people, objects, or situations and casts the blame onto another. Options 1 and 3 describe displacement in which the feeling is transferred to another person or object. Option 4 describes reaction formation in which a behavior is used that is directly opposite to a person’s unacceptable trait. Test-Taking Strategy: Knowledge of the defense mechanisms is needed to select the correct option. Focus on the issue, projection, and identify the defense mechanism that corresponds to the example presented in the situation. If you had difficulty with this question, review defense mechanisms. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 1155. 1784. A nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions with the client about this treatment. Which statement by the client indicates adequate understanding of cold therapy treatment? 1. “I need to apply the cold pack for at least 60 minutes.” 2. “I can lay on the ice by placing it between the bed and my body.” 3. “I should wrap the frozen ice pack in a warm towel to help adjust to the cold.”
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4. “I should check my pulse before using the ice on my joints.” Answer: 3 Rationale: Cold therapy should only be used for 15 to 20 minutes two or three times a day. The client needs to be instructed not to place ice directly between the skin and a firm surface. The weight of the body and the low temperature of the ice may produce ischemia. The skin should be checked for signs of injury. The frozen ice pack is taken from the freezer and should be wrapped in a warm towel to help the client adjust to the cold. Test-Taking Strategy: Use the process of elimination and visualize the procedure. This should help you eliminate options 1 and 2. Next, eliminate option 4 because it is not reasonable and is unnecessary. If you had difficulty with this question, review the procedure for cold pack therapy. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3rd ed.). St. Louis: Mosby, pp. 597, 605-609. Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 640. 1785. A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response by the student indicates an understanding of the anatomy of this structure? 1. “The uterus weighs about 2 oz.” 2. “The uterus weighs about 2.2 lb.” 3. “The uterus has a capacity of about 50 mL.” 4. “The uterus is round in shape and weighs approximately 1000 g.” Answer: 1 Rationale: Before conception, the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL. At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb) and has a sufficient capacity for the fetus, placenta, and amniotic fluid, a total of about 5000 mL. Test-Taking Strategy: Note the key word nonpregnant and attempt to visualize each of the items identified in the options. Remember that before pregnancy, the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL. Review the anatomical structure of the uterus if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 120. 1786. A nurse is caring for a new postoperative client and is monitoring the client for
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signs of shock. The nurse monitors for which signs of this postoperative complication? 1. Cold skin, drowsiness, and hypertension 2. Fever, irritability, and rapid respirations 3. Tachycardia, cold skin, and hypotension 4. Slow pulse, warm skin, and restlessness Answer: 3 Rationale: Postoperative hypotension or shock can have numerous causes, such as inadequate ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood loss. The manifestations of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and apprehension. Test-Taking Strategy: Use the process of elimination. Remember that when an option contains more than one part, all parts need to be correct for the option to be the answer to the question. Remembering that a drop in blood pressure and a rise in pulse are indicative of shock will direct you to the correct option. If you had difficulty with this question, review the signs of shock. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 750. 1787. A student nurse examines an Asian-American infant’s eyes and notes that the infant’s eyes are crossed. The registered nurse asks the student to interpret the finding. Which statement by the student indicates an understanding of this finding? 1. “It probably isn’t strabismus, but appears that way because of the child’s ethnic background.” 2. “You will want to call the pediatrician immediately because this could lead to a detached retina.” 3. “It probably is strabismus because the baby’s mother has abused tranquilizers.” 4. “Strabismus isn’t life threatening, but it requires surgery in the first 2 months to prevent the crossed eyes from being a lifelong condition.” Answer: 1 Rationale: Asian-American, American-Indian, and Alaskan-Native infants often have a pseudostrabismus because of a flattened nasal bridge. It will need to be distinguished from a true strabismus in the assessment. Options 2, 3, and 4 are inaccurate statements. Test-Taking Strategy: Use the process of elimination. Recalling the cultural differences in the physical assessment findings in an infant will direct you to option 1. Review these differences if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed.). Philadelphia: W.B. Saunders, p. 323.
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1788. A nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client’s identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is: 1. Defined as the failure to meet established standards of care 2. Defined as a crime that results in the injury of a client 3. Strictly prohibited by the Nurse Practice Act 4. Strictly prohibited by the institution’s own policies Answer: 1 Rationale: The legal definition of negligence is the failure to meet accepted standards of care. Option 2 is an incorrect definition of negligence, although injury may have indeed come to the client as a result of negligence. Both the institution and the Nurse Practice Act have provisions that identify and discourage acts of negligence. Test-Taking Strategy: To answer this question correctly, you must know the definition of negligence as applied to the profession of nursing. Options 3 and 4 are true in that the purpose of the Nurse Practice Act and institutional policies and procedures is to protect the public from harm, but the words “strictly prohibited” tends to make these options incorrect. From the remaining options, select option 1 because it is the umbrella (global) option. If you had difficulty with this question, review the concepts related to negligence. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 18, 283. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 414. 1789. A nurse is reviewing the health care record of a pregnant client at 16 weeks’ gestation. The nurse would expect documentation that the fundus of the uterus is noted at which of the following areas? 1. Just above the symphysis pubis 2. At the umbilicus 3. Midway between the symphysis pubis and the umbilicus 4. At the level of the xiphoid process Answer: 3 Rationale: At 12 weeks’ gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process. Test-Taking Strategy: Knowledge regarding the patterns of uterine growth is required to answer this question. Focus on the weeks of gestation identified in the question to assist in directing you to the correct option. If you are unfamiliar with the patterns of uterine growth during pregnancy, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity
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Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 350-351. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 425. 1790. A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds and then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, what interpretation should the nurse make? 1. The client is using the incentive spirometer correctly 2. The client should be repeating the sequence 10 to 20 times in each session 3. The client should be inhaling and exhaling quickly 4. The client should not be holding the breath following inhalation Answer: 2 Rationale: Incentive spirometer devices use a concept of sustained maximal inspiration. Each device has a means of setting an inspiratory goal. Correct use requires a spontaneous, slow, voluntary, deep breath. When full inhalation is reached, the breath is held for at least 3 seconds. This sequence is repeated 10 to 20 times an hour. Incentive spirometer exercises are most effective when used every hour while the client is awake. Test-Taking Strategy: Use the process of elimination focusing on the client’s performance described in the question. Noting the key words takes one breath and returns the incentive spirometer to the bedside and visualizing this procedure will direct you to option 2. If you had difficulty with this question, review the correct procedure for the use of an incentive spirometer. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 327-329. 1791. A client’s preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats/min with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which of the following actions should the nurse take first? 1. Report the vital signs immediately to the registered nurse (RN) 2. Compare these values with those recorded previously 3. Recheck the blood pressure in 5 minutes 4. Report only the apical pulse since it is above the normal range Answer: 2 Rationale: Preoperative assessment of vital signs provides important baseline data with which to compare following surgery. Anxiety and fear commonly cause elevations in the heart rate and blood pressure. The vital signs as stated in the question do not need to be
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reported to the RN immediately. The apical pulse is not above the normal range. Rechecking the blood pressure in 5 minutes is likely to show an unchanged blood pressure measurement. The nurse should compare these values with those recorded previously. Test-Taking Strategy: Use the process of elimination noting the key word first. Focus on the data in the question and note that the client is preoperative. Recalling the normal ranges for vital signs and the effects of anxiety and fear on the vital signs in the preoperative client will direct you to option 2. The first action should be to compare the values with those recorded previously. Review care to the preoperative client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 744. 1792. A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which of the following would the nurse determine is a harmful measure in preventing constipation? 1. Daily activity, such as walking or swimming 2. Drinking six to eight glasses of water daily 3. Increasing whole grains and fresh vegetables in the diet 4. Adding 1 tbsp of mineral oil to a bowl of cereal daily Answer: 4 Rationale: Mineral oil should not be used as a stool softener since it inhibits the absorption of fat-soluble vitamins in the body. Constipation should be treated with increased fluids (six to eight glasses per day) and a diet high in fiber. Increasing exercise is also an excellent way to improve gastric motility. Test-Taking Strategy: Use the process of elimination noting the key words a harmful measure. These words indicate a false-response question and that you need to select the incorrect intervention for treating constipation. Note that options 1, 2, and 3 are natural methods for increasing gastric motility. Option 4 is an unnatural measure and needs to be avoided. If you had difficulty with this question, review measures to prevent constipation. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 390, 433. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 149. 1793. A client has an intravenous infusion (IV) started before surgery for a right belowthe-knee amputation. In addition to the intravenous infusion, blood work is drawn and a
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surgical skin preparation is done. Which nursing diagnosis is most appropriate for the nurse to consider in providing preoperative care? 1. Deficient fluid volume related to IV therapy 2. Risk for excess fluid volume related to IV therapy 3. Acute pain related to surgery 4. Anxiety related to coping with preoperative therapies Answer: 4 Rationale: Before surgery most clients experience anxiety. Client anxiety is a priority concern before surgery and when treatments are performed. There is no data in the question to indicate signs of actual fluid volume deficit or overload. Postoperative concerns, such as acute pain, should be addressed in the preoperative period, but this is not the issue of the question. Test-Taking Strategy: Use the process of elimination focusing on the data in the question. Noting the key words prior to surgery will direct you to option 4. Remember to focus on the client concerns as a priority in the preoperative period. Review the defining characteristics for anxiety if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3rd ed.). St. Louis: Mosby, p. 492. Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 1219. 1794. A nurse is caring for a client who had a small bowel resection, is 1 day postoperative, and has continuous gastric suction attached to the nasogastric tube. Which of the following intravenous solutions would the nurse anticipate would most likely be prescribed for the client? 1. 25% albumin 2. 5% dextrose in water 3. Lactated Ringers solution 4. Normal saline Answer: 3 Rationale: Electrolyte solutions, such as lactated Ringers, are used to replace fluid from gastrointestinal (GI) tract losses. Albumin is used for shock and protein replacement. Five percent dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is essential for calories when a client is NPO. Test-Taking Strategy: Use the process of elimination noting that the client is 1 day postoperative. Knowledge of the components of IV solutions and noting that the client had GI surgery will direct you to option 3. If you had difficulty with this question, review the components of these IV solutions. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning
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Content Area: Fundamental Skills References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 210. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1160. 1795. A nurse is urging a client to cough and deep breathe after nephrectomy. The client tells the nurse, “That’s easy for you to say! You don’t have to do this.” The nurse interprets that the client’s statement is most likely a result of: 1. A stress response to the ordeal of surgery 2. A latent fear of needing dialysis if the surgery is unsuccessful 3. Effects of circulating metabolites that have not been excreted by the remaining kidney 4. Pain that is intensified because the location of the incision is near the diaphragm Answer: 4 Rationale: After nephrectomy the client may be in considerable pain. This is due to the size of the incision and its location near the diaphragm, which makes coughing and deep breathing so uncomfortable. For this reason, narcotics are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. Options 1, 2, and 3 are not specifically related to this client’s situation. Test-Taking Strategy: Use the process of elimination noting the key words most likely. Recalling that coughing and deep breathing intensifies pain after many surgical procedures and visualizing the location of the surgical incision will direct you to option 4. Review care to the client following nephrectomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 446. 1796. A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people is doing the evaluation. In formulating a response, the nurse understands that this is being done to: 1. Save the client and recipient valuable preoperative time 2. Prevent a conflict of interest by the team evaluating the recipient and team evaluating the donor 3. Help reduce the cost of the preoperative work-up 4. Have a sufficient number of people reviewing the case so no information is overlooked Answer: 2 Rationale: Both the kidney donor and recipient need thorough medical and psychological evaluation before transplant surgery. To avoid conflict of interest, evaluation of the donor is done by a team different from that caring for the donor. The psychosocial issues in living-related organ donation may be very complex, and conversations with the donor are held in strict confidence to preserve family relations.
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Test-Taking Strategy: Use the process of elimination and knowledge of concepts regarding client advocacy. Remember that in this situation one group cannot advocate for both parties simultaneously. If you had difficulty with this question, review the concepts related to organ donation. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Renal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2435. 1797. A nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia is red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action would be to: 1. Obtain a specimen of the discharge for culture 2. Document the findings 3. Notify the registered nurse immediately 4. Review the mother’s record to determine a history of gonorrhea Answer: 2 Rationale: The genitalia of a newborn female are frequently red and swollen. This edema disappears in a few days. A vaginal discharge of thick white mucus is seen in the first week of life. The mucus is occasionally blood tinged by about the third or fourth day and stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement, is the withdrawal of maternal hormones. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling that the findings noted in the question are normal and expected will direct you to option 2. If you had difficulty with this question, review normal newborn findings. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 688. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 529. 1798. A nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is: 1. Testosterone 2. Oxytocin 3. Prolactin 4. Progesterone Answer: 3
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Rationale: Prolactin stimulates the secretion of milk, called lactogenesis. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. Test-Taking Strategy: Knowledge regarding the functions of the various hormones in the female reproductive system is required to answer this question. Note the relation between the words “secretion of milk” in the question and the hormone “prolactin” in the correct option. If you had difficulty with this question, review the functions of the various hormones of the female reproductive system. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 762. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 70. 1799. A nurse is observing a nursing assistant talking to a client that is hearing impaired. The nurse would intervene if which of the following were performed by the nursing assistant during communication with the client? 1. The nursing assistant is facing the client when speaking 2. The nursing assistant is speaking clearly to the client 3. The nursing assistant is speaking directly into the impaired ear 4. The nursing assistant is speaking in a normal tone Answer: 3 Rationale: When communicating with a hearing-impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse needs to avoid talking directly into the impaired ear. Test-Taking Strategy: Note the key word intervene. This word indicates a false-response question and that you need to select the incorrect action by the nursing assistant. Use the process of elimination recalling that the nurse needs to avoid talking directly into the impaired ear. If you had difficulty with this question, review these techniques. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 587. 1800. A clinic nurse is providing instructions to a client regarding the use of a hearing
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aid. Which statement by the client indicates a need for further instructions? 1. “I should keep an extra battery available at all times.” 2. “I should wash the ear mold frequently with mild soap and water.” 3. “I should turn the hearing aid off after removing it from my ear.” 4. “I should not wear the hearing aid during an ear infection.” Answer: 3 Rationale: Nurses should have a basic knowledge of the care of a hearing aid to assist the client in its use. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback. The hearing aid should be turned off when not in use, and the client should keep an extra battery available at all times. The client should wash the ear mold frequently with mild soap and water with the use of a pipe cleaner to cleanse the cannula. The client should not wear the hearing aid during an ear infection. Test-Taking Strategy: Use the process of elimination noting the key words need for further instructions. These words indicate a false-response question and that you need to select the incorrect client statement. Knowledge regarding squealing feedback will assist in directing you to the correct option. If you had difficulty with this question, review client instructions regarding the use of the hearing aid. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 586.
1
Comprehensive Review CD Questions 1701-1800
{COMP:
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2
assess accurate placement of the tube. Review the principles related to NG tube feedings, if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1403, 1408. 1703. A client receiving total parenteral nutrition (TPN) is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position? 1. Supine 2. Prone 3. High-Fowler’s 4. Left side in Trendelenburg’s Answer: 4 Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg’s position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. Options 1, 2, and 3 identify incorrect positions. Test-Taking Strategy: Use the process of elimination and note the key word immediately. Eliminate options 1 and 2 first because they are both flat positions. From the remaining options, think about the principles of gravity and the anatomy of the cardiopulmonary system to direct you to option 4. Review the priority nursing actions when an air embolism occurs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1315. 1704. A nurse is checking a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the site. The nurse should do which of the following first? 1. Check for a blood return 2. Remove the IV 3. Apply a warm compress 4. Measure the area of infiltration Answer: 2 Rationale: Blanching, coolness, and edema of the IV site are all classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the first action by the nurse is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if
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3
the infiltrated solution is not damaging to the surrounding tissue. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed. Test-Taking Strategy: Note the key word first. Although all of the options may be appropriate, it is necessary to prioritize. The signs presented in the question identify infiltration. Infiltration indicates that the IV needs to be removed. Review the signs of infiltration and the appropriate initial interventions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1189. 1705. A client has just been treated with cardioversion. The nurse should assess which of the following first? 1. Status of airway 2. Oxygen flow rate 3. Level of consciousness 4. Blood pressure Answer: 1 Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority. Test-Taking Strategy: Note the key word first. Use the ABCs—airway, breathing, and circulation—to direct you to option 1. Review the priority nursing responsibilities following cardioversion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 577. 1706. A nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which of the following? 1. Stimulate the perioral cavity with a finger 2. Clap the hand or slap on the mattress 3. Stimulate the pads of the hands by firm pressure 4. Stimulate the ball of the foot by firm pressure Answer: 2 Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar reflex is elicited by
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4
stimulating the palm of the hand by firm pressure, and the plantar reflex is elicited by stimulating the ball of the foot by firm pressure. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 are similar and should be eliminated first. From the remaining options, focusing on the issue of the question, the Moro reflex, will assist in directing you to option 2. Review assessment of neonatal reflexes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 700. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 523, 524. 1707. A nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which of the following first? 1. Peripheral pulses 2. Temperature 3. Heart rate 4. Blood pressure (BP) Answer: 1 Rationale: The client who receives circumferential burns to the extremities is at risk for impaired peripheral circulation. The priority assessment would be to check for peripheral pulses to ensure that adequate circulation is present. Although the temperature, heart rate, and BP would also be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses. Test-Taking Strategy: Use the process of elimination. Focus on the key words first and circumferential burns of both legs to assist in directing you to the correct option. If you had difficulty with this question or are unfamiliar with the priority assessment in a client who sustained a circumferential burn of an extremity, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing References: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1629. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 525. 1708. A nurse is preparing to get a quadriplegic client out of bed into a chair. The nurse places which of the following items on the seat of the chair as the best device for pressure relief? 1. Water pad 2. Plastic lined absorbent pad 3. Pillow
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4. Air ring Answer: 1 Rationale: The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client’s weight on the device. These include foam, water, gel, or alternating air pads. A plastic lined pad absorbs moisture, but provides no pressure relief. A pillow provides cushion, but does not redistribute weight equally. An air ring relieves pressure in some spots, but causes pressure in others by its design. Test-Taking Strategy: The key words in the question are pressure relief and quadriplegic. Eliminate option 2 first because it does not provide any protection against pressure. Eliminate option 4 next because it redistributes weight unequally under this client. Choose correctly from the remaining options by recalling that the water pad will redistribute weight, and the pillow will not. Review the devices that provide pressure relief to prevent skin breakdown if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 279. 1709. A nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse if the procedure will be painful. The nurse should make which response to the client? 1. “No it is not painful.” 2. “You will receive a general anesthetic.” 3. “A local anesthetic will be given.” 4. “You will be heavily medicated before the procedure.” Answer: 3 Rationale: A local anesthetic is used to anesthetize the skin and subcutaneous tissue to minimize tissue discomfort with needle insertion. The client will feel some pain briefly when the sample is aspirated out of the marrow. Options 1, 2, and 4 are incorrect statements. Test-Taking Strategy: Focus on the diagnostic test and how this test is performed. Knowing that the procedure may be performed at the bedside will assist in eliminating options 2 and 4. Knowing that the procedure is invasive will assist in eliminating option 1. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 176. 1710. A nurse is administering intramuscular iron to an assigned client. The nurse
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should do which of the following to prevent skin staining around the injection site? 1. Use a Z-track method for administration 2. Administer the injection in the nondominant arm 3. Administer the injection in the thigh 4. Massage the site well after injection Answer: 1 Rationale: Proper technique for administering iron by the intramuscular route includes using a Z-track technique and changing the needle after drawing it up, but before the medication is given. The medication should be given in the upper outer quadrant of the buttock and not in exposed areas, such as the arms or thighs. The site should not be massaged after injection. Test-Taking Strategy: Use the process of elimination. Focusing on the issue, to prevent skin staining, will assist in eliminating options 2 and 3. Use principles of medication administration by the intramuscular route and focus on the medication being administered to direct you to option 1. Review the procedure for the administration of iron if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 711. 1711. A nurse has conducted dietary teaching with the client who has iron deficiency anemia. The nurse determines that the client understood the information if the client states to increase intake of which of the following foods? 1. Refined white bread 2. Egg whites 3. Pineapple 4. Kidney beans Answer: 4 Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver, and other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots. Test-Taking Strategy: Focus on the client’s diagnosis. Recalling the foods high in iron will direct you to option 4. Review foods high in iron if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Nix, S. (2005). Williams’ basic nutrition & diet therapy (11th ed.). St. Louis: Mosby, pp. 142-143.
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1712. A nurse is checking the skin on a client who is immobile and notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as a: 1. Stage 1 pressure ulcer 2. Stage 2 pressure ulcer 3. Stage 3 pressure ulcer 4. Stage 4 pressure ulcer Answer: 2 Rationale: In a stage 2 pressure ulcer, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and may characterize as an abrasion, blister, or shallow crater. The skin is intact in stage 1. A deep craterlike appearance occurs in stage 3, and sinus tracts develop in stage 4. Test-Taking Strategy: Use the process of elimination and knowledge of the characteristics associated with each stage of pressure ulcers. Focusing on the description in the question, partial-thickness skin loss of the upper layer of the skin, will direct you to option 2. If you had difficulty with this question, review the characteristics associated with each stage of pressure ulcers. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 273. 1713. A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder? 1. Drowsiness, headache, and tachypnea 2. Decreased respiratory depth and rate and dysrhythmias 3. Disorientation and dyspnea 4. Tachypnea, dizziness, and paresthesias Answer: 2 Rationale: The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth, nausea, vomiting, diarrhea, restlessness, numbness and tingling in the extremities, twitching in the extremities, hypokalemia, hypocalcemia, and dysrhythmias. Options 1, 2, and 4 are not associated with metabolic alkalosis. Test-Taking Strategy: Knowledge about the clinical manifestations of metabolic alkalosis will direct you to option 2. Remember that in this disorder the respiratory rate and depth decrease. Review the clinical manifestations of metabolic alkalosis if this question was difficult. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 165.
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1714. A nurse is assisting in monitoring a client who may be started on total parenteral nutrition (TPN). The nurse reviews the client’s laboratory results and determines that the client is at risk for severe malnutrition if the albumin level report indicates which critical level? 1. 5.0 g/dl 2. 4.5 g/dl 3. 3.9 g/dl 4. 2.8 g/dl Answer: 4 Rationale: The serum albumin level is a critical indicator of the need for TPN. The client whose albumin level is 2.8 g/dl is at severe risk for malnutrition. The normal serum albumin level in the adult is 3.4 to 5 g/dl. Options 1, 2, and 3 identify normal albumin levels. Test-Taking Strategy: Note the key words critical level. Knowing that the normal albumin level is 3.4 to 5 g/dl will direct you to option 4. Review this laboratory test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 148. 1715. One unit of packed red blood cells has been prescribed for a client postoperatively because the client’s hemoglobin level is low. The physician prescribes diphenhydramine (Benadryl) to be administered before the administration of the transfusion. The nurse determines that this medication has been prescribed to: 1. Prevent a rash and pruritus 2. Prevent a fever 3. Promote sedation 4. Promote bone marrow absorption Answer: 1 Rationale: An urticaria reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine. Options 2, 3, and 4 are incorrect statements. Acetaminophen (Tylenol), however, may be prescribed before the administration to assist in preventing an elevated temperature. Test-Taking Strategy: Focus on the medication. Recalling the classification of diphenhydramine and that it is an antihistamine will assist in directing you to option 1. Review blood transfusion reactions and their management if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills
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Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 333. 1716. A nurse is providing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure? 1. “I should douche just before I collect the specimen.” 2. “I should cleanse the perineum from back to front.” 3. “I need to collect the urine in the cup just after I start to urinate.” 4. “I need to bring the specimen to the laboratory within 48 hours after I collect it.” Answer: 3 Rationale: As part of correct procedure, the client should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results. It is not normal procedure to douche before collecting the specimen. Test-Taking Strategy: Use the process of elimination. Use basic principles related to hygiene to eliminate option 2. Recalling that the specimen should be brought to the laboratory after collection will assist in eliminating option 4. From the remaining options, noting the name of the type of sample “midstream” will direct you to option 3. If this question was difficult, review this procedure. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 701-702. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 1151. 1717. A physician has written an order for a preoperative client to have “enemas until clear.” The nurse has administered three enemas, and the client is still passing brown liquid stool. Which of the following actions should the nurse take next? 1. Wait 30 minutes, check the client’s electrolyte levels, and then administer another enema 2. Continue to administer the enemas until the stool is clear 3. Encourage the client to drink clear liquids and administer another enema in 1 hour 4. Notify the registered nurse (RN) Answer: 4 Rationale: Up to three enemas may be given when there is an order for enemas until clear. If more than three are necessary, the nurse notifies the RN who will then call the physician (or act based on agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1, 2, and 3 are incorrect for these reasons. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are similar. Also, use knowledge of basic bowel elimination procedures and
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consider the physiological effects that can occur with enema administration. This will assist in directing you to the correct option. Review the procedure for administering enemas if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A, (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 681. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 751. 1718. A client comes to the emergency room with lethargy; has deep, regular respirations; and a fruity odor to the breath. The client’s arterial blood gases (ABG) −
results are: pH of 7.25, PCO2 of 34 mm Hg, PO2 86 of mm Hg, HCO 3 of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Answer: 1 Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the PCO2 is greater than 45, whereas respiratory alkalosis is present when the PCO2 is less than 35. Metabolic −
acidosis is present when the pH is less than 7.35, and the HCO 3 is less than 22 mEq/L, −
whereas metabolic alkalosis is present when the pH is greater than 7.45, and the HCO 3 is greater than 27 mEq/L. This client’s ABG are consistent with metabolic acidosis. Test-Taking Strategy: Remember that in a metabolic imbalance you will find that the pH −
and the HCO 3 move in the same direction. Therefore options 3 and 4 are eliminated first. Next, remember that the pH is elevated with alkalosis and low in acidosis. Option 1 reflects a metabolic acidotic condition and describes the blood gas values as indicated in the question. Review the steps related to reading blood gas values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 165. Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 245. 1719. A client wishes to donate blood for a family member and asks the nurse about the
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procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility? 1. Eosinophil count 2. Monocyte count 3. Red blood cell count 4. Indirect Coombs’ test Answer: 4 Rationale: The indirect Coombs’ test detects circulating antibodies against red blood cells (RBCs), and is the “screening” component of the order to “type and screen” a client’s blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The direct Coombs’ test is used to detect idiopathic hemolytic anemia, by detecting the presence of autoantibodies against the client’s RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematological screening test. A red blood cell count is also part of a complete blood count and determines the number of circulating red blood cells, but does not determine compatibility. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are part of routine lab work, a complete blood count. Review the tests identified in the options if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 412. 1720. A nurse is monitoring a client for bradypnea. Which of the following is characteristic of this respiratory pattern? 1. Labored and increased in depth and rate 2. Regular but interspersed with periods of apnea 3. Abnormally deep, regular, with increased rate 4. Regular but abnormally slow Answer: 4 Rationale: Bradypnea is characterized by respirations that are regular but abnormally slow. Kussmaul’s respirations are abnormally deep, regular, and increased in rate. Hyperpnea is characterized as respirations that are labored and increased in depth and rate. Respirations that cease for a number of seconds are identified as apnea. Test-Taking Strategy: Note the relation of the word “bradypnea” in the question and the words “abnormally slow” in option 4. Review the characteristics of these types of respirations if this question was difficult. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 472.
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1721. A nurse has assisted with obtaining a set of arterial blood gases (ABG). The nurse avoids doing which of the following to properly obtain and send the specimen? 1. Records the client’s temperature on the requisition 2. Records the percent of oxygen on the requisition 3. Obtains a 3-mL syringe from the medication supply area 4. Places the specimen on ice Answer: 3 Rationale: The specimen is drawn into a heparinized syringe to prevent clotting of the blood. A 3-mL syringe taken from the medication supply area is not used. The other options are correct. The specimen should be placed on ice after it is obtained. The requisition is fully completed identifying pertinent client information, such as body temperature and amount of oxygen in use. Test-Taking Strategy: Note the key word avoids. This word indicates a false-response question and that you need to select the incorrect action. Recalling that a heparinized syringe is used to prevent clotting of the blood will direct you to the correct option. Review the procedure for obtaining ABG if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 249. 1722. A nurse is caring for a client whose magnesium level is 4.0 mg/dl, and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if the client has relief from which sign or symptom? 1. Muscular excitability 2. Loss of deep tendon reflexes 3. Twitches 4. Tetany Answer: 2 Rationale: The normal magnesium level is 1.6 to 2.6 mg/dl. A client with a magnesium level of 4.0 mEq/L is experiencing hypermagnesemia. Signs include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, tachycardia, hypotension, and loss of consciousness. Tetany, muscular excitability, and twitches are seen in a client with hypomagnesemia. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are similar in that they all reflect neurological excitability. If you had difficulty with this question, review the signs found in magnesium imbalances. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 244.
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1723. A nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gases results indicate that the client is experiencing respiratory alkalosis. The nurse would then evaluate the results of serum electrolytes to see if which electrolyte imbalance is present? 1. Hyponatremia 2. Hypokalemia 3. Hypercalcemia 4. Hyperchloremia Answer: 2 Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth; headache; light-headedness; vertigo; mental status changes; paresthesia, such as tingling of the fingers and toes; hypokalemia; hypocalcemia; tetany; and convulsions. Clinical manifestations do not include hyponatremia, hypercalcemia, or hyperchloremia. Test-Taking Strategy: Use the process of elimination and knowledge of the signs and symptoms of respiratory alkalosis to answer the question. Remember that hypokalemia occurs in respiratory alkalosis. If this question was difficult, review the clinical manifestations associated with respiratory alkalosis. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 162. 1724. A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Answer: 1 Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions, such as diarrhea or the creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for developing the acid-base disorders identified in options 2, 3, and 4. Test-Taking Strategy: Begin to answer this question by recalling that intestinal fluids are alkaline. With this in mind, you may eliminate options 2 and 4 first because alkaline secretions are lost in a client with an ileostomy. Note that the client condition described in the question is a client with a gastrointestinal disorder. This will direct you to choose the metabolic acidosis over the respiratory acidosis. If you had difficulty with this question, review the causes of metabolic acidosis. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 165. 1725. A nurse enters a laundry room to empty a bag of dirty linens and discovers that there is a fire in the laundry room. The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher to extinguish the fire. The nurse prepares to use the fire extinguisher by first: 1. Squeezing the handle on the extinguisher 2. Pulling the pin on the fire extinguisher 3. Obtaining a pair of gloves and putting them on before touching the extinguisher 4. Obtaining a mask and putting it on before using the extinguisher Answer: 2 Rationale: A fire can be extinguished by smothering it with a blanket or by the use of a fire extinguisher. To use the extinguisher, the pin is pulled first. The extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is then squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly. Although the nurse needs to be cautious when using an extinguisher, it is not necessary to don gloves or a mask. Additionally, these actions would delay the process of extinguishing the fire. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because these actions would delay the process of extinguishing the fire. Remember the mnemonic PASS to prioritize in the use of a fire extinguisher. P = Pull the pin; A =Aim at the base of the fire; S = Squeeze the handle; S = Sweep from side to side to coat the area evenly. If you had difficulty with this question, review the appropriate use of a fire extinguisher. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 991. 1726. A nurse is caring for a client with liver disease. Laboratory studies are performed, and the client’s serum calcium level is 13.0 mg/dl. The nurse checks to see that which of the following medications is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance? 1. Calcitonin (Calcimar) 2. Vitamin D 3. Calcium gluconate 4. Calcium chloride Answer: 1 Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dl. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are used to treat
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tetany that results from acute hypocalcemia. In hypercalcemia, large doses of vitamin D should be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. Test-Taking Strategy: Begin to answer this question by determining that the client is experiencing hypercalcemia. With this knowledge, you can eliminate options 3 and 4 because you would not administer medication that would further increase the calcium level. From the remaining options, remember that excessive vitamin D is a causative factor of hypercalcemia. If you had difficulty with this question, review the treatment for hypercalcemia. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 783. 1727. A nurse is assigned to care for a client on contact precautions. On review of the client’s record, the nurse notes that the client has a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client’s room and obtains which of the following necessary protective items? 1. Gloves, gown, and goggles 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves and a gown Answer: 1 Rationale: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves and a gown to be worn if direct client contact is anticipated. Shoe protectors are not necessary. Test-Taking Strategy: Note the key words contact precautions, irrigation, and frequent suctioning. Use the process of elimination in determining the necessary items required to care for this client. If you had difficulty with this question, review Transmission Based Precautions. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 930, 941. 1728. A nurse is doing discharge teaching with a client who has sickle cell disease. The nurse instructs the client to avoid which of the following factors that could precipitate a sickle cell crisis? 1. Mild exercise
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2. Fluid overload 3. Warm weather 4. Infection Answer: 4 Rationale: The client should avoid infections, which can increase metabolic demand and cause dehydration, precipitating a sickle cell crisis. The client should also avoid dehydration from other causes. Warm weather and mild exercise does not need to be avoided, but the client should take measures to prevent dehydration during these conditions. Fluids are important to prevent dehydration. Finally the client should avoid being in areas of high altitude or flying in nonpressurized aircraft because of lesser oxygen tension in these areas. Test-Taking Strategy: Use the process of elimination noting the key word avoid. Recalling the precipitating factors of sickle cell crisis will direct you to option 4. Review these precipitating factors if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 524. 1729. A client is admitted to the hospital with sickle cell crisis. The nurse checks this client for which frequent symptom of the disorder? 1. Bradycardia 2. Pain 3. Diarrhea 4. Blurred vision Answer: 2 Rationale: Sickling crisis often causes pain in the bones and joints, accompanied by joint swelling. Pain is a classic symptom of the disease and may require large doses of narcotic analgesics when it is severe. The symptoms listed in the other options are not part of the clinical picture. Test-Taking Strategy: To answer this question correctly, you must be familiar with the signs and symptoms of sickle cell crisis. Recalling that the primary treatment of sickle cell crisis focuses on the administration of fluids and on management of pain will enable you to eliminate the incorrect options. If this question was difficult, review the clinical manifestations associated with sickle cell crisis. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 525. 1730. A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted in the client?
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1. Increased blood pressure 2. Increased heart rate 3. Positive Trousseau’s sign 4. Hypoactive bowel sounds Answer: 3 Rationale: Signs of hypocalcemia include paresthesias, hyperactive reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include a decreased heart rate, hypotension, hyperactive bowel sounds, increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Options 1, 2, and 4 are signs of hypercalcemia. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are similar in that they both reflect an increase in relation to cardiovascular function. From the remaining options, it is necessary to know that a positive Trousseau’s sign is an indication of hypocalcemia. Review the findings noted in hypocalcemia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 470. 1731. A nurse has instructed a client in safety measures while using oxygen in the home. The nurse determines that the client needs additional instructions if the client verbalized to: 1. Keep the oxygen concentrator as close to the room wall as possible 2. Use a straight razor to shave while wearing the oxygen 3. Follow the oxygen prescription exactly 4. Forbid smoking or open flames within 10 feet of the oxygen source Answer: 1 Rationale: The oxygen concentrator is kept slightly away from the walls and corners to permit adequate airflow. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use. This could result in fire and injury to the client. Therefore a straight razor is used for shaving. The client should follow the oxygen prescription exactly. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include keeping the source out of direct sunlight; having telephone numbers for the physician, nurse, and oxygen vendor available; and teaching the client signs and symptoms requiring emergency care. Test-Taking Strategy: Note the key words needs additional instructions. These words indicate a false-response question and that you need to select the incorrect client statement. General principles regarding prescriptions will assist in eliminating option 3. From the remaining option, recall that the major hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. This will assist in eliminating options 2 and 4. Review oxygen safety measures if you had difficulty with this question. Level of Cognitive Ability: Comprehension
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Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills References: Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3rd ed). St. Louis: Mosby, p. 750. Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 318. 1732. A nurse has completed diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that further teaching is necessary when the client makes which of these statements? 1. “This diet will help to lower my blood pressure.” 2. “The reason I need lower salt intake is to reduce fluid retention.” 3. “This diet is not a replacement for my antihypertensive medications.” 4. “Canned foods are inexpensive and are good to use on a low-sodium diet.” Answer: 4 Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Canned foods use salt as a preservative and should not be encouraged as part of a low-sodium diet. Lifelong medication is necessary in the treatment of hypertension. Test-Taking Strategy: Use the process of elimination noting the key words further teaching is necessary. These words indicate a false-response question and that you need to select the incorrect client statement. Focusing on the issue, a low-sodium diet, will direct you to option 4. Review the components of a low-sodium diet if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. Saunders, pp. 156, 241, 243. 1733. A physician orders an intravenous fat emulsion solution for a client who will be receiving total parenteral nutrition (TPN). The nurse explains to the client that the fat emulsion solution is administered: 1. To increase the amount of fluid intake 2. To add bulk to the client’s system 3. To prevent fluid volume deficit 4. To provide essential fatty acids and additional calories Answer: 4 Rationale: Clients receiving their total nutrition parenterally for a prolonged period of time are at risk for developing essential fatty acid deficiency. Fat emulsions are given to meet client nonprotein caloric needs and provide essential fatty acids, which cannot be met by TPN administration alone. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Note the relation between “fat
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emulsion” in the question and “fatty acids” in the correct option. If you had difficulty with this question, review the purpose of administering fat emulsion during TPN therapy. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 532. 1734. A nurse teaches a client how to administer enoxaparin (Lovenox) subcutaneously. The nurse determines that the client understands the correct procedure if the client does which of the following on a return demonstration? 1. Bunches the skin before injection 2. Uses a 1-inch needle 3. Aspirates before injection 4. Massages after injection Answer: 1 Rationale: With subcutaneous injection of enoxaparin, the administration technique is the same as for heparin. The smallest gauge needle available (25 to 27 gauge) is used to prevent injection site hematoma. A “bunching” technique or Z-track technique is used, and the medication is injected deep into fatty abdominal tissue. Aspiration before injecting is not done, and the injection site is not massaged. The needle is withdrawn gently to minimize bleeding, and injection sites are rotated systematically. Test-Taking Strategy: Use the process of elimination. Recall that enoxaparin is a subcutaneously administered anticoagulant medication. Knowing this, select the option that is a standard subcutaneous injection technique. Review the subcutaneous procedure for injections if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: McKenry, L., & Salerno, E. (2001). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 91. 1735. A nurse is caring for a client with a nasogastric tube who has orders to have the tube irrigated once every 8 hours. The nurse ensures that which of the following solutions is placed in the client’s room to be used for the irrigation when the client’s serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L? 1. Sterile water 2. Normal saline 3. Tap water 4. 5% dextrose solution Answer: 2 Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, normal
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(isotonic) saline should be used rather that sterile water (hypotonic) for gastrointestinal or urinary tract irrigations. It is not ordinary clinical practice to irrigate with 5% dextrose solution. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 1 and 3 because they involve water. Select from the remaining options by knowing that the client’s condition (hyponatremia) requires use of an isotonic irrigating solution. Review the tonicity of fluids and the normal potassium and sodium serum levels if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 345. 1736. A client has a serum sodium level of 151 mEq/L, and the nurse conducts dietary teaching with the client about the types of foods to avoid. The nurse determines that the client needs further information if the client later states that which of the following is a good food choice? 1. American cheese 2. Rhubarb 3. Spinach 4. Fish Answer: 1 Rationale: The client’s laboratory value reflects hypernatremia since the normal serum sodium level is 135 to 145 mEq/L. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. These would include foods from animal sources, which contain physiological saline and highly processed meats and other foods that often have sodium added as a preservative. Spinach and rhubarb are good food sources of calcium. Fish is high in phosphorus. Test-Taking Strategy: Note the key words needs further information. These words indicate a false-response question and that you need to select the incorrect food item. Note that the client’s laboratory value reflects hypernatremia. Eliminate options 2 and 3 first because they are fruits and vegetables and are lower in sodium. Select from the remaining options by recalling that cheese is a dairy product and is higher in sodium. Review the food items high in sodium content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. Saunders, pp. 156, 241. 1737. A nurse suspects that a co-worker is substance impaired and is self-administering narcotic medications rather than administering them to clients as prescribed. Which of
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the following actions will the nurse take? 1. Confront the co-worker about the suspicion 2. Report the information to a supervisor 3. Call the impaired nurse organization and report the co-worker 4. Report the information to the police Answer: 2 Rationale: An impaired nurse is one who is unable to function effectively because of some type of substance abuse. Nurse practice acts require reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor who will then report to the Board of Nursing. Options 1, 3, and 4 are incorrect. Confronting the nurse may cause a conflict. The supervisor will report the substance abuse situation as necessary. Test-Taking Strategy: Follow the channel of organizational structure to report situations such as this one. By reporting the information, the nurse alerts the institution to the potential problem and sets the stage for further investigation and appropriate action. Review this content if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 25. Zerwekh, J., & Claborn, J. (2003). Nursing today: Transitions and trends (4th ed.). Philadelphia: W.B. Saunders, p. 437.
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_______ × 1 tablet = tablet per dose ______ × 1 tablet = 2 tablets Available 0.25 mg Test-Taking Strategy: Follow the formula for the calculation of the correct dose. It is not necessary to perform a conversion with this problem. Label each figure including the answer. Recheck your work with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, pp. 80-81.
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organisms in the pregnant woman with tuberculosis. Treatment must continue for a prolonged period of time. The preferred treatment for pregnant woman is daily isoniazid plus rifampin for a total of 9 months. Ethambutol is also added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing should be repeated at 3 months on the infant, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid would be given. Test-Taking Strategy: Knowledge regarding the therapeutic management for the mother with tuberculosis and for the newborn infant is required to answer this question. Eliminate options 1, 3, and 4 because of the absolute words “not,” “must,” and “required,” respectively. If you had difficulty with this question, review treatment measures for the mother with tuberculosis. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 1069-1070. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 730. 1744. A nurse is reinforcing information about health care to a pregnant client that is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to: 1. Prevent further stress on the maternal immune system 2. Reduce the risks of anemia during pregnancy 3. Minimize the possibility of preterm labor 4. Minimize the risk of premature rupture of the membranes Answer: 1 Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client and not getting appropriate rest can compromise the maternal immune system. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Although options 2, 3, and 4 are goals of care, option 1 represents the primary management issue for the HIV-infected client. Test-Taking Strategy: Use the process of elimination and focus on the diagnosis of the client. Note the key words primarily in the question and immune in the correct option. Although all of the options are important, the option that specifically relates to the client with HIV is option 1. Review care measures for the pregnant client with HIV if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 124, 430.
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Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 728. 1745. A pregnant client who is anemic tells the nurse that she is concerned about her baby’s condition following delivery. Which nursing response would best support the client? 1. “You will not have any problems if you follow all the advice the physician has given you.” 2. “Your baby will need to spend a few days in the neonatal intensive care unit following delivery.” 3. “Don’t worry about your baby. Complications are rare.” 4. “The effects of anemia on your baby are difficult to predict, but let’s review your plan of care to ensure that you are providing the best nutrition and growth potential.” Answer: 4 Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options 1 and 3 provide a false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client’s plan of care to clarify information and reassure the mother. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Eliminate options 1 and 3 because these options provide a false reassurance to the client. Eliminate option 2 next because this response will cause further concern in the client. If you had difficulty with this question, review therapeutic communication techniques and the effects of maternal anemia on the fetus. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 918-919. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 717-718.
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Time in minutes 1000 mL × 10 gtt 10000 _________________ = _________ = 20.8 or 21 gtt/min 480 minutes 480 Test-Taking Strategy: Use the formula for IV infusion rates when calculating these IV problems. Remember that you need to convert hours to minutes. Be careful with the multiplication and division. Remember to round the answer to the nearest whole number. Review the formula for calculating IV infusion rates if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, p. 212. 1747. A client with a fractured femur is placed in skeletal traction. The nurse should do which of the following to monitor for nerve injury? 1. Check the blood pressure 2. Check the neurovascular status of the affected extremity 3. Monitor the client’s ability to perform active range of motion (ROM) exercises to the affected extremity 4. Check the pin sites for drainage Answer: 2 Rationale: Bone fragments and tissue edema associated with a fracture can cause nerve damage. The nurse would assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active ROM exercises with an extremity that is fractured and in traction. Test-Taking Strategy: Focus on the issue, monitoring for nerve injury. Note the relation between the issue and option 2. Review the signs and symptoms of nerve injury following a fracture if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 150.
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Answer: 21 Rationale: Use the formula for calculating IV infusion rates. Convert 12 hours to minutes (12 hours × 60 minutes = 720 minutes). Formula: Total volume in mL × gtt factor ____________________________ = Flow rate in gtt per minute Time in minutes 1000 mL X 15 gtt 15000 _________________ = _________ = 20.8 or 21 gtt/min 720 minutes 720 Test-Taking Strategy: Use the formula for IV infusion rates when calculating these IV problems. Remember to convert hours to minutes. Be careful with the multiplication and division and use a calculator to check your answer. Review the formula for calculating IV infusion rates if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed.). Philadelphia: W.B. Saunders, p. 212. 1749. A nurse is assigned to care for a client that is Asian. The nurse enters the room and following a greeting and introduction to the client, the nurse begins to discuss the plan of care for the day. During the discussion, the client turns away from the nurse. The nurse should take which action? 1. Continue with the discussion 2. Ask the client if he or she can hear the nurse 3. Return later to continue with the discussion 4. Leave the room and ask for another nurse to be assigned to the client Answer: 1 Rationale: In Asian cultures, direct eye contact is often viewed as being rude. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Asking the client if he or she can hear the nurse or leaving the room and returning later to continue with the discussion may be viewed as a rude gesture by the client. Test-Taking Strategy: Knowledge of the characteristics of this cultural group and therapeutic communication techniques will assist in answering this question. Eliminate options 2, 3, and 4 because these are nontherapeutic actions. If you had difficulty with this question, review the communication practices of this cultural group. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 53.
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1750. A nurse reviews an assigned client’s laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse would determine that this is an expected finding if the client had which of the following health problems? 1. Ulcerative colitis 2. Diarrhea 3. Severe burn injury 4. Cushing’s syndrome Answer: 3 Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia. This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic ketoacidosis). The client with Cushing’s syndrome, ulcerative colitis, or the client with diarrhea is at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 1 and 2 first because they both reflect gastrointestinal losses. From the remaining options recalling that cell destruction causes potassium shifts will direct you to the correct option. Also, remember that Cushing’s syndrome presents a risk for hypokalemia, whereas Addison’s disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 783. 1751. A nursing student prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client, and the registered nurse asks the nursing student how the medication works. The student correctly responds that the medication works in the gastrointestinal tract by releasing: 1. Sodium ions in exchange for primarily bicarbonate ions 2. Sodium ions in exchange for primarily potassium ions 3. Bicarbonate in exchange for primarily sodium ions 4. Potassium ions in exchange for primarily sodium ions Answer: 2 Rationale: Sodium polystyrene sulfonate (Kayexalate) is a cation exchange resin used in the treatment of hyperkalemia. The resin either passes through the intestine or is retained in the colon. It releases sodium ions in exchange for primarily potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. Test-Taking Strategy: Focus on the name of the medication, Kayexalate, which indicates potassium excretion. This will assist in directing you to option 2. If you had difficulty with this question, review the action of this medication.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 980. 1752. A nurse is providing instructions to the nursing assistant who will be caring for a client with hand restraints. The nurse instructs the nursing assistant to check the client’s skin and circulation under the restraints: 1. Every 30 minutes 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours Answer: 1 Rationale: The nurse should instruct the nursing assistant to assess restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints should always be followed. Test-Taking Strategy: Focus on the issue, checking the client’s skin and circulation under the restraints. Since circulatory status is a primary concern with the use of restraints, it is best to select option 1. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 512. 1753. A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is: 1. 1 inch below the iliac crest 2. One fingerbreadth below the symphysis pubis 3. 1 inch below the coccyx 4. 1 cm above the ischial spines Answer: 4 Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Test-Taking Strategy: Knowledge that station is measured in centimeters and uses the ischial spines as a reference point will assist in answering this question. Note that options 1, 2, and 3 are similar in the use of “below,” which would be represented by a positive measurement in determining station. Review station if you had difficulty with this question.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 470, 472. 1754. A pediatric nurse arrives at work and is told to report (float) to the emergency room for the day because the emergency room is expecting numerous victims to arrive following a train accident. The nurse has never worked in the emergency room and is anxious about floating to this area. Which of the following is the appropriate nursing action? 1. Tell the nursing supervisor that she is feeling sick and needs to go home 2. Refuse to float to the emergency room 3. Discuss her anxieties and concerns about floating with the nursing supervisor. 4. Ask another pediatric nurse to float to the emergency room Answer: 3 Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, nurses discuss any anxieties and concerns about floating with the nursing supervisor. Options 1 and 2 may be interpreted as client abandonment. Although option 4 may be an alternative option at some point, it is not the appropriate action. Test-Taking Strategy: Note the key word appropriate. Eliminate options 1 and 2 because these actions may be interpreted as client abandonment. Next, eliminate option 4 because it is not within the realm of the nurse’s responsibilities to ask another nurse to float. Review nursing responsibilities related to “floating” if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 418-419. 1755. A 22-year-old client who was struck by a car while jogging is brought to the emergency room by the ambulance team. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted, but are unsuccessful. The client’s fiancée is with the client and tells the nurse that the client is an organ donor. In anticipation that the client’s eyes will be donated, which of the following should the nurse implement initially? 1. Call the National Eye Bank to confirm that the client is a donor 2. Position the deceased client supine and place dry sterile dressings over the eyes 3. Close the deceased client’s eyes and place a small ice pack on the eyes
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4. Ask the fiancée to obtain the client’s will from the lawyer Answer: 3 Rationale: When a corneal donation is anticipated, the client’s eyes are closed, and gauze pads with a small ice pack are placed on the client’s eyes. The head of the bed should also be elevated. Antibiotic eyedrops may also be prescribed. These actions will assist in preventing infection and edema. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Option 2 is incorrect, and option 4 is unnecessary. Calling the National Eye Bank to confirm that the client is a donor will delay necessary and immediate intervention. Test-Taking Strategy: Note the key word initially. This indicates that the nurse needs to take an action that will preserve the integrity of the deceased client’s eyes. Noting the words “close the deceased client’s eyes” in option 3 will direct you to this option. Review this procedure if you had difficulty with the question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1092. 1756. A nurse is collecting data from a pregnant client and is preparing to take the client’s blood pressure. The nurse positions the client: 1. Lying down 2. In a sitting position 3. On the right side 4. On the left side Answer: 2 Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client in the sitting position with the arm supported in a horizontal position at heart level. Options 1, 3, and 4 are incorrect, and these positions may cause physiological stress that will affect the blood pressure. Test-Taking Strategy: Use the process of elimination noting that options 1, 3, and 4 are similar. If you are unfamiliar with the procedure of performing a blood pressure on a pregnant client, review this procedure. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 840. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 143. 1757. A nurse is assisting in performing an assessment on a client that is 32 weeks’ gestation. The nurse measures the fundal height in centimeters and expects the findings
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to be which of the following? 1. 22 cm 2. 28 cm 3. 32 cm 4. 40 cm Answer: 3 Rationale: From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks’ gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect, and the pregnancy is further advanced than previously thought. If the estimated date of delivery is correct, it may be possible that more than one fetus is present. Test-Taking Strategy: Knowledge regarding the expected findings in fundal height in a pregnant client from 22 weeks’ gestation until term is required to answer this question. Recalling that in this client the fundal height measured in centimeters will be roughly plus or minus 2 cm of the gestational age of the fetus in weeks will direct you to option 3. If you are unfamiliar with this assessment technique, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 416. 1758. A nurse is reviewing the record of a client who has just been told that a pregnancy test result is positive. The physician has documented the presence of Goodell’s sign, and the nurse determines that this sign is indicative of: 1. A softening of the cervix 2. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus 3. The presence of human chorionic gonadotropin (hCG) in the urine 4. The presence of fetal movement Answer: 1 Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell’s sign. Cervical softening will be noted during pelvic examination by the examiner. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is due to blood circulation through the placenta. Human chorionic gonadotropin is noted in maternal urine in a urine pregnancy test. Goodell’s sign does not indicate the presence of fetal movement. Test-Taking Strategy: Knowledge regarding physiological findings in Goodell’s sign is required to answer this question. Remember that in the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell’s sign. If you had difficulty with this question, review the changes in the cervix that occur during pregnancy. Level of Cognitive Ability: Comprehension
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Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 352. 1759. A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse that the IV site is swollen. The nurse checks the IV site and notes that it is also cool and pale and that the IV has stopped running. The nurse documents that which of the following has probably occurred? 1. Infiltration 2. Phlebitis 3. Thrombosis 4. Infection Answer: 1 Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissue exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line. The other three options are likely to be accompanied by warmth at the site, not coolness. Test-Taking Strategy: To answer this question accurately, it is necessary to be familiar with the signs and symptoms that accompany complications of IV therapy. Focusing on the findings in the question will direct you to option 1. If this question was difficult, review the signs of infiltration. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 576. 1760. A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term? 1. “It is irregular, painless contractions that occur throughout pregnancy.” 2. “It is the soft blowing sound that can be heard when the uterus is auscultated.” 3. “It is the fetal movement that is felt by the mother.” 4. “It is the thinning of the lower uterine segment.” Answer: 3 Rationale: Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks’ gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, and this in known as uterine souffle. This sound is due to the blood circulation to the placenta and corresponds to the maternal pulse. Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the
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third trimester. A thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegar’s sign. Test-Taking Strategy: Knowledge regarding the term “quickening” is required to answer this question. Recalling that quickening is fetal movement will direct you to option 3. If you are unfamiliar with the signs associated with pregnancy, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 354, 398. 1761. A nurse is collecting data on a pregnant client and is preparing to auscultate the fetal heart sounds. The nurse prepares to use a fetoscope knowing that fetal heart sounds can be heard with a fetoscope by which week of gestation? 1. 8 to 10 weeks 2. 10 to 12 weeks 3. 14 to 16 weeks 4. 18 to 20 weeks Answer: 4 Rationale: Fetal heart sounds can be heard with a fetoscope by 18 to 20 weeks’ gestation. Options 1, 2, and 3 are incorrect because the fetal heart sounds cannot be heard with a fetoscope at these gestational times. Test-Taking Strategy: Knowledge regarding auscultation of fetal heart sounds is required to answer this question. Noting the key word fetoscope in the question will assist in directing you to option 4. If you are unfamiliar with the assessment of and auscultation of fetal heart sounds, review this procedure. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 418. 1762. A nurse-midwife is performing an assessment on a pregnant client and is assessing the client for the presence of ballottement. The nurse who is assisting understands that the nurse-midwife will implement which of the following to test for the presence of ballottement? 1. Auscultate for fetal heart sounds 2. Palpate the abdomen for fetal movement 3. Assess the cervix for thinning 4. Initiate a sudden tap on the cervix Answer: 4 Rationale: Near midpregnancy, a sudden tap on the cervix during a vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position. When the cervix is tapped, the fetus floats upward in the amniotic fluid. The examiner
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feels a rebound when the fetus falls down. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Knowledge regarding assessment of ballottement in the pregnant client is required to answer this question. Remember that ballottement relates to a rebound of the fetus. If you are unfamiliar with this assessment technique, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 583. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 136-137. 1763. A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBC) on a client. The licensed practical nurse who is assisting in caring for the client plans to remain with the client for how many minutes following the start of the infusion? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 60 minutes Answer: 2 Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most frequent period during which a transfusion reaction may occur. This enables the nurse to quickly detect a reaction and intervene quickly. Option 1 is not ample time to remain with the client. The time frames in options 3 and 4 are unnecessary. Test-Taking Strategy: Specific knowledge related to blood transfusion procedures is needed to answer this question accurately. Remember that the client needs to be directly monitored for the first 15 minutes of the transfusion. Review the procedure for administering blood transfusions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 623-624. 1764. A client is complaining of pain at the site of the intravenous (IV) infusion device. The nurse checks the IV site and determines that the client has phlebitis. Which of the following actions should the nurse take? 1. Slow the rate of the IV infusion 2. Notify the registered nurse (RN) 3. Apply ice packs to the site 4. Plan to assist with starting a new line in a proximal portion of the same vein Answer: 2 Rationale: Since phlebitis has occurred, the nurse notifies the RN who will notify the
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physician about the IV complication. The nurse should plan to remove the IV and apply warm moist compresses to the area to speed resolution of the inflammation. The nurse should plan to assist in restarting the IV in a different vein from the one with the phlebitis. Test-Taking Strategy: Focus on the issue, phlebitis at an IV site. Thinking about the physiological effect of each of the actions identified in the options will assist in directing you to option 2. Review nursing interventions related to phlebitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 576-577. 1765. A nurse caring for a Chinese-American client plans care considering the client’s view of illness. Which of the following most appropriately describes the ChineseAmerican’s view of illness? 1. Illness is caused by supernatural forces 2. Illness is a punishment for sins 3. Illness is a disharmonious state that may be caused by demons and spirits 4. Illness is due to an imbalance between yin and yang Answer: 4 Rationale: Chinese Americans believe that illness is due to an imbalance between yin and yang, which they believe is caused by prolonged sitting or lying or overexertion. In the African-American culture, illness is viewed as a disharmonious state that may be caused by demons and spirits. Hispanic Americans believe that illness occurs as a result of punishment for sins. Native Americans believe that illness is caused by supernatural forces. Test-Taking Strategy: Use the process of elimination and focus on the health beliefs of the Chinese-American culture. If you had difficulty with the question, review these various beliefs. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 54. 1766. A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client places a sign above the bed stating that the client should remain on bed rest: 1. With the foot of bed elevated as much as tolerated by client 2. In the high-Fowler’s position 3. With the head of bed elevated at least 60 degrees
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4. With the head of bed elevated no more than 30 degrees Answer: 4 Rationale: Following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The affected leg is kept straight, and the head is elevated no more than 30 degrees until hemostasis is adequately achieved. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are similar. From the remaining options, remembering that the affected leg is kept straight will assist in eliminating option 1. If you had difficulty with this question, review postcardiac catheterization care. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 292. 1767. A pregnant client asks a nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between: 1. 6 to 8 weeks’ gestation 2. 8 to 10 weeks’ gestation 3. 12 to 14 weeks’ gestation 4. 16 to 20 weeks’ gestation Answer: 4 Rationale: Fetal movement, called quickening, is not perceived until the second trimester. Between 16 to 20 weeks’ gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. Test-Taking Strategy: Knowledge regarding quickening and the detection of fetal movement by the mother are required to answer this question. Use the process of elimination, and in this situation it is best to select the option that indicates the greatest length of gestational time. If you are unfamiliar with the process of quickening, review this assessment finding. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 354. 1768. A client with an indwelling intravenous (IV) catheter has an order for an IV solution to be changed to 1000 mL of 0.9% sodium chloride to infuse at 100 mL/hr. When determining the rationale for the change in fluid, the nurse interprets that the client probably needs this type of solution because it: 1. Will increase the plasma osmolarity
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2. Will decrease the plasma osmolarity 3. Is isotonic with the plasma and other body fluids 4. Is hypotonic with the plasma and other body fluids Answer: 3 Rationale: Sodium chloride 0.9% is isotonic and is frequently used for intravenous infusion because it does not affect the plasma osmolarity. Options 1, 2, and 4 are incorrect regarding this type of solution. Test-Taking Strategy: Use the process of elimination and knowledge regarding the concepts related to body fluids. Remember that options that are similar are not likely to be correct. With this in mind, eliminate options 2 and 4. Remembering that the normal concentration of saline in the body is 0.9% will direct you to option 3. Review the various types of IV solutions if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1137. 1769. A physician is discussing the fluid balance of a postoperative client. The physician states that the client’s insensible fluid loss is approximately 600 mL daily. The nurse interprets that the physician is referring to fluid loss that is occurring thorough the: 1. Wound drain and skin 2. Skin and lungs 3. Nasogastric tube and wound drain 4. Foley catheter and nasogastric tube Answer: 2 Rationale: Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis without the client’s awareness. Sensible losses are those that are measurable and include wound drainage, gastrointestinal tract losses, and urine output. Test-Taking Strategy: Note the key words insensible fluid loss. Recalling that insensible losses cannot be measured will direct you to option 2. Review sensible and insensible fluid losses if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 48. 1770. A nurse is assigned to care for a group of clients on the clinical nursing unit. The nurse determines that third-spacing of fluids is least likely to develop in the client with: 1. Major burn 2. Renal failure 3. Laënnec’s cirrhosis 4. Hypertension
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Answer: 4 Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and the pericardial sac. Risk factors include the older client and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, and gastrointestinal malabsorption and malnutrition. Test-Taking Strategy: Use the process of elimination recalling the concepts of thirdspacing of fluids. Noting the key words least likely will direct you to option 4. If you had difficulty with this question, review these concepts and the causes of third-spacing. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 213, 218-219. 1771. A nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume in which of the following clients that is most at risk for this fluid imbalance? 1. A client with congestive heart failure 2. A client with acute renal failure 3. A client with an ileostomy 4. A client with major trauma Answer: 3 Rationale: The client with an ileostomy is at risk for deficient fluid volume because of increased gastrointestinal tract losses. Other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, or the presence of an ileostomy or colostomy. Clients who have heart failure, renal failure, or major trauma are at risk for excess fluid volume. Test-Taking Strategy: Read the question carefully noting that it asks for the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. Clients who have the disorders presented in options 1, 2, and 4 would be likely to retain fluid rather than lose it. If you had difficulty with this question, review the causes of deficient fluid volume. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 158-159,349-350. 1772. A nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which of the following assigned clients is most at risk for excess fluid
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volume? 1. The client with a draining abdominal wound 2. The client with a nasogastric tube to low suction 3. The client with renal failure 4. The client with an ileostomy Answer: 3 Rationale: The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. Other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. The client with an ileostomy, a draining abdominal wound, or a nasogastric tube is at risk for deficient fluid volume. Test-Taking Strategy: Use the process of elimination. Read the question carefully noting that it asks for the client at risk for an excess. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options 1, 2, and 4 lose fluid. The only condition that can cause an excess is the condition noted in option 3. If you had difficulty with this question, review the causes of excess fluid volume. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 159, 782. 1773. A nurse is caring for a client with cirrhosis who has a nursing diagnosis of excess fluid volume. The nurse would determine that the diagnosis is resolving if which of the following data is obtained by the nurse? 1. Increasing central venous pressure 2. Increasing pulse 3. Decreasing body weight 4. Decreasing urine output Answer: 3 Rationale: A sign that excess fluid volume is resolving is loss of body weight. The other options listed indicate that the client is retaining additional fluid. Assessment findings associated with excess fluid volume include cough, dyspnea, rales, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, elevated central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. These symptoms must reverse if the excess fluid volume is to be resolved. Test-Taking Strategy: Use the process of elimination and note the key word resolving. Recalling the effects of fluid on various physical assessment findings will direct you to option 3. If you had difficulty with this question, review the assessment signs noted in excess fluid volume. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation
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Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 159. 1774. A nurse is collecting data from a client with hypertension who is being treated with diuretic therapy. The nurse would monitor the client for hypokalemia if the client is receiving which of the following diuretics? 1. Triamterene (Dyrenium) 2. Amiloride HCL (Midamor) 3. Spironolactone (Aldactone) 4. Bumetanide (Bumex) Answer: 4 Rationale: Bumetanide (Bumex) is a loop diuretic, which places this client at risk for hypokalemia. The nurse assesses this client carefully for signs of hypokalemia, monitors serum potassium levels, and encourages intake of potassium sources in the diet. Spironolactone, triamterene, and amiloride HCL are potassium-sparing diuretics. Test-Taking Strategy: Use the process of elimination recalling the classifications of the various diuretics identified in the options. Remember that spironolactone, triamterene, and amiloride HCL are potassium-sparing diuretics. Review the classifications of these diuretics if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 143. 1775. A blood glucose measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother? 1. Administration of an oral hypoglycemic agent 2. Administration of NPH insulin on a daily basis 3. A 3-hour oral glucose tolerance test 4. A sliding scale regular insulin dose Answer: 3 Rationale: A maternal glucose is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour oral glucose tolerance test is recommended to determine the presence of gestational diabetes. Options 1, 2, and 4 would not be prescribed based solely on the maternal glucose levels. Further follow-up would be implemented. Test-Taking Strategy: Use the steps of the nursing process remembering that data collection is the first step. Eliminate options 1, 2, and 4 because they are similar in that they all identify the administration of medication to treat the elevated blood glucose. Option 3 is the only option that identifies further assessment of the client. Review measures to evaluate and treat elevated blood glucose levels in a pregnant client if you had difficulty with this question. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 359, 892. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 145.
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Answer: 2 Rationale: One large egg provides 66 mg of potassium. One half cup of raisins contains 700 mg of potassium. Four ounces of beef contain 420 mg, and 4 oz of pork contain 525 mg of potassium. Test-Taking Strategy: Note the key words needs further instruction. These words indicate a false-response question and that you need to select the item lowest in potassium. Learn the foods that are high and low in potassium content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 162.
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Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 663. 1779. A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is most important? 1. Recording that the count was incorrect 2. Informing the surgeon of the situation 3. Looking on the instrument table for the sponge 4. Asking the circulating nurse to look for the sponge Answer: 2 Rationale: The surgeon has the ultimate responsibility for the safety of the client and can stop the surgery until the sponge is found. Although documenting is necessary, this is not the most important action. Although options 3 and 4 may be appropriate, the physician needs to be informed about the missing sponge. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, a surgical sponge is missing. Noting the key words most important and recalling that the surgeon is ultimately responsible for the client will direct you to option 2. Review care to the intraoperative client if you had difficulty with this question. Phase of the Nursing Process: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 414. 1780. A client is brought to the emergency room and is unconscious. From the viewpoint of informed consent, a nurse determines that emergency treatment can be initiated to the unconscious client: 1. Only if the client’s family has given consent 2. Because emergency treatment can be provided under the emergency doctrine 3. Because the nurse is covered under liability insurance 4. As long as the nurse documents the care given accurately Answer: 2 Rationale: Emergency treatment can be provided under the “emergency doctrine.” This doctrine implies that the client would have consented to treatment if able because the alternative would have been death or disability. The emergency doctrine removes the need for obtaining informed consent before emergency treatment and care is initiated. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Option 1 is an unrealistic option because the client’s family may not be present. Additionally, this option contains the absolute word “only.” Options 3 and 4 are unrelated to the issue of informed consent. Additionally, option 4 is standard nursing procedure regardless of the situation. If you had difficulty with this question, review care to the client in emergency situations and the issues surrounding informed consent.
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Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Mosby’s medical, nursing, & allied health dictionary (2002). (6th ed.). St. Louis: Mosby, p. 588. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 417. 1781. A nurse positions a client for a surgical procedure. Which position can most likely lead to the potential for decreased lung expansion in the client? 1. Lithotomy 2. Supine 3. Lateral 4. Side lying Answer: 1 Rationale: The thoracic cage normally expands in all directions except posteriorly. In the lithotomy position, the expansion of the lungs is restricted at the ribs or sternum, and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Respiratory function is impaired because of this interference with normal movements. The volume of air that can be inspired is reduced. The positions in options 2, 3, and 4 would not interfere with the expansion of the lungs. Test-Taking Strategy: Use the process of elimination and visualize each position and its effect on lung expansion. The supine position in option 2 would not interfere with the expansion of the lungs; therefore eliminate this option. Eliminate options 3 and 4 because they are similar positions. The lithotomy position is the one that will most likely interfere with the expansion of the lungs. If you had difficulty with this question, review these positions. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 132. 1782. A nurse is caring for a home-bound older postoperative cardiovascular client. The caregiver’s daughter states to the nurse, “My mother has fallen out of bed three times.” Which observation by the nurse would indicate the need for intervention to ensure safety? 1. Client is oriented to person, place, and time 2. Caregiver leaves one side rail down while the client is in bed 3. Client’s bed is in a low position 4. Caregiver uses the overbed table for feedings Answer: 2 Rationale: Leaving a side rail down on the bed of an older client increases the risk of falling. The aging process also increases this client’s potential for falls; evaluating the safety of the environment is a necessity. Options 1, 3, and 4 identify observations that
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provide safety to the client. Test-Taking Strategy: Use the process of elimination focusing on the issue, an unsafe observation, and note the key words need for intervention to ensure safety. Option 1 indicates that the client is oriented, which would reduce the risk of falling. Options 3 and 4 also identify a safe and appropriate environment. Review the causes of falls in an older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 490-491, 499. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 964-965. 1783. A nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is most likely to react to a disagreement with this fellow employee by: l. Slamming cupboards in the office 2. Telling a friend that this employee hates her or him 3. Getting angry at the supervisor 4. Apologizing and offering to go out to lunch together Answer: 2 Rationale: The defense mechanism of projection is an unconscious process that projects emotionally unacceptable feelings to other people, objects, or situations and casts the blame onto another. Options 1 and 3 describe displacement in which the feeling is transferred to another person or object. Option 4 describes reaction formation in which a behavior is used that is directly opposite to a person’s unacceptable trait. Test-Taking Strategy: Knowledge of the defense mechanisms is needed to select the correct option. Focus on the issue, projection, and identify the defense mechanism that corresponds to the example presented in the situation. If you had difficulty with this question, review defense mechanisms. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 1155. 1784. A nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions with the client about this treatment. Which statement by the client indicates adequate understanding of cold therapy treatment? 1. “I need to apply the cold pack for at least 60 minutes.” 2. “I can lay on the ice by placing it between the bed and my body.” 3. “I should wrap the frozen ice pack in a warm towel to help adjust to the cold.”
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4. “I should check my pulse before using the ice on my joints.” Answer: 3 Rationale: Cold therapy should only be used for 15 to 20 minutes two or three times a day. The client needs to be instructed not to place ice directly between the skin and a firm surface. The weight of the body and the low temperature of the ice may produce ischemia. The skin should be checked for signs of injury. The frozen ice pack is taken from the freezer and should be wrapped in a warm towel to help the client adjust to the cold. Test-Taking Strategy: Use the process of elimination and visualize the procedure. This should help you eliminate options 1 and 2. Next, eliminate option 4 because it is not reasonable and is unnecessary. If you had difficulty with this question, review the procedure for cold pack therapy. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3rd ed.). St. Louis: Mosby, pp. 597, 605-609. Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 640. 1785. A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response by the student indicates an understanding of the anatomy of this structure? 1. “The uterus weighs about 2 oz.” 2. “The uterus weighs about 2.2 lb.” 3. “The uterus has a capacity of about 50 mL.” 4. “The uterus is round in shape and weighs approximately 1000 g.” Answer: 1 Rationale: Before conception, the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL. At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb) and has a sufficient capacity for the fetus, placenta, and amniotic fluid, a total of about 5000 mL. Test-Taking Strategy: Note the key word nonpregnant and attempt to visualize each of the items identified in the options. Remember that before pregnancy, the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL. Review the anatomical structure of the uterus if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 120. 1786. A nurse is caring for a new postoperative client and is monitoring the client for
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signs of shock. The nurse monitors for which signs of this postoperative complication? 1. Cold skin, drowsiness, and hypertension 2. Fever, irritability, and rapid respirations 3. Tachycardia, cold skin, and hypotension 4. Slow pulse, warm skin, and restlessness Answer: 3 Rationale: Postoperative hypotension or shock can have numerous causes, such as inadequate ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood loss. The manifestations of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and apprehension. Test-Taking Strategy: Use the process of elimination. Remember that when an option contains more than one part, all parts need to be correct for the option to be the answer to the question. Remembering that a drop in blood pressure and a rise in pulse are indicative of shock will direct you to the correct option. If you had difficulty with this question, review the signs of shock. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 750. 1787. A student nurse examines an Asian-American infant’s eyes and notes that the infant’s eyes are crossed. The registered nurse asks the student to interpret the finding. Which statement by the student indicates an understanding of this finding? 1. “It probably isn’t strabismus, but appears that way because of the child’s ethnic background.” 2. “You will want to call the pediatrician immediately because this could lead to a detached retina.” 3. “It probably is strabismus because the baby’s mother has abused tranquilizers.” 4. “Strabismus isn’t life threatening, but it requires surgery in the first 2 months to prevent the crossed eyes from being a lifelong condition.” Answer: 1 Rationale: Asian-American, American-Indian, and Alaskan-Native infants often have a pseudostrabismus because of a flattened nasal bridge. It will need to be distinguished from a true strabismus in the assessment. Options 2, 3, and 4 are inaccurate statements. Test-Taking Strategy: Use the process of elimination. Recalling the cultural differences in the physical assessment findings in an infant will direct you to option 1. Review these differences if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed.). Philadelphia: W.B. Saunders, p. 323.
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1788. A nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client’s identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is: 1. Defined as the failure to meet established standards of care 2. Defined as a crime that results in the injury of a client 3. Strictly prohibited by the Nurse Practice Act 4. Strictly prohibited by the institution’s own policies Answer: 1 Rationale: The legal definition of negligence is the failure to meet accepted standards of care. Option 2 is an incorrect definition of negligence, although injury may have indeed come to the client as a result of negligence. Both the institution and the Nurse Practice Act have provisions that identify and discourage acts of negligence. Test-Taking Strategy: To answer this question correctly, you must know the definition of negligence as applied to the profession of nursing. Options 3 and 4 are true in that the purpose of the Nurse Practice Act and institutional policies and procedures is to protect the public from harm, but the words “strictly prohibited” tends to make these options incorrect. From the remaining options, select option 1 because it is the umbrella (global) option. If you had difficulty with this question, review the concepts related to negligence. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills References: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 18, 283. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 414. 1789. A nurse is reviewing the health care record of a pregnant client at 16 weeks’ gestation. The nurse would expect documentation that the fundus of the uterus is noted at which of the following areas? 1. Just above the symphysis pubis 2. At the umbilicus 3. Midway between the symphysis pubis and the umbilicus 4. At the level of the xiphoid process Answer: 3 Rationale: At 12 weeks’ gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process. Test-Taking Strategy: Knowledge regarding the patterns of uterine growth is required to answer this question. Focus on the weeks of gestation identified in the question to assist in directing you to the correct option. If you are unfamiliar with the patterns of uterine growth during pregnancy, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity
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Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 350-351. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 425. 1790. A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds and then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, what interpretation should the nurse make? 1. The client is using the incentive spirometer correctly 2. The client should be repeating the sequence 10 to 20 times in each session 3. The client should be inhaling and exhaling quickly 4. The client should not be holding the breath following inhalation Answer: 2 Rationale: Incentive spirometer devices use a concept of sustained maximal inspiration. Each device has a means of setting an inspiratory goal. Correct use requires a spontaneous, slow, voluntary, deep breath. When full inhalation is reached, the breath is held for at least 3 seconds. This sequence is repeated 10 to 20 times an hour. Incentive spirometer exercises are most effective when used every hour while the client is awake. Test-Taking Strategy: Use the process of elimination focusing on the client’s performance described in the question. Noting the key words takes one breath and returns the incentive spirometer to the bedside and visualizing this procedure will direct you to option 2. If you had difficulty with this question, review the correct procedure for the use of an incentive spirometer. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, pp. 327-329. 1791. A client’s preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats/min with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which of the following actions should the nurse take first? 1. Report the vital signs immediately to the registered nurse (RN) 2. Compare these values with those recorded previously 3. Recheck the blood pressure in 5 minutes 4. Report only the apical pulse since it is above the normal range Answer: 2 Rationale: Preoperative assessment of vital signs provides important baseline data with which to compare following surgery. Anxiety and fear commonly cause elevations in the heart rate and blood pressure. The vital signs as stated in the question do not need to be
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reported to the RN immediately. The apical pulse is not above the normal range. Rechecking the blood pressure in 5 minutes is likely to show an unchanged blood pressure measurement. The nurse should compare these values with those recorded previously. Test-Taking Strategy: Use the process of elimination noting the key word first. Focus on the data in the question and note that the client is preoperative. Recalling the normal ranges for vital signs and the effects of anxiety and fear on the vital signs in the preoperative client will direct you to option 2. The first action should be to compare the values with those recorded previously. Review care to the preoperative client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 744. 1792. A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which of the following would the nurse determine is a harmful measure in preventing constipation? 1. Daily activity, such as walking or swimming 2. Drinking six to eight glasses of water daily 3. Increasing whole grains and fresh vegetables in the diet 4. Adding 1 tbsp of mineral oil to a bowl of cereal daily Answer: 4 Rationale: Mineral oil should not be used as a stool softener since it inhibits the absorption of fat-soluble vitamins in the body. Constipation should be treated with increased fluids (six to eight glasses per day) and a diet high in fiber. Increasing exercise is also an excellent way to improve gastric motility. Test-Taking Strategy: Use the process of elimination noting the key words a harmful measure. These words indicate a false-response question and that you need to select the incorrect intervention for treating constipation. Note that options 1, 2, and 3 are natural methods for increasing gastric motility. Option 4 is an unnatural measure and needs to be avoided. If you had difficulty with this question, review measures to prevent constipation. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 390, 433. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 149. 1793. A client has an intravenous infusion (IV) started before surgery for a right belowthe-knee amputation. In addition to the intravenous infusion, blood work is drawn and a
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surgical skin preparation is done. Which nursing diagnosis is most appropriate for the nurse to consider in providing preoperative care? 1. Deficient fluid volume related to IV therapy 2. Risk for excess fluid volume related to IV therapy 3. Acute pain related to surgery 4. Anxiety related to coping with preoperative therapies Answer: 4 Rationale: Before surgery most clients experience anxiety. Client anxiety is a priority concern before surgery and when treatments are performed. There is no data in the question to indicate signs of actual fluid volume deficit or overload. Postoperative concerns, such as acute pain, should be addressed in the preoperative period, but this is not the issue of the question. Test-Taking Strategy: Use the process of elimination focusing on the data in the question. Noting the key words prior to surgery will direct you to option 4. Remember to focus on the client concerns as a priority in the preoperative period. Review the defining characteristics for anxiety if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3rd ed.). St. Louis: Mosby, p. 492. Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 1219. 1794. A nurse is caring for a client who had a small bowel resection, is 1 day postoperative, and has continuous gastric suction attached to the nasogastric tube. Which of the following intravenous solutions would the nurse anticipate would most likely be prescribed for the client? 1. 25% albumin 2. 5% dextrose in water 3. Lactated Ringers solution 4. Normal saline Answer: 3 Rationale: Electrolyte solutions, such as lactated Ringers, are used to replace fluid from gastrointestinal (GI) tract losses. Albumin is used for shock and protein replacement. Five percent dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is essential for calories when a client is NPO. Test-Taking Strategy: Use the process of elimination noting that the client is 1 day postoperative. Knowledge of the components of IV solutions and noting that the client had GI surgery will direct you to option 3. If you had difficulty with this question, review the components of these IV solutions. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning
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Content Area: Fundamental Skills References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 210. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1160. 1795. A nurse is urging a client to cough and deep breathe after nephrectomy. The client tells the nurse, “That’s easy for you to say! You don’t have to do this.” The nurse interprets that the client’s statement is most likely a result of: 1. A stress response to the ordeal of surgery 2. A latent fear of needing dialysis if the surgery is unsuccessful 3. Effects of circulating metabolites that have not been excreted by the remaining kidney 4. Pain that is intensified because the location of the incision is near the diaphragm Answer: 4 Rationale: After nephrectomy the client may be in considerable pain. This is due to the size of the incision and its location near the diaphragm, which makes coughing and deep breathing so uncomfortable. For this reason, narcotics are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. Options 1, 2, and 3 are not specifically related to this client’s situation. Test-Taking Strategy: Use the process of elimination noting the key words most likely. Recalling that coughing and deep breathing intensifies pain after many surgical procedures and visualizing the location of the surgical incision will direct you to option 4. Review care to the client following nephrectomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 446. 1796. A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people is doing the evaluation. In formulating a response, the nurse understands that this is being done to: 1. Save the client and recipient valuable preoperative time 2. Prevent a conflict of interest by the team evaluating the recipient and team evaluating the donor 3. Help reduce the cost of the preoperative work-up 4. Have a sufficient number of people reviewing the case so no information is overlooked Answer: 2 Rationale: Both the kidney donor and recipient need thorough medical and psychological evaluation before transplant surgery. To avoid conflict of interest, evaluation of the donor is done by a team different from that caring for the donor. The psychosocial issues in living-related organ donation may be very complex, and conversations with the donor are held in strict confidence to preserve family relations.
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Test-Taking Strategy: Use the process of elimination and knowledge of concepts regarding client advocacy. Remember that in this situation one group cannot advocate for both parties simultaneously. If you had difficulty with this question, review the concepts related to organ donation. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Renal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2435. 1797. A nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia is red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action would be to: 1. Obtain a specimen of the discharge for culture 2. Document the findings 3. Notify the registered nurse immediately 4. Review the mother’s record to determine a history of gonorrhea Answer: 2 Rationale: The genitalia of a newborn female are frequently red and swollen. This edema disappears in a few days. A vaginal discharge of thick white mucus is seen in the first week of life. The mucus is occasionally blood tinged by about the third or fourth day and stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement, is the withdrawal of maternal hormones. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling that the findings noted in the question are normal and expected will direct you to option 2. If you had difficulty with this question, review normal newborn findings. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 688. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 529. 1798. A nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is: 1. Testosterone 2. Oxytocin 3. Prolactin 4. Progesterone Answer: 3
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Rationale: Prolactin stimulates the secretion of milk, called lactogenesis. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. Test-Taking Strategy: Knowledge regarding the functions of the various hormones in the female reproductive system is required to answer this question. Note the relation between the words “secretion of milk” in the question and the hormone “prolactin” in the correct option. If you had difficulty with this question, review the functions of the various hormones of the female reproductive system. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills References: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 762. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 70. 1799. A nurse is observing a nursing assistant talking to a client that is hearing impaired. The nurse would intervene if which of the following were performed by the nursing assistant during communication with the client? 1. The nursing assistant is facing the client when speaking 2. The nursing assistant is speaking clearly to the client 3. The nursing assistant is speaking directly into the impaired ear 4. The nursing assistant is speaking in a normal tone Answer: 3 Rationale: When communicating with a hearing-impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse needs to avoid talking directly into the impaired ear. Test-Taking Strategy: Note the key word intervene. This word indicates a false-response question and that you need to select the incorrect action by the nursing assistant. Use the process of elimination recalling that the nurse needs to avoid talking directly into the impaired ear. If you had difficulty with this question, review these techniques. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 587. 1800. A clinic nurse is providing instructions to a client regarding the use of a hearing
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aid. Which statement by the client indicates a need for further instructions? 1. “I should keep an extra battery available at all times.” 2. “I should wash the ear mold frequently with mild soap and water.” 3. “I should turn the hearing aid off after removing it from my ear.” 4. “I should not wear the hearing aid during an ear infection.” Answer: 3 Rationale: Nurses should have a basic knowledge of the care of a hearing aid to assist the client in its use. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback. The hearing aid should be turned off when not in use, and the client should keep an extra battery available at all times. The client should wash the ear mold frequently with mild soap and water with the use of a pipe cleaner to cleanse the cannula. The client should not wear the hearing aid during an ear infection. Test-Taking Strategy: Use the process of elimination noting the key words need for further instructions. These words indicate a false-response question and that you need to select the incorrect client statement. Knowledge regarding squealing feedback will assist in directing you to the correct option. If you had difficulty with this question, review client instructions regarding the use of the hearing aid. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 586.
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