Silvestri601-700
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PN Comprehensive Review CD Questions 601-700
{COMP: No Equations/Formulas; No questions}
601. A client with lung cancer says to the nurse, “I’m sick and tired of my family telling me not to worry and that a cure will be discovered before I know it.” The most therapeutic response by the nurse is: 1. “You’re feeling angry that your family is hoping for a cure?” 2. “Forget about what your family is saying. You have enough to worry about right now.” 3. “They are right. You shouldn’t be so worried.” 4. “Have you told your family how you feel?” Answer: 1 Rationale: Reflection is the therapeutic communication technique that redirects the client’s feelings back in order to validate what the client is saying. Questions that the client will be able to deal with more effectively include those that explore the client’s unwillingness to maintain hope and the client’s anger regarding the family’s hopefulness. Option 2 is nontherapeutic and instills concern in the client. Option 3 is nontherapeutic in that the nurse is agreeing with the family. Option 4 is somewhat premature and closes off facilitation of the client’s feelings. Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Options 2 and 3 can be easily eliminated because they are nontherapeutic. In option 4, the nurse is attempting to assess the client’s ability to openly discuss feelings with family members. While this may be appropriate, the timing is somewhat premature and closes off facilitation of the client’s feelings. Option 1 uses the therapeutic technique of reflection. Remember to always focus on the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 602. A nurse is preparing a client for a cardiac catheterization and the client says, “I don’t want to talk with you. You’re only a nurse; I want my doctor.” Which response by the nurse would be therapeutic? 1. “That’s fine, if that’s what you want; I’ll call your physician.” 2. “I’m assigned to prepare you for this procedure, so I need to complete my
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assignment.” 3. “So you’re saying that you want to talk to your physician?” 4. “I’m angry with the way you’ve dismissed me. I am an educated nurse and I know what I am doing.” Answer: 3 Rationale: In option 3, the nurse uses the therapeutic communication technique of reflection to redirect the client’s feelings back for validation. Option 2 is nontherapeutic and also addresses the legal issue of performing a procedure when in fact the client is refusing. Option 4 is clearly nontherapeutic and focuses on the nurse’s feelings rather than the client’s feelings. Although option 1 may seem appropriate, it does not reflect the client’s feelings nor does it provide an opportunity for the client to express feelings. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Options 2 and 4 can be easily eliminated first because they both are nontherapeutic responses. Next eliminate option 1 because it does not provide an opportunity for the client to express feelings. Remember to address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 603. A nurse is providing one-to-one supervision to a client who has attempted suicide. The client says to the nurse, “I can never do anything right. I’m such a loser. It didn’t even work when I tried to kill myself.” The appropriate nursing response is: 1. “You must do some things right.” 2. “Everything will get better; just wait and see.” 3. “You don’t do anything right?” 4. “You need to think about how you are feeling. You’re not a loser; you are just sick right now.” Answer: 3 Rationale: Option 3 allows the client to verbalize feelings; therefore the nurse can learn more about what the client really means by the statement. This option also repeats the client statement. Option 1 may be threatening because at this time the client is not feeling that way. Option 2 places the client’s feelings on hold. Option 4 is also inappropriate and places the client’s feelings on hold. Test-Taking Strategy: Use therapeutic communication techniques to select the correct option. Option 3 is the only option that addresses the client’s feelings and allows the communication to stay open. Options 1, 2, and 4 are nontherapeutic and do not encourage the client to further explore his or her feelings. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health
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Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 604. A client who is suicidal tells the nurse, “All I want to do is end it all.” The appropriate nursing response is which of the following? 1. “Your family would be upset if they heard you say that.” 2. “You are just tired; you don’t really mean that.” 3. “Did you have a bad night?” 4. “What do you mean by that?” Answer: 4 Rationale: Option 4 allows the client to tell you more about what the current thoughts are. Option 1 is false reassurance and does not address the client’s feelings. Option 2 does not address the client’s feelings. In fact, the nurse is expressing feelings that the client may not be experiencing. Option 3 changes the subject and may close communication. Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Eliminate option 1 because it does not address the client’s feelings and provides false reassurance. Option 2 also blocks communication and does not provide the client an opportunity to express feelings. Option 3 is a communication block because it changes the subject. Remember to always address client feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 605. A female client with myasthenia gravis comes to the physician’s office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. The appropriate nursing response is: 1. “What you need to do is join a support group.” 2. “You need to deal with this concern because it is a reality.” 3. “You need to look at the positives in life.” 4. “Have you thought about sharing your feelings with your husband?” Answer: 4 Rationale: Encouraging the client to share feelings with her husband directly addresses the issue of the question. Advising the client to join a support group will not address the client’s immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client’s concerns. Test-Taking Strategy: Focus on the issue of the question and use therapeutic communication techniques. Option 4 is the only option that addresses the client’s immediate concerns. Option 4 also encourages further communication between the client and the nurse regarding the client’s concerns. Remember, address the client’s feelings and concerns first. Review therapeutic communication techniques if you had difficulty
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with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Neurological Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 606. While providing care to a client, the nurse notes that the client is expressing anger and is verbally abrupt with the nurse. During further exploration of the client’s feelings, the nurse notes that the client angrily says that the doctor purposefully provided wrong information about the diagnosis and states, “The doctor lied to me.” Which of the following would be an inappropriate response to the client? l. “The doctor would never lie to you.” 2. “Can you tell me more about the information that you are referring to?” 3. “I’m not sure what information you are referring to.” 4. “Have you thought about talking to your doctor about this?” Answer: 1 Rationale: The response in option 1 could make the client defensive and block further communication because it expresses disagreement with the client’s statement. Options 2 and 3 attempt to clarify what the client is referring to. Option 4 attempts to explore if the client is comfortable talking to the doctor about this issue and encourages direct confrontation. Test-Taking Strategy: Note the key word inappropriate. This word indicates a false response question and that you need to select the incorrect response. Note that options 2 and 3 are similar and can be eliminated first. Eliminate option 4 next because the nurse is encouraging direct confrontation between the client and the doctor. Disagreeing or challenging a client’s response will hinder or block therapeutic communication. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 607. A nurse is admitting a client to the hospital with a diagnosis of chronic bronchitis. The physician has also documented the suspicion of pulmonary emphysema and has prescribed diagnostic studies. The nurse collects data from the client and notes that which of the following signs of chronic bronchitis is unassociated with emphysema? 1. Scant mucus production 2. Marked dyspnea 3. Marked weight loss 4. Cough that began before the onset of dyspnea Answer: 4 Rationale: Key features of pulmonary emphysema include dyspnea that is often marked,
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late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea. Test-Taking Strategy: Note the key word unassociated. This word indicates a false response question and that you need to select the incorrect sign. Recalling the differences between these two respiratory disorders and their associated manifestations will direct you to option 4. Review these differences if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 497. 608. A client has a large abdominal wound. The skin is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which of the following is the appropriate nursing action? 1. Apply Montgomery ties 2. Use hypoallergenic tape 3. Culture the skin around the wound 4. Cleanse the skin with povidone-iodine Answer: 1 Rationale: The nurse should apply Montgomery ties to prevent further skin breakdown as a result of tape irritation from frequent dressing changes. Hypoallergenic tape is used on clients either with thin and fragile skin or with skin that is sensitive to standard tape. Cleansing with povidone-iodine and obtaining a skin culture are incorrect nursing actions. Test-Taking Strategy: Use knowledge of basic concepts related to skin integrity and wound care materials to answer this question. Options 3 and 4 can be eliminated first because they will not assist in preventing further irritation. Eliminate option 2 next because hypoallergenic tape is used on clients either with thin and fragile skin or with skin that is sensitive to standard tape. Review the advantages and purpose of Montgomery ties 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: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 416. 609. A nurse reviews the care plan of an assigned client and notes that the client has a nursing diagnosis of disturbed sleep pattern. The nurse gives the client which of the following to best help the client achieve a restful night’s sleep? 1. A taco 2. A warm cup of tea 3. A filling bedtime snack
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4. A glass of warm milk Answer: 4 Rationale: Milk contains the essential amino acid tryptophan, which enhances sleep by promoting production of the neurotransmitter serotonin in the brain. The client should avoid spicy foods and a large intake just before bedtime. The client should also avoid caffeine after noon. Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated because it is a spicy food and is likely to cause indigestion. Option 2 can be eliminated because tea contains caffeine. Note the word “filling” in option 3. This word should also indicate that this is an incorrect option. Review measures that will promote sleep if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 416. 610. A nurse is getting ready to provide mouth care to an unconscious client. The nurse understands that which item is not used to perform this procedure? 1. Mouthwash and a soft toothbrush 2. Bite stick or a padded tongue blade 3. Laryngoscope 4. Oral suction catheter Answer: 3 Rationale: A soft toothbrush and mouthwash are needed to perform oral care. A bite stick or padded tongue blade is used to open the mouth; the nurse should not use gloved fingers to open the mouth to prevent injury to self. Small volumes of fluid are used in rinsing the mouth, and oral suctioning is used to prevent aspiration. A laryngoscope is not needed; this would be used for intubation. Test-Taking Strategy: Use the process of elimination and note the key words not used. This tells you that the correct option is an unnecessary piece of equipment. Use basic nursing knowledge related to hygiene measures and visualize the procedure to direct you to the correct option. Review the procedure for performing mouth care 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: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 20602061. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1044-1046. 611. A nurse is providing eye care to an unconscious client. The nurse wipes the eye
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with a clean, wet cotton ball, moving from the: 1. Upper eyelid to the lower eyelid 2. Lower eyelid to the upper eyelid 3. Inner canthus to the outer canthus 4. Outer canthus to the inner canthus Answer: 3 Rationale: The nurse cleanses the eye by wiping from the inner canthus to the outer canthus. This provides for best asepsis because it moves from a cleaner area to a dirtier one. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use basic nursing knowledge related to eye care to answer this question. Recalling the basic principles related to asepsis and visualization of the procedure will direct you to the correct option. Review this procedure 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. 1050. 612. A nurse is planning to teach a client with a continuous passive motion (CPM) device instructions about the device and its use. The nurse would not include which incorrect instruction when discussing the machine and its operation with the client? 1. Reset the degrees of flexion or extension according to comfort 2. Keep the knee aligned with the hinged joint on the machine 3. Use of the “stop-go” button 4. Leave the leg padding in the device Answer: 1 Rationale: The client is instructed about how to stop and start the CPM device and to leave the padding in the device for leg protection. The client should be taught proper positioning and alignment. The client should not try to adjust the flexion and extension settings. These are decided by the orthopedic surgeon and are maintained as ordered. Test-Taking Strategy: Note the key words incorrect instruction in the question. Read each option carefully and remember that the degree of flexion and extension is decided by the surgeon. Review the guidelines related to the use of a CPM device if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 791-792. 613. A client has been instructed in crutch-walking techniques and has been fitted for crutches. The nurse determines that the client understands proper fit of the crutches if the client states that the space between the axilla and the top crutch pad should be:
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1. 3 to 4 inches 2. 2 to 3 inches 3. 1½ to 2 inches 4. ½ to 1 inch Answer: 3 Rationale: The client should have a distance of 1½ to 2 inches between the axilla and the top of the crutch pad to prevent injury to the brachial nerve plexus while maintaining proper support. This measurement should be taken with the client holding the crutches with the elbows bent at a 30-degree angle. The other options are incorrect. Test-Taking Strategy: Use concepts related to basic client mobility to answer this question. Visualizing the distances identified in each of the options will direct you to option 3. Review the procedures related to crutch walking if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 805. 614. A nurse has taught a client with chronic pain how to operate a transcutaneous electrical nerve stimulation (TENS) unit. The client turns up the level of stimulation until there is an uncomfortable sensation. The nurse determines that the client understands the use of the device if the client takes which of the following actions next? 1. Shuts off the device immediately 2. Increases the device settings slightly 3. Adjusts the setting downward slightly 4. Adjusts the setting downward by half Answer: 3 Rationale: The client applies a TENS unit by placing two electrodes on the skin and adjusting the level of stimulation to one lead at a time. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximum stimulation necessary to block painful stimuli has been reached. The volume is then reduced slightly until no further muscle contractions occur. The other options are incorrect. Test-Taking Strategy: To answer this question accurately, you must be familiar with the TENS unit and its application. Option 2 can be easily eliminated because it does not make sense to turn the device higher if uncomfortable sensations are felt. Next eliminate option 1, knowing that this action would serve no useful purpose with this device. From the remaining options, recalling the purpose of this device will direct you to option 3. Review the procedure for using the TENS unit if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 589-591.
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615. A client is being seen in a clinic for symptoms of hyperinsulinism. The client asks the nurse for information about any necessary changes in the diet. Which of the following diets would be appropriate for a client with the diagnosis of hyperinsulinism? 1. Low-fiber, high-fat diet 2. Limit food intake to two meals per day 3. Large amounts of carbohydrates between low-protein meals 4. Small, frequent meals with protein, fat, and carbohydrates at each meal Answer: 4 Rationale: The definition of hyperinsulinism is an excessive insulin secretion in response to carbohydrate-rich foods, leading to hypoglycemia. It is often treated with a diet that provides for limited stimulation of the pancreas. Carbohydrates can produce a rapid rise in blood glucose levels. However, carbohydrates are necessary in the diet. Proteins do not stimulate insulin secretion. Fats are needed in the diet to provide calories. The best diet for hyperinsulinism will contain proteins and fats whenever carbohydrates are consumed. Diets high in soluble fiber may be beneficial. Test-Taking Strategy: Use the process of elimination and knowledge of the causes of high insulin levels. Option 1 suggests a high-fat diet, which would promote obesity and atherosclerosis. Option 2 would provide for long periods of fasting, which could lead to hypoglycemic episodes. Option 3 would increase insulin secretion and worsen the problems of hyperinsulinism. Option 4 is the best, healthiest choice for the client. Review the treatment for this disorder 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: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 781, 786. 616. A nurse is reinforcing instructions about home safety measures to a parent. Which statement by the parent indicates a need for further instructions? 1. “I need to place all toxic substances in a locked area after labeling them.” 2. “I need to keep the Poison Control Center telephone number available.” 3. “I need to make sure to keep medications in child-proof bottles.” 4. “I need to refer to medication as ‘candy for when you are sick’.” Answer: 4 Rationale: Home safety measures are very important to prevent unnecessary childhood poisoning or death. Toxic substances should be labeled with green poison stickers and should be placed in a locked area out of reach of children. The Poison Control Center telephone number should be visible near all telephones. Medications should be stored in child-proof containers. Medicine should not be referred to as “candy.” This could tempt a child to try to eat it when the parents are not in the immediate vicinity. Test-Taking Strategy: Note the key words need for further instructions in the question. These words indicate a false response question and that you need to select the incorrect statement. Noting the word “candy” in option 4 will direct you to this option. Review
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home safety and poison control measures if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 977-978. 617. An older client with arthritis of the hands and fingers is having difficulty using a metered dose inhaler (MDI). The nurse suggests to ask the physician for an order to use a(n): 1. Spacer device 2. Nebulizer 3. Oral (pill) form of the medication 4. Intravenous (IV) form of the medication Answer: 1 Rationale: For a client with arthritis or other conditions that limit the use of the hands, the use of a spacer may prove beneficial. A spacer device allows the medication to be delivered deep into pulmonary tissues, even if the client has difficulty with coordination. MDIs may be difficult to use because it takes coordination and adequate hand motion to hold the canister, depress the canister, and inhale. A spacer is especially useful for clients who are older or who have difficulty using an MDI. The other options are incorrect. Test-Taking Strategy: Because specific medication information is not presented in the question, you cannot know if other forms of the medication are available. This helps you eliminate options 3 and 4. From the remaining options, recall the purpose of nebulizers and spacers. This will direct you to option 1. Review the procedures related to selfadministration of inhaled medications 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. 867. 618. A client has a noninfected pressure ulcer on the left heel. The nurse should use which of the following sterile solutions to cleanse the wound as part of a dressing change procedure? 1. Hydrogen peroxide 2. Povidone-iodine 3. Water 4. Normal saline Answer: 4 Rationale: Normal saline (0.9%) should be used for cleansing ulcers, unless there is a specific order for another solution. Normal saline is isotonic (unlike water) and does not damage cells that are needed for healing (as povidone-iodine and hydrogen peroxide do). Test-Taking Strategy: Use knowledge of basic concepts related to wound care to answer
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this question. Noting the key words noninfected and cleanse the wound and recalling that normal saline is an isotonic solution will direct you to option 4. Review the basic procedures related to wound care 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. 750. 619. A nurse is assigned to care for a hearing-impaired client. The nurse should avoid which approach because it is unlikely to enhance communication and preserve the client’s self-esteem? 1. Turn down the volume on the radio or TV 2. Use many exaggerated hand gestures while talking 3. Stand directly in front of the client while speaking 4. Speak slowly and clearly Answer: 2 Rationale: When communicating with a hearing-impaired client, the nurse stands directly in front of the client or angles the mouth so that sound reaches the client’s better ear. The nurse speaks slowly and clearly in a normal tone of voice. Competing noises such as a radio and TV should be minimized. The nurse can use gestures as long as they are appropriate and used in moderation. All these approaches will enhance the communication process and minimize the client’s self-consciousness about hearing loss. Test-Taking Strategy: Use the process of elimination. Noting the key word avoid in the question and the word “exaggerated” in option 2 will direct you to this option. Review these communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 108. 620. A client with severe uterine bleeding is admitted to the labor and birthing department. Which of the following data would best alert the nurse to early signs of hypovolemic shock? 1. Diminished peripheral pulses 2. Decreased blood pressure 3. Cold and clammy skin 4. Restlessness and agitation Answer: 4 Rationale: Early signs of hypovolemic shock include restlessness, anxiety, and agitation. Later signs of hypovolemic shock include a falling blood pressure, diminished peripheral pulses, pallor, cold and clammy skin, and a urine output less than 30 ml per hour. Options 1, 2, and 3 are all signs of late hypovolemic shock. Option 4 is the correct
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option. Test-Taking Strategy: Note the key word early and use the process of elimination. Remember, the early signs of hypovolemic shock include restlessness, anxiety, and agitation. Review these signs if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 286-287. 621. An older female client complains of leaking urine whenever she sneezes, coughs, or laughs. The nurse identifies that which of the following is occurring in this client? 1. Reflex incontinence 2. Functional incontinence 3. Urge incontinence 4. Stress incontinence Answer: 4 Rationale: Stress incontinence is caused by coughing, laughing, and other activities that increase intraabdominal pressure. Reflex incontinence, sometimes called overflow incontinence, is a loss of urine that is uncontrollable and occurs at predictable intervals. Functional incontinence is also involuntary and occurs often in clients with cognitive deficits, although the urinary and nervous systems are intact. Urge incontinence occurs following the sensation of an urgent need to void. Test-Taking Strategy: To answer this question accurately, you must be familiar with the various types of incontinence and their differentiating factors. Focusing on the factors identified in the question that lead to the incontinence will assist in directing you to option 4. Review the various types of incontinence 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: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 248. 622. A nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. The nurse tells the client that which of the following activities is not harmful in the postoperative period? 1. Bending below the waist 2. Lifting objects that weigh more than 20 pounds 3. Reading magazines and newspapers 4. Watching television Answer: 4 Rationale: The client is taught to avoid activities that raise intraocular pressure because it could cause complications in the postoperative period. For this reason, the client should avoid bending over, lifting heavy objects, straining, sneezing, and making sudden
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movements. The client is also taught to avoid activities that cause rapid eye movements because these would be irritating in the presence of postoperative inflammation. For this reason, the client is told not to read. Watching television is permissible because the eye does not need to move rapidly with this activity and it does not increase the intraocular pressure. Test-Taking Strategy: Note the key words not harmful and recall the types of activities that increase intraocular pressure or are otherwise irritating to the eye. Eliminate options 1 and 2 first, because they obviously increase intraocular pressure. From the remaining options select option 4 because it is less taxing to the eyes. Review home care instructions for the client following eye surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1056. 623. A nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further instructions? 1. “I need to wear an eye shield at night.” 2. “I need to sleep on the back or the right side.” 3. “I need to call the doctor if I have an oral temperature higher than 98.6° F.” 4. “I need to wear sunglasses during the day.” Answer: 3 Rationale: The client is generally taught to report a temperature of 101° F or greater. The client should also report chills, pain unrelieved by medication, bleeding, foulsmelling drainage, or redness at the surgical site. The client should protect the eye by wearing sunglasses during the day and an eye shield at night. The client should lie on the back or the nonoperative side unless otherwise instructed by the surgeon. Test-Taking Strategy: Note the key words need for further instructions in the question. These words indicate a false response question and that you need to select the incorrect client statement. Note that options 1, 2, and 4 all provide protection to the operative eye. Additionally, knowing that a temperature of 101° F or greater would require physician notification will direct you to option 3. Review these client instructions if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 572-573. 624. A client who had previously undergone cataract surgery tells the ambulatory care nurse about the sudden onset of vision changes. The client has begun seeing flashing lights and floaters in the eye. Based on the client’s history, the nurse interprets that the client is at risk of developing:
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1. Glaucoma 2. Recurrent cataract 3. Detached retina 4. Papilledema Answer: 3 Rationale: Clients with a history of cataract surgery, myopia, or trauma or with a family history of retinal conditions are at greater risk for developing a detached retina. Signs and symptoms include sudden onset of flashing lights or floaters. The client may also have loss of peripheral vision or a sudden shadow in the field of vision. Clients with these risk factors should be taught the signs and symptoms of detached retina and to report them promptly. Options 1, 2, and 4 are not associated risks. Test-Taking Strategy: Use the process of elimination. Focusing on the symptoms presented in the question (flashing lights and floaters) will assist in directing you to option 3. Review the signs of a detached retina 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/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 573. 625. A client with primary open-angle glaucoma has been prescribed pilocarpine (Pilocar) ophthalmic drops, and the client asks the nurse how this medication works. The nurse tells the client that the medication lowers intraocular pressure by: 1. Dilating the pupil 2. Reducing intracranial pressure 3. Increasing the outflow of aqueous humor 4. Reducing production of aqueous humor Answer: 3 Rationale: Miotic agents (pilocarpine) increase contractions of the ciliary muscle and constrict the pupil, thereby increasing the outflow of aqueous humor. Beta-adrenergic blocking agents reduce intraocular pressure by decreasing the production of aqueous humor. Options 1 and 2 are not actions of this medication. Test-Taking Strategy: Use the process of elimination. Focusing on the diagnosis of the client and recalling the pathophysiology associated with glaucoma will assist you in eliminating the incorrect options. Review the action of this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 577. 626. A client with glaucoma has impaired vision. The nurse interprets that the client needs information about the condition if the client states that:
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1. Nightlights have been placed in the hallway at home 2. It is important to make appointments for periodic eye examinations 3. The family will drive the client for shopping and errands 4. There is no reason to avoid driving at dusk Answer: 4 Rationale: The client with impaired vision as a result of glaucoma should take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and avoiding driving at dusk or dawn. The client should also understand the need for ongoing monitoring of vision status. Test-Taking Strategy: Use the process of elimination and note the key words needs information about the condition. These words indicate a false response question and that you need to select the incorrect client statement. Use basic principles for working with clients with impaired vision to answer this question. Also, focusing on safety measures related to sight will direct you to option 4. Review these safety measures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Adult Health/Eye References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 580. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1070. 627. A client arrives at the urgent care center with a chemical burn of the right eye. The first priority of the nurse is to prepare the client for: 1. Application of a cold compress to the right eye 2. Application of a warm compress to the right eye 3. Application of a light bandage to the right eye 4. Flushing the eye with copious amounts of sterile solution Answer: 4 Rationale: When the client has suffered a chemical burn of the eye, the nurse immediately flushes the eye with a sterile solution for 15 continuous minutes. If a sterile eye irrigation solution is not available, running water may be used. Applying compresses or bandages do not rid the eye of the damaging chemical. Warm compresses may be used for eye infections. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid. Test-Taking Strategy: Focus on the type of eye injury to assist in directing you to option 4. It would seem reasonable that if a chemical eye injury occurred, flushing would be the priority. Review emergency eye care if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing:
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Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 445. 628. A nurse is preparing to instill an otic solution into an adult client’s right ear. The nurse would avoid which of the following in this procedure? 1. Pulling the auricle upward and backward 2. Touching the tip of the dropper to the edge of the ear canal 3. Warming the solution to room temperature 4. Placing the client in a left side-lying position Answer: 2 Rationale: The dropper is not allowed to touch any object or any part of the client’s skin. The solution is warmed before use. The client is placed on the side, with the affected ear directed upward. The nurse pulls the auricle upward and backward, and instills the medication by holding the dropper about 1 cm above the ear canal. Test-Taking Strategy: Use the process of elimination and note the key word avoid. This word indicates a false response question and that you need to select the incorrect action. Visualizing each of the descriptions in the options and recalling the principles of aseptic technique will direct you to option 2. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 652. 629. A nurse is providing instructions to a client with chronic vertigo. The nurse instructs the client about which safety measure to prevent injury or exacerbation of symptoms? 1. Remove throw rugs and clutter in the home 2. Turn the head from side to side if dizziness occurs 3. Drive only when there is no dizziness 4. Go to a sofa or a bed and lie down when vertigo starts Answer: 1 Rationale: The client with chronic vertigo should avoid driving and using public transportation because the sudden movements could begin an attack. The client should change positions slowly, and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should keep the home environment free of clutter for general safety. The client should remove throw rugs, because the effort of trying to regain balance after slipping could trigger the onset of vertigo. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 4 first, because they put the client at greatest risk of injury secondary to vertigo. From the remaining options, select option 1 knowing that the client with chronic vertigo should not drive. Also, note the absolute word “only” in option 3. Review these safety measures if you had difficulty with this question. Level of Cognitive Ability: Application
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Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 309-310, 359. 630. A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder? 1. Tendency to stay home alone 2. Refusal to answer the telephone 3. Denial of hearing loss 4. Proper use of hearing aid Answer: 4 Rationale: Presbycusis is a progressive sensorineural hearing loss that occurs as part of the aging process. Some clients do not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Test-Taking Strategy: Use the process of elimination and note the key words successfully adapted. A review of each of the options shows that the only option with positive wording is option 4. The incorrect options indicate a need for further adaptation. Review the psychosocial issues related to a client with a hearing impairment if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Ear References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 154. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1092. 631. A client has just been told by the physician that she has breast cancer. The client responds, “Oh, no; this has to be a big mistake.” The nurse interprets that the client’s initial reaction is one of: 1. Anxiety 2. Fear 3. Denial 4. Rage Answer: 3 Rationale: The client’s response is one of denial. This is a common response to hearing distressing news and is a defense mechanism. As an initial reaction, the client’s denial is not of great concern to the nurse. Denial is also the first stage of the grieving process, which is experienced by clients diagnosed with cancer. Test-Taking Strategy: Use the process of elimination and knowledge of psychological responses and coping strategies to answer this question. Focus on the client’s statement
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to help direct you to the correct option. Review defense mechanisms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Oncology Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 22-23. 632. A nurse in the ambulatory care setting has just scheduled a client for a mammogram the following week. The nurse gives the client which instruction about test preparation? 1. The client may consume only a liquid diet the day before the test 2. The client should not use skin lotions on the day of the test 3. The client may wear a necklace on the day of the procedure 4. The client should be sure to use underarm deodorant before the test Answer: 2 Rationale: Mammography is a type of radiographic procedure. Therefore the client is advised not to wear jewelry or metal objects on the day of the examination. There is no special dietary preparation. The client should avoid the use of lotions or underarm deodorant on the day of the test. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first because of the word “only.” From the remaining options, recalling the procedure for mammography and that lotions or deodorants should not be applied to the skin will assist in directing you to the correct option. Review preprocedure instructions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 765. 633. A nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats? 1. Steatorrhea 2. Bloody diarrhea 3. Electrolyte disturbances 4. Gastrointestinal reflux disease Answer: 1 Rationale: The pancreas makes digestive enzymes that aid absorption. Chronic pancreatitis interferes with absorption of nutrients. Fat absorption is limited because of the lack of pancreatic lipase. Steatorrhea by definition means fatty stools, typically a result of malabsorption problems. Options 2, 3, and 4 are rarely associated with chronic pancreatitis. Test-Taking Strategy: Use the process of elimination and recall the pathophysiology related to pancreatitis. Knowledge of the definition of steatorrhea will direct you to
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option 1. Steatorrhea occurs when absorption of fat is not possible. Options 2, 3, and 4 are rarely associated with chronic pancreatitis and therefore should be eliminated as options. Review the definition of steatorrhea and the pathophysiology related to pancreatitis 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: Nix, S. (2005). Williams’ basic nutrition & diet therapy (11th ed.). St. Louis: Mosby, p. 331. 634. A clinic nurse has given a client the materials needed to test the stool for occult blood as part of routine screening for colorectal cancer. The client asks the nurse if there are any special precautions that must be followed in doing this test. The nurse tells the client to avoid eating which of the following for at least a day before performing the test? 1. Cheese 2. Bananas 3. Green peas 4. Red meat Answer: 4 Rationale: The client should avoid eating red meat for at least 24 hours before obtaining the sample. This will help prevent false-positive results, because red meat contains animal blood. The items in options 1, 2, or 3 do not need to be avoided. Test-Taking Strategy: Use the process of elimination. Recalling that the test measures blood cells in the stool will assist in eliminating each of the incorrect options and direct you to option 4. Review the instructions for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 401-403. Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 830-832. 635. A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse tells the client which of the following about the procedure? 1. The client can wear only a wristwatch for jewelry 2. Expect the MRI machine to make noises 3. The client cannot eat or drink after midnight on the day of the test 4. The MRI scanner is a large and spacious machine Answer: 2 Rationale: The MRI scanner is a narrow, tube-like machine that uses magnetic fields and radiofrequency waves to produce two- and three-dimensional cross-sectional views of a
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body area being studied. The machine is narrow and confined and makes a variety of noises during the procedure. The client may not wear any metal objects in the scanner, and clients with implanted metal devices may be ineligible for this diagnostic test. There are no dietary restrictions prior to the procedure. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first because of the absolute word “only.” From the remaining options, you must be familiar with this diagnostic test and its unique characteristics. Review the preprocedure instructions for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 404. 636. A nurse is reviewing the laboratory results of a client receiving chemotherapy for cancer. The nurse reports which abnormal result to the physician? 1. Red blood cell (RBC) count, 4.4 million/mm3 2. White blood cell (WBC) count, 6000/mm3 3. Platelet count, 40,000/mm3 4. Hematocrit, 38% Answer: 3 Rationale: Hematological toxicity from chemotherapy occurs when there is decreased production of blood components (RBCs, WBCs, and platelets) owing to the effects of antineoplastic agents. Each of the values in the options listed is normal, with the exception of option 3, which is low. The nurse reports this finding, because this value places the client at risk for bleeding. Test-Taking Strategy: Use the process of elimination and use knowledge of the normal values for common laboratory tests to answer this question. Option 3 is the only option that identifies an abnormal laboratory value. Review these normal values if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 940. 637. A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The physician inserts a nasogastric tube and prescribes a standard formula tube feeding to run at 50 ml per hour. The nurse plans care knowing that which of the following is true regarding enteral feedings? 1. Enteral feedings are a frequent cause of sepsis 2. Tube feedings should be refrigerated until just before use 3. The caloric value of enteral feedings is generally 5.0 to 10.0 kcal/ml 4. Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI)
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tract Answer: 4 Rationale: Enteral nutrition can include providing nutrients by mouth, nasogastric tube, gastrostomy tubes, or percutaneous endoscopic gastrostomy (PEG). The common element to each of these methods of delivery is the fact that the client must have normal GI digestive capabilities. If the client does not have a normal GI tract, other methods of nutrient delivery must be sought, such as total parenteral nutrition. Enteral feedings may cause aspiration pneumonia resulting from regurgitation of formula into the lungs; however, these feedings are not generally associated with sepsis. Tube feedings should be given at room temperature to avoid problems with diarrhea. The caloric value of most standard enteral feeding formulas is 1.0 to 2.0 kcal/ml. Test-Taking Strategy: Focus on the issue of the question—enteral feedings. Use the process of elimination and knowledge regarding this type of nutrition to answer the question. Remember that enteral feedings require a normal functioning GI tract. Review these types of feedings 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 477-480. 638. A nurse is assigned to the care of a client with an unsealed internal radiation source. The nurse plans the client’s care to avoid spending more than how much time in the client’s room during the 8-hour work shift? 1. 2 hours 2. 60 minutes 3. 30 minutes 4. 15 minutes Answer: 3 Rationale: The maximum time limit for exposure to the client with an unsealed internal radiation source is 30 minutes every 8 hours. The nurse should strictly adhere to this guideline and should also wear a dosimetry badge to measure actual exposure. Test-Taking Strategy: Specific knowledge regarding the radiation exposure guidelines is needed to answer this question accurately. Review these guidelines if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 362. 639. A nurse is discussing chemotherapy with a client who has been diagnosed with cancer. The nurse tells the client that an advantage of continuous intravenous (IV) chemotherapy is that it:
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1. Uses smaller doses to kill cancer cells, so it is less toxic to normal tissues 2. Has the shortest duration of therapy for all cancer sites 3. Has the fewest number of side effects 4. Is the least expensive form of therapy Answer: 1 Rationale: Continuous IV chemotherapy may be done over a period of hours, days, or weeks. A distinct advantage is that it exposes a tumor constantly to a small medication dose, which allows tumor cells to be killed while having fewer toxic effects to normal tissues. The other options are incorrect. The cost and duration of therapy (options 2 and 4) depend on the individual situation. The side effects depend on the agents used. Test-Taking Strategy: An understanding of the purpose and principles of chemotherapy is needed to answer this question correctly. Remember, continuous IV chemotherapy exposes a tumor constantly to a small medication dose, which allows tumor cells to be killed while having fewer toxic effects to normal tissues. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 372. 640. A client is receiving chemotherapy that carries a risk of phototoxicity as an adverse effect. The nurse determines that the client has not experienced this side effect if the client remains free of which of the following? 1. Ecchymoses 2. Erythema 3. Warts 4. Petechiae Answer: 2 Rationale: Typical photosensitivity reactions involve a “sunburn” reaction of the skin. It is characterized by erythema and blister formation. Warts result from viruses, while ecchymoses and petechiae indicate bleeding. Test-Taking Strategy: Focus on the issue—a phototoxicity reaction. Recalling the description of phototoxicity will direct you to option 2. Review the characteristics of this adverse effect if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 386. 641. A nurse reviews the care plan of a client with cancer and notes that the client has a nursing diagnosis of Imbalanced Nutrition: less than body requirements related to side effects of therapy. To enhance appetite and nutrition, the nurse advises the client to
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avoid: 1. Foods that are near room temperature 2. Sources of lean animal protein 3. Small, frequent meals 4. Strong-smelling foods Answer: 4 Rationale: The client with cancer is advised to avoid strong-smelling foods that may aggravate anorexia or be distasteful to the client. The client should increase intake of calories and sources of lean protein. The client should also eat small, frequent meals. Foods that are near room temperature, or that are neither too hot nor too cold, are better tolerated by the client. Other measures that can help improve appetite include rinsing the mouth before eating and dining in an aesthetically pleasing environment. Test-Taking Strategy: Use the process of elimination. The key word avoid in the question guides you to look for an option that is not helpful to the client. Recalling the principles of general nutrition for the client who is debilitated should direct you to option 4. Review the measures that will enhance appetite and nutrition if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 370. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 336. 642. A nurse reviews the care plan of a client with cancer undergoing chemotherapy. The nurse notes that the client has a nursing diagnosis of risk for Disturbed Body Image related to possible alopecia. The nurse plans to tell the client which of the following about hair loss and regrowth to assist the client in coping with this possible change? 1. Facial hair and body hair are not affected 2. Regrown hair may have a different color and texture 3. Hair loss is permanent for most people 4. Hair loss begins within 1 day of the first treatment Answer: 2 Rationale: Hair loss is often temporary, and hair grows back once treatments are completed. Hair may have a different color and/or texture when it regrows. Hair loss often begins within 14 days of beginning treatment. Body hair and facial hair also are affected. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because of the words “not,” “permanent,” and “1 day” in these options, respectively. Review the effects of chemotherapy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology
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Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 729. 643. A registered nurse asks a licensed practical nurse (LPN) to gather and bring into the client’s room the equipment that is necessary to discontinue a dose of intravenous (IV) chemotherapy on a client with cancer. The LPN leaves which of the following unnecessary items on the cart outside the room? 1. Gown 2. Latex gloves 3. Disposal bag for equipment 4. Face mask Answer: 1 Rationale: Equipment needed when handling chemotherapy agents includes disposable latex gloves and a mask to protect the skin, the mouth, and the nose. A gown is not necessary unless it is part of agency policy. A disposable bag is useful for discarding used equipment. This provides a physical barrier to minimize risk of skin contact by others. Test-Taking Strategy: Use the process of elimination. Evaluate each of the options in terms of the area that it protects. The essential equipment covers an exposed body surface or area of the nurse (skin, nose, mouth, or eyes) or minimizes risk to others. The unnecessary item covers clothing, which is not particularly useful when discontinuing an infusion. Review the guidelines related to administering chemotherapy 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: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 375. 644. Immediately following cataract repair, the client’s affected conjunctiva and eyelids are edematous. The nurse tells the client that this is: 1. Abnormal, because only the conjunctiva should be affected 2. Abnormal, because only the eyelids should be affected 3. Unusual, and should be reported if not improved within 24 hours 4. Normal, and should subside within 3 days Answer: 4 Rationale: After surgery to remove cataracts, it is normal for edema of the conjunctiva, sclera, and eyelids to be present. This is due to the trauma of surgery and should resolve in 3 or fewer days following surgery. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that edema can occur following trauma will direct you to option 4. Also, note the absolute words “only” in options 1 and 2 and “not” in option 3. Review the expected findings following this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity
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Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 451. 645. A client has undergone cataract removal without an intraocular lens implant. The client is visibly upset because his vision is blurry. The nurse should do which of the following to provide realistic reassurance to this client? 1. Explain that vision will improve with adjustment to aphakic lenses 2. Reassure the client that bright color contrasts in the environment will help 3. Tell the client that there are resources available for the legally blind 4. Determine whether the client knows any other people who have gone blind Answer: 1 Rationale: The client who had cataracts removed without intraocular lens implant will have blurry vision. The vision improves with the wearing of aphakic lenses. Depending on the degree of visual impairment preoperatively, this may or may not be an actual worsening of the client’s original vision. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they contain the word “blind.” The client is not necessarily blind after this procedure. From the remaining options, recalling the intended effects of this surgery will direct you to option 1. Review the effects of cataract surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1064. 646. A male client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to avoid which of the following to prevent barotrauma during takeoff and landing? 1. Sucking on a piece of hard candy 2. Keeping the mouth motionless 3. Swallowing a few times 4. Yawing occasionally Answer: 2 Rationale: Clients who are susceptible to barotrauma should do any of a variety of mouth movements to equalize pressure in the ear, particularly during takeoff and landing of an aircraft. These include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva’s maneuver may also be helpful. The client should avoid sitting with the mouth motionless during this time because it enhances pressure buildup behind the tympanic membrane. Test-Taking Strategy: Use the process of elimination and note the key word avoid in the question. Evaluate each of the options in terms of the degree of motion. Remember that
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options that are similar are not likely to be correct. All the incorrect options for this question as it is stated are similar because they involve movement of the mouth. Review these client teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear References: Ignatavicius, D., & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care (4th ed.). Philadelphia: W.B. Saunders, p. 1067. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1786. 647. A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse tells the client to be sure to do which of the following immediately after discharge? 1. Avoid taking any medication for pain except aspirin 2. Go swimming as long as the head is kept above water 3. Use a shower cap to protect the ears if taking a shower 4. Wash the hair in 2 minutes or less to avoid water buildup in the ears Answer: 3 Rationale: It is important to avoid getting water in the ears following insertion of ear tubes. For this reason, swimming, showering, and hair washing are avoided after surgery for a period of time that is specified by the surgeon. A shower cap or earplug may be used during showering if allowed by the physician. The client should take medication as advised for postoperative discomfort. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are similar. From the remaining options, use knowledge of principles related to postoperative care and ear surgery to direct you to option 3. Review these client teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 595. 648. An adult client with a history of ear infections calls the ambulatory care clinic to make an appointment because of a right earache accompanied by a sensation of fullness. The client also complains of nausea and has a temperature of 100.6° F. The nurse first questions the client about whether: 1. Any medications have relieved the pain 2. The client hears ringing in that ear 3. There is a history of recent head injury 4. There is a history of recent upper respiratory tract infection (URI) Answer: 4 Rationale: Otitis media in the adult is typically one-sided and presents as an acute
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process with earache, fullness in the ear, nausea with possible vomiting, and fever. The client may complain of decreased ability to hear in that ear. The nurse takes a client history first, assessing whether the client had a recent URI. It is unnecessary to question the client about head injury or ringing in the ear. The nurse may ask the client whether anything relieves the pain, but the pain that accompanies ear infection is not usually relieved until antibiotic therapy is started. Test-Taking Strategy: Use the process of elimination and note the key word first. Recalling that an URI is associated with ear infections will assist in directing you to the correct option. Review the etiology associated with ear infections if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1985. 649. A client is recovering at home after suffering a cerebrovascular accident (CVA) 2 weeks ago. A home caregiver states that the client has difficulty swallowing food and fluids. Which nursing action would be appropriate as a first action? 1. Observe the client feeding him or herself 2. Observe the caregiver feeding the client 3. Arrange for a home health aide to assist at mealtimes 4. Instruct the caregiver to use a feeding syringe to feed the client Answer: 1 Rationale: It is not uncommon for a client to have difficulty swallowing after having a CVA. Often the client has hemiplegia. The client’s arm may be paralyzed, and the client has to learn to use an opposite arm to feed self. Using a different arm may require rehabilitation and retraining. Also, a client may have partial paralysis of the mouth, tongue, or esophagus. To best assist the client, the nurse should first assess the situation by watching the client feed him or herself. Perhaps the problem lies in the feeding technique, the type of feeding tool used, the types of foods being served, or a combination of problems. Having someone else feed the client may be necessary if the client is determined to be unable to feed self, but this action does not promote independence in the client. A feeding syringe is not recommended for feeding most clients. Test-Taking Strategy: Use the process of elimination and note the key word first. In this situation the problem is the client’s inability to feed him or herself. Eliminate options 2 and 3 first because they are similar. Next, eliminate option 4 knowing that this is not an appropriate action. The first step would be to determine what the client’s capabilities are before giving the responsibility of feeding the client to someone else. Review care to the client following a CVA 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
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Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 426-427. 650. A nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers: 1. That aspiration is a primary concern 2. To maintain the client in a supine position 3. To change the NG tube with every other feeding 4. To increase the rate of the feeding if the infusion rate falls behind schedule Answer: 1 Rationale: Nasogastric tube feedings are beneficial but present several significant possible complications such as diarrhea, contaminated formulas, lactose intolerance, dumping syndrome, or excess fluid volume. The most common complication is aspiration pneumonia, which is caused by regurgitation of formula contents from the stomach into the respiratory tract. Keeping the head of the bed elevated to 30 degrees at all times assists in the prevention of this complication. An NG tube can remain in place for weeks to months, depending on the type of tube that is inserted, and is not changed with every other feeding. Problems with diarrhea may be caused by infusing a formula that is too cold, is contaminated, or is of the wrong consistency. Infusion of formula at a rate that is too rapid may also be a cause of diarrhea; the rate of the infusion should not be increased to “catch up” if the procedure falls behind schedule. Test-Taking Strategy: Use the process of elimination and the ABCs—airway, breathing, and circulation—to answer the question. This will direct you to option 1. A client in a supine position, even if just for a moment (such as when changing bed linens), could develop aspiration pneumonia. Option 3 is incorrect because nasogastric tubes may be left in place for weeks to months depending on the type of tube inserted. Option 4 could lead to fluid overload problems. Review care to the client with an NG tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension 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. 478. 651. A nurse is teaching a client how to use a new hearing aid. As part of the information given, the nurse would tell the client to: 1. Not worry about providing any special care to the hearing aid 2. Rub a small amount of petrolatum (Vaseline) in the ear before insertion 3. Check the battery to assure that it is working before use 4. Leave the hearing aid in place while showering Answer: 3 Rationale: The client should check the battery of the hearing aid before use. Lubricants or other solvents are not used around or on the devices. It should be cleaned according to the manufacturer’s directions, which usually consist of washing with warm soapy water
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followed by thorough drying. The hearing aid should be removed for showering, because it should not get wet between recommended washings. It should also be put away in its case at night for protection against damage. Test-Taking Strategy: Focus on the issue—care to a hearing aid. Reading each option carefully will easily direct you to option 3. Review client instructions related to a hearing aid if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 298. 652. A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works most effectively if it is taken at least: 1. 2 days before a triggering event 2. 1 day before a triggering event 3. 12 hours before a triggering event 4. 1 hour before a triggering event Answer: 4 Rationale: To be most effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate (Dramamine), scopolamine (Transderm-Scōp), meclizine (Bonine), promethazine (Phenergan), and prochlorperazine (Compazine). Test-Taking Strategy: Specific knowledge about the optimal time frames for this type of medication is needed to answer this question correctly. Noting that the issue of the question relates to the use of medication to prevent motion sickness will direct you to option 4. Review the guidelines related to these medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 272. 653. A nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation? 1. Either excessive itching or tearing of the eyes 2. A blank spot in the field of vision 3. Difficulty with driving at night and blurred vision 4. Pain in the eyes when in dim light Answer: 3 Rationale: A cataract is characterized by a cloudy lens, which results in blurred vision and difficulty driving at night. There is sometimes monocular diplopia, photophobia, and
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glare. The client does not experience eye pain. The other options are incorrect. Test-Taking Strategy: Focus on the issue—untreated cataracts. Recalling that blurred vision is a characteristic of this disorder will direct you to option 3. Review the characteristics of cataracts if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 570. 654. A nurse is evaluating the results of a client’s serum laboratory studies. Which result indicates a deficiency of protein intake? 1. Triglycerides, 140 mg/dl 2. Blood glucose, 78 mg/dl 3. Albumin, 2.6 mg/dl 4. Hemoglobin, 15 g/dl Answer: 3 Rationale: Albumin is a type of protein, and decreased serum levels (option 3) can indicate a number of problems, including malnutrition and decreased protein intake. The normal albumin level is 3.4 to 5 g/dl. The triglycerides, blood glucose, and hemoglobin levels are all within normal ranges. Triglycerides are a type of lipid consisting of three fatty acids bound to glycerol, and glucose is the most elemental form of carbohydrate. Hemoglobin carries oxygen in the red blood cells. Test-Taking Strategy: Focus on the issue—a deficiency of protein intake. Recalling the relationship between protein and albumin will direct you to option 3. Also recalling the normal laboratory values for the tests identified in the options will direct you to option 3. Review these normal laboratory values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 148. 655. A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the physician’s explanation of the disorder. The nurse would tell the client that: 1. The lens of the eye becomes opaque and decreases vision 2. The blood vessels in the back of the eye rupture and bleed 3. There is a reduction in the amount of aqueous humor produced in the eye 4. The pressure within the eye increases from excess fluid or blockage of drainage Answer: 4 Rationale: Open-angle glaucoma results either from an increase in the production of aqueous humor or from obstruction to its drainage from the eye. Option 1 describes cataract formation. Options 2 and 3 are incorrect. Test-Taking Strategy: Focus on the issue—open-angle glaucoma and its
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pathophysiology. Recalling that glaucoma increases the pressure within the eye will direct you to option 4. Review the characteristics of glaucoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 576. 656. A client who has just obtained a hearing aid is receiving suggestions about its use and maintenance from a nurse. The nurse tells the client that it is helpful to: 1. Leave the hearing aid on both night and day 2. Keep an extra battery available 3. Change the battery if the aid makes a whistling noise 4. Reattach the ear mold after cleaning it to the hearing aid while it is still damp Answer: 2 Rationale: The client should keep an extra hearing aid battery available. The hearing aid should be shut off when not in use so that the battery is not drained. If the hearing aid makes a whistling noise, the client should adjust its position in the ear. After cleaning the ear mold, the client should dry it thoroughly before reattaching it to the hearing aid. Test-Taking Strategy: Focus on the issue—care of a hearing aid. Recalling that a battery is a key component of the hearing aid will assist in directing you to option 2. Review client instructions regarding a hearing aid if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 298. 657. A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse would avoid instilling which of the following solutions into the ear to aid in removal of the insect? 1. Mineral oil 2. Water 3. Ether solution 4. Lidocaine Answer: 2 Rationale: Water should not be used in the ear canal if an insect is trapped in it. The water will cause the insect to swell, making its removal more difficult. The other solutions are acceptable because they will either kill or stupefy the insect. Test-Taking Strategy: Note the key word avoid. Recalling that water will cause the insect to swell will direct you to option 2. Review care to the client with a foreign body in the ear if you had difficulty with this question. Level of Cognitive Ability: Application
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1985. 658. A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). The nurse should plan to do which of the following next? 1. Notify the physician immediately 2. Make a notation in the nurse’s notes 3. Make a note for the nurse on the evening shift to give the medication 4. Do nothing; because no further action is required Answer: 2 Rationale: If a client misses or refuses a dose of medication, the nurse should record in the nurse’s notes the reason that the medication was not given. It is unnecessary to notify the physician immediately because of the nature of the medication and the client’s reason for refusal. The licensed practical nurse should, however, inform the registered nurse. Option 3 is incorrect, because medications are not left for the nurse on the next shift to administer because of client refusal. Option 4 is incorrect. An explanation of the missed dose should be recorded. Test-Taking Strategy: Use basic principles of medication administration to answer this question and note the key word next. Recalling the importance of documentation will direct you to option 2. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 81. 659. A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is necessary when caring for this client? 1. Provide oral fluids three times per day 2. Check around the stoma site for skin irritation 3. Medicate with antidiarrheal medications every day 4. Use sterile technique with all procedures Answer: 2 Rationale: A gastrostomy tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. As a result of the surgical incision, occasionally gastric contents leak out onto the client’s skin. Gastric contents are highly acidic and can cause major skin irritation. The skin irritation may lead to infection. The nurse must monitor the insertion site for skin irritation. Option 1 is incorrect, and generally the client with a G-tube is unable to tolerate oral intake. Antidiarrheal medications are not administered every day. Aseptic, not sterile, technique is needed in caring for the client. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because the client generally does not have the capability of swallowing and therefore needs the G-
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tube. Eliminate option 3 because antidiarrheal medications are not administered every day. Eliminate option 4 because aseptic, not sterile, technique is necessary when working with G-tubes. Review care to the client with a G-tube 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. 481. 660. A client who fell asleep while apparently smoking in bed awakens and rings the call bell for the nurse. The nurse enters the room and sees that the client’s bedspread is in flames. The nurse should take which action first? 1. Hurry to get a fire extinguisher to put out the fire 2. Pull the nearest fire alarm switch 3. Get the client out of the room 4. Put water into a wash basin and try to douse the fire Answer: 3 Rationale: The principles of fire safety can be easily remembered by recalling the acronym RACE. This stands for rescue (option 3), alarm (option 2), confine (or contain), and extinguish (options 1 and 4). Option 3 is the first action the nurse should take. Option 2 should be done next, followed by option 1. Option 4 is not part of standard procedure for health care agencies, although it is an attempt to put out the fire. Test-Taking Strategy: Use basic principles of fire safety to answer this question. Note that the question contains the key word first. Use client safety and the acronym RACE as the guide in directing you to option 3. Review the rules of fire safety 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 312. 661. A nurse is assigned to care for a client on the fourth day of hospitalization who is recovering from partial thickness burns to 60% of body surfaces. The client’s vital signs are temperature 102.8° F, pulse rate 98 beats per minute, respirations 24 breaths per minute, and blood pressure 105/64 mm Hg. Total parenteral nutrition (TPN) is infusing at 82 ml per hour. Based on these data, the nurse plans to initially: 1. Recheck the vital signs in 1 hour 2. Check the client for signs of infection 3. Change the TPN solution and IV tubing 4. Discontinue the TPN and culture the tip of the catheter and the insertion site Answer: 2 Rationale: The client is recovering from serious burns. The burn client is prone to
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several complications such as infection and sepsis. A temperature of 102.8° F is significant. On the fourth hospital day, infection may be the problem. The site of the infection may be the burns, the TPN infusion or TPN site, or other problems. As an initial action, the nurse needs to check the client for signs of infection and then notify the registered nurse, who will contact the physician for further orders. Test-Taking Strategy: Focus on the issue of the question and note the key word initially. Use the steps of the nursing process, noting that option 2 is the only option that addresses data collection. Review the signs of complications in a burn 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1039. 662. A male client states that he has removed all dairy foods from his diet because he is lactose intolerant. The nurse plans care for the client knowing that: 1. Calcium and protein are valuable nutrients and need to be supplemented in some form 2. Calcium supplements alone will be needed to supplement for dairy products 3. Lactose enzymes must be taken to eliminate the effects of lactose intolerance 4. Leafy, green vegetables will provide all of the necessary calcium Answer: 1 Rationale: Calcium and protein need to be supplemented in some form in the diet of the client with lactose intolerance. Lactose enzymes may help clients with lactose intolerance, but they may not eliminate the client’s problems. An individual generally does not consume enough leafy, green vegetables daily to obtain sufficient calcium. Test-Taking Strategy: Focus on the issue of the question. Note the absolute words in options 2 (alone), 3 (must), and 4 (all). Review this nutritional disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning 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. 676. 663. A client is admitted to an acute care facility with complications of celiac disease. Which question would be most helpful initially in obtaining information for the nursing care plan? 1. “What types of pasta can you eat?” 2. “What is your understanding of celiac disease?” 3. “What types of food do you like to eat?” 4. “Have you eliminated whole-wheat bread from your diet?” Answer: 2 Rationale: Celiac disease is also known as gluten-induced enteropathy. It causes
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diseased intestinal villi, which results in decreased absorptive surfaces and malabsorption syndrome. Clients with celiac disease must maintain a gluten-free diet, which eliminates all products, made from wheat, rye, oats, barley, buckwheat, or graham. Many products may contain gluten without the client’s knowledge. Beer, pasta, crackers, cereals, and many more substances contain gluten. It is often very difficult for a client to learn all of the food substances that must be eliminated from a diet. Also, it is often very difficult for a client to adhere to a strict diet. Test-Taking Strategy: Note the key word initially and use teaching/learning principles to answer the question. Initially it is important to determine the client’s level of knowledge. Option 2 gives the client a chance to explain his understanding of the disease. With this background information, the nurse will be better able to assess the problem and assist the client. Review teaching/learning principles 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: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 849. 664. A client has been on total parenteral nutrition (TPN) for 8 weeks at home. The physician orders that the client be weaned off TPN by 50 ml/hour/day until discontinued. The client asks the nurse, “Why doesn’t the doctor just stop the TPN instead of dragging it on for 3 days?” The best nursing response would be to explain that the physician is concerned about which phenomenon? 1. Dehydration 2. Hypokalemia 3. Hypernatremia 4. Rebound hypoglycemia Answer: 4 Rationale: Clients receiving TPN are obtaining high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusions rates are tapered down. Before discontinuing the TPN, the body must adjust to the lowered glucose levels. If the TPN were suddenly withdrawn, the client would probably have rebound hypoglycemia. Options 1, 2, and 3 are not concerns when the TPN is discontinued. Test-Taking Strategy: The focus of the question is on the complications of TPN when it is discontinued. Recalling that a concern of TPN that needs to be monitored is the effect of the high glucose concentrations and its effect on insulin levels will direct you to option 4. Review the procedures when discontinuing TPN if you had difficulty with this question. Level of Cognitive Ability: Comprehension 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. 487.
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665. A client has been receiving total parenteral nutrition (TPN) at 125 ml/hour for 5 days. On data collection, the nurse notes bilateral rales (crackles) and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which nursing action would be appropriate as a first action? 1. Notify the registered nurse of the findings 2. Encourage the client to cough and deep breathe 3. Check the client’s medication orders for a diuretic 4. Slow the TPN infusion rate to 100 ml/hour Answer: 1 Rationale: The client is showing signs of fluid retention and possible excess fluid intake. Rales, edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces. The problem may or may not be related to the TPN. Other possible causes of fluid retention include impaired respiratory and cardiovascular function, impaired kidney function, or a combination of factors. The nurse needs to notify the registered nurse of the findings. The registered nurse will then notify the physician for further orders. Option 2 will have little if any effect on peripheral edema and weight gain. Option 3 infers that a diuretic will help the situation, and it is possible that the physician will order a diuretic; however, the physician needs to be aware of the change in the physical condition of the client. The nurse should not increase or decrease the rate of TPN infusions without a physician’s order. Test-Taking Strategy: Note that the TPN has been infusing for 5 days. Focus on the data regarding the client and think about the potential complications associated with TPN infusions. Eliminate option 2 because this action will not assist the client, considering the client’s signs and symptoms. Eliminate options 3 and 4 because these actions should not be implemented without further physician instructions. Review the complications associated with the administration of TPN and the associated nursing interventions 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. 990. 666. A physician orders a total parenteral nutrition (TPN) solution to start at 50 ml/hour by infusion pump via an established subclavian central line. After 2 hours of receiving the TPN infusion, the client suddenly complains of difficulty in breathing and chest pain. Which action would the nurse prepare to do first? 1. Auscultate the lung sounds 2. Clamp the TPN infusion 3. Obtain a blood glucose level 4. Obtain an electrocardiogram (ECG) Answer: 2 Rationale: A complication of a subclavian central line can be an embolism as a result of air or thrombus. A sudden onset of chest pain shortly after the initiation of TPN may mean that this complication has developed. The central line is clamped, not discontinued,
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and the physician is notified immediately. Option 1 is an appropriate action but not the first action. Option 3 is not a priority because the client’s symptoms do not indicate the presence of hypoglycemia or hyperglycemia. The physician will probably order an ECG, but this action would not be the initial action in this situation. Test-Taking Strategy: Use the process of elimination. Focusing on the complaints “difficulty in breathing and chest pain” should assist in directing you to option 2. Review the complications of TPN 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: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 536. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 989. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 664. 667. A nurse is assigned to care for a client receiving total parenteral nutrition (TPN) via the left subclavian vein. The nurse would include which priority routine measure in the plan of care for the client? 1. Check the insertion site for signs of infection 2. Maintain the client in a semi-Fowler’s position on his or her back at all times 3. Encourage the client to cough and deep breathe 4. Take the blood pressure hourly Answer: 1 Rationale: TPN that is infusing via a central line, such as through the subclavian vein, is more likely to become infected than a standard peripheral IV line. Infection may quickly lead to sepsis. The insertion site should be inspected every 4 to 6 hours. It is not necessary to place the client in a semi-Fowler’s position on his or her back at all times. It is advisable to encourage the client to cough and deep breathe, but this action does not relate to the issue of the question. It is not necessary to take the blood pressure hourly. Test-Taking Strategy: Focus on the issue of the question and read each option carefully. Note the key word priority. Eliminate option 2 because of the absolute word “all” and option 4 because of the word “hourly.” From the remaining options, recalling that infection is a primary concern will assist in directing you to option 1. Review nursing care to a client with TPN 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 References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 537. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 989.
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668. A client arrives in the emergency room with a complaint of severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, the initial nursing action would be which of the following? 1. Obtaining orthostatic vital signs 2. Preparing to insert a total parenteral nutrition infusion 3. Preparing to insert a nasogastric tube feeding 4. Checking the client’s skin for irritation because of diarrhea Answer: 1 Rationale: The initial nursing action is to determine the client’s level of dehydration. Orthostatic vital signs (blood pressure and pulse rate measurements while lying, sitting, and standing) are actions to determine the probability of fluid losses. A decrease of more than 10 to 20 mm Hg in blood pressure and an increased pulse rate of 10 to 20 beats per minute probably indicate significant intravascular fluid volume deficit. With a significant history of nausea, vomiting, and diarrhea accompanied by weight loss, the client is potentially facing a life-threatening problem. Generally, the fluid levels must be increased quickly with lactated Ringer’s or normal saline intravenous solutions as prescribed. Option 4 may be an intervention but is not the initial action. Options 2 and 3 are not initial measures to treat dehydration. Test-Taking Strategy: Focus on the issue of the question and the client’s symptoms and note the key word initial. Using the steps of the nursing process will assist in eliminating options 3 and 4. From the remaining options, select option 1 based on the situation presented and because this option addresses the ABCs—airway, breathing, and circulation. Review care to the client at risk for dehydration 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 424. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 159. 669. A client who had knee surgery 4 days ago calls the nurse at the physician’s office and reports that he has not had a bowel movement since before surgery. Which question would most assist the nurse in the collection of data regarding the client’s problem? 1. “When was your last pill for pain?” 2. “How often do you take a laxative?” 3. “Do you eat meats?” 4. “What foods and drinks have you had since you’ve been home?” Answer: 4 Rationale: Constipation is the probable cause of the client’s lack of stools. It is marked by difficult or infrequent passage of stools that are hard and dry. Constipation has numerous causative factors including psychogenic issues, lack of physical activity, inadequate intake of food and fiber, and medication influences. A client recovering from
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knee surgery may have several factors influencing elimination patterns. The question in option 4 will elicit data regarding the client’s intake and will assist in determining whether an inadequate intake of food and fiber exists. Test-Taking Strategy: Focus on the issue of the question—the cause of the constipation. Options 1 and 2 can be eliminated first because they are unrelated to the issue of the question. From the remaining options, eliminate option 3 because it will not elicit adequate information that will assist the nurse in determining the cause of the constipation. Review the causes of constipation 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 566-567, 749. 670. A caregiver states that the client seems to be losing weight and that the client eats only about 25% of the food that is offered. The caregiver asks the nurse about feeding the client by a tube into the stomach. The initial response by the nurse would be which of the following? 1. “Tube feedings are only for long-term feeding problems.” 2. “Tube feedings can provide adequate amounts of required nutrients.” 3. “Tube feedings often result in complications such as aspiration pneumonia.” 4. “Tube feedings are not helpful in cases of intractable vomiting or severe diarrhea.” Answer: 2 Rationale: Tube feedings are an alternative for temporary or permanent nutritional maintenance. Enteral tube feedings are generally safer and significantly less costly than peripheral or total parenteral nutrition. Weight loss and a dietary intake of only 25% indicate that alternative sources of nutritional intake should be sought. Option 1 is incorrect because tube feedings are often temporary measures. Option 3 may be correct; however, it is not the best response to a caregiver seeking initial information. Option 4 is unrelated to the situation of this question. Test-Taking Strategy: Focus on the issue of the question and use the process of elimination noting the key word initial. Eliminate option 4 first because it is unrelated to the situation of this question. Next, eliminate option 3 because it is not the best response to a caregiver seeking initial information and may produce fear in the caregiver. From the remaining options, recalling that tube feedings may be used as a temporary measure of providing nutrition will assist in directing you to option 2. Review the concepts and purposes related to tube feedings 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. 477. 671. A client is admitted to the maternity unit at 5 AM and has remained at station 0, with
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strong contractions every 3 minutes. The fetal heart rate (FHR) is 140 beats per minute. It is 7 PM, no progress has occurred, and the FHR is decreasing. Which of the following nursing actions is appropriate? 1. Prepare the client for induction of labor 2. Turn the client to the left side 3. Prepare the client for a cesarean delivery 4. Palpate the bladder for fullness Answer: 3 Rationale: An indication for a cesarean delivery is failure of labor to progress accompanied by fetal distress. In this situation, the nurse will prepare the client for this procedure. Option 1 would not be indicated in this case because the client has been in labor for 14 hours and the FHR is beginning to decrease. Options 2 and 4 are nursing actions for all clients in labor. Placing the client on the left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. Keeping the bladder empty allows the fetus to descend. Test-Taking Strategy: Focus on the data provided in the question and note the key words the FHR is decreasing. Use the process of elimination recalling that in this situation, it is most important to deliver the baby as quickly as possible. Review care to the client in labor and the indications for a cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 249-250. 672. A nurse is preparing a client for an emergency cesarean delivery. Which of the following are the most important data to collect regarding the client? 1. Was the informed consent form signed? 2. Was a Foley catheter inserted? 3. When was the last oral intake? 4. Were a complete blood cell count and urinalysis performed? Answer: 3 Rationale: The status of oral intake is the most important data to collect. This information will provide the basis for the type of anesthesia used to prevent aspiration during surgery and postoperatively. Options 1, 2, and 4 are all routine preoperative procedures. Test-Taking Strategy: Note the key words emergency cesarean delivery. This tells you that the client may not have been on an NPO status. Use the ABCs—airway, breathing, and circulation—to assist in directing you to option 3. Remember that aspiration is a risk of some types of anesthesia and the NPO status needs to be determined. Review care to a client requiring emergency cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum
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Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 252. 673. A nurse encourages a new mother and her spouse to discuss the necessary cesarean delivery, focusing on the delivery of the baby instead of the surgical aspect of the procedure. Which nursing statement would provide the best encouragement? 1. “Tell me about the delivery of your baby.” 2. “Your surgery went well.” 3. “You will be able to have other children vaginally.” 4. “The surgery will not limit you in having more pregnancies.” Answer: 1 Rationale: It is important for the mother and her spouse to think of the procedure as the birth of the baby. The mother may become disappointed because she was unable to deliver vaginally, complicating the postpartum phase. Option 2 brings the surgery to focus and can inhibit the mother from bonding with the neonate. Options 3 and 4 place the focus on the future, and the mother needs to focus on the birth of the baby. Test-Taking Strategy: Focus on the issue of the question noting the key words provide the best encouragement. Eliminate options 3 and 4 first because they are similar. From the remaining options, select option 1 because it focuses on the issue of the question and addresses the client’s feelings. Review the psychosocial aspects of a cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 250. 674. Oxytocin (Pitocin) is prescribed to be administered intravenously to a client after a cesarean delivery. The nurse understands that this medication has been prescribed because the action of the medication is to: 1. Stimulate the uterus to contract, control uterine atony, and reduce blood loss 2. Stimulate the production of progesterone for breast-feeding 3. Stimulate the production of estrogen 4. Prevent infection Answer: 1 Rationale: The action of oxytocin is to stimulate the uterus to contract, to control uterine atony, and therefore reduce hemorrhage. Options 2, 3, and 4 are not actions of this medication. Test-Taking Strategy: Knowledge of the action of this medication is necessary in answering this question. Recalling that this medication is used to induce labor will assist in directing you to option 1. Review the action of this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning
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Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 252. 675. A nurse is preparing a client for a cesarean delivery. A Foley catheter is to be inserted into the client’s bladder, and the client asks the nurse why the Foley catheter is necessary. The nurse appropriately replies by telling the client which of the following? 1. “To prevent infection.” 2. “It reduces the risk of injury to the bladder when the surgical incision is made.” 3. “To get an accurate output.” 4. “So that the baby can engage into the birth canal.” Answer: 2 Rationale: A Foley catheter is inserted preoperatively to keep the bladder empty to reduce the risk of injury to the bladder when the surgical incision is made. Options 1, 3, and 4 are not the reasons for inserting a Foley catheter. Test-Taking Strategy: Use the process of elimination and knowledge regarding the basic principles related to the purpose of a Foley catheter to answer the question. Note the relationship between “cesarean delivery” in the question and “surgical incision” in the correct option. Review preoperative care for a cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 250. 676. A nurse is assigned to care for a client in the maternity unit with a diagnosis of dystocia. The nurse prepares the client for which of the following techniques used to relieve shoulder dystocia? 1. Leopold’s maneuver 2. McRobert’s maneuver 3. Placing the client in the lithotomy position 4. Lying the client on the left side Answer: 2 Rationale: The McRobert’s maneuver is used to relieve shoulder dystocia. It is described as the woman flexing her thighs sharply against her abdomen to straighten the pelvic curve. This procedure will assist the fetus to move past the pelvic curve of the woman. Leopold’s maneuver is used to locate the position and presentation of the fetus. Options 3 and 4 are positions, not techniques, and will not assist in relieving shoulder dystocia. Test-Taking Strategy: Use the process of elimination and knowledge regarding the techniques used to relieve shoulder dystocia. Eliminate options 3 and 4 first because these options are positions, not techniques. Recalling that the Leopold maneuver is used to locate the position and presentation of the fetus will direct you to option 2 from the remaining options. Review these maneuvers if you had difficulty with this question. Level of Cognitive Ability: Application
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 241. 677. A nurse reviews the laboratory results for a client with leukemia receiving chemotherapy. The nurse notes that the white blood cell (WBC) count is 2000/mm3. The nurse analyzes the results as: 1. Lower than normal, signifying leukopenia 2. Indicating infection 3. Higher than normal, indicating metastasis 4. Normal Answer: 1 Rationale: Chemotherapy agents cause medication-induced leukopenia, and treatment focuses on this side effect. The normal WBC count is 5000/mm3 to 10,000/mm3. An elevated WBC count would most likely indicate infection. Option 3 is an incorrect statement. Test-Taking Strategy: Use the process of elimination and note the key word chemotherapy in the question. Knowing that chemotherapy destroys both normal WBCs and cancer cells is necessary to answer the question. Additionally, recalling the normal WBC count will easily direct you to option 1. Review this normal value if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Oncology Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 940. 678. A nurse provides instructions to a client at risk for thrombophlebitis regarding measures to prevent its occurrence. Which statement by the client indicates an understanding of the measures to prevent thrombophlebitis? 1. “I need to avoid pregnancy by taking oral contraceptives.” 2. “I should avoid sitting or standing in one position for long periods of time.” 3. “I can finally stop wearing these support stockings that you gave me.” 4. “I will be sure to maintain my fluid intake to at least four glasses daily.” Answer: 2 Rationale: Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, maintain normal coagulability, and prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily is an inadequate amount of fluid. Test-Taking Strategy: Use the process of elimination and knowledge regarding the measures that can reduce venous stasis to answer this question. Note the key words
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understanding of the measures. Remember that avoidance of standing or sitting in one position will prevent venous stasis. Review the measures that will prevent thrombophlebitis 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: Adult Health/Cardiovascular Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 732-733, 750. 679. A nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which of the following problems would the nurse expect to note on the plan of care? 1. Anxiety related to a slow progress of labor 2. Anxiety related to parenting 3. Anxiety related to the inability to relax 4. Anxiety related to maternal exhaustion Answer: 1 Rationale: An experience can be influenced by past experiences, culture, support from family or significant other, or by preparation. Dystocia can cause a slowed progress of labor. Maternal anxiety is compounded by the crisis of the slow labor. Options 2, 3, and 4 are unrelated to dystocia. Test-Taking Strategy: Focus on the issue—a diagnosis of dystocia. Recalling the definition of dystocia will direct you to option 1. Review this condition if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 239-240. 680. A nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which of the following? 1. Presence of vaginal bleeding 2. Characteristics of contractions 3. Signs of hyperglycemia 4. Presence of edema Answer: 2 Rationale: Dystocia is a slowed labor process. A prolonged labor is a potential for fetal distress. The nurse would specifically monitor the characteristics of the contractions. Options 1, 3, and 4 are unrelated to this condition. Test-Taking Strategy: Focus on the issue—a diagnosis of dystocia—and note the key words specifically collects. Recalling the definition of dystocia will direct you to option 2. Also, options 1, 3, and 4 are unrelated to this condition. Review this disorder if you had difficulty with this question.
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Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 240. 681. Precipitate delivery is described as a time period of less than 3 hours from the onset of labor to the birth of the baby. If this situation occurred and delivery is imminent, which of the following would be the best nursing action? 1. Leave the client and immediately contact the physician 2. Attempt to keep the baby from being born until the physician arrives 3. Don sterile gloves and gently guide the baby’s head and shoulders 4. Place the client in Trendelenburg position Answer: 3 Rationale: The baby is the priority. In an emergency situation, the nurse assists the client in the delivery by donning sterile gloves and gently guiding the head and shoulders of the baby. The client should not be left alone. Options 2 and 4 are inappropriate and could cause distress to the fetus. Test-Taking Strategy: Note the key words delivery is imminent. Use the process of elimination, noting that the only option that addresses this issue is option 3. Options 1 and 2 are incorrect because the client should not be left alone and because waiting for the physician or keeping the client from delivering could injure the fetus. Option 4 is the position for placing the client when a prolapsed cord is suspected. Review care to the client with a precipitate delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & womaen’s health care (8th ed.). St. Louis: Mosby, pp. 1003-1005. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 679-680. 682. Following a precipitate delivery and initial care of the baby, the placenta must be delivered. Of the following, which would be the appropriate method to use to deliver the placenta? 1. Wait 30 minutes and gently pull the placenta 2. Wrap the cord around a sponge stick and pull hard 3. Gently guide the placenta out after spontaneous separation 4. The nurse never delivers the placenta Answer: 3 Rationale: The placenta is allowed to separate spontaneously; then it is gently guided out. The placenta is attached to the uterine wall, and if it is pulled or left in the uterus, hemorrhage would occur. There may be situations when it is necessary for a nurse to assist in the delivery of the placenta.
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Test-Taking Strategy: Use the process of elimination, noting the word “pull” in options 1 and 2 and the word “never” in option 4. Review care to the client with a precipitate delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & womaen’s health care (8th ed.). St. Louis: Mosby, pp. 1003-1005. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 679-680. 683. A nurse is caring for a client during a precipitate delivery and the delivery of the placenta. The nurse knows that it is important that the uterus contracts to prevent hemorrhage. In addition to fundal massage, the nurse understands that which nursing action will promote uterine contraction? 1. Adding oxytocin (Pitocin) to the intravenous (IV) infusion 2. Increasing the IV infusion rate 3. Keeping the client in the lithotomy position 4. Putting the baby to the mother’s breast and letting the baby suck Answer: 4 Rationale: Nipple stimulation causes the posterior pituitary of the woman to secrete natural oxytocin, which causes the uterine muscles to contract. This is a method that can be an independent action of the nurse. Options 1 and 2 are not appropriate and require a physician’s order. Option 3 will not assist in the contraction of the uterus. Test-Taking Strategy: Focus on the issue, a nursing action, and use knowledge regarding the measures that stimulate uterine contraction to assist in answering the question. Option 3 can be eliminated first. Next, eliminate options 1 and 2 because they are inappropriate and require a physician’s order. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 179, 190. 684. A nurse is caring for a client in preterm labor who is receiving terbutaline sulfate (Brethine) to stop uterine activity. During this medication therapy, the nurse implements nursing interventions to monitor which specific body organs that can be affected by this medication? 1. Kidneys and lungs 2. Heart and kidneys 3. Heart and lungs 4. Lungs and gastrointestinal tract Answer: 3
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Rationale: Terbutaline sulfate affects the smooth muscles of the uterus, which decreases contractions. It also affects the contractibility of the smooth muscles of the heart and lungs and can cause serious complications to the cardiopulmonary systems. It does not affect the kidneys or gastrointestinal tract. Test-Taking Strategy: Use knowledge regarding this medication to answer the question but if you need to guess, use the ABCs—airway, breathing, and circulation—to direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1019. 685. A nurse is caring for a client who is in preterm labor. While caring for the client, the client’s membranes rupture. The initial nursing action is to: 1. Place the client in Trendelenburg position 2. Notify the physician 3. Monitor the fetal heart rate (FHR) 4. Administer oxygen Answer: 3 Rationale: When the membranes rupture, the fetus can drop down in the birth canal. This increases the chances of compressing the umbilical cord and compromising the oxygen flow to the fetus. The initial nursing action is to monitor the FHR. The Trendelenburg position is used if the cord is compressed. The physician needs to be notified and oxygen may be administered to the client, but the initial action is stated in option 3. Test-Taking Strategy: Use the principles of prioritizing when answering this question. Remembering that the fetus is the concern will direct you to option 3. Also remember that data collection is the first step of the nursing process. Option 3 is the only option that addresses data collection. Review care to the pregnant client whose membranes rupture if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 248. 686. A client in preterm labor is prescribed bed rest. The nurse assists the client to which of the following most advantageous positions? 1. Lateral 2. Supine 3. Semi-Fowler’s 4. Trendelenburg Answer: 1
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Rationale: The lateral position takes pressure off the aorta and the inferior vena cava. This increases the blood supply to the uterus. Although the supine and semi-Fowler’s positions may be used, they are not the most advantageous positions. Trendelenburg position is used if a compressed umbilical cord is suspected. Test-Taking Strategy: Note the key words most advantageous. Use the process of elimination recalling that the lateral position assists in preventing vena cava syndrome. Review positions for the pregnant client who has been prescribed bed rest if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 97. 687. A nurse is reviewing the records of clients scheduled for visits at the physician’s office. Which of the following clients would be at most risk for uterine rupture? 1. A client with a history of abruptio placentae 2. A client with a history of a previous cesarean birth 3. A client with a history of placenta previa 4. A client with a history of preterm labor Answer: 2 Rationale: A client with a history of a previous cesarean birth is at most risk for uterine rupture. When a client has a cesarean delivery, an incision is made in the uterine wall. The site of the incision can produce a weakened area in the uterine wall. The conditions identified in options 1, 3, and 4 do not place the client at risk for uterine rupture. Test-Taking Strategy: Focus on the key words risk for uterine rupture. Use knowledge regarding the causes of uterine rupture and the process of elimination to assist in directing you to option 2. Review these causes if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 247. 688. A nurse is caring for a client who was admitted to the maternity unit at 8 AM. The client has contractions occurring every 2 minutes, lasting 1½ minutes, and is dilated 4 cm with cervical effacement of 60%. At 10:30 AM, the contractions cease. The client complains of chest pain and manifests signs and symptoms of shock. The nurse quickly plans care suspecting which of the following? 1. Abruptio placentae 2. Placenta previa 3. Ruptured uterus 4. Preterm labor Answer: 3
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Rationale: The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock due to bleeding in the abdomen. The manifestations identified in the question are not characteristic of abruptio placentae, placenta previa, or preterm labor. Test-Taking Strategy: Focus on the data provided in the question to assist in the process of elimination. Noting the key words signs and symptoms of shock will assist in directing you to option 3. Review the manifestations of a ruptured uterus if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 199-200. 689. A nurse assists to develop a plan of care for a multigravida client who is in labor. The client has a history of cesarean birth, and the nurse determines that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for: 1. Signs of shock 2. Complaints of indigestion 3. Leg pain 4. Abdominal pain Answer: 1 Rationale: The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock resulting from bleeding in the abdomen. Options 2, 3, and 4 are not manifestations of a ruptured uterus. Test-Taking Strategy: Knowledge of the manifestations associated with a ruptured uterus is required to answer this question. Recalling that bleeding can occur in this condition will direct you to option 1. Review the manifestations of a ruptured uterus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 199. 690. A nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing: 1. Marginal placenta previa 2. Complete placenta previa 3. Partial placenta previa 4. Abruptio placentae Answer: 2 Rationale: Complete placenta previa completely covers the internal cervical os whereas
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partial or marginal does not. Abruptio placentae would be identified by signs and symptoms exhibited by the client rather than by ultrasound. Test-Taking Strategy: Use the process of elimination. Note the relationship between “covering the entire internal cervical os” in the question and “complete” in the correct option. If you are unfamiliar with the findings associated with the types of placenta previa, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 216. 691. A nurse is caring for a client with placenta previa. The nurse understands that the client is at high risk for infection and hemorrhage as a result of this condition. The nurse plans care understanding that the client is at high risk for infection and hemorrhage in the postpartum period because of which of the following? 1. Increased uterine contractions postdelivery 2. Increased vaginal secretions, preventing healing at the vaginal site 3. Fewer muscle fibers in the lower segment and increased risk of vaginal organisms reaching the placental site 4. Having sexual intercourse 6 weeks postpartum Answer: 3 Rationale: In placenta previa, the placenta is in the lower segment of the uterus near or over the internal cervical os. After delivery, the muscle tissue in that segment has fewer muscle fibers and the weak contractions cannot compress the open vessels at the site. Infection is a high risk because the placenta site is located near the vagina and any vaginal organisms can easily travel to the uterus causing infection. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Knowledge regarding the complications associated with placenta previa and the causes of the complications is required to answer this question. Note the relationship of the word “infection” in the question and the words “vaginal organisms” in the correct option. Review these complications if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 216-217. 692. A nurse is caring for a client with abruptio placentae. During labor, the priority nursing action would be to monitor: 1. Vital signs 2. Frequency, duration, and intensity of contractions 3. Vaginal discharge 4. Effacement and dilation of the cervix
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Answer: 1 Rationale: In abruptio placentae, the placenta has become detached. It could be marginal where bleeding is noted, or concealed where there is no evidence of bleeding. The client will manifest signs of shock if bleeding occurs, and this complication will be noted by a change in vital signs. Although options 2, 3, and 4 identify items that will be monitored in the client in labor, these are not specifically associated with the issue of the question. Test-Taking Strategy: Focus on the issue of the question and use knowledge regarding care to the client with abruptio placentae to answer this question. Note the key word priority. Recalling that bleeding is a concern will direct you to option 1. Review care to the client with abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 218. 693. A client with a colostomy is demonstrating adequate adjustment to the alteration in body image and is asked to speak to a group of individuals who also have colostomies, but are unable to adjust to this change. The client declines the invitation to speak and reports an extreme fear of speaking. The nurse analyzes this information and determines that the client’s fear would be considered a: 1. Social phobia 2. Agoraphobia 3. Claustrophobia 4. Hypochondria Answer: 1 Rationale: Social phobia focuses more on specific situations, such as fear of speaking, performing, or eating in public. Agoraphobia is the fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia also involves the possibility of experiencing a sense of helplessness or embarrassment. Avoidance of such situations usually results in the reduction of social and professional interactions. Claustrophobia is the fear of closed-in places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. Test-Taking Strategy: Knowledge regarding the specific types of phobias and associated client behaviors is required to answer this question. Focusing on the key words fear of speaking will direct you to option 1. Review the different types of phobias if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 186.
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694. A nurse collects a urine specimen for a urinalysis from a client recently diagnosed with polycystic disease of the kidneys. The nurse documents that the urine is dilute and that the specific gravity of the urine is low. Based on this documentation, which of the following specific gravity results was present? 1. 1.000 2. 1.010 3. 1.020 4. 1.030 Answer: 1 Rationale: Specific gravity is a measure of the concentration of particles in the urine. A normal range of urine specific gravity is approximately 1.005 to 1.030. Early in polycystic kidney disease, the ability of the kidneys to concentrate urine decreases. Options 2, 3, and 4 indicate a normal range for specific gravity. Test-Taking Strategy: Knowledge regarding the normal specific gravity of urine is required to answer this question. Additionally, knowing that polycystic kidney disease decreases the kidneys’ ability to concentrate urine, you would expect that the results of the specific gravity within the urinalysis would indicate more dilute urine. In this case, a specific gravity of 1.000, which indicates a low concentration of urine, is the only correct option. If you had difficulty with this question, review normal specific gravity of urine and the characteristics associated with polycystic kidney disease. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1013. 695. A tuberculin test (Mantoux test) is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse evaluates the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which of the following findings did the nurse note to make this interpretation? 1. An area of induration at the test site measuring 2 mm 2. An area of induration at the test site measuring 7 mm 3. Redness and swelling at the test site without induration 4. Redness and swelling at the test site with an induration measuring 3 mm Answer: 2 Rationale: Normally, an area of induration greater than 15 mm is considered positive in low-risk individuals. However, an area of induration that measures 5 mm or greater in people with HIV infection is considered positive. Redness and swelling do not indicate a positive test result. Test-Taking Strategy: Focus on the issue—that the client has HIV. Recall that in a person infected with HIV, an area of induration 5 mm or greater is considered positive. If you had difficulty with this question, review the Mantoux test and interpretation of the test results. Level of Cognitive Ability: Comprehension
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1846. Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 765-766. 696. A client is scheduled to have electroconvulsive therapy (ECT), and the nurse is assisting in preparing a plan of care for the client. Which of the following problems would the nurse include in the plan as a priority? 1. Fear 2. Anxiety 3. Altered health maintenance 4. Risk for aspiration Answer: 4 Rationale: Risk for aspiration is a priority. Aspiration is prevented by placing the client on an NPO status for 6 to 8 hours before the treatment, removing dentures, and administering glycopyrrolate (Robinul) or atropine as prescribed. Although options 1 and 2 could also be a concern, they are not the priority. Likewise, option 3 may be an appropriate concern, but again is not the priority. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer this question. Physiological needs are the priority, so select the option that addresses these needs. Additionally, use the ABCs—airway, breathing, and circulation. The airway is the concern with the risk of aspiration. If you had difficulty with this question, review procedures related to ECT. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 608. 697. Iron dextran (InFeD) is prescribed to be administered intramuscularly to a client. The nurse prepares the medication and determines that the appropriate method of administration is: 1. Using the Z-track technique 2. Injecting into the deltoid muscle 3. Using a ⅝-inch needle on a large syringe 4. Applying heat to the injection site prior to administration Answer: 1 Rationale: A disadvantage of administering iron dextran intramuscularly is that it causes pain and discoloration at the injection site. When intramuscular administration is prescribed, the medication should be injected deep into the buttock with the Z-track technique. Z-track injection keeps the iron dextran deep in the muscle, thereby minimizing leakage and surface discoloration. The Z-track technique is used for injection
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of medications that can stain or irritate the skin. A ⅝-inch needle is used for subcutaneous injections. Option 4 is an incorrect action. Test-Taking Strategy: Use the process of elimination. Remember that oral iron preparations stain the teeth. This will direct you to option 1 as the correct option, because this method prevents skin-staining. If you had difficulty with this question, review the technique for the intramuscular administration of iron dextran. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 463. 698. A client with acquired immunodeficiency syndrome (AIDS) is receiving intravenous (IV) pentamidine isethionate (Pentam). The nurse assigned to care for the client monitors for signs of which toxic effect related to the administration of this medication? 1. Hypertension 2. Anorexia 3. Dizziness 4. Hypoglycemia Answer: 4 Rationale: Pentamidine isethionate causes severe hypoglycemia that may be fatal. Other toxic effects include hypotension, dysrhythmias, leukopenia, nephrotoxicity, StevensJohnson syndrome, hyperglycemia, and insulin-dependent diabetes mellitus. Anorexia and dizziness are side effects that may occur with the administration of this medication but are not toxic effects. Hypertension is unrelated to the administration of this medication. Test-Taking Strategy: Note the key words toxic effect. Knowledge of the toxic effects associated with the use of this medication will assist in directing you to the correct option. Remember, pentamidine isethionate causes severe hypoglycemia that may be fatal. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 843-844. 699. A nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated to this problem? 1. Purulent nasal discharge 2. Chronic cough 3. Headache more pronounced in the evening 4. Anosmia Answer: 3
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Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough resulting from nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse upon arising after sleep. Test-Taking Strategy: Note the key word unrelated. Use knowledge of signs and symptoms of upper respiratory tract problems to answer this question. Remember, chronic sinusitis is characterized by a headache that is worse upon arising after sleep. Review these signs and symptoms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 370. 700. A clinic nurse is assisting in caring for a large numbers of clients whose chief complaint is the presence of flu-like symptoms. Which of the following recommendations by the nurse is least helpful in working with these clients? 1. Increase intake of liquids 2. Take antipyretics for fever 3. Get a flu shot immediately 4. Get plenty of rest Answer: 3 Rationale: Immunization against influenza is a prophylactic measure, and is not used to treat flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and ingesting nutritious foods and beverages. Medications such as antipyretics and analgesics may also be used for symptom management. Test-Taking Strategy: Note the key words least helpful. These words indicate a false response question and that you need to select the incorrect measure. Recalling that a flu shot is a prophylactic measure will assist in directing you to the correct option. Review the guidelines related to immunization against influenza if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/ Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 479-480.
PN Comprehensive Review CD Questions 601-700
{COMP: No Equations/Formulas; No
601. A client with lung cancer says to the nurse, “I’m sick and tired of my family telling me not to worry and that a cure will be discovered before I know it.” The most therapeutic response by the nurse is: 1. “You’re feeling angry that your family is hoping for a cure?” 2. “Forget about what your family is saying. You have enough to worry about right now.” 3. “They are right. You shouldn’t be so worried.” 4. “Have you told your family how you feel?” Answer: 1 Rationale: Reflection is the therapeutic communication technique that redirects the client’s feelings back in order to validate what the client is saying. Questions that the client will be able to deal with more effectively include those that explore the client’s unwillingness to maintain hope and the client’s anger regarding the family’s hopefulness. Option 2 is nontherapeutic and instills concern in the client. Option 3 is nontherapeutic in that the nurse is agreeing with the family. Option 4 is somewhat premature and closes off facilitation of the client’s feelings. Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Options 2 and 3 can be easily eliminated because they are nontherapeutic. In option 4, the nurse is attempting to assess the client’s ability to openly discuss feelings with family members. While this may be appropriate, the timing is somewhat premature and closes off facilitation of the client’s feelings. Option 1 uses the therapeutic technique of reflection. Remember to always focus on the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 602. A nurse is preparing a client for a cardiac catheterization and the client says, “I don’t want to talk with you. You’re only a nurse; I want my doctor.” Which response by the nurse would be therapeutic? 1. “That’s fine, if that’s what you want; I’ll call your physician.” 2. “I’m assigned to prepare you for this procedure, so I need to complete my
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assignment.” 3. “So you’re saying that you want to talk to your physician?” 4. “I’m angry with the way you’ve dismissed me. I am an educated nurse and I know what I am doing.” Answer: 3 Rationale: In option 3, the nurse uses the therapeutic communication technique of reflection to redirect the client’s feelings back for validation. Option 2 is nontherapeutic and also addresses the legal issue of performing a procedure when in fact the client is refusing. Option 4 is clearly nontherapeutic and focuses on the nurse’s feelings rather than the client’s feelings. Although option 1 may seem appropriate, it does not reflect the client’s feelings nor does it provide an opportunity for the client to express feelings. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Options 2 and 4 can be easily eliminated first because they both are nontherapeutic responses. Next eliminate option 1 because it does not provide an opportunity for the client to express feelings. Remember to address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 603. A nurse is providing one-to-one supervision to a client who has attempted suicide. The client says to the nurse, “I can never do anything right. I’m such a loser. It didn’t even work when I tried to kill myself.” The appropriate nursing response is: 1. “You must do some things right.” 2. “Everything will get better; just wait and see.” 3. “You don’t do anything right?” 4. “You need to think about how you are feeling. You’re not a loser; you are just sick right now.” Answer: 3 Rationale: Option 3 allows the client to verbalize feelings; therefore the nurse can learn more about what the client really means by the statement. This option also repeats the client statement. Option 1 may be threatening because at this time the client is not feeling that way. Option 2 places the client’s feelings on hold. Option 4 is also inappropriate and places the client’s feelings on hold. Test-Taking Strategy: Use therapeutic communication techniques to select the correct option. Option 3 is the only option that addresses the client’s feelings and allows the communication to stay open. Options 1, 2, and 4 are nontherapeutic and do not encourage the client to further explore his or her feelings. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health
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Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 604. A client who is suicidal tells the nurse, “All I want to do is end it all.” The appropriate nursing response is which of the following? 1. “Your family would be upset if they heard you say that.” 2. “You are just tired; you don’t really mean that.” 3. “Did you have a bad night?” 4. “What do you mean by that?” Answer: 4 Rationale: Option 4 allows the client to tell you more about what the current thoughts are. Option 1 is false reassurance and does not address the client’s feelings. Option 2 does not address the client’s feelings. In fact, the nurse is expressing feelings that the client may not be experiencing. Option 3 changes the subject and may close communication. Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Eliminate option 1 because it does not address the client’s feelings and provides false reassurance. Option 2 also blocks communication and does not provide the client an opportunity to express feelings. Option 3 is a communication block because it changes the subject. Remember to always address client feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 605. A female client with myasthenia gravis comes to the physician’s office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. The appropriate nursing response is: 1. “What you need to do is join a support group.” 2. “You need to deal with this concern because it is a reality.” 3. “You need to look at the positives in life.” 4. “Have you thought about sharing your feelings with your husband?” Answer: 4 Rationale: Encouraging the client to share feelings with her husband directly addresses the issue of the question. Advising the client to join a support group will not address the client’s immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client’s concerns. Test-Taking Strategy: Focus on the issue of the question and use therapeutic communication techniques. Option 4 is the only option that addresses the client’s immediate concerns. Option 4 also encourages further communication between the client and the nurse regarding the client’s concerns. Remember, address the client’s feelings and concerns first. Review therapeutic communication techniques if you had difficulty
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with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Neurological Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 606. While providing care to a client, the nurse notes that the client is expressing anger and is verbally abrupt with the nurse. During further exploration of the client’s feelings, the nurse notes that the client angrily says that the doctor purposefully provided wrong information about the diagnosis and states, “The doctor lied to me.” Which of the following would be an inappropriate response to the client? l. “The doctor would never lie to you.” 2. “Can you tell me more about the information that you are referring to?” 3. “I’m not sure what information you are referring to.” 4. “Have you thought about talking to your doctor about this?” Answer: 1 Rationale: The response in option 1 could make the client defensive and block further communication because it expresses disagreement with the client’s statement. Options 2 and 3 attempt to clarify what the client is referring to. Option 4 attempts to explore if the client is comfortable talking to the doctor about this issue and encourages direct confrontation. Test-Taking Strategy: Note the key word inappropriate. This word indicates a false response question and that you need to select the incorrect response. Note that options 2 and 3 are similar and can be eliminated first. Eliminate option 4 next because the nurse is encouraging direct confrontation between the client and the doctor. Disagreeing or challenging a client’s response will hinder or block therapeutic communication. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 88. 607. A nurse is admitting a client to the hospital with a diagnosis of chronic bronchitis. The physician has also documented the suspicion of pulmonary emphysema and has prescribed diagnostic studies. The nurse collects data from the client and notes that which of the following signs of chronic bronchitis is unassociated with emphysema? 1. Scant mucus production 2. Marked dyspnea 3. Marked weight loss 4. Cough that began before the onset of dyspnea Answer: 4 Rationale: Key features of pulmonary emphysema include dyspnea that is often marked,
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late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea. Test-Taking Strategy: Note the key word unassociated. This word indicates a false response question and that you need to select the incorrect sign. Recalling the differences between these two respiratory disorders and their associated manifestations will direct you to option 4. Review these differences if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 497. 608. A client has a large abdominal wound. The skin is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which of the following is the appropriate nursing action? 1. Apply Montgomery ties 2. Use hypoallergenic tape 3. Culture the skin around the wound 4. Cleanse the skin with povidone-iodine Answer: 1 Rationale: The nurse should apply Montgomery ties to prevent further skin breakdown as a result of tape irritation from frequent dressing changes. Hypoallergenic tape is used on clients either with thin and fragile skin or with skin that is sensitive to standard tape. Cleansing with povidone-iodine and obtaining a skin culture are incorrect nursing actions. Test-Taking Strategy: Use knowledge of basic concepts related to skin integrity and wound care materials to answer this question. Options 3 and 4 can be eliminated first because they will not assist in preventing further irritation. Eliminate option 2 next because hypoallergenic tape is used on clients either with thin and fragile skin or with skin that is sensitive to standard tape. Review the advantages and purpose of Montgomery ties 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: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 416. 609. A nurse reviews the care plan of an assigned client and notes that the client has a nursing diagnosis of disturbed sleep pattern. The nurse gives the client which of the following to best help the client achieve a restful night’s sleep? 1. A taco 2. A warm cup of tea 3. A filling bedtime snack
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4. A glass of warm milk Answer: 4 Rationale: Milk contains the essential amino acid tryptophan, which enhances sleep by promoting production of the neurotransmitter serotonin in the brain. The client should avoid spicy foods and a large intake just before bedtime. The client should also avoid caffeine after noon. Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated because it is a spicy food and is likely to cause indigestion. Option 2 can be eliminated because tea contains caffeine. Note the word “filling” in option 3. This word should also indicate that this is an incorrect option. Review measures that will promote sleep if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 416. 610. A nurse is getting ready to provide mouth care to an unconscious client. The nurse understands that which item is not used to perform this procedure? 1. Mouthwash and a soft toothbrush 2. Bite stick or a padded tongue blade 3. Laryngoscope 4. Oral suction catheter Answer: 3 Rationale: A soft toothbrush and mouthwash are needed to perform oral care. A bite stick or padded tongue blade is used to open the mouth; the nurse should not use gloved fingers to open the mouth to prevent injury to self. Small volumes of fluid are used in rinsing the mouth, and oral suctioning is used to prevent aspiration. A laryngoscope is not needed; this would be used for intubation. Test-Taking Strategy: Use the process of elimination and note the key words not used. This tells you that the correct option is an unnecessary piece of equipment. Use basic nursing knowledge related to hygiene measures and visualize the procedure to direct you to the correct option. Review the procedure for performing mouth care 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: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 20602061. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1044-1046. 611. A nurse is providing eye care to an unconscious client. The nurse wipes the eye
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with a clean, wet cotton ball, moving from the: 1. Upper eyelid to the lower eyelid 2. Lower eyelid to the upper eyelid 3. Inner canthus to the outer canthus 4. Outer canthus to the inner canthus Answer: 3 Rationale: The nurse cleanses the eye by wiping from the inner canthus to the outer canthus. This provides for best asepsis because it moves from a cleaner area to a dirtier one. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use basic nursing knowledge related to eye care to answer this question. Recalling the basic principles related to asepsis and visualization of the procedure will direct you to the correct option. Review this procedure 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. 1050. 612. A nurse is planning to teach a client with a continuous passive motion (CPM) device instructions about the device and its use. The nurse would not include which incorrect instruction when discussing the machine and its operation with the client? 1. Reset the degrees of flexion or extension according to comfort 2. Keep the knee aligned with the hinged joint on the machine 3. Use of the “stop-go” button 4. Leave the leg padding in the device Answer: 1 Rationale: The client is instructed about how to stop and start the CPM device and to leave the padding in the device for leg protection. The client should be taught proper positioning and alignment. The client should not try to adjust the flexion and extension settings. These are decided by the orthopedic surgeon and are maintained as ordered. Test-Taking Strategy: Note the key words incorrect instruction in the question. Read each option carefully and remember that the degree of flexion and extension is decided by the surgeon. Review the guidelines related to the use of a CPM device if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 791-792. 613. A client has been instructed in crutch-walking techniques and has been fitted for crutches. The nurse determines that the client understands proper fit of the crutches if the client states that the space between the axilla and the top crutch pad should be:
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1. 3 to 4 inches 2. 2 to 3 inches 3. 1½ to 2 inches 4. ½ to 1 inch Answer: 3 Rationale: The client should have a distance of 1½ to 2 inches between the axilla and the top of the crutch pad to prevent injury to the brachial nerve plexus while maintaining proper support. This measurement should be taken with the client holding the crutches with the elbows bent at a 30-degree angle. The other options are incorrect. Test-Taking Strategy: Use concepts related to basic client mobility to answer this question. Visualizing the distances identified in each of the options will direct you to option 3. Review the procedures related to crutch walking if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 805. 614. A nurse has taught a client with chronic pain how to operate a transcutaneous electrical nerve stimulation (TENS) unit. The client turns up the level of stimulation until there is an uncomfortable sensation. The nurse determines that the client understands the use of the device if the client takes which of the following actions next? 1. Shuts off the device immediately 2. Increases the device settings slightly 3. Adjusts the setting downward slightly 4. Adjusts the setting downward by half Answer: 3 Rationale: The client applies a TENS unit by placing two electrodes on the skin and adjusting the level of stimulation to one lead at a time. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximum stimulation necessary to block painful stimuli has been reached. The volume is then reduced slightly until no further muscle contractions occur. The other options are incorrect. Test-Taking Strategy: To answer this question accurately, you must be familiar with the TENS unit and its application. Option 2 can be easily eliminated because it does not make sense to turn the device higher if uncomfortable sensations are felt. Next eliminate option 1, knowing that this action would serve no useful purpose with this device. From the remaining options, recalling the purpose of this device will direct you to option 3. Review the procedure for using the TENS unit if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 589-591.
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615. A client is being seen in a clinic for symptoms of hyperinsulinism. The client asks the nurse for information about any necessary changes in the diet. Which of the following diets would be appropriate for a client with the diagnosis of hyperinsulinism? 1. Low-fiber, high-fat diet 2. Limit food intake to two meals per day 3. Large amounts of carbohydrates between low-protein meals 4. Small, frequent meals with protein, fat, and carbohydrates at each meal Answer: 4 Rationale: The definition of hyperinsulinism is an excessive insulin secretion in response to carbohydrate-rich foods, leading to hypoglycemia. It is often treated with a diet that provides for limited stimulation of the pancreas. Carbohydrates can produce a rapid rise in blood glucose levels. However, carbohydrates are necessary in the diet. Proteins do not stimulate insulin secretion. Fats are needed in the diet to provide calories. The best diet for hyperinsulinism will contain proteins and fats whenever carbohydrates are consumed. Diets high in soluble fiber may be beneficial. Test-Taking Strategy: Use the process of elimination and knowledge of the causes of high insulin levels. Option 1 suggests a high-fat diet, which would promote obesity and atherosclerosis. Option 2 would provide for long periods of fasting, which could lead to hypoglycemic episodes. Option 3 would increase insulin secretion and worsen the problems of hyperinsulinism. Option 4 is the best, healthiest choice for the client. Review the treatment for this disorder 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: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 781, 786. 616. A nurse is reinforcing instructions about home safety measures to a parent. Which statement by the parent indicates a need for further instructions? 1. “I need to place all toxic substances in a locked area after labeling them.” 2. “I need to keep the Poison Control Center telephone number available.” 3. “I need to make sure to keep medications in child-proof bottles.” 4. “I need to refer to medication as ‘candy for when you are sick’.” Answer: 4 Rationale: Home safety measures are very important to prevent unnecessary childhood poisoning or death. Toxic substances should be labeled with green poison stickers and should be placed in a locked area out of reach of children. The Poison Control Center telephone number should be visible near all telephones. Medications should be stored in child-proof containers. Medicine should not be referred to as “candy.” This could tempt a child to try to eat it when the parents are not in the immediate vicinity. Test-Taking Strategy: Note the key words need for further instructions in the question. These words indicate a false response question and that you need to select the incorrect statement. Noting the word “candy” in option 4 will direct you to this option. Review
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home safety and poison control measures if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 977-978. 617. An older client with arthritis of the hands and fingers is having difficulty using a metered dose inhaler (MDI). The nurse suggests to ask the physician for an order to use a(n): 1. Spacer device 2. Nebulizer 3. Oral (pill) form of the medication 4. Intravenous (IV) form of the medication Answer: 1 Rationale: For a client with arthritis or other conditions that limit the use of the hands, the use of a spacer may prove beneficial. A spacer device allows the medication to be delivered deep into pulmonary tissues, even if the client has difficulty with coordination. MDIs may be difficult to use because it takes coordination and adequate hand motion to hold the canister, depress the canister, and inhale. A spacer is especially useful for clients who are older or who have difficulty using an MDI. The other options are incorrect. Test-Taking Strategy: Because specific medication information is not presented in the question, you cannot know if other forms of the medication are available. This helps you eliminate options 3 and 4. From the remaining options, recall the purpose of nebulizers and spacers. This will direct you to option 1. Review the procedures related to selfadministration of inhaled medications 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. 867. 618. A client has a noninfected pressure ulcer on the left heel. The nurse should use which of the following sterile solutions to cleanse the wound as part of a dressing change procedure? 1. Hydrogen peroxide 2. Povidone-iodine 3. Water 4. Normal saline Answer: 4 Rationale: Normal saline (0.9%) should be used for cleansing ulcers, unless there is a specific order for another solution. Normal saline is isotonic (unlike water) and does not damage cells that are needed for healing (as povidone-iodine and hydrogen peroxide do). Test-Taking Strategy: Use knowledge of basic concepts related to wound care to answer
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this question. Noting the key words noninfected and cleanse the wound and recalling that normal saline is an isotonic solution will direct you to option 4. Review the basic procedures related to wound care 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. 750. 619. A nurse is assigned to care for a hearing-impaired client. The nurse should avoid which approach because it is unlikely to enhance communication and preserve the client’s self-esteem? 1. Turn down the volume on the radio or TV 2. Use many exaggerated hand gestures while talking 3. Stand directly in front of the client while speaking 4. Speak slowly and clearly Answer: 2 Rationale: When communicating with a hearing-impaired client, the nurse stands directly in front of the client or angles the mouth so that sound reaches the client’s better ear. The nurse speaks slowly and clearly in a normal tone of voice. Competing noises such as a radio and TV should be minimized. The nurse can use gestures as long as they are appropriate and used in moderation. All these approaches will enhance the communication process and minimize the client’s self-consciousness about hearing loss. Test-Taking Strategy: Use the process of elimination. Noting the key word avoid in the question and the word “exaggerated” in option 2 will direct you to this option. Review these communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 108. 620. A client with severe uterine bleeding is admitted to the labor and birthing department. Which of the following data would best alert the nurse to early signs of hypovolemic shock? 1. Diminished peripheral pulses 2. Decreased blood pressure 3. Cold and clammy skin 4. Restlessness and agitation Answer: 4 Rationale: Early signs of hypovolemic shock include restlessness, anxiety, and agitation. Later signs of hypovolemic shock include a falling blood pressure, diminished peripheral pulses, pallor, cold and clammy skin, and a urine output less than 30 ml per hour. Options 1, 2, and 3 are all signs of late hypovolemic shock. Option 4 is the correct
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option. Test-Taking Strategy: Note the key word early and use the process of elimination. Remember, the early signs of hypovolemic shock include restlessness, anxiety, and agitation. Review these signs if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 286-287. 621. An older female client complains of leaking urine whenever she sneezes, coughs, or laughs. The nurse identifies that which of the following is occurring in this client? 1. Reflex incontinence 2. Functional incontinence 3. Urge incontinence 4. Stress incontinence Answer: 4 Rationale: Stress incontinence is caused by coughing, laughing, and other activities that increase intraabdominal pressure. Reflex incontinence, sometimes called overflow incontinence, is a loss of urine that is uncontrollable and occurs at predictable intervals. Functional incontinence is also involuntary and occurs often in clients with cognitive deficits, although the urinary and nervous systems are intact. Urge incontinence occurs following the sensation of an urgent need to void. Test-Taking Strategy: To answer this question accurately, you must be familiar with the various types of incontinence and their differentiating factors. Focusing on the factors identified in the question that lead to the incontinence will assist in directing you to option 4. Review the various types of incontinence 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: Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 248. 622. A nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. The nurse tells the client that which of the following activities is not harmful in the postoperative period? 1. Bending below the waist 2. Lifting objects that weigh more than 20 pounds 3. Reading magazines and newspapers 4. Watching television Answer: 4 Rationale: The client is taught to avoid activities that raise intraocular pressure because it could cause complications in the postoperative period. For this reason, the client should avoid bending over, lifting heavy objects, straining, sneezing, and making sudden
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movements. The client is also taught to avoid activities that cause rapid eye movements because these would be irritating in the presence of postoperative inflammation. For this reason, the client is told not to read. Watching television is permissible because the eye does not need to move rapidly with this activity and it does not increase the intraocular pressure. Test-Taking Strategy: Note the key words not harmful and recall the types of activities that increase intraocular pressure or are otherwise irritating to the eye. Eliminate options 1 and 2 first, because they obviously increase intraocular pressure. From the remaining options select option 4 because it is less taxing to the eyes. Review home care instructions for the client following eye surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1056. 623. A nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further instructions? 1. “I need to wear an eye shield at night.” 2. “I need to sleep on the back or the right side.” 3. “I need to call the doctor if I have an oral temperature higher than 98.6° F.” 4. “I need to wear sunglasses during the day.” Answer: 3 Rationale: The client is generally taught to report a temperature of 101° F or greater. The client should also report chills, pain unrelieved by medication, bleeding, foulsmelling drainage, or redness at the surgical site. The client should protect the eye by wearing sunglasses during the day and an eye shield at night. The client should lie on the back or the nonoperative side unless otherwise instructed by the surgeon. Test-Taking Strategy: Note the key words need for further instructions in the question. These words indicate a false response question and that you need to select the incorrect client statement. Note that options 1, 2, and 4 all provide protection to the operative eye. Additionally, knowing that a temperature of 101° F or greater would require physician notification will direct you to option 3. Review these client instructions if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 572-573. 624. A client who had previously undergone cataract surgery tells the ambulatory care nurse about the sudden onset of vision changes. The client has begun seeing flashing lights and floaters in the eye. Based on the client’s history, the nurse interprets that the client is at risk of developing:
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1. Glaucoma 2. Recurrent cataract 3. Detached retina 4. Papilledema Answer: 3 Rationale: Clients with a history of cataract surgery, myopia, or trauma or with a family history of retinal conditions are at greater risk for developing a detached retina. Signs and symptoms include sudden onset of flashing lights or floaters. The client may also have loss of peripheral vision or a sudden shadow in the field of vision. Clients with these risk factors should be taught the signs and symptoms of detached retina and to report them promptly. Options 1, 2, and 4 are not associated risks. Test-Taking Strategy: Use the process of elimination. Focusing on the symptoms presented in the question (flashing lights and floaters) will assist in directing you to option 3. Review the signs of a detached retina 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/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 573. 625. A client with primary open-angle glaucoma has been prescribed pilocarpine (Pilocar) ophthalmic drops, and the client asks the nurse how this medication works. The nurse tells the client that the medication lowers intraocular pressure by: 1. Dilating the pupil 2. Reducing intracranial pressure 3. Increasing the outflow of aqueous humor 4. Reducing production of aqueous humor Answer: 3 Rationale: Miotic agents (pilocarpine) increase contractions of the ciliary muscle and constrict the pupil, thereby increasing the outflow of aqueous humor. Beta-adrenergic blocking agents reduce intraocular pressure by decreasing the production of aqueous humor. Options 1 and 2 are not actions of this medication. Test-Taking Strategy: Use the process of elimination. Focusing on the diagnosis of the client and recalling the pathophysiology associated with glaucoma will assist you in eliminating the incorrect options. Review the action of this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 577. 626. A client with glaucoma has impaired vision. The nurse interprets that the client needs information about the condition if the client states that:
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1. Nightlights have been placed in the hallway at home 2. It is important to make appointments for periodic eye examinations 3. The family will drive the client for shopping and errands 4. There is no reason to avoid driving at dusk Answer: 4 Rationale: The client with impaired vision as a result of glaucoma should take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and avoiding driving at dusk or dawn. The client should also understand the need for ongoing monitoring of vision status. Test-Taking Strategy: Use the process of elimination and note the key words needs information about the condition. These words indicate a false response question and that you need to select the incorrect client statement. Use basic principles for working with clients with impaired vision to answer this question. Also, focusing on safety measures related to sight will direct you to option 4. Review these safety measures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Adult Health/Eye References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 580. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1070. 627. A client arrives at the urgent care center with a chemical burn of the right eye. The first priority of the nurse is to prepare the client for: 1. Application of a cold compress to the right eye 2. Application of a warm compress to the right eye 3. Application of a light bandage to the right eye 4. Flushing the eye with copious amounts of sterile solution Answer: 4 Rationale: When the client has suffered a chemical burn of the eye, the nurse immediately flushes the eye with a sterile solution for 15 continuous minutes. If a sterile eye irrigation solution is not available, running water may be used. Applying compresses or bandages do not rid the eye of the damaging chemical. Warm compresses may be used for eye infections. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid. Test-Taking Strategy: Focus on the type of eye injury to assist in directing you to option 4. It would seem reasonable that if a chemical eye injury occurred, flushing would be the priority. Review emergency eye care if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing:
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Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 445. 628. A nurse is preparing to instill an otic solution into an adult client’s right ear. The nurse would avoid which of the following in this procedure? 1. Pulling the auricle upward and backward 2. Touching the tip of the dropper to the edge of the ear canal 3. Warming the solution to room temperature 4. Placing the client in a left side-lying position Answer: 2 Rationale: The dropper is not allowed to touch any object or any part of the client’s skin. The solution is warmed before use. The client is placed on the side, with the affected ear directed upward. The nurse pulls the auricle upward and backward, and instills the medication by holding the dropper about 1 cm above the ear canal. Test-Taking Strategy: Use the process of elimination and note the key word avoid. This word indicates a false response question and that you need to select the incorrect action. Visualizing each of the descriptions in the options and recalling the principles of aseptic technique will direct you to option 2. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 652. 629. A nurse is providing instructions to a client with chronic vertigo. The nurse instructs the client about which safety measure to prevent injury or exacerbation of symptoms? 1. Remove throw rugs and clutter in the home 2. Turn the head from side to side if dizziness occurs 3. Drive only when there is no dizziness 4. Go to a sofa or a bed and lie down when vertigo starts Answer: 1 Rationale: The client with chronic vertigo should avoid driving and using public transportation because the sudden movements could begin an attack. The client should change positions slowly, and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should keep the home environment free of clutter for general safety. The client should remove throw rugs, because the effort of trying to regain balance after slipping could trigger the onset of vertigo. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 4 first, because they put the client at greatest risk of injury secondary to vertigo. From the remaining options, select option 1 knowing that the client with chronic vertigo should not drive. Also, note the absolute word “only” in option 3. Review these safety measures if you had difficulty with this question. Level of Cognitive Ability: Application
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Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 309-310, 359. 630. A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder? 1. Tendency to stay home alone 2. Refusal to answer the telephone 3. Denial of hearing loss 4. Proper use of hearing aid Answer: 4 Rationale: Presbycusis is a progressive sensorineural hearing loss that occurs as part of the aging process. Some clients do not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Test-Taking Strategy: Use the process of elimination and note the key words successfully adapted. A review of each of the options shows that the only option with positive wording is option 4. The incorrect options indicate a need for further adaptation. Review the psychosocial issues related to a client with a hearing impairment if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Ear References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 154. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1092. 631. A client has just been told by the physician that she has breast cancer. The client responds, “Oh, no; this has to be a big mistake.” The nurse interprets that the client’s initial reaction is one of: 1. Anxiety 2. Fear 3. Denial 4. Rage Answer: 3 Rationale: The client’s response is one of denial. This is a common response to hearing distressing news and is a defense mechanism. As an initial reaction, the client’s denial is not of great concern to the nurse. Denial is also the first stage of the grieving process, which is experienced by clients diagnosed with cancer. Test-Taking Strategy: Use the process of elimination and knowledge of psychological responses and coping strategies to answer this question. Focus on the client’s statement
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to help direct you to the correct option. Review defense mechanisms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Oncology Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 22-23. 632. A nurse in the ambulatory care setting has just scheduled a client for a mammogram the following week. The nurse gives the client which instruction about test preparation? 1. The client may consume only a liquid diet the day before the test 2. The client should not use skin lotions on the day of the test 3. The client may wear a necklace on the day of the procedure 4. The client should be sure to use underarm deodorant before the test Answer: 2 Rationale: Mammography is a type of radiographic procedure. Therefore the client is advised not to wear jewelry or metal objects on the day of the examination. There is no special dietary preparation. The client should avoid the use of lotions or underarm deodorant on the day of the test. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first because of the word “only.” From the remaining options, recalling the procedure for mammography and that lotions or deodorants should not be applied to the skin will assist in directing you to the correct option. Review preprocedure instructions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 765. 633. A nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats? 1. Steatorrhea 2. Bloody diarrhea 3. Electrolyte disturbances 4. Gastrointestinal reflux disease Answer: 1 Rationale: The pancreas makes digestive enzymes that aid absorption. Chronic pancreatitis interferes with absorption of nutrients. Fat absorption is limited because of the lack of pancreatic lipase. Steatorrhea by definition means fatty stools, typically a result of malabsorption problems. Options 2, 3, and 4 are rarely associated with chronic pancreatitis. Test-Taking Strategy: Use the process of elimination and recall the pathophysiology related to pancreatitis. Knowledge of the definition of steatorrhea will direct you to
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option 1. Steatorrhea occurs when absorption of fat is not possible. Options 2, 3, and 4 are rarely associated with chronic pancreatitis and therefore should be eliminated as options. Review the definition of steatorrhea and the pathophysiology related to pancreatitis 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: Nix, S. (2005). Williams’ basic nutrition & diet therapy (11th ed.). St. Louis: Mosby, p. 331. 634. A clinic nurse has given a client the materials needed to test the stool for occult blood as part of routine screening for colorectal cancer. The client asks the nurse if there are any special precautions that must be followed in doing this test. The nurse tells the client to avoid eating which of the following for at least a day before performing the test? 1. Cheese 2. Bananas 3. Green peas 4. Red meat Answer: 4 Rationale: The client should avoid eating red meat for at least 24 hours before obtaining the sample. This will help prevent false-positive results, because red meat contains animal blood. The items in options 1, 2, or 3 do not need to be avoided. Test-Taking Strategy: Use the process of elimination. Recalling that the test measures blood cells in the stool will assist in eliminating each of the incorrect options and direct you to option 4. Review the instructions for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 401-403. Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 830-832. 635. A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse tells the client which of the following about the procedure? 1. The client can wear only a wristwatch for jewelry 2. Expect the MRI machine to make noises 3. The client cannot eat or drink after midnight on the day of the test 4. The MRI scanner is a large and spacious machine Answer: 2 Rationale: The MRI scanner is a narrow, tube-like machine that uses magnetic fields and radiofrequency waves to produce two- and three-dimensional cross-sectional views of a
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body area being studied. The machine is narrow and confined and makes a variety of noises during the procedure. The client may not wear any metal objects in the scanner, and clients with implanted metal devices may be ineligible for this diagnostic test. There are no dietary restrictions prior to the procedure. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first because of the absolute word “only.” From the remaining options, you must be familiar with this diagnostic test and its unique characteristics. Review the preprocedure instructions for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 404. 636. A nurse is reviewing the laboratory results of a client receiving chemotherapy for cancer. The nurse reports which abnormal result to the physician? 1. Red blood cell (RBC) count, 4.4 million/mm3 2. White blood cell (WBC) count, 6000/mm3 3. Platelet count, 40,000/mm3 4. Hematocrit, 38% Answer: 3 Rationale: Hematological toxicity from chemotherapy occurs when there is decreased production of blood components (RBCs, WBCs, and platelets) owing to the effects of antineoplastic agents. Each of the values in the options listed is normal, with the exception of option 3, which is low. The nurse reports this finding, because this value places the client at risk for bleeding. Test-Taking Strategy: Use the process of elimination and use knowledge of the normal values for common laboratory tests to answer this question. Option 3 is the only option that identifies an abnormal laboratory value. Review these normal values if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 940. 637. A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The physician inserts a nasogastric tube and prescribes a standard formula tube feeding to run at 50 ml per hour. The nurse plans care knowing that which of the following is true regarding enteral feedings? 1. Enteral feedings are a frequent cause of sepsis 2. Tube feedings should be refrigerated until just before use 3. The caloric value of enteral feedings is generally 5.0 to 10.0 kcal/ml 4. Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI)
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tract Answer: 4 Rationale: Enteral nutrition can include providing nutrients by mouth, nasogastric tube, gastrostomy tubes, or percutaneous endoscopic gastrostomy (PEG). The common element to each of these methods of delivery is the fact that the client must have normal GI digestive capabilities. If the client does not have a normal GI tract, other methods of nutrient delivery must be sought, such as total parenteral nutrition. Enteral feedings may cause aspiration pneumonia resulting from regurgitation of formula into the lungs; however, these feedings are not generally associated with sepsis. Tube feedings should be given at room temperature to avoid problems with diarrhea. The caloric value of most standard enteral feeding formulas is 1.0 to 2.0 kcal/ml. Test-Taking Strategy: Focus on the issue of the question—enteral feedings. Use the process of elimination and knowledge regarding this type of nutrition to answer the question. Remember that enteral feedings require a normal functioning GI tract. Review these types of feedings 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 477-480. 638. A nurse is assigned to the care of a client with an unsealed internal radiation source. The nurse plans the client’s care to avoid spending more than how much time in the client’s room during the 8-hour work shift? 1. 2 hours 2. 60 minutes 3. 30 minutes 4. 15 minutes Answer: 3 Rationale: The maximum time limit for exposure to the client with an unsealed internal radiation source is 30 minutes every 8 hours. The nurse should strictly adhere to this guideline and should also wear a dosimetry badge to measure actual exposure. Test-Taking Strategy: Specific knowledge regarding the radiation exposure guidelines is needed to answer this question accurately. Review these guidelines if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 362. 639. A nurse is discussing chemotherapy with a client who has been diagnosed with cancer. The nurse tells the client that an advantage of continuous intravenous (IV) chemotherapy is that it:
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1. Uses smaller doses to kill cancer cells, so it is less toxic to normal tissues 2. Has the shortest duration of therapy for all cancer sites 3. Has the fewest number of side effects 4. Is the least expensive form of therapy Answer: 1 Rationale: Continuous IV chemotherapy may be done over a period of hours, days, or weeks. A distinct advantage is that it exposes a tumor constantly to a small medication dose, which allows tumor cells to be killed while having fewer toxic effects to normal tissues. The other options are incorrect. The cost and duration of therapy (options 2 and 4) depend on the individual situation. The side effects depend on the agents used. Test-Taking Strategy: An understanding of the purpose and principles of chemotherapy is needed to answer this question correctly. Remember, continuous IV chemotherapy exposes a tumor constantly to a small medication dose, which allows tumor cells to be killed while having fewer toxic effects to normal tissues. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 372. 640. A client is receiving chemotherapy that carries a risk of phototoxicity as an adverse effect. The nurse determines that the client has not experienced this side effect if the client remains free of which of the following? 1. Ecchymoses 2. Erythema 3. Warts 4. Petechiae Answer: 2 Rationale: Typical photosensitivity reactions involve a “sunburn” reaction of the skin. It is characterized by erythema and blister formation. Warts result from viruses, while ecchymoses and petechiae indicate bleeding. Test-Taking Strategy: Focus on the issue—a phototoxicity reaction. Recalling the description of phototoxicity will direct you to option 2. Review the characteristics of this adverse effect if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 386. 641. A nurse reviews the care plan of a client with cancer and notes that the client has a nursing diagnosis of Imbalanced Nutrition: less than body requirements related to side effects of therapy. To enhance appetite and nutrition, the nurse advises the client to
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avoid: 1. Foods that are near room temperature 2. Sources of lean animal protein 3. Small, frequent meals 4. Strong-smelling foods Answer: 4 Rationale: The client with cancer is advised to avoid strong-smelling foods that may aggravate anorexia or be distasteful to the client. The client should increase intake of calories and sources of lean protein. The client should also eat small, frequent meals. Foods that are near room temperature, or that are neither too hot nor too cold, are better tolerated by the client. Other measures that can help improve appetite include rinsing the mouth before eating and dining in an aesthetically pleasing environment. Test-Taking Strategy: Use the process of elimination. The key word avoid in the question guides you to look for an option that is not helpful to the client. Recalling the principles of general nutrition for the client who is debilitated should direct you to option 4. Review the measures that will enhance appetite and nutrition if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 370. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 336. 642. A nurse reviews the care plan of a client with cancer undergoing chemotherapy. The nurse notes that the client has a nursing diagnosis of risk for Disturbed Body Image related to possible alopecia. The nurse plans to tell the client which of the following about hair loss and regrowth to assist the client in coping with this possible change? 1. Facial hair and body hair are not affected 2. Regrown hair may have a different color and texture 3. Hair loss is permanent for most people 4. Hair loss begins within 1 day of the first treatment Answer: 2 Rationale: Hair loss is often temporary, and hair grows back once treatments are completed. Hair may have a different color and/or texture when it regrows. Hair loss often begins within 14 days of beginning treatment. Body hair and facial hair also are affected. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because of the words “not,” “permanent,” and “1 day” in these options, respectively. Review the effects of chemotherapy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology
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Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 729. 643. A registered nurse asks a licensed practical nurse (LPN) to gather and bring into the client’s room the equipment that is necessary to discontinue a dose of intravenous (IV) chemotherapy on a client with cancer. The LPN leaves which of the following unnecessary items on the cart outside the room? 1. Gown 2. Latex gloves 3. Disposal bag for equipment 4. Face mask Answer: 1 Rationale: Equipment needed when handling chemotherapy agents includes disposable latex gloves and a mask to protect the skin, the mouth, and the nose. A gown is not necessary unless it is part of agency policy. A disposable bag is useful for discarding used equipment. This provides a physical barrier to minimize risk of skin contact by others. Test-Taking Strategy: Use the process of elimination. Evaluate each of the options in terms of the area that it protects. The essential equipment covers an exposed body surface or area of the nurse (skin, nose, mouth, or eyes) or minimizes risk to others. The unnecessary item covers clothing, which is not particularly useful when discontinuing an infusion. Review the guidelines related to administering chemotherapy 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: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 375. 644. Immediately following cataract repair, the client’s affected conjunctiva and eyelids are edematous. The nurse tells the client that this is: 1. Abnormal, because only the conjunctiva should be affected 2. Abnormal, because only the eyelids should be affected 3. Unusual, and should be reported if not improved within 24 hours 4. Normal, and should subside within 3 days Answer: 4 Rationale: After surgery to remove cataracts, it is normal for edema of the conjunctiva, sclera, and eyelids to be present. This is due to the trauma of surgery and should resolve in 3 or fewer days following surgery. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that edema can occur following trauma will direct you to option 4. Also, note the absolute words “only” in options 1 and 2 and “not” in option 3. Review the expected findings following this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity
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Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 451. 645. A client has undergone cataract removal without an intraocular lens implant. The client is visibly upset because his vision is blurry. The nurse should do which of the following to provide realistic reassurance to this client? 1. Explain that vision will improve with adjustment to aphakic lenses 2. Reassure the client that bright color contrasts in the environment will help 3. Tell the client that there are resources available for the legally blind 4. Determine whether the client knows any other people who have gone blind Answer: 1 Rationale: The client who had cataracts removed without intraocular lens implant will have blurry vision. The vision improves with the wearing of aphakic lenses. Depending on the degree of visual impairment preoperatively, this may or may not be an actual worsening of the client’s original vision. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they contain the word “blind.” The client is not necessarily blind after this procedure. From the remaining options, recalling the intended effects of this surgery will direct you to option 1. Review the effects of cataract surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1064. 646. A male client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to avoid which of the following to prevent barotrauma during takeoff and landing? 1. Sucking on a piece of hard candy 2. Keeping the mouth motionless 3. Swallowing a few times 4. Yawing occasionally Answer: 2 Rationale: Clients who are susceptible to barotrauma should do any of a variety of mouth movements to equalize pressure in the ear, particularly during takeoff and landing of an aircraft. These include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva’s maneuver may also be helpful. The client should avoid sitting with the mouth motionless during this time because it enhances pressure buildup behind the tympanic membrane. Test-Taking Strategy: Use the process of elimination and note the key word avoid in the question. Evaluate each of the options in terms of the degree of motion. Remember that
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options that are similar are not likely to be correct. All the incorrect options for this question as it is stated are similar because they involve movement of the mouth. Review these client teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear References: Ignatavicius, D., & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care (4th ed.). Philadelphia: W.B. Saunders, p. 1067. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1786. 647. A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse tells the client to be sure to do which of the following immediately after discharge? 1. Avoid taking any medication for pain except aspirin 2. Go swimming as long as the head is kept above water 3. Use a shower cap to protect the ears if taking a shower 4. Wash the hair in 2 minutes or less to avoid water buildup in the ears Answer: 3 Rationale: It is important to avoid getting water in the ears following insertion of ear tubes. For this reason, swimming, showering, and hair washing are avoided after surgery for a period of time that is specified by the surgeon. A shower cap or earplug may be used during showering if allowed by the physician. The client should take medication as advised for postoperative discomfort. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are similar. From the remaining options, use knowledge of principles related to postoperative care and ear surgery to direct you to option 3. Review these client teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 595. 648. An adult client with a history of ear infections calls the ambulatory care clinic to make an appointment because of a right earache accompanied by a sensation of fullness. The client also complains of nausea and has a temperature of 100.6° F. The nurse first questions the client about whether: 1. Any medications have relieved the pain 2. The client hears ringing in that ear 3. There is a history of recent head injury 4. There is a history of recent upper respiratory tract infection (URI) Answer: 4 Rationale: Otitis media in the adult is typically one-sided and presents as an acute
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process with earache, fullness in the ear, nausea with possible vomiting, and fever. The client may complain of decreased ability to hear in that ear. The nurse takes a client history first, assessing whether the client had a recent URI. It is unnecessary to question the client about head injury or ringing in the ear. The nurse may ask the client whether anything relieves the pain, but the pain that accompanies ear infection is not usually relieved until antibiotic therapy is started. Test-Taking Strategy: Use the process of elimination and note the key word first. Recalling that an URI is associated with ear infections will assist in directing you to the correct option. Review the etiology associated with ear infections if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1985. 649. A client is recovering at home after suffering a cerebrovascular accident (CVA) 2 weeks ago. A home caregiver states that the client has difficulty swallowing food and fluids. Which nursing action would be appropriate as a first action? 1. Observe the client feeding him or herself 2. Observe the caregiver feeding the client 3. Arrange for a home health aide to assist at mealtimes 4. Instruct the caregiver to use a feeding syringe to feed the client Answer: 1 Rationale: It is not uncommon for a client to have difficulty swallowing after having a CVA. Often the client has hemiplegia. The client’s arm may be paralyzed, and the client has to learn to use an opposite arm to feed self. Using a different arm may require rehabilitation and retraining. Also, a client may have partial paralysis of the mouth, tongue, or esophagus. To best assist the client, the nurse should first assess the situation by watching the client feed him or herself. Perhaps the problem lies in the feeding technique, the type of feeding tool used, the types of foods being served, or a combination of problems. Having someone else feed the client may be necessary if the client is determined to be unable to feed self, but this action does not promote independence in the client. A feeding syringe is not recommended for feeding most clients. Test-Taking Strategy: Use the process of elimination and note the key word first. In this situation the problem is the client’s inability to feed him or herself. Eliminate options 2 and 3 first because they are similar. Next, eliminate option 4 knowing that this is not an appropriate action. The first step would be to determine what the client’s capabilities are before giving the responsibility of feeding the client to someone else. Review care to the client following a CVA 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
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Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 426-427. 650. A nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers: 1. That aspiration is a primary concern 2. To maintain the client in a supine position 3. To change the NG tube with every other feeding 4. To increase the rate of the feeding if the infusion rate falls behind schedule Answer: 1 Rationale: Nasogastric tube feedings are beneficial but present several significant possible complications such as diarrhea, contaminated formulas, lactose intolerance, dumping syndrome, or excess fluid volume. The most common complication is aspiration pneumonia, which is caused by regurgitation of formula contents from the stomach into the respiratory tract. Keeping the head of the bed elevated to 30 degrees at all times assists in the prevention of this complication. An NG tube can remain in place for weeks to months, depending on the type of tube that is inserted, and is not changed with every other feeding. Problems with diarrhea may be caused by infusing a formula that is too cold, is contaminated, or is of the wrong consistency. Infusion of formula at a rate that is too rapid may also be a cause of diarrhea; the rate of the infusion should not be increased to “catch up” if the procedure falls behind schedule. Test-Taking Strategy: Use the process of elimination and the ABCs—airway, breathing, and circulation—to answer the question. This will direct you to option 1. A client in a supine position, even if just for a moment (such as when changing bed linens), could develop aspiration pneumonia. Option 3 is incorrect because nasogastric tubes may be left in place for weeks to months depending on the type of tube inserted. Option 4 could lead to fluid overload problems. Review care to the client with an NG tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension 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. 478. 651. A nurse is teaching a client how to use a new hearing aid. As part of the information given, the nurse would tell the client to: 1. Not worry about providing any special care to the hearing aid 2. Rub a small amount of petrolatum (Vaseline) in the ear before insertion 3. Check the battery to assure that it is working before use 4. Leave the hearing aid in place while showering Answer: 3 Rationale: The client should check the battery of the hearing aid before use. Lubricants or other solvents are not used around or on the devices. It should be cleaned according to the manufacturer’s directions, which usually consist of washing with warm soapy water
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followed by thorough drying. The hearing aid should be removed for showering, because it should not get wet between recommended washings. It should also be put away in its case at night for protection against damage. Test-Taking Strategy: Focus on the issue—care to a hearing aid. Reading each option carefully will easily direct you to option 3. Review client instructions related to a hearing aid if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 298. 652. A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works most effectively if it is taken at least: 1. 2 days before a triggering event 2. 1 day before a triggering event 3. 12 hours before a triggering event 4. 1 hour before a triggering event Answer: 4 Rationale: To be most effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate (Dramamine), scopolamine (Transderm-Scōp), meclizine (Bonine), promethazine (Phenergan), and prochlorperazine (Compazine). Test-Taking Strategy: Specific knowledge about the optimal time frames for this type of medication is needed to answer this question correctly. Noting that the issue of the question relates to the use of medication to prevent motion sickness will direct you to option 4. Review the guidelines related to these medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 272. 653. A nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation? 1. Either excessive itching or tearing of the eyes 2. A blank spot in the field of vision 3. Difficulty with driving at night and blurred vision 4. Pain in the eyes when in dim light Answer: 3 Rationale: A cataract is characterized by a cloudy lens, which results in blurred vision and difficulty driving at night. There is sometimes monocular diplopia, photophobia, and
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glare. The client does not experience eye pain. The other options are incorrect. Test-Taking Strategy: Focus on the issue—untreated cataracts. Recalling that blurred vision is a characteristic of this disorder will direct you to option 3. Review the characteristics of cataracts if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 570. 654. A nurse is evaluating the results of a client’s serum laboratory studies. Which result indicates a deficiency of protein intake? 1. Triglycerides, 140 mg/dl 2. Blood glucose, 78 mg/dl 3. Albumin, 2.6 mg/dl 4. Hemoglobin, 15 g/dl Answer: 3 Rationale: Albumin is a type of protein, and decreased serum levels (option 3) can indicate a number of problems, including malnutrition and decreased protein intake. The normal albumin level is 3.4 to 5 g/dl. The triglycerides, blood glucose, and hemoglobin levels are all within normal ranges. Triglycerides are a type of lipid consisting of three fatty acids bound to glycerol, and glucose is the most elemental form of carbohydrate. Hemoglobin carries oxygen in the red blood cells. Test-Taking Strategy: Focus on the issue—a deficiency of protein intake. Recalling the relationship between protein and albumin will direct you to option 3. Also recalling the normal laboratory values for the tests identified in the options will direct you to option 3. Review these normal laboratory values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 148. 655. A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the physician’s explanation of the disorder. The nurse would tell the client that: 1. The lens of the eye becomes opaque and decreases vision 2. The blood vessels in the back of the eye rupture and bleed 3. There is a reduction in the amount of aqueous humor produced in the eye 4. The pressure within the eye increases from excess fluid or blockage of drainage Answer: 4 Rationale: Open-angle glaucoma results either from an increase in the production of aqueous humor or from obstruction to its drainage from the eye. Option 1 describes cataract formation. Options 2 and 3 are incorrect. Test-Taking Strategy: Focus on the issue—open-angle glaucoma and its
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pathophysiology. Recalling that glaucoma increases the pressure within the eye will direct you to option 4. Review the characteristics of glaucoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 576. 656. A client who has just obtained a hearing aid is receiving suggestions about its use and maintenance from a nurse. The nurse tells the client that it is helpful to: 1. Leave the hearing aid on both night and day 2. Keep an extra battery available 3. Change the battery if the aid makes a whistling noise 4. Reattach the ear mold after cleaning it to the hearing aid while it is still damp Answer: 2 Rationale: The client should keep an extra hearing aid battery available. The hearing aid should be shut off when not in use so that the battery is not drained. If the hearing aid makes a whistling noise, the client should adjust its position in the ear. After cleaning the ear mold, the client should dry it thoroughly before reattaching it to the hearing aid. Test-Taking Strategy: Focus on the issue—care of a hearing aid. Recalling that a battery is a key component of the hearing aid will assist in directing you to option 2. Review client instructions regarding a hearing aid if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Ear Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 298. 657. A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse would avoid instilling which of the following solutions into the ear to aid in removal of the insect? 1. Mineral oil 2. Water 3. Ether solution 4. Lidocaine Answer: 2 Rationale: Water should not be used in the ear canal if an insect is trapped in it. The water will cause the insect to swell, making its removal more difficult. The other solutions are acceptable because they will either kill or stupefy the insect. Test-Taking Strategy: Note the key word avoid. Recalling that water will cause the insect to swell will direct you to option 2. Review care to the client with a foreign body in the ear if you had difficulty with this question. Level of Cognitive Ability: Application
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Ear Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1985. 658. A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). The nurse should plan to do which of the following next? 1. Notify the physician immediately 2. Make a notation in the nurse’s notes 3. Make a note for the nurse on the evening shift to give the medication 4. Do nothing; because no further action is required Answer: 2 Rationale: If a client misses or refuses a dose of medication, the nurse should record in the nurse’s notes the reason that the medication was not given. It is unnecessary to notify the physician immediately because of the nature of the medication and the client’s reason for refusal. The licensed practical nurse should, however, inform the registered nurse. Option 3 is incorrect, because medications are not left for the nurse on the next shift to administer because of client refusal. Option 4 is incorrect. An explanation of the missed dose should be recorded. Test-Taking Strategy: Use basic principles of medication administration to answer this question and note the key word next. Recalling the importance of documentation will direct you to option 2. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 81. 659. A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is necessary when caring for this client? 1. Provide oral fluids three times per day 2. Check around the stoma site for skin irritation 3. Medicate with antidiarrheal medications every day 4. Use sterile technique with all procedures Answer: 2 Rationale: A gastrostomy tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. As a result of the surgical incision, occasionally gastric contents leak out onto the client’s skin. Gastric contents are highly acidic and can cause major skin irritation. The skin irritation may lead to infection. The nurse must monitor the insertion site for skin irritation. Option 1 is incorrect, and generally the client with a G-tube is unable to tolerate oral intake. Antidiarrheal medications are not administered every day. Aseptic, not sterile, technique is needed in caring for the client. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because the client generally does not have the capability of swallowing and therefore needs the G-
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tube. Eliminate option 3 because antidiarrheal medications are not administered every day. Eliminate option 4 because aseptic, not sterile, technique is necessary when working with G-tubes. Review care to the client with a G-tube 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. 481. 660. A client who fell asleep while apparently smoking in bed awakens and rings the call bell for the nurse. The nurse enters the room and sees that the client’s bedspread is in flames. The nurse should take which action first? 1. Hurry to get a fire extinguisher to put out the fire 2. Pull the nearest fire alarm switch 3. Get the client out of the room 4. Put water into a wash basin and try to douse the fire Answer: 3 Rationale: The principles of fire safety can be easily remembered by recalling the acronym RACE. This stands for rescue (option 3), alarm (option 2), confine (or contain), and extinguish (options 1 and 4). Option 3 is the first action the nurse should take. Option 2 should be done next, followed by option 1. Option 4 is not part of standard procedure for health care agencies, although it is an attempt to put out the fire. Test-Taking Strategy: Use basic principles of fire safety to answer this question. Note that the question contains the key word first. Use client safety and the acronym RACE as the guide in directing you to option 3. Review the rules of fire safety 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 312. 661. A nurse is assigned to care for a client on the fourth day of hospitalization who is recovering from partial thickness burns to 60% of body surfaces. The client’s vital signs are temperature 102.8° F, pulse rate 98 beats per minute, respirations 24 breaths per minute, and blood pressure 105/64 mm Hg. Total parenteral nutrition (TPN) is infusing at 82 ml per hour. Based on these data, the nurse plans to initially: 1. Recheck the vital signs in 1 hour 2. Check the client for signs of infection 3. Change the TPN solution and IV tubing 4. Discontinue the TPN and culture the tip of the catheter and the insertion site Answer: 2 Rationale: The client is recovering from serious burns. The burn client is prone to
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several complications such as infection and sepsis. A temperature of 102.8° F is significant. On the fourth hospital day, infection may be the problem. The site of the infection may be the burns, the TPN infusion or TPN site, or other problems. As an initial action, the nurse needs to check the client for signs of infection and then notify the registered nurse, who will contact the physician for further orders. Test-Taking Strategy: Focus on the issue of the question and note the key word initially. Use the steps of the nursing process, noting that option 2 is the only option that addresses data collection. Review the signs of complications in a burn 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1039. 662. A male client states that he has removed all dairy foods from his diet because he is lactose intolerant. The nurse plans care for the client knowing that: 1. Calcium and protein are valuable nutrients and need to be supplemented in some form 2. Calcium supplements alone will be needed to supplement for dairy products 3. Lactose enzymes must be taken to eliminate the effects of lactose intolerance 4. Leafy, green vegetables will provide all of the necessary calcium Answer: 1 Rationale: Calcium and protein need to be supplemented in some form in the diet of the client with lactose intolerance. Lactose enzymes may help clients with lactose intolerance, but they may not eliminate the client’s problems. An individual generally does not consume enough leafy, green vegetables daily to obtain sufficient calcium. Test-Taking Strategy: Focus on the issue of the question. Note the absolute words in options 2 (alone), 3 (must), and 4 (all). Review this nutritional disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning 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. 676. 663. A client is admitted to an acute care facility with complications of celiac disease. Which question would be most helpful initially in obtaining information for the nursing care plan? 1. “What types of pasta can you eat?” 2. “What is your understanding of celiac disease?” 3. “What types of food do you like to eat?” 4. “Have you eliminated whole-wheat bread from your diet?” Answer: 2 Rationale: Celiac disease is also known as gluten-induced enteropathy. It causes
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diseased intestinal villi, which results in decreased absorptive surfaces and malabsorption syndrome. Clients with celiac disease must maintain a gluten-free diet, which eliminates all products, made from wheat, rye, oats, barley, buckwheat, or graham. Many products may contain gluten without the client’s knowledge. Beer, pasta, crackers, cereals, and many more substances contain gluten. It is often very difficult for a client to learn all of the food substances that must be eliminated from a diet. Also, it is often very difficult for a client to adhere to a strict diet. Test-Taking Strategy: Note the key word initially and use teaching/learning principles to answer the question. Initially it is important to determine the client’s level of knowledge. Option 2 gives the client a chance to explain his understanding of the disease. With this background information, the nurse will be better able to assess the problem and assist the client. Review teaching/learning principles 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: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 849. 664. A client has been on total parenteral nutrition (TPN) for 8 weeks at home. The physician orders that the client be weaned off TPN by 50 ml/hour/day until discontinued. The client asks the nurse, “Why doesn’t the doctor just stop the TPN instead of dragging it on for 3 days?” The best nursing response would be to explain that the physician is concerned about which phenomenon? 1. Dehydration 2. Hypokalemia 3. Hypernatremia 4. Rebound hypoglycemia Answer: 4 Rationale: Clients receiving TPN are obtaining high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusions rates are tapered down. Before discontinuing the TPN, the body must adjust to the lowered glucose levels. If the TPN were suddenly withdrawn, the client would probably have rebound hypoglycemia. Options 1, 2, and 3 are not concerns when the TPN is discontinued. Test-Taking Strategy: The focus of the question is on the complications of TPN when it is discontinued. Recalling that a concern of TPN that needs to be monitored is the effect of the high glucose concentrations and its effect on insulin levels will direct you to option 4. Review the procedures when discontinuing TPN if you had difficulty with this question. Level of Cognitive Ability: Comprehension 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. 487.
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665. A client has been receiving total parenteral nutrition (TPN) at 125 ml/hour for 5 days. On data collection, the nurse notes bilateral rales (crackles) and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which nursing action would be appropriate as a first action? 1. Notify the registered nurse of the findings 2. Encourage the client to cough and deep breathe 3. Check the client’s medication orders for a diuretic 4. Slow the TPN infusion rate to 100 ml/hour Answer: 1 Rationale: The client is showing signs of fluid retention and possible excess fluid intake. Rales, edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces. The problem may or may not be related to the TPN. Other possible causes of fluid retention include impaired respiratory and cardiovascular function, impaired kidney function, or a combination of factors. The nurse needs to notify the registered nurse of the findings. The registered nurse will then notify the physician for further orders. Option 2 will have little if any effect on peripheral edema and weight gain. Option 3 infers that a diuretic will help the situation, and it is possible that the physician will order a diuretic; however, the physician needs to be aware of the change in the physical condition of the client. The nurse should not increase or decrease the rate of TPN infusions without a physician’s order. Test-Taking Strategy: Note that the TPN has been infusing for 5 days. Focus on the data regarding the client and think about the potential complications associated with TPN infusions. Eliminate option 2 because this action will not assist the client, considering the client’s signs and symptoms. Eliminate options 3 and 4 because these actions should not be implemented without further physician instructions. Review the complications associated with the administration of TPN and the associated nursing interventions 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. 990. 666. A physician orders a total parenteral nutrition (TPN) solution to start at 50 ml/hour by infusion pump via an established subclavian central line. After 2 hours of receiving the TPN infusion, the client suddenly complains of difficulty in breathing and chest pain. Which action would the nurse prepare to do first? 1. Auscultate the lung sounds 2. Clamp the TPN infusion 3. Obtain a blood glucose level 4. Obtain an electrocardiogram (ECG) Answer: 2 Rationale: A complication of a subclavian central line can be an embolism as a result of air or thrombus. A sudden onset of chest pain shortly after the initiation of TPN may mean that this complication has developed. The central line is clamped, not discontinued,
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and the physician is notified immediately. Option 1 is an appropriate action but not the first action. Option 3 is not a priority because the client’s symptoms do not indicate the presence of hypoglycemia or hyperglycemia. The physician will probably order an ECG, but this action would not be the initial action in this situation. Test-Taking Strategy: Use the process of elimination. Focusing on the complaints “difficulty in breathing and chest pain” should assist in directing you to option 2. Review the complications of TPN 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: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 536. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 989. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 664. 667. A nurse is assigned to care for a client receiving total parenteral nutrition (TPN) via the left subclavian vein. The nurse would include which priority routine measure in the plan of care for the client? 1. Check the insertion site for signs of infection 2. Maintain the client in a semi-Fowler’s position on his or her back at all times 3. Encourage the client to cough and deep breathe 4. Take the blood pressure hourly Answer: 1 Rationale: TPN that is infusing via a central line, such as through the subclavian vein, is more likely to become infected than a standard peripheral IV line. Infection may quickly lead to sepsis. The insertion site should be inspected every 4 to 6 hours. It is not necessary to place the client in a semi-Fowler’s position on his or her back at all times. It is advisable to encourage the client to cough and deep breathe, but this action does not relate to the issue of the question. It is not necessary to take the blood pressure hourly. Test-Taking Strategy: Focus on the issue of the question and read each option carefully. Note the key word priority. Eliminate option 2 because of the absolute word “all” and option 4 because of the word “hourly.” From the remaining options, recalling that infection is a primary concern will assist in directing you to option 1. Review nursing care to a client with TPN 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 References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 537. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 989.
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668. A client arrives in the emergency room with a complaint of severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, the initial nursing action would be which of the following? 1. Obtaining orthostatic vital signs 2. Preparing to insert a total parenteral nutrition infusion 3. Preparing to insert a nasogastric tube feeding 4. Checking the client’s skin for irritation because of diarrhea Answer: 1 Rationale: The initial nursing action is to determine the client’s level of dehydration. Orthostatic vital signs (blood pressure and pulse rate measurements while lying, sitting, and standing) are actions to determine the probability of fluid losses. A decrease of more than 10 to 20 mm Hg in blood pressure and an increased pulse rate of 10 to 20 beats per minute probably indicate significant intravascular fluid volume deficit. With a significant history of nausea, vomiting, and diarrhea accompanied by weight loss, the client is potentially facing a life-threatening problem. Generally, the fluid levels must be increased quickly with lactated Ringer’s or normal saline intravenous solutions as prescribed. Option 4 may be an intervention but is not the initial action. Options 2 and 3 are not initial measures to treat dehydration. Test-Taking Strategy: Focus on the issue of the question and the client’s symptoms and note the key word initial. Using the steps of the nursing process will assist in eliminating options 3 and 4. From the remaining options, select option 1 based on the situation presented and because this option addresses the ABCs—airway, breathing, and circulation. Review care to the client at risk for dehydration 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 424. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 159. 669. A client who had knee surgery 4 days ago calls the nurse at the physician’s office and reports that he has not had a bowel movement since before surgery. Which question would most assist the nurse in the collection of data regarding the client’s problem? 1. “When was your last pill for pain?” 2. “How often do you take a laxative?” 3. “Do you eat meats?” 4. “What foods and drinks have you had since you’ve been home?” Answer: 4 Rationale: Constipation is the probable cause of the client’s lack of stools. It is marked by difficult or infrequent passage of stools that are hard and dry. Constipation has numerous causative factors including psychogenic issues, lack of physical activity, inadequate intake of food and fiber, and medication influences. A client recovering from
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knee surgery may have several factors influencing elimination patterns. The question in option 4 will elicit data regarding the client’s intake and will assist in determining whether an inadequate intake of food and fiber exists. Test-Taking Strategy: Focus on the issue of the question—the cause of the constipation. Options 1 and 2 can be eliminated first because they are unrelated to the issue of the question. From the remaining options, eliminate option 3 because it will not elicit adequate information that will assist the nurse in determining the cause of the constipation. Review the causes of constipation 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 566-567, 749. 670. A caregiver states that the client seems to be losing weight and that the client eats only about 25% of the food that is offered. The caregiver asks the nurse about feeding the client by a tube into the stomach. The initial response by the nurse would be which of the following? 1. “Tube feedings are only for long-term feeding problems.” 2. “Tube feedings can provide adequate amounts of required nutrients.” 3. “Tube feedings often result in complications such as aspiration pneumonia.” 4. “Tube feedings are not helpful in cases of intractable vomiting or severe diarrhea.” Answer: 2 Rationale: Tube feedings are an alternative for temporary or permanent nutritional maintenance. Enteral tube feedings are generally safer and significantly less costly than peripheral or total parenteral nutrition. Weight loss and a dietary intake of only 25% indicate that alternative sources of nutritional intake should be sought. Option 1 is incorrect because tube feedings are often temporary measures. Option 3 may be correct; however, it is not the best response to a caregiver seeking initial information. Option 4 is unrelated to the situation of this question. Test-Taking Strategy: Focus on the issue of the question and use the process of elimination noting the key word initial. Eliminate option 4 first because it is unrelated to the situation of this question. Next, eliminate option 3 because it is not the best response to a caregiver seeking initial information and may produce fear in the caregiver. From the remaining options, recalling that tube feedings may be used as a temporary measure of providing nutrition will assist in directing you to option 2. Review the concepts and purposes related to tube feedings 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. 477. 671. A client is admitted to the maternity unit at 5 AM and has remained at station 0, with
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strong contractions every 3 minutes. The fetal heart rate (FHR) is 140 beats per minute. It is 7 PM, no progress has occurred, and the FHR is decreasing. Which of the following nursing actions is appropriate? 1. Prepare the client for induction of labor 2. Turn the client to the left side 3. Prepare the client for a cesarean delivery 4. Palpate the bladder for fullness Answer: 3 Rationale: An indication for a cesarean delivery is failure of labor to progress accompanied by fetal distress. In this situation, the nurse will prepare the client for this procedure. Option 1 would not be indicated in this case because the client has been in labor for 14 hours and the FHR is beginning to decrease. Options 2 and 4 are nursing actions for all clients in labor. Placing the client on the left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. Keeping the bladder empty allows the fetus to descend. Test-Taking Strategy: Focus on the data provided in the question and note the key words the FHR is decreasing. Use the process of elimination recalling that in this situation, it is most important to deliver the baby as quickly as possible. Review care to the client in labor and the indications for a cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 249-250. 672. A nurse is preparing a client for an emergency cesarean delivery. Which of the following are the most important data to collect regarding the client? 1. Was the informed consent form signed? 2. Was a Foley catheter inserted? 3. When was the last oral intake? 4. Were a complete blood cell count and urinalysis performed? Answer: 3 Rationale: The status of oral intake is the most important data to collect. This information will provide the basis for the type of anesthesia used to prevent aspiration during surgery and postoperatively. Options 1, 2, and 4 are all routine preoperative procedures. Test-Taking Strategy: Note the key words emergency cesarean delivery. This tells you that the client may not have been on an NPO status. Use the ABCs—airway, breathing, and circulation—to assist in directing you to option 3. Remember that aspiration is a risk of some types of anesthesia and the NPO status needs to be determined. Review care to a client requiring emergency cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum
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Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 252. 673. A nurse encourages a new mother and her spouse to discuss the necessary cesarean delivery, focusing on the delivery of the baby instead of the surgical aspect of the procedure. Which nursing statement would provide the best encouragement? 1. “Tell me about the delivery of your baby.” 2. “Your surgery went well.” 3. “You will be able to have other children vaginally.” 4. “The surgery will not limit you in having more pregnancies.” Answer: 1 Rationale: It is important for the mother and her spouse to think of the procedure as the birth of the baby. The mother may become disappointed because she was unable to deliver vaginally, complicating the postpartum phase. Option 2 brings the surgery to focus and can inhibit the mother from bonding with the neonate. Options 3 and 4 place the focus on the future, and the mother needs to focus on the birth of the baby. Test-Taking Strategy: Focus on the issue of the question noting the key words provide the best encouragement. Eliminate options 3 and 4 first because they are similar. From the remaining options, select option 1 because it focuses on the issue of the question and addresses the client’s feelings. Review the psychosocial aspects of a cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 250. 674. Oxytocin (Pitocin) is prescribed to be administered intravenously to a client after a cesarean delivery. The nurse understands that this medication has been prescribed because the action of the medication is to: 1. Stimulate the uterus to contract, control uterine atony, and reduce blood loss 2. Stimulate the production of progesterone for breast-feeding 3. Stimulate the production of estrogen 4. Prevent infection Answer: 1 Rationale: The action of oxytocin is to stimulate the uterus to contract, to control uterine atony, and therefore reduce hemorrhage. Options 2, 3, and 4 are not actions of this medication. Test-Taking Strategy: Knowledge of the action of this medication is necessary in answering this question. Recalling that this medication is used to induce labor will assist in directing you to option 1. Review the action of this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning
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Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 252. 675. A nurse is preparing a client for a cesarean delivery. A Foley catheter is to be inserted into the client’s bladder, and the client asks the nurse why the Foley catheter is necessary. The nurse appropriately replies by telling the client which of the following? 1. “To prevent infection.” 2. “It reduces the risk of injury to the bladder when the surgical incision is made.” 3. “To get an accurate output.” 4. “So that the baby can engage into the birth canal.” Answer: 2 Rationale: A Foley catheter is inserted preoperatively to keep the bladder empty to reduce the risk of injury to the bladder when the surgical incision is made. Options 1, 3, and 4 are not the reasons for inserting a Foley catheter. Test-Taking Strategy: Use the process of elimination and knowledge regarding the basic principles related to the purpose of a Foley catheter to answer the question. Note the relationship between “cesarean delivery” in the question and “surgical incision” in the correct option. Review preoperative care for a cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 250. 676. A nurse is assigned to care for a client in the maternity unit with a diagnosis of dystocia. The nurse prepares the client for which of the following techniques used to relieve shoulder dystocia? 1. Leopold’s maneuver 2. McRobert’s maneuver 3. Placing the client in the lithotomy position 4. Lying the client on the left side Answer: 2 Rationale: The McRobert’s maneuver is used to relieve shoulder dystocia. It is described as the woman flexing her thighs sharply against her abdomen to straighten the pelvic curve. This procedure will assist the fetus to move past the pelvic curve of the woman. Leopold’s maneuver is used to locate the position and presentation of the fetus. Options 3 and 4 are positions, not techniques, and will not assist in relieving shoulder dystocia. Test-Taking Strategy: Use the process of elimination and knowledge regarding the techniques used to relieve shoulder dystocia. Eliminate options 3 and 4 first because these options are positions, not techniques. Recalling that the Leopold maneuver is used to locate the position and presentation of the fetus will direct you to option 2 from the remaining options. Review these maneuvers if you had difficulty with this question. Level of Cognitive Ability: Application
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 241. 677. A nurse reviews the laboratory results for a client with leukemia receiving chemotherapy. The nurse notes that the white blood cell (WBC) count is 2000/mm3. The nurse analyzes the results as: 1. Lower than normal, signifying leukopenia 2. Indicating infection 3. Higher than normal, indicating metastasis 4. Normal Answer: 1 Rationale: Chemotherapy agents cause medication-induced leukopenia, and treatment focuses on this side effect. The normal WBC count is 5000/mm3 to 10,000/mm3. An elevated WBC count would most likely indicate infection. Option 3 is an incorrect statement. Test-Taking Strategy: Use the process of elimination and note the key word chemotherapy in the question. Knowing that chemotherapy destroys both normal WBCs and cancer cells is necessary to answer the question. Additionally, recalling the normal WBC count will easily direct you to option 1. Review this normal value if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Oncology Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 940. 678. A nurse provides instructions to a client at risk for thrombophlebitis regarding measures to prevent its occurrence. Which statement by the client indicates an understanding of the measures to prevent thrombophlebitis? 1. “I need to avoid pregnancy by taking oral contraceptives.” 2. “I should avoid sitting or standing in one position for long periods of time.” 3. “I can finally stop wearing these support stockings that you gave me.” 4. “I will be sure to maintain my fluid intake to at least four glasses daily.” Answer: 2 Rationale: Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, maintain normal coagulability, and prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily is an inadequate amount of fluid. Test-Taking Strategy: Use the process of elimination and knowledge regarding the measures that can reduce venous stasis to answer this question. Note the key words
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understanding of the measures. Remember that avoidance of standing or sitting in one position will prevent venous stasis. Review the measures that will prevent thrombophlebitis 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: Adult Health/Cardiovascular Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 732-733, 750. 679. A nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which of the following problems would the nurse expect to note on the plan of care? 1. Anxiety related to a slow progress of labor 2. Anxiety related to parenting 3. Anxiety related to the inability to relax 4. Anxiety related to maternal exhaustion Answer: 1 Rationale: An experience can be influenced by past experiences, culture, support from family or significant other, or by preparation. Dystocia can cause a slowed progress of labor. Maternal anxiety is compounded by the crisis of the slow labor. Options 2, 3, and 4 are unrelated to dystocia. Test-Taking Strategy: Focus on the issue—a diagnosis of dystocia. Recalling the definition of dystocia will direct you to option 1. Review this condition if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 239-240. 680. A nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which of the following? 1. Presence of vaginal bleeding 2. Characteristics of contractions 3. Signs of hyperglycemia 4. Presence of edema Answer: 2 Rationale: Dystocia is a slowed labor process. A prolonged labor is a potential for fetal distress. The nurse would specifically monitor the characteristics of the contractions. Options 1, 3, and 4 are unrelated to this condition. Test-Taking Strategy: Focus on the issue—a diagnosis of dystocia—and note the key words specifically collects. Recalling the definition of dystocia will direct you to option 2. Also, options 1, 3, and 4 are unrelated to this condition. Review this disorder if you had difficulty with this question.
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Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 240. 681. Precipitate delivery is described as a time period of less than 3 hours from the onset of labor to the birth of the baby. If this situation occurred and delivery is imminent, which of the following would be the best nursing action? 1. Leave the client and immediately contact the physician 2. Attempt to keep the baby from being born until the physician arrives 3. Don sterile gloves and gently guide the baby’s head and shoulders 4. Place the client in Trendelenburg position Answer: 3 Rationale: The baby is the priority. In an emergency situation, the nurse assists the client in the delivery by donning sterile gloves and gently guiding the head and shoulders of the baby. The client should not be left alone. Options 2 and 4 are inappropriate and could cause distress to the fetus. Test-Taking Strategy: Note the key words delivery is imminent. Use the process of elimination, noting that the only option that addresses this issue is option 3. Options 1 and 2 are incorrect because the client should not be left alone and because waiting for the physician or keeping the client from delivering could injure the fetus. Option 4 is the position for placing the client when a prolapsed cord is suspected. Review care to the client with a precipitate delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & womaen’s health care (8th ed.). St. Louis: Mosby, pp. 1003-1005. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 679-680. 682. Following a precipitate delivery and initial care of the baby, the placenta must be delivered. Of the following, which would be the appropriate method to use to deliver the placenta? 1. Wait 30 minutes and gently pull the placenta 2. Wrap the cord around a sponge stick and pull hard 3. Gently guide the placenta out after spontaneous separation 4. The nurse never delivers the placenta Answer: 3 Rationale: The placenta is allowed to separate spontaneously; then it is gently guided out. The placenta is attached to the uterine wall, and if it is pulled or left in the uterus, hemorrhage would occur. There may be situations when it is necessary for a nurse to assist in the delivery of the placenta.
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Test-Taking Strategy: Use the process of elimination, noting the word “pull” in options 1 and 2 and the word “never” in option 4. Review care to the client with a precipitate delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & womaen’s health care (8th ed.). St. Louis: Mosby, pp. 1003-1005. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 679-680. 683. A nurse is caring for a client during a precipitate delivery and the delivery of the placenta. The nurse knows that it is important that the uterus contracts to prevent hemorrhage. In addition to fundal massage, the nurse understands that which nursing action will promote uterine contraction? 1. Adding oxytocin (Pitocin) to the intravenous (IV) infusion 2. Increasing the IV infusion rate 3. Keeping the client in the lithotomy position 4. Putting the baby to the mother’s breast and letting the baby suck Answer: 4 Rationale: Nipple stimulation causes the posterior pituitary of the woman to secrete natural oxytocin, which causes the uterine muscles to contract. This is a method that can be an independent action of the nurse. Options 1 and 2 are not appropriate and require a physician’s order. Option 3 will not assist in the contraction of the uterus. Test-Taking Strategy: Focus on the issue, a nursing action, and use knowledge regarding the measures that stimulate uterine contraction to assist in answering the question. Option 3 can be eliminated first. Next, eliminate options 1 and 2 because they are inappropriate and require a physician’s order. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 179, 190. 684. A nurse is caring for a client in preterm labor who is receiving terbutaline sulfate (Brethine) to stop uterine activity. During this medication therapy, the nurse implements nursing interventions to monitor which specific body organs that can be affected by this medication? 1. Kidneys and lungs 2. Heart and kidneys 3. Heart and lungs 4. Lungs and gastrointestinal tract Answer: 3
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Rationale: Terbutaline sulfate affects the smooth muscles of the uterus, which decreases contractions. It also affects the contractibility of the smooth muscles of the heart and lungs and can cause serious complications to the cardiopulmonary systems. It does not affect the kidneys or gastrointestinal tract. Test-Taking Strategy: Use knowledge regarding this medication to answer the question but if you need to guess, use the ABCs—airway, breathing, and circulation—to direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1019. 685. A nurse is caring for a client who is in preterm labor. While caring for the client, the client’s membranes rupture. The initial nursing action is to: 1. Place the client in Trendelenburg position 2. Notify the physician 3. Monitor the fetal heart rate (FHR) 4. Administer oxygen Answer: 3 Rationale: When the membranes rupture, the fetus can drop down in the birth canal. This increases the chances of compressing the umbilical cord and compromising the oxygen flow to the fetus. The initial nursing action is to monitor the FHR. The Trendelenburg position is used if the cord is compressed. The physician needs to be notified and oxygen may be administered to the client, but the initial action is stated in option 3. Test-Taking Strategy: Use the principles of prioritizing when answering this question. Remembering that the fetus is the concern will direct you to option 3. Also remember that data collection is the first step of the nursing process. Option 3 is the only option that addresses data collection. Review care to the pregnant client whose membranes rupture if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 248. 686. A client in preterm labor is prescribed bed rest. The nurse assists the client to which of the following most advantageous positions? 1. Lateral 2. Supine 3. Semi-Fowler’s 4. Trendelenburg Answer: 1
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Rationale: The lateral position takes pressure off the aorta and the inferior vena cava. This increases the blood supply to the uterus. Although the supine and semi-Fowler’s positions may be used, they are not the most advantageous positions. Trendelenburg position is used if a compressed umbilical cord is suspected. Test-Taking Strategy: Note the key words most advantageous. Use the process of elimination recalling that the lateral position assists in preventing vena cava syndrome. Review positions for the pregnant client who has been prescribed bed rest if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 97. 687. A nurse is reviewing the records of clients scheduled for visits at the physician’s office. Which of the following clients would be at most risk for uterine rupture? 1. A client with a history of abruptio placentae 2. A client with a history of a previous cesarean birth 3. A client with a history of placenta previa 4. A client with a history of preterm labor Answer: 2 Rationale: A client with a history of a previous cesarean birth is at most risk for uterine rupture. When a client has a cesarean delivery, an incision is made in the uterine wall. The site of the incision can produce a weakened area in the uterine wall. The conditions identified in options 1, 3, and 4 do not place the client at risk for uterine rupture. Test-Taking Strategy: Focus on the key words risk for uterine rupture. Use knowledge regarding the causes of uterine rupture and the process of elimination to assist in directing you to option 2. Review these causes if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 247. 688. A nurse is caring for a client who was admitted to the maternity unit at 8 AM. The client has contractions occurring every 2 minutes, lasting 1½ minutes, and is dilated 4 cm with cervical effacement of 60%. At 10:30 AM, the contractions cease. The client complains of chest pain and manifests signs and symptoms of shock. The nurse quickly plans care suspecting which of the following? 1. Abruptio placentae 2. Placenta previa 3. Ruptured uterus 4. Preterm labor Answer: 3
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Rationale: The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock due to bleeding in the abdomen. The manifestations identified in the question are not characteristic of abruptio placentae, placenta previa, or preterm labor. Test-Taking Strategy: Focus on the data provided in the question to assist in the process of elimination. Noting the key words signs and symptoms of shock will assist in directing you to option 3. Review the manifestations of a ruptured uterus if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 199-200. 689. A nurse assists to develop a plan of care for a multigravida client who is in labor. The client has a history of cesarean birth, and the nurse determines that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for: 1. Signs of shock 2. Complaints of indigestion 3. Leg pain 4. Abdominal pain Answer: 1 Rationale: The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock resulting from bleeding in the abdomen. Options 2, 3, and 4 are not manifestations of a ruptured uterus. Test-Taking Strategy: Knowledge of the manifestations associated with a ruptured uterus is required to answer this question. Recalling that bleeding can occur in this condition will direct you to option 1. Review the manifestations of a ruptured uterus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 199. 690. A nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing: 1. Marginal placenta previa 2. Complete placenta previa 3. Partial placenta previa 4. Abruptio placentae Answer: 2 Rationale: Complete placenta previa completely covers the internal cervical os whereas
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partial or marginal does not. Abruptio placentae would be identified by signs and symptoms exhibited by the client rather than by ultrasound. Test-Taking Strategy: Use the process of elimination. Note the relationship between “covering the entire internal cervical os” in the question and “complete” in the correct option. If you are unfamiliar with the findings associated with the types of placenta previa, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 216. 691. A nurse is caring for a client with placenta previa. The nurse understands that the client is at high risk for infection and hemorrhage as a result of this condition. The nurse plans care understanding that the client is at high risk for infection and hemorrhage in the postpartum period because of which of the following? 1. Increased uterine contractions postdelivery 2. Increased vaginal secretions, preventing healing at the vaginal site 3. Fewer muscle fibers in the lower segment and increased risk of vaginal organisms reaching the placental site 4. Having sexual intercourse 6 weeks postpartum Answer: 3 Rationale: In placenta previa, the placenta is in the lower segment of the uterus near or over the internal cervical os. After delivery, the muscle tissue in that segment has fewer muscle fibers and the weak contractions cannot compress the open vessels at the site. Infection is a high risk because the placenta site is located near the vagina and any vaginal organisms can easily travel to the uterus causing infection. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Knowledge regarding the complications associated with placenta previa and the causes of the complications is required to answer this question. Note the relationship of the word “infection” in the question and the words “vaginal organisms” in the correct option. Review these complications if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 216-217. 692. A nurse is caring for a client with abruptio placentae. During labor, the priority nursing action would be to monitor: 1. Vital signs 2. Frequency, duration, and intensity of contractions 3. Vaginal discharge 4. Effacement and dilation of the cervix
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Answer: 1 Rationale: In abruptio placentae, the placenta has become detached. It could be marginal where bleeding is noted, or concealed where there is no evidence of bleeding. The client will manifest signs of shock if bleeding occurs, and this complication will be noted by a change in vital signs. Although options 2, 3, and 4 identify items that will be monitored in the client in labor, these are not specifically associated with the issue of the question. Test-Taking Strategy: Focus on the issue of the question and use knowledge regarding care to the client with abruptio placentae to answer this question. Note the key word priority. Recalling that bleeding is a concern will direct you to option 1. Review care to the client with abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 218. 693. A client with a colostomy is demonstrating adequate adjustment to the alteration in body image and is asked to speak to a group of individuals who also have colostomies, but are unable to adjust to this change. The client declines the invitation to speak and reports an extreme fear of speaking. The nurse analyzes this information and determines that the client’s fear would be considered a: 1. Social phobia 2. Agoraphobia 3. Claustrophobia 4. Hypochondria Answer: 1 Rationale: Social phobia focuses more on specific situations, such as fear of speaking, performing, or eating in public. Agoraphobia is the fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia also involves the possibility of experiencing a sense of helplessness or embarrassment. Avoidance of such situations usually results in the reduction of social and professional interactions. Claustrophobia is the fear of closed-in places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. Test-Taking Strategy: Knowledge regarding the specific types of phobias and associated client behaviors is required to answer this question. Focusing on the key words fear of speaking will direct you to option 1. Review the different types of phobias if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 186.
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694. A nurse collects a urine specimen for a urinalysis from a client recently diagnosed with polycystic disease of the kidneys. The nurse documents that the urine is dilute and that the specific gravity of the urine is low. Based on this documentation, which of the following specific gravity results was present? 1. 1.000 2. 1.010 3. 1.020 4. 1.030 Answer: 1 Rationale: Specific gravity is a measure of the concentration of particles in the urine. A normal range of urine specific gravity is approximately 1.005 to 1.030. Early in polycystic kidney disease, the ability of the kidneys to concentrate urine decreases. Options 2, 3, and 4 indicate a normal range for specific gravity. Test-Taking Strategy: Knowledge regarding the normal specific gravity of urine is required to answer this question. Additionally, knowing that polycystic kidney disease decreases the kidneys’ ability to concentrate urine, you would expect that the results of the specific gravity within the urinalysis would indicate more dilute urine. In this case, a specific gravity of 1.000, which indicates a low concentration of urine, is the only correct option. If you had difficulty with this question, review normal specific gravity of urine and the characteristics associated with polycystic kidney disease. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1013. 695. A tuberculin test (Mantoux test) is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse evaluates the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which of the following findings did the nurse note to make this interpretation? 1. An area of induration at the test site measuring 2 mm 2. An area of induration at the test site measuring 7 mm 3. Redness and swelling at the test site without induration 4. Redness and swelling at the test site with an induration measuring 3 mm Answer: 2 Rationale: Normally, an area of induration greater than 15 mm is considered positive in low-risk individuals. However, an area of induration that measures 5 mm or greater in people with HIV infection is considered positive. Redness and swelling do not indicate a positive test result. Test-Taking Strategy: Focus on the issue—that the client has HIV. Recall that in a person infected with HIV, an area of induration 5 mm or greater is considered positive. If you had difficulty with this question, review the Mantoux test and interpretation of the test results. Level of Cognitive Ability: Comprehension
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1846. Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 765-766. 696. A client is scheduled to have electroconvulsive therapy (ECT), and the nurse is assisting in preparing a plan of care for the client. Which of the following problems would the nurse include in the plan as a priority? 1. Fear 2. Anxiety 3. Altered health maintenance 4. Risk for aspiration Answer: 4 Rationale: Risk for aspiration is a priority. Aspiration is prevented by placing the client on an NPO status for 6 to 8 hours before the treatment, removing dentures, and administering glycopyrrolate (Robinul) or atropine as prescribed. Although options 1 and 2 could also be a concern, they are not the priority. Likewise, option 3 may be an appropriate concern, but again is not the priority. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer this question. Physiological needs are the priority, so select the option that addresses these needs. Additionally, use the ABCs—airway, breathing, and circulation. The airway is the concern with the risk of aspiration. If you had difficulty with this question, review procedures related to ECT. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 608. 697. Iron dextran (InFeD) is prescribed to be administered intramuscularly to a client. The nurse prepares the medication and determines that the appropriate method of administration is: 1. Using the Z-track technique 2. Injecting into the deltoid muscle 3. Using a ⅝-inch needle on a large syringe 4. Applying heat to the injection site prior to administration Answer: 1 Rationale: A disadvantage of administering iron dextran intramuscularly is that it causes pain and discoloration at the injection site. When intramuscular administration is prescribed, the medication should be injected deep into the buttock with the Z-track technique. Z-track injection keeps the iron dextran deep in the muscle, thereby minimizing leakage and surface discoloration. The Z-track technique is used for injection
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of medications that can stain or irritate the skin. A ⅝-inch needle is used for subcutaneous injections. Option 4 is an incorrect action. Test-Taking Strategy: Use the process of elimination. Remember that oral iron preparations stain the teeth. This will direct you to option 1 as the correct option, because this method prevents skin-staining. If you had difficulty with this question, review the technique for the intramuscular administration of iron dextran. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 463. 698. A client with acquired immunodeficiency syndrome (AIDS) is receiving intravenous (IV) pentamidine isethionate (Pentam). The nurse assigned to care for the client monitors for signs of which toxic effect related to the administration of this medication? 1. Hypertension 2. Anorexia 3. Dizziness 4. Hypoglycemia Answer: 4 Rationale: Pentamidine isethionate causes severe hypoglycemia that may be fatal. Other toxic effects include hypotension, dysrhythmias, leukopenia, nephrotoxicity, StevensJohnson syndrome, hyperglycemia, and insulin-dependent diabetes mellitus. Anorexia and dizziness are side effects that may occur with the administration of this medication but are not toxic effects. Hypertension is unrelated to the administration of this medication. Test-Taking Strategy: Note the key words toxic effect. Knowledge of the toxic effects associated with the use of this medication will assist in directing you to the correct option. Remember, pentamidine isethionate causes severe hypoglycemia that may be fatal. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 843-844. 699. A nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated to this problem? 1. Purulent nasal discharge 2. Chronic cough 3. Headache more pronounced in the evening 4. Anosmia Answer: 3
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Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough resulting from nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse upon arising after sleep. Test-Taking Strategy: Note the key word unrelated. Use knowledge of signs and symptoms of upper respiratory tract problems to answer this question. Remember, chronic sinusitis is characterized by a headache that is worse upon arising after sleep. Review these signs and symptoms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 370. 700. A clinic nurse is assisting in caring for a large numbers of clients whose chief complaint is the presence of flu-like symptoms. Which of the following recommendations by the nurse is least helpful in working with these clients? 1. Increase intake of liquids 2. Take antipyretics for fever 3. Get a flu shot immediately 4. Get plenty of rest Answer: 3 Rationale: Immunization against influenza is a prophylactic measure, and is not used to treat flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and ingesting nutritious foods and beverages. Medications such as antipyretics and analgesics may also be used for symptom management. Test-Taking Strategy: Note the key words least helpful. These words indicate a false response question and that you need to select the incorrect measure. Recalling that a flu shot is a prophylactic measure will assist in directing you to the correct option. Review the guidelines related to immunization against influenza if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/ Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 479-480.
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