Silvestri701-800

PN~Comp~Review~CD~701-800~1

PN Comprehensive Review CD Questions 701-800 {COMP: formula: 719; fill-in-the-blank: 719} 701. A 52-year-old male client is seen in the physician’s office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 lb. Vital signs are: temperature 98° F oral, pulse 86 beats/min, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dl. Which of the following questions should the nurse ask the client first? 1. “Do you exercise regularly?” 2. “Are you considering trying to lose weight?” 3. “Is there a history of diabetes mellitus in your family?” 4. When was the last time you had your blood pressure checked?” Answer: 4 Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is also a contributing risk factor. The client’s nonmodifiable risk factors are age and gender. Since the client has several risk factors, the nurse places priority on the client’s major modifiable risk factors. Test-Taking Strategy: Use the process of elimination and note the key word first. Options 1 and 2 are similar and can be eliminated first. Option 4 is the priority over option 3 because of the obvious degree of abnormality of the blood pressure. Review the risk factors associated with CAD and hypertension 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/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 579. 702. Levothyroxine sodium (Synthroid) is prescribed for a client with hypothyroidism. The nurse instructs the client to take the medication: 1. In the morning 2. At bedtime 3. At lunchtime 4. At dinnertime Answer: 1 Rationale: Synthetic levothyroxine sodium (Synthroid) increases basal metabolic rate and is used to treat hypothyroidism. It is administered in the morning (on an empty stomach) to prevent insomnia. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar and indicate administering the medication with food. From the

PN~Comp~Review~CD~701-800~2 remaining options, recalling the action and purpose of this medication will direct you to option 1. Review the guidelines for administering 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: Mosby’s 2005 Drug consult for nurses. (2005). St. Louis: Mosby, p. 1167. 703. A nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. Which statement by the client indicates that a knowledge deficit exists regarding insulin pump therapy? 1. “If my blood sugars are elevated, I can bolus myself with additional insulin as ordered.” 2. “I’ll need to check my blood sugars before meals in case I need a premeal insulin bolus.” 3. “Now that I have this pump, I don’t have to worry about insulin reactions or ketoacidosis ever happening again.” 4. “I still need to follow a diet and exercise plan even though I don’t inject myself daily anymore.” Answer: 3 Rationale: All of the statements are correct in regard to insulin pump therapy except option 3. Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject to the usual complications associated with insulin administration without the use of a pump. Test-Taking Strategy: Knowledge of the basics of insulin therapy is helpful to answer this question even if you know little about insulin pump therapy. Options 1, 2, and 4 are logical statements regarding the use of endogenous insulin. Option 3, however, presumes a guarantee from the usual complications of insulin therapy. No biomedical equipment is capable of being 100% safe. Additionally the option also contains the word “ever,” which is an absolute word. Review the principles of insulin pump therapy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 484. 704. A client with Graves’ disease has exophthalmos and is experiencing photophobia. Which intervention would best assist the client with this problem? 1. Administer methimazole (Tapazole) every 8 hours around the clock 2. Lubricate the eyes with tap water every 2 to 4 hours 3. Instruct the client to avoid straining or heavy lifting since this can increase eye

PN~Comp~Review~CD~701-800~3 pressure 4. Obtain dark glasses for the client Answer: 4 Rationale: Medical therapy for Graves’ disease does not help to alleviate the clinical manifestation of exophthalmos. Since photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the symptom. Other interventions may be used to relieve the drying that occurs from not being able to completely close the eyes; however, the question is asking what the nurse can do for photophobia. Tap water, which is hypotonic, could actually cause more swelling to the eye since it could pull fluid into the interstitial space. In addition, there is a risk of an eye infection developing in the client since the solution is not sterile. There is no need to prevent straining with exophthalmos. Test-Taking Strategy: Focus on the issue, photophobia. Knowledge of what photophobia means will help you to answer the question. Methimazole, a medical treatment for Graves’ disease, does not affect the progression of exophthalmos or alleviate the photophobia. Likewise options 2 and 3 will not relieve the photophobia. Review the measures that relieve photophobia 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/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1255-1256. 705. A nurse is assigned to care for a client who had a subtotal thyroidectomy. The nurse reviews the plan of care and determines that the priority nursing diagnosis for this client in the immediate postoperative period would be which of the following? 1. Risk for deficient fluid volume related to T3 and T4 deficits promoting sodium and water loss 2. Risk for infection related to high glucose levels following removal of the thyroid 3. Risk for decreased cardiac output related to hemorrhage 4. Risk for impaired urinary elimination related to hypercalcemia and renal calculi formation Answer: 3 Rationale: Hemorrhage is one of the most severe complications that can occur following thyroidectomy. The nurse must check the neck dressing for bleeding and monitor vital signs frequently to detect early signs of hemorrhage, which could lead to shock. T3 and T4 do not regulate fluid volumes in the body. Removal of the thyroid may affect glucose levels indirectly, but will not put the client at risk for infection. This is a problem more likely to be seen with a client with uncontrolled diabetes mellitus. Hypercalcemia and renal calculi are associated with hyperparathyroidism. Test-Taking Strategy: Focus on the key words priority and immediate postoperative period. Knowledge of thyroid function will assist to eliminate options 1, 2, and 4. Also, use the ABCs—airway, breathing, and circulation. Circulation will be affected if hemorrhage develops. Review care to the client following thyroidectomy if you had

PN~Comp~Review~CD~701-800~4 difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 885-886. 706. A nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a PaO2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which nursing diagnosis would be most appropriate? 1. Fatigue related to debilitated state 2. Impaired gas exchange related to increased pulmonary secretions 3. Ineffective airway clearance related to dilated bronchioles 4. Impaired gas exchange related to pneumonia Answer: 2 Rationale: Restlessness and low PaO2 are hallmark signs of impaired gas exchange. Although many clients with pneumonia experience fatigue, this diagnosis would not be the most appropriate because of the low PaO2. Dilated bronchioles would be a goal for treatment and not part of the problem. Pneumonia is a medical diagnosis. Test-Taking Strategy: Use the process of elimination. Avoid nursing diagnoses that address a medical diagnosis; therefore eliminate option 4. Eliminate option 1 next because it is unrelated to the issue. From the remaining options, knowing that the bronchioles are not dilated in pneumonia will assist in directing you to option 2. Review care to the client with pneumonia and the defining characteristics for impaired gas exchange if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 481-483. 707. A client with tuberculosis (TB) is started on rifampin (Rifadin). The nurse teaches the client about the medication and tells the client: 1. Not to worry about jaundice because an orange discoloration of the skin is common 2. To wear glasses instead of soft contact lenses 3. To always take the medication on an empty stomach 4. That as soon as the cultures come back negative the medication may be stopped Answer: 2 Rationale: Soft contact lenses may be permanently damaged by the orange discoloration that rifampin causes in body fluids. Any sign of jaundice should always be reported. If rifampin is not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months even if cultures are negative. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because an

PN~Comp~Review~CD~701-800~5 orange discoloration of the skin indicates jaundice and should be reported. Eliminate option 3 next because of the absolute word “always.” From the remaining options, use knowledge of the actions and uses of rifampin and the treatment for TB to direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 939. 708. A nurse reviews the physician’s orders for a client with Guillain-Barré syndrome Which order if noted in the client’s record should the nurse question? 1. Vital signs every 2 to 4 hours 2. Clear liquid diet 3. Passive range-of-motion (ROM) exercises three times daily 4. Bilateral calf measurements three times daily Answer: 2 Rationale: Clients with Guillain-Barré syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Clients with Guillain-Barré syndrome are at risk for hypotension and hypertension, bradycardia, and respiratory depression, and require frequent monitoring of vital signs. Passive ROM exercises can help prevent contractures, and checking calf measurements can help detect deep vein thrombosis, for which they are at risk. Test-Taking Strategy: Use the process of elimination and note the key words should the nurse question. Even if you were unaware of the problems with Guillain-Barré syndrome and dysphagia, options 1, 3, and 4 are generally part of routine nursing care. Review the manifestations associated with this disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 394-395. 709. A nurse is assisting in caring for a client with multiple myeloma and has been monitoring the administration of an intravenous solution infusing at 100 mL per hour. Which finding would indicate a positive response to this treatment? 1. Weight increase of 1 kg 2. White blood cell count of 6000 per mm 3. Respirations of 18 breaths per minute 4. Creatinine of 1.0 mg/dl Answer: 4 Rationale: In multiple myeloma, hydration is essential to prevent renal damage resulting from the Bence Jones protein precipitating in the renal tubules and from excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal

PN~Comp~Review~CD~701-800~6 status. Options 1, 2, and 3 will not evaluate a response to this treatment. Test-Taking Strategy: Use the process of elimination and recall that renal failure is a concern in multiple myeloma. Eliminate options 2 and 3 because hydration does not relate to white blood cell count or respirations. Weight gain is not a positive sign when concerned with renal status; therefore eliminate option 1. Review care to the client with multiple myeloma 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 References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 428. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 428. 710. A comatose client is admitted to the hospital. Laboratory values are as follows: Blood glucose 368 mg/dl, arterial pH 7.2, arterial bicarbonate 14 mEq/L, and positive test result for serum ketones. The client’s admitting diagnosis is diabetic ketoacidosis (DKA). During the initial data collection, the nurse would expect to note which of the following? 1. Hypertension 2. Moist mucous membranes 3. Fruity breath odor 4. Slow regular breathing Answer: 3 Rationale: Diabetic ketoacidosis is usually preceded by a day or more of polyuria and polydipsia associated with marked fatigue, nausea, and vomiting. A fruity breath odor, dry cracked mucous membranes, hypotension, and rapid, deep breathing would be noted. Test-Taking Strategy: Use the process of elimination. Recalling that rapid, deep breathing; fruity breath; and dehydration are associated with DKA will assist in answering the question. Review the manifestations associated with DKA 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/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 488. 711. Which statement by the spouse of a client with end-stage liver failure indicates the need for additional interventions by the multidisciplinary team for the management of pain? 1. “If the pain increases, I must let the physician know immediately.” 2. “I should have my husband try the breathing exercises to help control pain.” 3. “This narcotic will cause very deep sleep, which is what my husband needs.” 4. “If constipation is a problem, increased fluids will help.”

PN~Comp~Review~CD~701-800~7 Answer: 3 Rationale: Changes in level of consciousness are a potential indicator of narcotic overdose and indicative of numerous fluid, electrolyte, and oxygenation deficits. It is important for the spouse to understand the differences in sleep related to the relief of pain and changes in neurological status related to deficits. Option 3 is therefore the correct option. Options 1, 2, and 4 all are indicative of an understanding of appropriate steps to be taken in the management of pain. Test-Taking Strategy: Use the process of elimination. Note the key words need for additional interventions. These words indicate a false-response question and that you need to select the incorrect statement. Option 1 is an accurate statement. Even though the client is end-stage, increases in pain level must be noted and interventions taken to relieve that pain. Option 2 is also correct because nonpharmacological interventions are very useful in the relief of pain. Option 4 is correct and relates to a general principle. Review care to the client with end-stage liver disease 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: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, pp. 220-232, 1152-1153. 712. A nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to a nursing assistant. The nursing assistant notifies the nurse that the client’s vital signs are elevated, and the client is complaining of pain and dyspnea. Which of the following is appropriate regarding the nurse’s next action? 1. The nurse need not carry out further data collection because the nursing assistant is very experienced and trustworthy 2. The nurse requests that the nursing assistant offer the client an analgesic, which has been prescribed 3. The nurse places a call to the physician and reports the client’s complaints 4. The nurse checks the client and gathers additional data before calling the physician Answer: 4 Rationale: The nurse must not depend upon the judgment of a nursing assistant because the nurse is responsible for supervising those to whom client care has been delegated. Option 1 is therefore incorrect. Option 2 is inappropriate because this action is not delegated to the nursing assistant. A call to the physician may be warranted, but the nurse has insufficient data at this time, making option 3 incorrect. To provide the client with the degree of care required, the nurse must gather additional information and analyze that information before notifying the physician, making option 4 the correct choice. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are similar, indicating that the nurse does not gather any additional data. From the remaining options, option 4 reflects the process of data collection and therefore is the appropriate option. Review the role of the nurse in delegating and supervising tasks

PN~Comp~Review~CD~701-800~8 delegated to others 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: Delegating/Prioritizing Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 122-123. 713. An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A nurse is assigned to assist a community health nurse to care for the clients affected by this outbreak. The nurse understands that the initial activity is to: 1. Determine what common food item was ingested by those affected 2. Review the signs and symptoms related to the Salmonella bacteria 3. Involve the Centers for Disease Control and Prevention (CDC) 4. Teach the basic methods for preventing food contamination to those affected Answer: 1 Rationale: The initial step is to determine what food has been ingested. Option 2 involves teaching and is not the appropriate initial action. Options 3 and 4 involve potential interventions. Test-Taking Strategy: The key words are initial activity. Use the nursing process to answer the question. The only option that addresses data collection is option 1. Review the principles related to community health nursing 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. 981. 714. A nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery? 1. Adequate prenatal care 2. Appropriate maternal nutrition and weight gain 3. Spontaneous rupture of membranes 2 hours ago 4. History of substance abuse during pregnancy Answer: 4 Rationale: Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include low socioeconomic status, poor prenatal care and nutrition, and a history of substance abuse during pregnancy. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 are optimal findings and present no additional risk. Knowledge of the risk factors helps you

PN~Comp~Review~CD~701-800~9 accurately select between options 3 and 4. Additionally, noting the words “2 hours ago” in option 3, which should assist in eliminating this option. Review the risk factors related to neonatal sepsis if you had difficulty with this question. Level of Cognitive Ability: Analysis Clients 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. 282-284. 715. A client who consumes alcohol frequently is in the first trimester of pregnancy. The nurse initiates interventions to assist the client to cease alcohol consumption to: 1. Promote the normal psychosocial adaptation of the mother to pregnancy 2. Reduce the potential for fetal growth restriction in utero 3. Minimize the potential for placental abruptions during the intrapartum period 4. Reduce the risk of teratogenic effects to developing fetal organs, tissue, and structures Answer: 4 Rationale: The first trimester, “organogenesis,” is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this crucial period depend, not only on the amount of alcohol consumed, but on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, the purpose of ceasing alcohol consumption. Option 4 specifically relates to the issue of the question. Also, recalling that the first trimester is characterized by the differentiation and development of fetal organs, systems, and structures will direct you to option 4. If you had difficulty with this question, review the effects of alcohol on the fetus in the first trimester of pregnancy. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 114. 716. An adolescent girl is seen for the third time in 6 months for the treatment of vaginal candidal infections. The nurse is aware that additional tests may be indicated to identify an undiagnosed underlying chronic disease. Which test would the nurse anticipate that would most likely be prescribed? 1. Pap smear 2. Blood culture 3. Throat culture 4. Blood glucose level Answer: 4 Rationale: A high blood glucose level is an indicator of diabetes mellitus. In females candidal infections of the genitourinary tract are a common manifestation of diabetes

PN~Comp~Review~CD~701-800~10 mellitus. Pap smears are specific for detecting cancer of the cervix. A throat culture may show a candidal infection, but this test is unrelated to an undiagnosed underlying chronic disease. An infection of the blood is an acute systemic disease. Test-Taking Strategy: Use the process of elimination and note the key words underlying chronic disease. Options 1, 2, and 3 do not necessarily identify a chronic disease. Review the relationship between vaginal candidal infections and diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1250. 717. A nurse is collecting data on a client admitted to the hospital who has myxedema. Which data collection technique will provide data that is necessary to support the admitting diagnosis? 1. Inspection of facial features 2. Palpation of the adrenal glands 3. Percussion of the thyroid gland 4. Auscultation of lung sounds Answer: 1 Rationale: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and a blank expression that are characteristic of myxedema. The techniques in options 2, 3, and 4 will not reveal any data that would support the diagnosis of myxedema. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 because they do not relate to the thyroid gland. Palpation rather than percussion of the thyroid is the preferred technique when evaluating the thyroid gland, so option 3 can be eliminated. Review the manifestations associated with myxedema 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/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 887-888. 718. A nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). The nurse reviews the client’s plan of care and notes that which nursing diagnosis has the highest priority for this client? 1. Self-care deficit 2. Risk for infection 3. Imbalanced nutrition 4. Activity intolerance Answer: 2

PN~Comp~Review~CD~701-800~11 Rationale: Clients with HIV often show some evidence of immune dysfunction, and may have increased vulnerability to infection. Options 1 and 4 are not physiological problems. Although imbalanced nutrition is a concern, infection is specifically related to HIV and is a priority. Test-Taking Strategy: Use the process of elimination and recall the pathophysiology related to HIV. Remember that individuals with HIV are vulnerable to infection. Not every client with HIV will have problems with activity, self-care, or nutrition. Review the priorities of care for a client with HIV if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 340. 719. A physician’s order reads “meperidine hydrochloride (Demerol) 125 mg intramuscular route stat.” The medication vial reads 100 mg/mL. How many milliliters of the medication would the nurse draw into the syringe for injection? Answer: 1.25 Rationale: Use the following formula for calculating the appropriate medication dose. In this question, it is not necessary to perform a conversion. Desired 125 mg _________ x Volume = _______ x 1 mL = 1.25 mL Available 100 mg Test-Taking Strategy: Follow the formula for calculating the correct dose. Once you have performed the calculation, recheck your work using a calculator. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 80. 720. A client with a prior history of suicide attempts is admitted to the mental health unit. A diagnosis of depression has been made. A therapist who was working with the client in an outpatient clinic calls the nurse and reports that the client was having severe suicidal thoughts. Keeping this information in mind, the nurse focuses the initial data collection of the client on: 1. The presence of existing suicidal thoughts 2. The client’s interaction with peers 3. Food intake for past 24 hours 4. The past treatment regimen Answer: 1

PN~Comp~Review~CD~701-800~12 Rationale: The most critical information from the therapist’s report is that the client was having severe suicidal thoughts; therefore the nurse needs further information about existing thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse and the health care facility must make sure that the client is safe. The other items should be assessed; however, data collection related to the potential for suicide is most important. Test-Taking Strategy: Use the process of elimination. Note the relationship between “severe suicidal thoughts” in the question and in the correct option. Additionally, option 1 is the priority. Review care to the suicidal client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M.(2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 288. 721. A nurse caring for a client at home arrives at the client’s home and finds the client in the bedroom, unconscious, with a pill bottle in hand. The pill bottle contains the selective serotonin reuptake inhibitor, sertraline (Zoloft). Which of the following would the nurse check first? 1. Blood pressure 2. Respirations 3. Pulse 4. Urinary output Answer: 2 Rationale: In an emergency situation, the nurse should determine breathlessness first, then pulselessness. Blood pressure would be checked after these parameters were determined. Urinary output is also important, but not the priority at this time. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—as the guide for answering this question. Respirations specifically relate to breathing and airway. Review emergency care to the client with an overdose of medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 2052-2056. 722. A client is scheduled for a right femoral-popliteal bypass graft. The nurse reviews the plan of care for the client and notes that the client has a nursing diagnosis of ineffective tissue perfusion. The nurse takes which action before surgery to address this nursing diagnosis? 1. Completes a preoperative checklist 2. Marks the location of the pedal pulses on the right leg

PN~Comp~Review~CD~701-800~13 3. Has the client void before surgery 4. Checks the results of any baseline coagulation studies Answer: 2 Rationale: A nursing diagnosis of ineffective tissue perfusion in the client scheduled for femoral-popliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care. Test-Taking Strategy: Use the process of elimination noting the key words to address this nursing diagnosis. In this case, each of the incorrect options is an action that is part of routine preoperative care and is not specific to this nursing diagnosis. Note the relationship between “ineffective tissue perfusion” in the question and “pedal pulses” in the correct option. Review care to the client scheduled for a femoral-popliteal bypass graft 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/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 338. 723. A nurse is positioning a client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client: 1. Lying on the left side with a pillow under the chest wall 2. Lying on the right side with a pillow under the head 3. Supine with the head of bed elevated at a 45- to 60-degree angle 4. Supine with slight Trendelenburg’s position Answer: 3 Rationale: The client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. Options 1, 2, and 4 are incorrect positions. Test-Taking Strategy: Use the process of elimination. If you are uncertain how to proceed with this question, imagine each of the positions described. Evaluate how the heart is sitting in the chest with each position and how easily the pericardial sac could be accessed with a needle. This should help you eliminate the incorrect options. 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/Cardiovascular Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 860. 724. A nurse explains to a mother that her newborn is being admitted to the neonatal intensive care unit with a probable diagnosis of fetal alcohol syndrome (FAS) and

PN~Comp~Review~CD~701-800~14 explains this syndrome to the mother. The nurse determines that the mother understands this syndrome when the mother states: 1. “Withdrawal symptoms will occur after 3 days.” 2. “Mental retardation is unlikely to happen.” 3. “Withdrawal symptoms are tremors, crying, seizures, and reflexes that aren’t normal.” 4. “The reason the child is so large is because of the fetal alcohol syndrome.” Answer: 3 Rationale: The long-term prognosis for newborns with FAS is poor. Symptoms of withdrawal include tremors, abnormal reflexes, sleeplessness, seizures, abdominal distention, hyperactivity, and uncontrollable crying. Central nervous system (CNS) disorders are the most common problems associated with FAS. Because of the CNS disorders, children born with FAS are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after life or, at the latest, within the first 3 days of life. Most newborns with FAS are mildly to severely mentally retarded. The newborn is usually growth deficient at birth. Test-Taking Strategy: Use the process of elimination and knowledge regarding FAS to answer this question. Options 2 and 4 can be eliminated first because of the word “unlikely” in option 2 and of the words “so large” in option 4. From the remaining options, it is necessary to know that withdrawal symptoms can appear within 6 to 12 hours after life or, at the latest, within the first 3 days of life. Review the manifestations associated with FAS if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1074. 725. A female client is admitted to the inpatient mental health unit. When asked her name, she responds, “I am Elizabeth, the Queen of England.” The nurse recognizes this response as a(n): 1. Visual illusion 2. Auditory hallucination 3. Grandiose delusion 4. Loose association Answer: 3 Rationale: A delusion is a personal belief that is almost certainly not true and resists modification. An illusion is a misperception or misinterpretation of externally real stimuli. A hallucination is a false perception. Loose association is thinking characterized by speech in which ideas shift from one subject to another that are unrelated. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because the client is not having any visual or auditory disturbances. Option 4 is eliminated next because there is no indication of any examples of shifting of one subject to another. Making a reference to being a “royal” is a grandiose assumption. Review the

PN~Comp~Review~CD~701-800~15 characteristics of a grandiose delusion if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 112. 726. When a client has been raped, which action should a nurse take during the examination in the emergency room? 1. Try to avoid talking about what the client can expect to allay anxiety 2. Provide the person who accompanies the victim to the emergency room with a description of the procedures 3. Give the victim a concise description of the usual steps for a rape examination 4. Explain procedures to be completed and why these procedures are necessary Answer: 4 Rationale: The individual who has been raped needs to trust the nurse in the emergency room. She or he must receive an explanation of the procedures and, also very importantly, why these are being completed. Option 2 does not address the client. Avoidance of talking and providing a concise description will not provide support and reassurance to the client. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first because it does not address the client. Eliminate option 1 next because the nurse would not avoid talking to the client. Eliminate option 3 because a “concise description” may increase anxiety. Review immediate care to the client who has been raped if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Mental Health References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 274. Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 811. 727. During admission data collection, a nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has an interference in the area of: 1. Muscle strength and flexibility 2. Balance and coordination 3. Sensation and reflexes 4. Bowel and bladder function Answer: 2 Rationale: The nurse is performing one test of cerebellar function, and in this case is checking for ataxia. Examples of disorders that include interferences in this area could be Parkinson’s disease, multiple sclerosis, or cerebrovascular accident. This test does not

PN~Comp~Review~CD~701-800~16 identify the problems addressed in options 1, 3, or 4. Test-Taking Strategy: Use the process of elimination. Note that the question contains information about the leg tremors. Using nursing knowledge try to think of interferences that might contain that sign or symptom. Also note the relationship between “tremors” in the question and “coordination” in option 2. Review data collection techniques for cerebellar function if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2030. 728. A 32-week gestation woman is brought into the emergency room after an automobile accident. The client is bleeding vaginally, and fetal assessment indicates moderate fetal distress. What will the nurse plan to do first in an attempt to reduce the stress on the fetus? 1. Maintain intravenous fluids at a keep-open rate 2. Administer oxygen with a facemask at 7 to 10 L/min 3. Elevate the head of the bed to a semi-Fowler position 4. Set up for an immediate cesarean delivery Answer: 2 Rationale: Administering oxygen will increase the amount of oxygen for transport to the fetus. This action is essential regardless of the cause or amount of bleeding. Although options 1, 3, and 4 may be necessary at some point during the care of the client, they are not the priority. Additionally, there is no data in the question that indicates that an immediate cesarean delivery is necessary. Test-Taking Strategy: Use the process of elimination and note the key words moderate fetal distress. Using the ABCs—airway, breathing, and circulation—guides you to option 2. Review the measures to reduce the stress on the fetus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 390, 660. 729. A physician orders the deflation of the esophageal balloon of a SengstakenBlakemore tube in a client. The nurse assisting in caring for the client monitors the client closely knowing that following the deflation, this client may be at risk for: 1. Increased ascites 2. Esophageal necrosis 3. Hemorrhaging again from the esophageal varices 4. Esophageal rupture Answer: 3

PN~Comp~Review~CD~701-800~17 Rationale: A Sengstaken-Blakemore tube is inserted in cirrhosis clients with ruptured esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissue, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices. Test-Taking Strategy: Use the process of elimination. Remembering that the esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding will assist in directing you to the correct option. Review the complications associated with this type of tube if you are unfamiliar with them. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 228. 730. A nurse assists the cardiac client to identify resources to help her care for her 18month-old child during the last trimester of pregnancy. The nurse also encourages the client to use breathing and relaxation techniques twice a day. The purpose of these strategies is to: 1. Help the client prepare for labor and delivery 2. Reduce excessive maternal stress and fatigue 3. Prepare the 18-month-old child for maternal separation during hospitalization 4. Avoid exposure to potential pathogens and resulting infections Answer: 2 Rationale: A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The strategies identified in this question would primarily reduce excessive maternal stress and fatigue. Options 1, 3, and 4 are not the purpose of these strategies. Test-Taking Strategy: Use the process of elimination focusing on the issue of the question, the purpose of these strategies in a pregnant client with cardiac disease. Recalling the needs of the pregnant client with cardiac disease will direct you to option 2. Review these strategies if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 225. 731. A nurse is collecting data on a pregnant client. The nurse includes which question to determine if the client is at risk for toxoplasmosis parasite infection during pregnancy? 1. “How many sexual partners have you had during the pregnancy?” 2. “Have you experienced any high fevers or unusual rashes during the first 6 weeks of

PN~Comp~Review~CD~701-800~18 your pregnancy?” 3. “Have you been exposed to children with rashes or gastrointestinal symptoms?” 4. “Do you have any cats at home, and do you handle the kitty litter?” Answer: 4 Rationale: Toxoplasmosis is a systemic, usually asymptomatic illness, caused by the protozoan parasite. Humans acquire the infection from inadequately cooked meat, eggs, or milk; ingesting or inhaling the oocyst stage of the parasite excreted in feline feces in contaminated soil; or from contaminated blood-product transmission. Other than transplacental infection, this disease is rarely transmitted from human to human. During pregnancy, the parasite may be transmitted across the placenta and cause severe infection to the developing embryo or fetus. Test-Taking Strategy: Use the process of elimination. Recalling the transmission of toxoplasmosis will easily direct you to option 4. Remember that humans acquire the infection from inadequately cooked meat, eggs, or milk; ingesting or inhaling the oocyst stage of the parasite excreted in feline feces in contaminated soil; or from contaminated blood-product transmission. Review the cause of this infection 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 Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 110. 732. A nurse understands that becoming familiar with the cultural beliefs and practices of a childbearing woman may facilitate positive outcomes during pregnancy since: 1. All women are comfortable discussing sexual practices with their health care providers 2. Many women exist in traditional relationships with their sexual partners, thus discussing and making decisions about reproductive issues may be difficult for some 3. All males are knowledgeable about issues related to the spread of sexually transmitted diseases 4. Safe sex practices are common among couples 18 years of age and older Answer: 2 Rationale: The nurse providing care for women in their childbearing years must be familiar with the cultural framework within which the client lives and operates. Once this is achieved, appropriate communication techniques can be employed to facilitate client assessment and care and to identify health-promotion educational strategies. Options 1, 3, and 4 identify statements that generalize childbearing clients. Option 2 identifies a basic nursing philosophy that recognizes the importance of understanding the client’s cultural background as the initial step in establishing the nurse-client relationship. Test-Taking Strategy: Use the process of elimination and knowledge regarding the importance of understanding the cultural beliefs and practices of the client. Avoid stereotypical statements as identified in option 4. Eliminate options 1 and 3 because of the absolute word “all.” Review the importance of understanding cultural practices if you had difficulty with this question. Level of Cognitive Ability: Comprehension

PN~Comp~Review~CD~701-800~19 Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Fundamental Skills Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 44, 102. 733. A nurse is reviewing the test results for the rubella screening with a pregnant 24year-old client. The test results are positive, indicating immunity, and the client asks if it is safe for her 15-month-old toddler to receive the vaccine. The best response is: 1. “You are still susceptible to rubella, so your toddler should receive the vaccine.” 2. “Most children do not receive the vaccine until 5 years of age.” 3. “It is not advised for children of pregnant women to be vaccinated during their mother’s pregnancy.” 4. “Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time.” Answer: 4 Rationale: All pregnant women should be screened during pregnancy for prior rubella exposure. All children of pregnant women (12 to 15 months of age) should receive their immunizations according to schedule since there is no definitive evidence that the vaccine virus is transmitted from person to person. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to the Rubivirus, which is traditionally spread by oral droplets and transplacentally. Test-Taking Strategy: Use the process of elimination and knowledge of rubella disease transmission and pregnancy to direct you to option 4. Noting the key words indicating immunity will direct you to option 4. Review content related to rubella during pregnancy 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: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 109, 742. 734. A pregnant client has a positive pulmonary identification of the tuberculosis (TB) organism, and isoniazid (INH) and rifampin (Rifadin) are prescribed. The nurse plans to do which of the following when reinforcing home care instructions? 1. Review daily nutritional intake with the client 2. Encourage the client to stop taking medications during the last trimester of pregnancy 3. Inform the client that follow-up care after delivery will not be necessary 4. Tell the client that newborns and infants are usually not susceptible to tuberculosis infection following delivery and will not need to be tested Answer: 1 Rationale: Social conditions placing pregnant women at risk for TB include poverty, crowded living conditions, and malnutrition. In the case of acute disease during the antenatal period, a 9-month course of isoniazid (INH) and rifampin (Rifadin) is suggested. Follow-up sputum screenings and evaluation are essential to establish

PN~Comp~Review~CD~701-800~20 treatment effectiveness postdelivery. Teaching the client about the importance of an adequate nutritional intake needs to be included in the home care instructions. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology and transmission of TB to answer this question. This will assist in eliminating options 2, 3, and 4. Review these home care instructions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 111. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 730-731. 735. A nurse instructs a pregnant human immunodeficiency virus (HIV)-positive client to report any early signs of vaginal discharge or perineal tenderness to the health care provider immediately. The nurse tells the client that this is important to: 1. Relieve anxiety for the pregnant client 2. Eliminate the need for further unnecessary screenings 3. Assist in identifying potential infections that may need to be treated 4. Minimize the financial cost of caring for an HIV-positive client Answer: 3 Rationale: The HIV-positive client may be further at risk for superimposed infections during pregnancy. Among these include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms may alert the members of the health care team that further assessment and testing is necessary to diagnose and manage additional maternal and fetal physiological risks. Options 1, 2, and 4 are not the priority of care when promoting maternal-fetal well-being. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question. Note the relationship between “vaginal discharge or perineal tenderness” in the question and “infections” in the correct option. Review the purpose of health care instructions in the client with HIV if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 340. 736. A nurse discusses infant feeding options with the human immunodeficiency virus (HIV)-positive client following a vaginal delivery of a 6-lb full-term infant. The nurse tells the client that the appropriate method of feeding is: 1. Breast-feeding for 6 months 2. Breast-feeding for 9 months

PN~Comp~Review~CD~701-800~21 3. Nasogastric tube feeding 4. Bottle-feeding with a tolerated formula Answer: 4 Rationale: Perinatal transmission of HIV can occur during the antenatal period, during labor and birth, or in the postpartum period if the client is breast-feeding. This information will assist the client to choose a feeding method that will support parenting and the normal physiological development of her infant. Option 4 represents the best choice when considering current knowledge of HIV transmission during pregnancy. Test-Taking Strategy: Use the process of elimination and knowledge regarding the transmission of HIV infection to answer this question. Eliminate option 3 first because it is an unnecessary invasive technique for the infant. Next, eliminate options 1 and 2 because they are similar. Review infant feeding techniques for the mother with HIV if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 110, 225. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 177. 737. A nurse encourages the human immunodeficiency virus (HIV)-positive childbearing woman to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. These interventions are implemented primarily to: 1. Prevent further stress on the maternal immune system 2. Reduce the risks of anemia during pregnancy 3. Minimize the possibility of preterm labor 4. Minimize the risk of premature rupture of membranes Answer: 1 Rationale: The pregnant client with HIV needs to avoid practices that can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such practices may place both the mother and fetus at additional risk during the pregnancy. Option 1 represents the primary nursing management issue for the HIVinfected client. Test-Taking Strategy: Use the process of elimination and note the key word primarily. Recalling the relationship of HIV to the immune system will direct you to option 1. Review the effects of HIV if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 666. 738. During the antenatal period, the nurse weighs and plots the weight gain pattern of the human immunodeficiency virus (HIV)-infected client routinely and discusses the

PN~Comp~Review~CD~701-800~22 findings. The primary purpose of this action is to: 1. Document trends in weight gain patterns 2. Observe for early signs of pregnancy-induced hypertension 3. Identify adequate weight gain throughout pregnancy to ensure appropriate fetal development 4. Compare weight gain patterns among HIV-positive clients. Answer: 3 Rationale: Pregnant HIV-positive clients are at risk for alterations in nutritional status, especially when consuming less than body requirements. Plotting weight gain patterns throughout pregnancy will help to support adequate fetal development and reassure the client that a safe environment is being promoted for her developing fetus. Option 3 represents one of the primary purposes to monitor weight gain pattern. Test-Taking Strategy: Focus on the issue of the question, the HIV-infected client, and recall that during pregnancy the nurse is concerned about both the mother and the fetus. This thought process will direct you to option 3. Also note that this option is the umbrella (global) one. Review the effects of HIV on the mother and fetus 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: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 665. 739. During an initial prenatal visit, the client’s hemoglobin (Hgb) level is drawn, and the results are recorded in the client’s record. The nurse determines the findings to be abnormal and indicative of iron deficiency anemia. Which additional client data would also support this finding? 1. Pink mucous membranes 2. Daily headaches and fatigue 3. Increased vaginal secretions 4. Increased frequency of voiding Answer: 2 Rationale: Anemia is a common problem in pregnancy and is characterized by an Hgb level of less than 10.5 to 11 g/dL. Iron deficiency anemia and folic acid deficiency are two common types of anemia that present a concern during pregnancy. Options 1, 3, and 4 are findings that are normal during the first trimester of pregnancy. Option 2 is abnormal and may reflect complications caused by decreased oxygen supply to vital organs, thus supporting the laboratory findings. Test-Taking Strategy: Focus on the issue of the question, iron deficiency anemia. Use the process of elimination, knowledge of the manifestations that occur in this type of anemia, and knowledge regarding the normal and abnormal findings in pregnancy to answer the question. Note that option 2 is the only abnormal finding. Review the associated manifestations of iron deficiency anemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension

PN~Comp~Review~CD~701-800~23 Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 657. 740. A nurse caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. What intervention would best facilitate the client’s participation in infant care? 1. Encouraging the client to take pain medication as ordered 2. Maintaining the client in supine position whenever possible 3. Limiting fluid intake to keep the bladder empty 4. Promoting family members to care for the infant Answer: 1 Rationale: Nursing responsibilities for the care of a client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler’s position to facilitate drainage and lessen congestion, and providing appropriate analgesia. Option 1 is the only nursing intervention that demonstrates the nurse’s understanding of both the physiological and psychosocial needs of the postpartum client experiencing endometritis. Keeping the client comfortable will facilitate interest in caring for the infant. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology associated with endometritis. Option 4 can be eliminated first because the client is the mother. Knowing that options 2 and 3 identify inappropriate nursing interventions for the client with endometritis will assist in directing you to option 1. Review the pathophysiology associated with endometritis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 292. 741. A nurse is collecting data on a client admitted to the hospital with hepatitis. Which objective data would indicate that the client might have suffered liver damage? 1. Brown stools 2. Blood-tinged urine 3. Pruritus 4. Amber urine Answer: 3 Rationale: Significant damage to liver cells renders them unable to metabolize bilirubin. When a red blood cell is broken down, hemoglobin is released. The heme portion is catabolized into unconjugated bilirubin. The liver then takes that unconjugated bilirubin and transforms it into conjugated bilirubin that passes into the hepatic ducts and eventually into the bowel, providing the normal brown color to stool. When bilirubin is

PN~Comp~Review~CD~701-800~24 not metabolized by the liver, it accumulates in the circulation, and is minimally excreted by the skin, causing jaundice and pruritus. It is also eliminated unchanged by the kidneys, causing urine to become dark brown. Test-Taking Strategy: Use the process of elimination. Recalling the pathophysiology associated with hepatitis and the manifestations associated with liver damage will direct you to the correct option. Review these clinical manifestations 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/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 721. 742. A nurse is reviewing the physician’s orders of a client admitted to the hospital with a diagnosis of liver disease. Which medication order would the nurse question? 1. Lorazepam (Ativan) 2. Acetaminophen (Tylenol) 3. Furosemide (Lasix) 4. Omeprazole (Prilosec) Answer: 2 Rationale: Acetaminophen can cause hepatotoxicity, and its use is avoided in the client with liver disease. Furosemide and omeprazole do not adversely affect liver function. Lorazepam can cause liver damage in high doses or with long-term therapy, but can still be used (with caution) in the client with liver disease. Test-Taking Strategy: Use the process of elimination and knowledge regarding the medications that are hepatotoxic to answer this question. Remember that acetaminophen is hepatotoxic. Review the contraindications associated with acetaminophen if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 8. 743. A nurse planning care for a client with hepatitis plans to meet the client’s safety needs by: 1. Monitoring prothrombin time and partial thromboplastin time 2. Bathing with tepid water 3. Assisting with meals 4. Weighing and recording a weight daily Answer: 1 Rationale: When liver function is impaired, as in the client with hepatitis, some important body functions do not occur. The liver synthesizes fibrinogen, prothrombin, and factors needed for normal blood clotting. Without those clotting ingredients,

PN~Comp~Review~CD~701-800~25 bleeding may occur either internally or externally. Monitoring coagulation studies provides the nurse with information needed to plan ways to reduce the risk of hemorrhage when providing care. Assisting with meals would not be an issue unless dysphagia was present. Daily weight is often part of a nursing care plan, but is more related to fluid balance than safety. Tepid baths may decrease the pruritus associated with jaundice, but this is not a safety issue. Test-Taking Strategy: Use the process of elimination. Focus on the issue of the question, safety. Recalling the pathophysiology associated with hepatitis and that the risk of bleeding is a concern will direct you to option 1. Review care to the client with hepatitis 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/Gastrointestinal References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 232. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 721. 744. A nurse collects data from a pregnant client with iron deficiency anemia for additional risk factors associated with the anemia. Which finding would support potential further maternal compromise? 1. Appropriate intake of chicken and green leafy vegetables 2. Vaginal spotting times two since the last prenatal visit 3. Daily intake of elemental iron 4. Daily intake of six to eight glasses of water Answer: 2 Rationale: A variety of factors can further complicate the potential maternal and fetal effects of iron deficiency anemia during pregnancy. Such factors would include geographic location, socioeconomic status, daily nutrition and fluid intake, compliance to supplemental medication regimes, and blood loss during pregnancy. Options 1 and 4 represent appropriate client behaviors during pregnancy to ensure adequate nutrition and fluid balance. Option 3 represents daily supplementation during pregnancy. A history of vaginal spotting may compromise maternal hemoglobin levels even further during the antenatal period. Test-Taking Strategy: Focus on the issues of the question, iron deficiency anemia and potential further maternal compromise. Use the process of elimination noting that options 1, 3, and 4 represent appropriate client behaviors during pregnancy. Review the causes of iron deficiency anemia during pregnancy 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: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 717.

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745. A pregnant anemic client is concerned about her baby’s condition following delivery. Which nursing response would best support the client? 1. “You will not have any problems if you follow all the advice the physician has given you.” 2. “Your baby will need to spend a few days in the neonatal intensive care unit following delivery.” 3. “Don’t worry about your baby; complications are rare.” 4. “The effects of anemia on your baby are difficult to predict, but let’s review your plan of care to ensure you are providing the best nutrition and growth potential.” Answer: 4 Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client’s plan of care to clarify information and reassure the mother. Test-Taking Strategy: Use therapeutic communication techniques and knowledge regarding the effects of anemia to answer the question. Options 1 and 3 identify false reassurances. Option 2 is incorrect and will cause anxiety and fear in the client. Review therapeutic communication techniques and the effects of anemia on the fetus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Antepartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 717. 746. During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. This action primarily will: 1. Stimulate the labor process. 2. Prevent the necessity of a cesarean delivery. 3. Prevent dehydration and hypoxemia. 4. Eliminate the need for analgesic administration. Answer: 3 Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion can stimulate the sickling process during the intrapartum period. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for both the mother and fetus during labor. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination and knowledge regarding the effects of sickle cell anemia in the pregnant client. Note the relationship between “IV fluid intake and oxygen consumption” in the question and “dehydration and hypoxemia”

PN~Comp~Review~CD~701-800~27 in the correct option. Review the effects of sickle cell anemia 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. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 226. 747. A nurse in a postpartum unit identifies which client as being most at risk for developing endometritis following delivery? 1. A primigravida with a normal spontaneous vaginal delivery 2. A gravida II who delivered vaginally following an 18-hour labor 3. A woman experiencing an elective cesarean delivery at 38 weeks gestation 4. An adolescent experiencing an emergency cesarean delivery for fetal distress Answer: 4 Rationale: Endometritis is an acute infection of the mucous lining of the uterus that occurs immediately after delivery. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. Options 1, 2, and 3 do not describe the client “most at risk” to develop endometritis following delivery. Test-Taking Strategy: Use the process of elimination. Recalling that cesarean delivery is the primary risk factor for uterine infection will assist in eliminating options 1 and 2. From the remaining options, recalling that this serious complication is most likely to occur after emergency procedures will then direct you to option 4. Review the risk factors associated with endometritis 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/Postpartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 163-164. 748. A nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery? 1. Instruct the client in proper positioning of the infant to facilitate breast-feeding 2. Encourage early ambulation and the return to daily activities 3. Review hand washing techniques and perineal care with the client 4. Discuss the normal involution process with the client Answer: 3 Rationale: Postpartum endometritis is frequently associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand washing techniques and perineal care with the client during the postpartum period would reduce the risk of possible bacterial invasion of the myometrium. Options 1, 2, and 4 are not specific to minimizing the risk associated with

PN~Comp~Review~CD~701-800~28 contracting postpartum endometritis. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, minimizing the risk of postpartum endometritis. Although all the options listed may promote adaptation of the postpartum client following delivery, option 3 is the most effective in preventing the transmission of organisms into the reproductive tract. Review measures that will minimize the risk of postpartum endometritis 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: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 46. 749. A nurse is monitoring a client at risk for postpartum endometritis. Which symptom(s) noted during the first 24 hours after delivery may support this diagnosis? 1. Maternal oral temperature of 100.2° F 2. Uterus two fingerbreadths below midline and firm 3. Abdominal tenderness and chills 4. Increased perspiration and appetite Answer: 3 Rationale: Symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 1, 2, and 4 represent normal maternal physiological responses in the immediate postpartum period. These changes represent the normal adaptation of reproductive organs (involution) and maternal physiological responses caused by the decreased hormone levels and fluid losses that occur during labor. Test-Taking Strategy: Use the process of elimination and knowledge regarding the normal and abnormal findings in the postpartum period. This will direct you to option 3. Review these symptoms 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/Postpartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1047. 750. A nurse is collecting admission data on a client with hepatitis. Which of the following findings would be of most concern to the nurse? 1. Blurred vision or diplopia 2. Urinary frequency or urgency 3. Confusion or drowsiness 4. Diarrhea or constipation Answer: 3

PN~Comp~Review~CD~701-800~29 Rationale: Hepatitis impairs liver function. If the liver is unable to perform its metabolic and detoxification functions, waste products begin to accumulate in the body. Many of those wastes are protein byproducts, especially ammonia, that are harmful to the central nervous system. Increased ammonia levels are the primary cause of the neurological changes seen in liver disease, beginning first with drowsiness and confusion. Test-Taking Strategy: Use the process of elimination noting the key words “of most concern.” Use knowledge regarding the pathophysiology associated with hepatitis to direct you to option 3. Remember that increased ammonia levels are the primary cause of the neurological changes seen in liver disease, beginning first with drowsiness and confusion. Review the clinical manifestations and complications associated with hepatitis 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/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1340. 751. A nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the physician? 1. Hepatitis B surface antigen (HBsAg) that is in the normal range 2. Aspartate aminotransferase (AST) that is slightly elevated 3. Delta antigen that is slightly elevated 4. Alanine transaminase (ALT) that is notably elevated Answer: 4 Rationale: As tissue in the body are injured, enzymes present in the cells are released and can be monitored through blood tests. It is important to recognize which enzymes are found in which tissue. AST is found in high concentration in heart muscle and is indicative of heart damage. ALT is found primarily in the liver, and a notably elevated level would indicate liver damage. Antigens are agents that trigger cell damage; antigens do not result from the damage. Test-Taking Strategy: Use the process of elimination and knowledge regarding the important laboratory findings in hepatitis. Noting the words “notably elevated” in option 4 will direct you to this option as the laboratory result to be reported. Review the laboratory findings in hepatitis if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 721. 752. A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to do which of the following to decrease the possibility of spreading the infection?

PN~Comp~Review~CD~701-800~30 1. Wear a mask when in contact with people outside the family until medications are effective 2. Wear a mask when at home with family members 3. Obtain a weekly sputum culture to follow the course of the infection 4. Obtain a bacille Calmette-Guérin (BCG) vaccination to protect other people from exposure Answer: 1 Rationale: TB is an airborne illness. In the home situation, family members are best protected by careful hand washing. Since they are already exposed, masks would not be of much benefit. However, masks to protect people outside the family can be beneficial and should be recommended. Sputum cultures may be ordered to evaluate the effectiveness of therapy, but not on a weekly basis. BCG is a vaccine that produces increased resistance to TB. BCG is recommended in areas where there is a high rate of TB, but it renders future skin tests invalid in those who receive it. Test-Taking Strategy: Use the process of elimination and note the key words decrease the possibility of spreading the infection. Focusing on this issue will assist in eliminating options 3 and 4. From the remaining options, eliminate option 2 recalling that in the home situation family members have already been exposed by the time the diagnosis is confirmed, but those outside the family can be protected with a mask. Review home care measures for the client with TB 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 References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1849. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 375-379. 753. In developing a plan of care for a client hospitalized with tuberculosis (TB), which of the following is the most important fact for the nurse to consider? 1. TB is primarily a respiratory infection that requires airborne precautions 2. The client will need special assistance to perform activities of daily living (ADL) 3. The client will need to increase fluid intake to at least 3000 mL a day 4. The client will need to be taught proper breathing techniques Answer: 1 Rationale: TB is a respiratory infection that requires the use of airborne precautions to prevent transmission of infection. Planning care in such a way as to decrease the transmission of infection to others provides for safety. Plans to increase fluid intake or assist with ADL are pertinent to many clients, but are not of highest priority. Proper breathing techniques have no relevance in care of the client with TB. Test-Taking Strategy: Use the process of elimination and knowledge regarding the methods of transmission of TB to answer this question. Recalling that TB is transmitted via the airborne route will direct you to option 1. Review the method of transmission of TB if you had difficulty with this question.

PN~Comp~Review~CD~701-800~31 Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 506. 754. A gastric analysis is prescribed for a client with a suspected diagnosis of tuberculosis (TB). The nurse understands that this test may be prescribed as a part of the work-up to determine the diagnosis because: 1. Anorexia and weight loss are frequently symptoms of tuberculosis 2. Extrapulmonary TB may be found in the gastrointestinal tract 3. The bacillus is often swallowed with contaminated food 4. People frequently swallow small amounts of sputum rather than expectorating them Answer: 4 Rationale: Gastric analysis is a test that aspirates stomach contents and examines them for many factors, the primary one being pH. Since many people cough and swallow rather than spit out their sputum, viewing stomach contents can be diagnostic. Anorexia and weight loss cannot be detected with gastric analysis and neither can extrapulmonary TB. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Focus on the issue, a gastric analysis. Noting that this test is being performed as a diagnostic measure will direct you to option 4. Remember that the tubercle bacillus is found in the sputum. Review diagnostic procedures for TB if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning 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. 586-587. 755. A nurse is assigned to care for a client who has human immunodeficiency virus (HIV). In planning to care for the client, the nurse understands that the most important principle to decrease the risk of infection for the nurse is: 1. How and when to use the personal protective equipment supplied 2. Knowing the HIV status of every client on the unit 3. How far away from the client to stand when giving care 4. Determining whether the client has been placed in protective isolation Answer: 1 Rationale: HIV is a blood-borne illness with a long latency period between the introduction of the virus and positive results on a blood test. This makes it unrealistic and unreliable to test every client on a hospital unit. Testing every client is also questionable from an ethical perspective. Protective isolation is meant to protect the client with decreased immune function, not to protect the nurse. Standing far away from

PN~Comp~Review~CD~701-800~32 the client isolates the client emotionally and does not protect the nurse unless there is risk of splatter from blood. The Centers for Disease Control and Prevention guidelines are specific regarding when and how to use protective equipment and are a nurse’s best protection. Test-Taking Strategy: Use the process of elimination and focus on the issue, decreasing the risk of infection. Recalling the principles related to standard precautions will direct you to option 1. Review these principles 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: Fundamental Skills Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 224-225. 756. A nurse is monitoring the fluid balance of a client with human immunodeficiency virus (HIV). Since loss of subcutaneous adipose tissue and muscle atrophy occurs in clients with HIV, the nurse understands that which of the following will provide the most reliable indicator of fluid balance in this client? 1. Presence of vomiting and/or diarrhea 2. Decreased urine output and hypotension 3. Moistness of the skin 4. Skin turgor with tenting Answer: 2 Rationale: With the loss of muscle mass and adipose tissue, the overlying skin loses its support. The usual elasticity of skin becomes a less reliable indicator of body fluid status. Vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body since there are systems, such as the kidney, that can help to reestablish equilibrium. Decreased urine output and hypotension more accurately correlate with loss of fluid in this client population. Test-Taking Strategy: Use the process of elimination and note the key words most reliable indicator. Eliminate options 3 and 4 first because they are similar. From the remaining options, focus on the key words to direct you to option 2. Review the pathophysiology of HIV and the indicators of fluid balance if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 231-234, 2378-2380. Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 216. 757. A nurse has reinforced instructions to a new mother about how to perform

PN~Comp~Review~CD~701-800~33 postpartum exercises. The nurse determines that the client understood the instructions if she states that: 1. She should alternately contract and relax the muscles of the perineal area 2. The use of postpartum exercises can result in stress urinary incontinence 3. Exercise should be delayed for 4 weeks to allow healing time 4. Strenuous exercises should be started while in the hospital Answer: 1 Rationale: Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence. Test-Taking Strategy: Use the process of elimination and note the key words understood the instructions. Focusing on the issue, proper knowledge of the procedure and importance of postpartum exercises, will direct you to option 1. Review postpartum instructions related to exercise if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 210-211. 758. A newborn infant has coarctation of the aorta (COA). The nurse would expect to note which of the following findings in the infant? 1. Cool upper extremities 2. Hepatomegaly 3. Blood pressure low in the upper extremities and high in the lower extremities 4. Bounding radial pulses, absent or weak femoral and pedal pulses Answer: 4 Rationale: When there is narrowing within the aorta, there is increased pressure proximal to the defect and decreased pressure distal to it. Therefore one would expect bounding pulses in the arms and weak or absent pulses in the femoral and/or pedal areas. With decreased blood supply to the lower extremities, those areas would be cool to touch. The upper extremities would be warm. The other options are incorrect. Test-Taking Strategy: Review each of the options listed, anticipating the effects of coarctation on the circulatory dynamics of the infant. Eliminate options 1 and 3 first, which are the opposite of the expected findings. Hepatomegaly is an associated finding if the infant goes into heart failure as a complication of COA. With this in mind, eliminate option 2. Review the manifestations associated with COA 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/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.).

PN~Comp~Review~CD~701-800~34 Philadelphia: W.B. Saunders, pp. 619-620. 759. A 1-year-old child has an order for Lanoxin (digoxin) to treat congestive heart failure (CHF). The nurse would plan on withholding the ordered dose of the medication if: 1. A dose is missed, and 1 hour has elapsed 2. The child has a fever 3. The child’s pulse is less than 80 beats/min 4. The child’s pulse is more than 100 beats/min Answer: 3 Rationale: The normal pulse rate for a 1-year-old child is about 100 beats/min. A dose missed is withheld if 4 hours have elapsed. Fever is not a contraindication to giving the medication. Knowing that a sign of digoxin toxicity is a decreased heart rate, the most likely choice is option 3, which indicates a relative bradycardia. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating option 1. A dose missed is withheld if 4 hours have elapsed. Recalling that a fever is not a contraindication to giving the medication, eliminate option 2 next. Choose correctly between the remaining options by recalling the direction of change in the pulse rate that would occur with digoxin toxicity. Knowing that a sign of digoxin toxicity is a decreased heart rate will direct you to option 3. Review the guidelines related to administering digoxin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 624. 760. A 1-year old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse would avoid doing which of the following to protect the infant from injury? 1. Keep a padded tongue blade at the bedside for use during a seizure 2. Refrain from giving the infant toys to play with that have bright blinking lights on them 3. Keep the side rails and other hard objects padded 4. Turn the infant to the side during a seizure Answer: 1 Rationale: Attempting to place something in a child’s mouth during a seizure in not helpful even if it is padded. The mouth is usually clenched and one would have to use force to open the mouth. The nurse must attempt to keep the airway clear and can do that by positioning (option 4). Option 2 may be helpful in preventing a seizure, and option 3 safeguards the client’s physical safety. 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. With this in mind, eliminate options 3 and 4, which are obviously helpful actions. Choose between the remaining options knowing that either tongue blades can be dangerous or that avoiding toys with lights would be a helpful intervention. Review

PN~Comp~Review~CD~701-800~35 seizure precautions 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: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 550. 761. A 1-year old child who was born 2 months premature is hospitalized. The nurse would plan to encourage the child to do which of the following to maintain developmental skills while hospitalized? 1. Sit independently 2. Build a tower of three blocks 3. Indicate wants by pointing or grunting 4. Walk independently Answer: 1 Rationale: For premature infants, calculate the developmental age by deducting the time of prematurity from the age of the child until they reach the age of 2 years. In this case subtract 2 months from 1 year to equal 10 months of age. A 10-month-old can sit independently. By 15 months of age, a child should walk independently and indicate wants by pointing and grunting. By 18 months of age, a child should be able to build a tower of three blocks. Test-Taking Strategy: Use knowledge of how to calculate the developmental age of the prematurely born child and concepts of growth and development to answer this question. This will direct you to option 1. Review this content if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 388, 393. 762. A nurse is collecting data on a client who is pregnant with twins. Which of the following signs would alert the nurse to a potential problem specifically related to the twin pregnancy? 1. Hypertension 2. Uterine size is large for gestational age 3. Slightly elevated blood glucose level 4. Mother is Rh negative Answer: 1 Rationale: The mother with a multiple-gestation pregnancy is at a higher risk for preeclampsia than if she had a singleton pregnancy. Maternal well-being should be monitored for signs and symptoms of preeclampsia and preterm labor. A classic sign of preeclampsia is hypertension. A slightly elevated blood glucose level and Rh sensitization are concerns, but are not unique to a multiple pregnancy. Uterine size may

PN~Comp~Review~CD~701-800~36 be large for gestational age in a multiple-gestation pregnancy. Test-Taking Strategy: Use the process of elimination and knowledge regarding the risks associated with a multiple-gestation pregnancy to answer this question. Recalling that the client is at increased risk for preeclampsia will direct you option 1. Review the risks associated with a multiple-gestation pregnancy 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/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 838, 1003. 763. A nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which of the following would the nurse expect to note when collecting data on the client? 1. Elevated blood pressure, proteinuria, and edema 2. Regression of pregnancy symptoms and absence of fetal heart tones 3. Uterine size greater than expected for gestational age 4. Intractable vomiting and dehydration Answer: 2 Rationale: Symptoms of an intrauterine fetal demise include decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. Many symptoms of pregnancy may diminish, such as uterine size and breast size and tenderness. Option 1 identifies signs of preeclampsia. Option 4 is associated with hyperemesis gravidarum. Test-Taking Strategy: It is important to know that fetal demise means fetal death. Note the relationship between “fetal demise” in the question and “absence of fetal heart tones” in the correct option. Review the signs associated with fetal demise 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/Postpartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 876-877. 764. A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which of the following to determine if the client is ready to begin sitting up? 1. Puts both of the client’s hip joints through full range of motion 2. Measures the pulse and blood pressure with the bed flat and again with the head of the bed elevated 3. Loosens the vest to determine the client’s strength for trunk support 4. Inspects the halo vest pin sites for drainage, redness, and pain Answer: 2 Rationale: Clients with cervical cord injuries may lose control over peripheral vasoconstriction, causing postural (orthostatic) hypotension when upright. A drop of 15

PN~Comp~Review~CD~701-800~37 mm Hg in the systolic pressure or 10 mm Hg in the diastolic pressure accompanied by an increase in heart rate when the head is elevated may indicate autonomic insufficiency that can cause dizziness or syncope in the upright position. Assessment of skin integrity of the pin sites is important, but does not affect sitting readiness. Hip range of motion is not affected initially in this type of cord injury. The halo vest is not loosened by the nurse. The vest provides trunk stability for sitting. Test-Taking Strategy: Focus on the issue of the question “if the client is ready to begin sitting up.” Recalling that postural (orthostatic) hypotension is a concern and focusing on the issue will direct you to option 2. Review care to the client with a halo vest 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/Neurological References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 990-992. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 1622-1623, 1629. 765. A client admitted from the emergency department has a C4 spinal cord injury. The nurse performs which of the following first when collecting data on the client? 1. Takes the temperature 2. Checks extremity muscle strength 3. Observes for dyskinesias 4. Checks the respiratory rate Answer: 4 Rationale: Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Dyskinesias occur in cerebellar disorders so are not important in cord-injured clients, unless a head injury is suspected. Test-Taking Strategy: Remembering that a cord injury, particularly at the level of C4, can affect respiratory status will assist in directing you to the correct option. The ABCs— airway, breathing, and circulation—can guide priorities in this situation. Respiratory rate will be diminished if respiratory muscles are weakened or paralyzed. Review care to the client with a cervical injury if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 651. 766. In positioning a client for a surgical procedure, the nurse understands that the respiratory system is most vulnerable to which of the following positions?

PN~Comp~Review~CD~701-800~38 1. Lithotomy 2. Supine 3. Lateral 4. Sims Answer: 1 Rationale: The thoracic cage normally expands in all directions except posteriorly. In this position, the expansion of the lungs is restricted at the ribs or sternum, and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Respiratory function is impaired because of this interference with normal movements. The volume of air that can be inspired is reduced. Options 2, 3, and 4 will not compromise lung expansion as much as the lithotomy position would. Test-Taking Strategy: Use the process of elimination and note the key words most vulnerable. Options 3 and 4 are similar; therefore eliminate these options. From the remaining options, attempt to visualize each of these positions and their effect on the process of respiration. The supine position would not interfere with the expansion of the lungs as the lithotomy position would. Review these positions 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, pp. 250-254, 373. 767. Streptokinase (Streptase) is being administered to a client following an acute inferior myocardial infarction. The nurse plans care knowing that the primary purpose of streptokinase (Streptase) is to: 1. Inhibit further clot formation 2. Reduce myocardial oxygen demand 3. Prevent platelet aggregation 4. Dissolve the thrombus Answer: 4 Rationale: Streptokinase is a thrombolytic medication that causes lysis of blood clots. Anticoagulants prevent further clot formation. Beta-blockers, nitrates, and calcium channel blockers are used to reduce myocardial oxygen demand. Streptokinase does not prevent platelet aggregation. Test-Taking Strategy: Knowledge of thrombolytic medications and their action is necessary to answer this question. Remembering that streptokinase can dissolve a clot will assist in answering questions similar to this one. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 989.

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768. For a client with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which of the following client activities will contribute to achieving this goal? 1. Elevating the legs when in bed 2. Sleeping in the supine position 3. Seasoning beef with a meat tenderizer 4. Using a bedside commode for stools Answer: 4 Rationale: Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client’s legs increases venous return to the heart, increasing cardiac workload. The supine position can increase respiratory effort and decrease oxygenation. This increases cardiac workload. Meat tenderizers are high in sodium. Test-Taking Strategy: Use the process of elimination and focus on the issue, reducing cardiac workload. Option 2 can be eliminated because generally the supine position is not an appropriate position for a cardiac or pulmonary client. Next eliminate option 3 because meat tenderizers are high in sodium, and sodium leads to fluid retention. Visualize each of the remaining options and think about their effect in reducing cardiac workload. This will direct you to option 4. Review measures that reduce cardiac workload if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 322. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 500. 769. A child is sent to the school nurse by the teacher. The nurse notes that the child has a rash and suspects that the child has erythema infectiosum (fifth disease). The nurse bases this determination on which observation? 1. Discrete rose-pink maculopapular rash on the trunk 2. Highly pruritic, profuse macule to papule rash on the trunk 3. Discrete pinkish red maculopapular rash that spreads rapidly to the trunk 4. Erythema on the face that has a “slapped face” appearance Answer: 4 Rationale: The classic rash of erythema infectiosum or fifth disease is the erythema on the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic profuse macule to papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles). Test-Taking Strategy: Knowledge regarding the characteristics associated with erythema infectiosum is required to answer the question. Note that in options 1, 2, and 3 a similarity exists in that the rash is identified as being present on the trunk. Option 4

PN~Comp~Review~CD~701-800~40 addresses a rash on the face. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 252. 770. A client is taking a monoamine oxidase (MAO) inhibitor. The nurse plans care knowing that: 1. These medications increase the amount of MAO in the liver 2. Hypotensive crisis may be precipitated by foods that contain tyramine and tryptophan 3. Headache, hypertension, and nausea and vomiting may indicate toxicity 4. Increased salivation is an expected side effect Answer: 3 Rationale: Headache, hypertension, tachycardia, and nausea and vomiting are precursors to hypertensive crisis. Hypertensive crisis is caused by the ingestion of foods that contain tyramine and tryptophan while a client is taking MAO inhibitors. These medications act by decreasing the amount of MAO in the liver, which is necessary for the breakdown and use of tyramine and tryptophan. Hypertensive crisis may lead to circulatory collapse, intracranial hemorrhage, and death. Option 4 is incorrect. Test-Taking Strategy: Knowledge of the action and side effects of MAO inhibitors is necessary to answer this question. Recalling that hypertensive crisis is a concern with the use of these medications will direct you to option 3. Review this content if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 219. 771. A client has returned to the nursing unit following abdominal hysterectomy. To thoroughly check the client for postoperative bleeding, the nurse would do which of the following? 1. Check the abdominal dressing 2. Check the perineal pad 3. Ask the client about sensation of moistness 4. Roll the client to one side after checking the perineal pad and dressing Answer: 4 Rationale: The nurse should roll the client to one side after checking the perineal pad and abdominal dressing. This allows the nurse to check the rectal area, where blood may pool by gravity, particularly if the client is lying supine. Options 1, 2, and 3 are not thorough assessments. Test-Taking Strategy: Use the process of elimination. Note the key words thoroughly check. Note that option 4 is the umbrella (global) option. Review care to the client

PN~Comp~Review~CD~701-800~41 following abdominal hysterectomy 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. 948. 772. A nurse is caring for a client who is receiving hydralazine (Apresoline). The nurse evaluates the effectiveness of the medication by monitoring which of the following client parameters? 1. Blood pressure 2. Cardiac rate 3. Urine output 4. Blood glucose level Answer: 1 Rationale: Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. It is a vasodilator medication that decreases afterload. The blood pressure needs to be monitored. Options 2, 3, and 4 are not specifically related to determining the effectiveness of this medication. Test-Taking Strategy: To answer this question accurately, it is necessary to be familiar with the classification of this medication. If you knew that this medication was an antihypertensive, you would easily be directed to option 1. Also note the name of the medication and use medical terminology (Apresoline) to assist in determining the correct option. Review the action and use of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 528. 773. A client has received atropine sulfate intravenously during a surgical procedure. The nurse monitors the client for which of the following effects of the atropine sulfate in the postoperative period? 1. Bradycardia 2. Excessive salivation 3. Diarrhea 4. Urine retention Answer: 4 Rationale: Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urine retention. The nurse monitors the client for any of these effects in the postoperative period. Test-Taking Strategy: Specific knowledge of the action and effects of this medication is necessary to answer this question accurately. Recalling that atropine sulfate is an

PN~Comp~Review~CD~701-800~42 anticholinergic will direct you to option 4. Review the side effects 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: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 97. 774. A nurse is monitoring a client taking an antipsychotic medication for signs of neuroleptic malignant syndrome (NMS). The nurse would expect to note which of the following if NMS occurred? 1. Bradycardia 2. Dysphagia 3. Hypotension 4. Hyperpyrexia Answer: 4 Rationale: Hyperpyrexia up to 107° F may be present in NMS. Symptoms develop suddenly and may include respiratory distress and muscle rigidity. As the condition progresses, there is evidence of tachycardia, hypertension, increasing respiratory distress, confusion, and delirium. The presence and severity of symptoms are compounded when two or more antipsychotics are taken concomitantly. Test-Taking Strategy: Consider the physiological responses that occur in NMS to answer this question. The word “malignant” in the question can be most closely associated with hyperthermia, making option 4 the correct answer. Review the physiological manifestations that occur in NMS if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Morrison-Valfre, M.(2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 334. 775. A nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. The nurse checks for the major symptoms associated with subdural hematoma when the nurse: 1. Tests for contractures of the extremities 2. Tests for equality of extremities when stimulating reflexes 3. Monitors urinary output patterns 4. Checks the urine for blood Answer: 2 Rationale: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can, especially if actively bleeding, cause changes in the stimuli responses in the extremities on the opposite side of the body. Option 1 is incorrect because contractures would not occur this soon after delivery. Options 3 and 4 are incorrect. An infant, after delivery, would normally be incontinent of urine. Blood in the urine would

PN~Comp~Review~CD~701-800~43 indicate abdominal trauma. Test-Taking Strategy: Focus on the issue, the major symptoms associated with subdural hematoma. Recalling that a method of assessing for complications and active bleeding into the cranial cavity would be a neurological assessment will assist in eliminating options 3 and 4. From the remaining options, eliminate option 1 because, although contractures of the extremities could occur as residual effects, they would not occur immediately following the time of injury. Checking newborn reflexes is a basic assessment for determining neurological complications in this age group. Review the symptoms associated with subdural hematoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1513. 776. A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following arterial blood gas results would the nurse most likely expect to note? 1. PO2 of 68 mm Hg and PCO2 of 40 mm Hg 2. PO2 of 55 mm Hg and PCO2 of 40 mm Hg 3. PO2 of 70 mm Hg and PCO2 of 50 mm Hg 4. PO2 of 60 mm Hg and PCO2 of 50 mm Hg Answer: 4 Rationale: During an acute exacerbation, the arterial blood gases deteriorate with decreasing PO2 levels and increasing PCO2 levels. In the early stages of COPD, arterial blood gases demonstrate mild to moderate hypoxemia with the PO2 in the high 60s to high 70s (mm Hg) and normal arterial PCO2. As the condition advances, hypoxemia increases and hypercapnia may result. Test-Taking Strategy: Note the key words acute exacerbation. Remembering that in COPD, a low PO2 and an elevated PCO2 is the likely occurrence will assist in directing you to the correct option. Review the clinical manifestations in COPD 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/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 500. 777. A nurse is monitoring a client receiving a blood transfusion for signs of circulatory overload. The nurse understands that which of the following is a clinical indication of circulatory overload? 1. Decreased blood pressure 2. Fatigue

PN~Comp~Review~CD~701-800~44 3. Moist productive cough 4. Flat neck veins Answer: 3 Rationale: Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in lung bases, distended neck veins, and an increase in blood pressure are clinical indications of circulatory overload caused from excessive infusion amounts or too rapid an infusion rate. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination and focus on the issue, circulatory overload. Note the relationship of the issue and the word “moist” in option 3. Review the signs of circulatory overload if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 521. 778. A client with myasthenia gravis is experiencing prolonged periods of weakness. The physician orders a test dose of edrophonium (Tensilon), and the client becomes weaker. The nurse interprets this test result as: 1. Normal 2. Positive 3. Myasthenic crisis 4. Cholinergic crisis Answer: 4 Rationale: Edrophonium is administered to differentiate overdose of medication (cholinergic crisis) from the need for increased medication (myasthenic crisis). Worsening of the symptoms after edrophonium is administered indicates a cholinergic crisis (overdose of the medication) or a negative Tensilon test result. Test-Taking Strategy: Knowledge regarding the Tensilon test and the interpretation of the results is required to answer the question. Remember that worsening of the symptoms after edrophonium is administered indicates a cholinergic crisis. If you are unfamiliar with this test and distinguishing between cholinergic and myasthenic crisis, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 1035-1036. 779. A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of a prolapsed cord. The nurse’s initial action is to: 1. Call the physician 2. Monitor fetal heart rate

PN~Comp~Review~CD~701-800~45 3. Transfer the client to the labor room 4. Place the client in Trendelenburg’s position and push the presenting part upward Answer: 4 Rationale: On inspection of the perineum, if it is noted that the cord is compressed (prolapsed) by the presenting part, the client is immediately placed into Trendelenburg’s position, and the presenting part is pushed upward to relieve the cord compression. This position is maintained until the physician evaluates the client further. Options 1, 2, and 3 may be appropriate actions, but are not the initial actions. Test-Taking Strategy: The key words are prolapsed cord and initial action, which indicates an immediate action on the nurse’s part to relieve cord compression. The only action that will achieve this is option 4. The physician is notified after positioning the client. Review care to the client when a prolapsed cord occurs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 199. 780. A nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. The nurse would first: 1. Stop the infusion immediately and notify the physician 2. Check that the tubing is securely attached 3. Increase the IV flow rate to assess for further leaking 4. Remove the tape, slow the IV rate, and discontinue the IV Answer: 2 Rationale: If there is leakage at the IV site, the nurse should first locate the source. The nurse should assess the site further to be certain that all connections are secure. The nurse should not increase the IV flow rate. Although it is true that it may leak more, increasing the IV flow rate may also cause more tissue damage if the IV was infiltrating. Although the infusion most likely will need to be stopped, the physician would not need to be notified. Slowing and discontinuing the IV is also premature. The IV must first be assessed as to the cause of the leaking. Test-Taking Strategy: Note the key word first. Use the steps of the nursing process to answer the question. Remember that data collection is the first step of the nursing process. Option 2 is the only option that addresses data collection. Review care to the client with a peripheral IV 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. 1165. 781. A nurse checks the water seal chamber of a closed chest drainage system and

PN~Comp~Review~CD~701-800~46 notes fluctuations in the chamber. Based on this finding, the nurse determines that: 1. An air leak is present 2. The tubing is kinked 3. The lung has re-expanded 4. The system is functioning as expected Answer: 4 Rationale: Fluctuations in the water seal chamber are normal during inhalation and exhalation until the lung re-expands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate an air leak, kinking, or that the lung has reexpanded. Test-Taking Strategy: Use the process of elimination and focus on the issue, fluctuations in the water seal chamber of a closed chest drainage system. Remember that fluctuations in the water seal chamber are normal during inhalation and exhalation until the lung reexpands. Review the normal expectations and the indications of complications 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/Respiratory References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 385. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 473-474. 782. A nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is termed: 1. Reality therapy 2. Short-term psychotherapy 3. Psychoanalytic therapy 4. Psychodrama Answer: 4 Rationale: Psychodrama involves enactment of emotionally charged situations. Reality therapy is used for individuals with cognitive impairment. Both short-term psychotherapy and psychoanalytic therapy depend on techniques drawn from psychoanalysis. Test-Taking Strategy: Use the process of elimination. Note the relation between the words “the client enacts situations” and option 4. Review the components of psychodrama if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Keltner, N., Schwecke, L., & Bostrom, C. (2003). Psychiatric nursing (4th ed.). St. Louis: Mosby, p. 147.

PN~Comp~Review~CD~701-800~47 783. A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers and knows that the clubbing is most likely due to: 1. Peripheral hypoxia 2. Delayed physical growth 3. Chronic hypertension 4. Destruction of bone marrow Answer: 1 Rationale: Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxemia and polycythemia. Options 2, 3, and 4 are not causes of clubbing. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Hypoxia relates to oxygenation, a concern with this disorder. Review the causes of clubbing if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 87-88. 784. A nurse witnesses a client going into pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client’s baseline. As an immediate action before help arrives, the nurse would: 1. Suction the client vigorously 2. Place the client in high Fowler’s position 3. Begin assembling medications that are anticipated to be given 4. Call the respiratory therapy department for a ventilator Answer: 2 Rationale: The client in pulmonary edema is placed in high Fowler’s position if the blood pressure is adequate. Vigorous suctioning may deplete the client of vital oxygen at a time when the respiratory system is compromised. Assembling medications is useful, but not critical to the immediate well-being of the client. The client may or may not need mechanical ventilation. Test-Taking Strategy: Use the process of elimination. The key words respiratory distress and immediate help you eliminate options 3 and 4. From the remaining options, note that option 2 will enhance the client’s respirations, and option 1 may impair oxygenation as implied by the word “vigorous” in that option. Review immediate care measures for the client with pulmonary edema 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/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 390.

PN~Comp~Review~CD~701-800~48 785. A nurse is assisting in caring for a client with a myocardial infarction and is asked to assist in monitoring the client for cardiogenic shock. The nurse would monitor for which peripheral vascular manifestations associated with cardiogenic shock? 1. Flushed, dry skin with bounding pedal pulses 2. Warm, moist skin with irregular pedal pulses 3. Cool, dry skin with alternating weak and strong pedal pulses 4. Cool, clammy skin with weak or thready pedal pulses Answer: 4 Rationale: Classic signs of cardiogenic shock include increased pulse (weak and thready), decreased blood pressure, decreased urine output, signs of cerebral ischemia (confusion and agitation), and cool, clammy skin. Test-Taking Strategy: Focus on the issue, the manifestations associated with shock. The word “clammy” in option 4 should direct you to this option. Review the signs of cardiogenic shock 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/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 314. 786. A nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. The nurse evaluates the client’s understanding of the care related to the pacemaker when the nurse: 1. Asks the client to take the pulse in the wrist or neck and checks the accuracy of the client’s reading 2. Determines if the client knows not to operate a microwave oven 3. Determines if the client knows that he can resume sexual activity immediately 4. Asks the client to move the arms and shoulders vigorously to check pacemaker functioning Answer: 1 Rationale: Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately. The client needs to identify any variation in the pulse rate or rhythm and report the variation to the physician immediately. Clients can safely operate microwave ovens, radios, electric blankets, lawn mowers, leaf blowers, and cars. Proper grounding must be ensured if the client is to operate electric typewriters, copying machines, and personal computers. Sexual activity is not resumed until 6 weeks after surgery. The arms and shoulders should not be moved vigorously for 6 weeks after insertion. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 because of the word “immediately” and option 4 because of the word “vigorously.” From the remaining options, select option 1 because of the knowledge that a pacemaker assists in controlling cardiac rate and rhythm. Review client teaching points regarding a pacemaker if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation

PN~Comp~Review~CD~701-800~49 Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 300. 787. A nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. The nurse is aware that this finding: 1. Is expected following this type of surgery 2. Represents a malfunction of the chest tube drainage system 3. Indicates the need for autotransfusion 4. May represent hemorrhage and requires further data collection Answer: 4 Rationale: Within the first 2 hours following surgery, 100 to 300 mL of drainage is expected. An amount of 700 mL is excessive and indicates that hemorrhage may be occurring and that the client requires further data collection. The physician should be notified. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Noting the key words grossly bloody drainage should provide you with the clue that will direct you to option 4. Grossly bloody drainage indicates hemorrhage particularly with the amount of drainage specified in the question. Review the expected findings following segmental resection 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/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1862. 788. A nurse is assigned to assist in caring for a client with a chest tube drainage system. In planning for the client, the nurse has which of the following available in the event that the drainage system needs to be changed? 1. Vaseline gauze dressing 2. A 40-mL syringe 3. Rubber-shod clamps 4. Wall suction catheter Answer: 3 Rationale: If the drainage system needs to be changed, the registered nurse will use rubber-shod clamps to clamp the tube near the client’s chest while the drainage system is changed. This procedure is done quickly and with the assistance of another nurse. The clamps are removed immediately after reconnection of the new drainage system. Agency procedure regarding clamping chest tubes is always followed, and a physician’s order for clamping the tube may be required. If clamps must be used, the best time to apply them is after an expiration. An occlusive dressing, such as a Vaseline gauze dressing, is used when a chest tube is removed. Options 2 and 4 are not necessary for changing a drainage system.

PN~Comp~Review~CD~701-800~50 Test-Taking Strategy: Focus on the issue, changing a drainage system. Visualizing this procedure will direct you to option 3. Review care to the client with a chest tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1865-1866. 789. A client begins to drain small amounts of red blood from a tracheostomy tube 24 hours after a supraglottic laryngectomy. The nurse would: 1. Notify the registered nurse 2. Increase the frequency of suctioning 3. Add moisture to the oxygen delivery system 4. Document the character and amount of drainage Answer: 1 Rationale: Immediately following laryngectomy, there is a small amount of bleeding from the tracheostomy, which resolves within the first few hours. Bleeding 24 hours after the surgery may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential life-threatening situation, and the registered nurse needs to be notified, who will then contact the physician. Although the other options may be appropriate, they do not address the urgency of the problem. Failure to notify the physician in a timely fashion places the client at risk. Test-Taking Strategy: Note the key words red blood and 24 hours after. This should indicate that a potential complication exists and direct you to option 1. Review the complications following laryngectomy 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, p. 1114. 790. A client receiving total parenteral nutrition (TPN) complains of nausea, excessive thirst, and increased frequency of voiding. The nurse next checks which of the following client data? 1. Serum blood urea nitrogen (BUN) and creatinine 2. Capillary blood glucose level 3. Last serum potassium level 4. Rectal temperature Answer: 2 Rationale: The symptoms exhibited by the client are consistent with hyperglycemia. The nurse would need to check the client’s blood glucose level to verify this data. Clients receiving TPN are at risk for hyperglycemia related to the increased glucose load of the

PN~Comp~Review~CD~701-800~51 solution. The other options would not provide any information that would correlate with the client symptoms. Test-Taking Strategy: Focus on the data in the question. Note that the symptoms portrayed by the client are consistent with hyperglycemia, which is a complication of TPN. This would allow you to eliminate each of the incorrect options without difficulty. Review the complications associated with TPN 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/Gastrointestinal Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 486-488. 791. A client with Cushing’s disease is being admitted to the hospital after a stab wound to the abdomen. The nurse reviews the client’s plan of care and places highest priority on which nursing diagnosis developed for this client? 1. Anxiety 2. Risk for infection 3. Disturbed body image 4. Ineffective health maintenance Answer: 2 Rationale: The client with a stab wound has a break in the body’s first line of defense against infection. The client with Cushing’s disease is at great risk for infection because of excess cortisol secretion and subsequent impaired antibody function and decreased proliferation of lymphocytes. The client may also have ineffective health maintenance, disturbed body image, and anxiety, but these are not the highest priority at this time. Test-Taking Strategy: Use the process of elimination and note the key words highest priority. Use Maslow’s Hierarchy of Needs theory. Note that option 2 addresses the physiological need. Review the characteristics of Cushing’s syndrome if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 876. 792. A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse notes that the flap has a slightly blue hue. The nurse concludes: 1. This is a normal expectation 2. Heat should be applied to the area 3. Venous circulation is impaired 4. The client is exhibiting generalized hypoxia Answer: 3 Rationale: The blue color is a sign of venous engorgement resulting from venous stasis,

PN~Comp~Review~CD~701-800~52 which increases local tissue hypoxia and can lead to necrosis of the area affected. This is not a normal expectation. Heat application would cause more damage to the tissue. There is no evidence to support option 4. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first knowing that this situation is not normal. Eliminate option 4 next because the question does not provide data to support this option. From the remaining options, basic principles associated with the application of heat should assist in eliminating option 2. Review care to the client following radical neck dissection 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/Integumentary Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1795. 793. A female adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen (Tylenol). Her boyfriend broke up with her 2 weeks ago, and she stopped eating at that time and has lost 15 pounds. The nurse assists in developing a plan of care and avoids which intervention? 1. Offer frequent nutritious snacks 2. Provide meals on an isolation tray that contains no glass or metal utensils 3. Stand the client in front of a mirror to show her how thin she is 4. Offer bland, easy to digest foods Answer: 3 Rationale: The client has been denying herself food as a means of self-harm. Reinforcing her success at this time is not therapeutic. Meeting her nutritional needs (options 1, 2, and 4) is the nursing care priority. Test-Taking Strategy: Use the process of elimination and note the key word avoids in the stem of the question. This word indicates a false-response question and that you need to select the incorrect intervention. Option 3 is the only option that does not address nutrition or a physiological need. Review the needs of a client who attempted suicide if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 289. 794. A female manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, the nurse should: 1. Remain silent because verbal interaction would be too stimulating 2. Tell the client that she will be allowed to rejoin the others when she can behave 3. Ask the client if she understands why the seclusion is necessary

PN~Comp~Review~CD~701-800~53 4. Inform the client that she is being secluded to help regain control of herself Answer: 4 Rationale: The client needs to be removed to a nonstimulating environment because of the client’s behavior. Options 1, 2, and 3 are nontherapeutic. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion. Test-Taking Strategy: Use the process of elimination. Look for the option that presents reality most clearly to the client. Option 4 is the only option that provides a clear and direct purpose of the seclusion. Review care to the client being placed in seclusion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 262-264. 795. A nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse would document that the treatment has been successful when the: 1. Client is awake and talking 2. Carboxyhemoglobin levels are less than 5% 3. Heart monitor shows sinus tachycardia 4. Client is sleeping soundly Answer: 2 Rationale: Normal carboxyhemoglobin levels are less than 5%. Clients can be awake and talking with abnormally high levels. Other symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression. Test-Taking Strategy: Use the process of elimination and focus on the issue, carbon monoxide poisoning. Note the key words treatment has been successful. Option 2 is the only option that specifically addresses this issue. Review the normal carboxyhemoglobin levels 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/Respiratory Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 215-216. 796. A nurse is assisting in assessing the twelfth cranial nerve in the client who sustained a cerebrovascular (CVA) accident. When assessing the twelfth cranial nerve, the nurse understands that the client should be asked to: 1. Extend the arms 2. Turn the head toward the nurse’s arm 3. Extend the tongue 4. Focus the eyes on the object held by the nurse Answer: 3 Rationale: To assess the function of the twelfth cranial (hypoglossal) nerve, the nurse

PN~Comp~Review~CD~701-800~54 would assess the client’s ability to extend the tongue. Impairment of the twelfth cranial nerve can occur with a CVA. Options 1, 2, and 4 are unrelated to assessing this cranial nerve. Test-Taking Strategy: Recalling that the twelfth cranial nerve is the hypoglossal nerve will assist in directing you to option 3. Review the cranial nerves and the method of testing these nerves 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/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2029. 797. A nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observation by the nurse is inconsistent with the need for suctioning? 1. Low peak inspiratory pressure on the ventilator 2. Gurgling sounds with respiration 3. Restlessness 4. Presence of rhonchi in the lungs Answer: 1 Rationale: Indications for suctioning include moist, wet respirations, restlessness, rhonchi on auscultation of lungs, visible mucus bubbling in the ETT, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator. A low peak inspiratory pressure would indicate a leak in the mechanical ventilation system. Test-Taking Strategy: Focus on the issue, the need for suctioning, and note the key word inconsistent. Rhonchi and gurgling sounds are obvious indications for suctioning and are therefore eliminated as possible answers to this question. Recalling that restlessness is a sign of hypoxia (which could result from the need for suctioning) helps you to eliminate this option. This leaves option 1. Since the client needing suctioning would trigger the high-pressure alarm, not the low-pressure alarm, it is the item inconsistent with the need for suctioning and is the answer to this question. Review the indications for suctioning 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/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1888. 798. A nurse is preparing a client for the administration of a Mantoux test. The nurse determines that which body area is the most appropriate area for injection of the medication? 1. Inner aspect of forearm that is not heavily pigmented 2. Inner aspect of forearm that is close to a burn scar

PN~Comp~Review~CD~701-800~55 3. Dorsal aspect of the upper arm near a mole 4. Dorsal aspect of the upper arm that has a small amount of hair Answer: 1 Rationale: Intradermal injections are most commonly given in the inner aspect of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is removed from hairy areas or lesions, which could interfere with reading the results. Test-Taking Strategy: Using general principles regarding the administration of medications will direct you to option 1. Review these general principles and the procedure for administering intradermal injections if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 677-678. 799. A nurse is planning therapeutic measures for a client who experienced a rib fracture 2 days earlier. The nurse understands that which item would not be helpful? 1. Rest 2. Local heat 3. Ice 4. Analgesics Answer: 3 Rationale: Common therapies for fractured ribs include rest, analgesics, and the local application of heat. Heat has an analgesic effect and speeds resolution of inflammation. Test-Taking Strategy: Use the process of elimination and note the key words 2 days earlier and would not be helpful. Recalling that ice is used only in the first 24 hours after an injury will direct you to option 3. Review care related to measures in treating a rib fracture if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1902. 800. A client with pleural effusion had a thoracentesis, and a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. The nurse interprets that this result is most consistent with: 1. Trauma 2. Infection 3. Congestive heart failure (CHF) 4. Liver failure Answer: 1

PN~Comp~Review~CD~701-800~56 Rationale: Pleural effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, CHF, liver or renal failure, malignancy, or inflammatory processes. Test-Taking Strategy: Use the process of elimination. Knowing that infection would be accompanied by white blood cells, not red blood cells, helps you to eliminate option 2 first. From the remaining options recalling that the fluid portion of the serum would accumulate with liver failure and cardiac failure will direct you to option 1. Review the causes and expected findings in pleural effusion 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/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 383.