Question 1 The admitting office calls the nursing unit and informs the nurse in charge that a child

with rheumatic fever will be arriving in the unit for admission. On admission, the nurse prepares to ask the mother of the child which question to elicit assessment information specific to the development of rheumatic fever? Has the child complained of headaches? Did the child have a sore throat or an unexplained fever within the last 2 months? Has the child had nausea or vomiting? Has the child complained of back pain? Question 1 Explanation: ANSWER: Did the child have a sore throat or an unexplained fever within the last 2 months? ; RATIONALE: Rheumatic fever characteristically presents 2-6 weeks after an untreated or partially treated group A beta hemolytic streptococcal infections of the upper respiratory tract. Initially the nurse determines whether the child has a sore throat or an unexplained fever within the past 2 months. Question 2 A nurse is completing an assessment with a client with chronic airflow limitations and notes that the client has a barrel chest. The nurse expects that this client has which of the following forms of chronic airflow limitation? Emphysema Bronchial asthma and bronchitis Bronchial asthma Chronic obstructive bronchitis Question 2 Explanation: ANSWER: Emphysema ; RATIONALE: The client with emphysema has hyper inflation of the alveoli and flattening of the diaphragm. This lead to increased anteropoasterior diameter referred to as barrel chest. Question 3 A nurse is assigned to a female client who is newly admitted to the mental health unit for anorexia nervosa. The nurse visits the client in her room and found out that the client is engaged in rigorous pushups. Which nursing action is most appropriate? Tell the client that she is not allowed to exercise rigorously. Interrupt the client and weigh her immediately. Interrupt the client and offer to take her for a walk. Allow the client to complete her exercise program. Question 3 Explanation: ANSWER: Interrupt the client and offer to take her for a walk. ; RATIONALE: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits to rigorous activities.

The physician scheduled the client with peptic ulcer disease for a pyloroplasty. The client wants clarification about the procedure discussed by the physician. Unfortunately, the physician is on emergency call. The client asks the nurse about the pyloroplasty procedure. The nurse plans to respond knowing that a pyloroplasty involves: Removing the distal portion of the stomach Removal of the ulcer and a large portion of the cells that produce hydrochloric acid An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum Cutting the vagus nerve Question 4 Explanation: ANSWER: An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. ; RATIONALE: Option c describes the procedure for a pyloroplasty. Question 5 A nurse is caring for a post partum client and monitoring for signs of bleeding. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? An increase in the respiratory rate from 18 to 22 breaths per minute An increase in the pulse rate from 88 to 102 beats per minute A BP change from 130/88 to 124/80 mmHg A temperature of 100.4 degree Fahrenheit Question 5 Explanation: ANSWER: An increase in the pulse rate from 88 to 102 beats per minute ; RATIONALE: During the fourth stage of labor, the maternal blood pressure, pulse and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes but a decreased in blood pressure would not be the earliest sign of hemorrhage. Question 6 A nurse formulated a plan of care for a client experiencing dystocia and includes several nursing intervention in the plan of care. The nurse emphasizes the plan of car and selects which of the following nursing interventions as the highest priority? Providing comfort measures Monitoring the fetal heart rate Keeping the significant other informed of the progress of the labor Changing the clients position frequently Question 6 Explanation: ANSWER: Monitoring the fetal heart rate ; RATIONALE: The priority is to monitor the fetal heart rate. Although providing comfort measures changing the clients position frequently, and keeping the significant others informed of the progress of the labor are components of the plan of care, the fetal status would be the priority Question 7

Question 4

On the day before discharge from the hospital, the nurse provides instruction to the client who delivered a healthy baby by cesarean

delivery. Which of the following statement if made by the client indicates a need for further instruction? "I will begin abdominal exercises immediately.

Keep the television and a soft light on during the night Play soft music during the night, and maintain a well-lit room Move the client net to the nurses station

I will turn on my side and push up with my arms to get out of bed. Use a night light and turn off the television I will lift nothing heavier than the newborn infant for at least 2 weeks. I will notify the physician if I develop a fever. Question 7 Explanation: ANSWER: "I will begin abdominal exercises immediately. ; RATIONALE: Abdominal exercises should not start immediately following abdominal surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Question 8 A client is admitted in the mental health unit and diagnosed with major depression recurrent with psychotic features. What would be the most important plan of care that would create a safe environment for the client? Imbalanced Nutrition 12 months Disturbed Thought Processes 4 months Self-Care Deficit Deficient Knowledge Question 8 Explanation: ANSWER: Disturbed Thought Processes ; RATIONALE: Major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designates the diagnosis of major depression, one also must deal with the clients psychosis. Psychosis is defined as a state in which a persons mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the persons capacity to deal with the demand of life. Question 9 The nurse is assigned to monitor the condition of a 1 day postpartum client in the postpartum room. The nurse notes that the lochia discharge of the client is red and has a foul-smelling odor. The nurse determines that this assessment findings is: Indicates the need for increasing ambulation Indicates the presence of infection Normal Indicates the need for increasing oral fluids Question 9 Explanation: ANSWER: Indicates the presence of infection ; RATIONALE: Lochia, the discharge present after birth, is not for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia indicates infection and these findings are not normal. Question 11 Explanation: ANSWER: 12 months ; RATIONALE: For children with human immunodeficiency virus infection, a minimum of 12 months of treatment with isoniazid is recommended. Question 12 The nursing instructor provides a lecture to the nursing students regarding some rights of the clients. The instructor asks the student to identify a situation that represents an example of battery. Which of the following items indicates an understanding of a violation of this right? Threatening the client that he cannot leave the hospital Sharing the clients record to other personnel not involve in providing care Threatening the client that he cannot leave the hospital Performing a procedure without consent of the client Question 12 Explanation: ANSWER: Performing a procedure without consent of the client ; RATIONALE: Performing a procedure without consent of the client is a form of battery. Threatening the client to give medication is an example of assault. Threatening the client cannot leave the hospital constitute false imprisonment and sharing the clients data is a form of invasion of privacy. Question 13 The mother of a child with a diagnosis of esophageal atresia with tracheoesopahgeal fistula brings her child to the clinic. A nurse reviews the record of the infant. And the nurse expects to note which most likely sign of this condition documented in the record? Choking with feedings Question 10 A nurse in night shift is making rounds. The nurse enters the clients room and found out that the client becomes disoriented and confused. The best initial nursing intervention is to: Severe projectile vomiting Incessant crying Coughing at night time Question 10 Explanation: ANSWER: Use a night light and turn off the television ; RATIONALE: Provision of a consistent daily routine and a low stimulating environment is important when the client is oriented Noise, including radio and television, may add to the confusion and disorientation. Question 11 The physician prescribed Isoniazid (INH) to a 2-year old child with human immunodeficiency virus infection who has a positive Mantoux test. The mother of the child asks the nurse how long will her child need to take the prescribed medicine. The nurse informs the mother that the medication will need to be taken for: 6 months 9 months

Question 13 Explanation: ANSWER: Choking with feedings ; RATIONALE: Any child who exhibits the 3 C coughing and choking with feedings and unexplained cyanosis- should be suspected of tracheoesopahgeal fistula. Question 14 The surgeon scheduled the client with hip fracture to be on Bucks extension traction before the surgery. The client asks the nurse why there is a need for the application of this traction. The nurses response is based on the understanding that Bucks extension traction primarily: Provides comforts by reducing muscles spasms and provide fracture immobilization Provides rigid immobilization of the fractured site Lengthens the fractured leg to prevent severing of blood vessels Allows bony healing to begin before surgery Question 14 Explanation: ANSWER: Provides comforts by reducing muscles spasms and provide fracture immobilization ; RATIONALE: Traction reduces muscle spasms and helps to immobilize the fracture Question 15 A nurse is making rounds; he enters a clients room. The client is begging to the nurse to be released from the hospital. The nurse checks the clients records and found out that the client was voluntarily admitted two days ago with a diagnosis of an anxiety disorder. Which of the following will the nurse take? Tell the client that discharge is not possible at this time Contact the physician Persuade the client to stay a few more days Call the clients family Question 15 Explanation: ANSWER: Contact the physician ; RATIONALE: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states requires that the client submit a written release notice to the facility staff, who reevaluates the clients condition for possible conversion to involuntary status, according to criteria established by law. Question 16 The client has a left-sided weakness and using a cane. The nurse observes the client walking using a cane. The nurse would intervene and correct the client if the nurse observed that the client: Moves the cane when the right leg is moved Leans on the cane when the right leg swings through Hold the cane on the right side Keeps the cane 6 inches out to the side of the right foot Question 16 Explanation: ANSWER: Moves the cane when the right leg is moved ; RATIONALE: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support and move forward with the affected leg.

Question 17 The client had an emergency coronary artery bypass surgery. The wife of the client ask the nurse about the purpose of the dressing on the left leg of her husband, the nurse best explain to the clients wife that: A filter is inserted in the leg to prevent embolization This is the access site for the heart-lung machine The arteries in distal extremities are examined during surgery The saphenous vein was used to bypass the coronary artery Question 17 Explanation: ANSWER: The saphenous vein was used to bypass the coronary artery. ; RATIONALE: This response provide information and reduces anxiety. The nurse should understand that the greater saphenous vein in the leg is used to bypass the diseased coronary artery because the surgical team can obtain the vein while the other team perform the chest surgery, this shortens the surgical time and risk of surgery. Question 18 A physician ordered to administer Apmhotericin B (Fungizone) intravenously to the client diagnosed with histoplasmosis. The nurse plans to do which of the following during administration of the medication? monitor for hypothermia assess the intravenous infusion site administer a concurrent fluid challenge monitor for an excessive urine output Question 18 Explanation: ANSWER: Assess the intravenous infusion site ; RATIONALE: Apmhotericin B is a toxic medication, which can produce symptoms during administration such as chills, fever, headache, vomiting, and impaired renal function. The medication is very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Question 19 The nurse is caring for a client with an internal radiation implant. The nurse should observe which of the following principles? Limit the time with the client to 1 hour per shift. Do not allow pregnant women into the clients room. Individuals less than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client. Remove dosimeter badge when entering the clients room. Question 19 Explanation: ANSWER: Do not allow pregnant women into the clients room. ; RATIONALE: The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the clients room. Children younger than 16 years of age and pregnant women are not allowed in the clients room. Question 20 A client who has a cancer of the pancreas is admitted to the hospital for surgery. The surgery includes the removal of the stomach, the head of the pancreas, the distal end of the duodenum, the spleen.

Following surgery, the nurse must be aware which manifestation by the client that requires immediate attention? Jaundice Hyperglycemia Weight loss Indigestion Question 20 Explanation: ANSWER: Hyperglycemia ; RATIONALE: When the head of the pancreas is removed, the client has a greatly reduced number of insulin-producing cells and hyperglycemia will occur. Immediate attention is necessary Question 21 A nurse is caring for a client with multiple myeloma. In reviewing the laboratory results, which of the following would the nurse expect to note specifically in this disorder? Increased calcium level Increased white blood cells Decreased blood urea nitrogen Decreased number of plasma cells in the bone marrow Question 21 Explanation: ANSWER: Increased calcium level ; RATIONALE: Findings indicates of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the released of calcium from the deteriorating bone tissue and an elevated blood urea nitrogen level. Question 22 A client is starting a therapy with oxtriphylline (Choledyl). A nurse plans to teach the client to limit the intake of which of the following while taking the medication? Oysters, lobster and shrimp Grapefruit, oranges and pineapple Cottage cheese, cream cheese, and dairy creamers Coffee, cola and chocolate Question 22 Explanation: ANSWER: Coffee, cola and chocolate ; RATIONALE: Oxtriphylline is a xanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine containing food when taking this medication. Question 23 A nurse is assisting in planning care to a newly admitted client. On entering the room of the client, the nurse notes that the clients legs are elevated, the trunk is position flat and the head and shoulder are slightly elevated. The position of the client is appropriate for prevention of: Increased Intracranial Pressure Respiratory insufficiency A head injury Shock

Question 23 Explanation: ANSWER: Shock ; RATIONALE: A client in shock is placed in a modified Trendelenburg position that includes elevating the legs, leaving the trunk flat and elevated head and shoulders. This position promotes increase venous return from the lower extremities without compressing the abdominal organ against the diaphragm Question 24 The nurse is planning to conduct a teaching session with the female client who is diagnosed with urethritis caused by infection with Chlamydia. The nurse would plan to include which of the following points in the teaching session? Sexual partners during the last 12 months should be notified and treated. The infection can be prevented by using spermicidal to alter the pH in the perineal area. The most serious complication of this infection is sterility. Medication therapy should be continued for 3 weeks without interruption. Question 24 Explanation: ANSWER: The most serious complication of this infection is sterility. ; RATIONALE: The most serious complication of the chlamydial infection is sterility. The infection can be prevented by the use of latex condoms. Question 25 The nurse is discharging a client with chronic anxiety. The nurse wants to ensure a safe environment for the client. The most appropriate maintenance goal should focus on which of the following? Ignoring feeling of anxiety Identifying anxiety-producing situations Continued contact with a crisis counselor Eliminating all anxiety form daily situations Question 25 Explanation: ANSWER: Identifying anxiety-producing situations ; RATIONALE: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety producing situations, and this option does not encourage the development of internal strength. Ignoring feelings will not resolve anxiety. Question 26 The nurse is caring for a client who had skeletal traction applied to the left leg. The client asks the nurse how long he will stay in that condition. While talking to the nurse, the client complains of severe left leg pain. Which of the following actions should the nurse take first? Check the clients alignment in bed Medicate the client with an analgesic Call the physician Provide pin care Question 26 Explanation: ANSWER: Check the clients alignment in bed ; RATIONALE: The nurse realigns the client and if that is ineffective then calls the physician.

Question 27 The home health care nurse visits a client with cancer. The client is complaining of pain. The most appropriate nursing assessment of the clients pain would include which of the following? The clients pain rating

the following would the nurse anticipate to be prescribed for the client? Placing the affected leg in a dependent position. Immobilization of the affected leg Bathroom privileges

The nurses impression of the clients pain Out of bed Nonverbal cues from the client Pain relief after appropriate nursing intervention Question 27 Explanation: ANSWER: The clients pain rating ; RATIONALE: The clients self report is a critical component of pain assessment. The nurse should ask the client about the description of the pain and listen carefully to the clients words used to describe the pain. The nurses impression of the clients pain is not appropriate in determining the clients level of pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measures. Question 28 The community health nurse is promoting cancer awareness program and conducting a lecture on the female clients about breast examination. The nurse would instruct the clients to perform the examination: Every month during ovulation 1 week after menstruation begins At the onset on menstruation period Weekly at the same time of the day Question 28 Explanation: ANSWER: 1 week after menstruation begins ; RATIONALE: The breast self-examination should be performed monthly seven days after the menstruation period. Question 29 A newly nursing graduate is attending an orientation regarding the nursing model of practice implemented in the hospital. The nurse is told that the nursing model is a primary nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice? Critical paths are used in providing client care The nurse manager assigns tasks to the staff members Nursing staff are led by an RN leader in providing care to a group of clients A single registered nurse is responsible for planning and providing individualized nursing care Question 29 Explanation: ANSWER: A single registered nurse is responsible for planning and providing individualized nursing care ; RATIONALE: Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goaldirected, individualized client care. Question 30 The nurse is caring for a client who suffered a second and third degree burns on the anterior lower legs and anterior thorax. The client is just finished for an autograft and grafting procedure. Which of The home health nurse is scheduled to visit a client at home and found out that the client is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care? The nurse does not ask any questions in fear that the client is in denial and will throw the nurse out of the home. How much do you use and what effect does it have on you Why did you get started on these drugs? How long did you think you could take these drugs without someone finding out Question 32 Explanation: ANSWER: How much do you use and what effect does it have on you ; RATIONALE: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being judgmental and direct. Over my dead body you will! Shes here and here she stays until the doctor says different You seem very upset. Lets talk at the nurses station. I want to help you. It would be best if you agree to let you daughter stay here for now. Question 31 Explanation: ANSWER: You seem very upset. Lets talk at the nurses station. I want to help you. It would be best if you agree to let you daughter stay here for now. ; RATIONALE: When a suspected abused child is admitted to the hospital for further evaluation and protection, the physician will usually work with the parents so they will agree to the admission. If the parents refuse to agree to the admission, the hospital can request an immediate court order to retain the child for a specific length of time. Question 32 Question 30 Explanation: ANSWER: Immobilization of the affected leg ; RATIONALE: Autograft placed over joints or on the lower extremities often are elevated and immobilized following surgery for 3-7 days. This period immobilization allows the autograft time to adhere and attach to the wound bed. Question 31 A nurse is caring for a 12 year old female client who is a victim of physical and sexual abuse. The client is newly admitted in the hospital and the nurse performs assessment about the case of the client. Following assessment, the nurse found out that the childs father is the abuser. That time, the father arrives and angrily approaches the nurse and says, Im taking my daughter home. Shes told me what you people are up to and were out of here! The nurse makes which therapeutic response to the childs father? Your daughter is sick and needs to be here. Listen to me. If you attempt to take your daughter from this unit, the police will bring her back.

Question 33 A nurse is caring for a client taking Trimethoprim-sulfamethoxazole (Bactrim) A nurse instructed the client to report sign of symptoms that might be developed during the course of the therapy: Nausea Sore throat Diarrhea Headache Question 33 Explanation: ANSWER: Sore throat ; RATIONALE: Clients taking Trimethoprim-sulfamethoxazole should be informed about early signs of blood disorder that can occur from this medication. Question 34

Every 5minutes for the first half hour, every 15 minutes for two hours, every 30minutes for four hours and then every hour as needed Every 30minutes for the first hour, every hour for two hours, then every four hours as needed Every hour for two hours, then every four hours as needed Every 15minutes for the first hour, every 30minutes for the second hour, every hour for 4 hours and then every four hour as needed. Question 36 Explanation: ANSWER: Every 15minutes for the first hour, every 30minutes for the second hour, every hour for 4 hours and then every four hour as needed. ; RATIONALE: When the post operative client arrives from the post anesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes for the first hour, every 30 minutes for the second hour, and then every hour for four hours and every four hour as needed. Question 37

A client comes to the clinic for a check up and complains skin irritation. The client is advised to be back in the clinic 1 week for scratch skin test. The nurse provides which instruction to the client? Shower using an antibacterial soap on the morning of the test

A client newly diagnosed as having Type I diabetes. The nurse explain to the client that self-monitoring of blood glucose is preferred to urine glucose testing because it is: More accurate

Do not ingest anything before the test Done by the client Discontinue the prescribed antihistamine 5days before the test Easier to perform Consume only fluids on the day of the test Not influence by drainage Question 34 Explanation: ANSWER: Discontinue the prescribed antihistamine 5days before the test. ; RATIONALE: Client preparation for a scratch skin test includes informing the client to discontinue the administration of systemic corticosteroids or antihistamines for at least 5days before the test. This medication must be discontinues to prevent suppression of the inflammatory response to the allergen. Question 35 A home care nurse arrives at the clients home for the scheduled home visit. The client tells the home care nurse of his decision to refuse external cardiac massage. Which of the following is the most appropriate initial nursing action? Notify the physician of the clients request Document the clients request in the home care nursing care plan Conduct a client conference with the home care staff to share the clients request Discuss the clients request with the family Question 39 Question 35 Explanation: ANSWER: Notify the physician of the clients request ; RATIONALE: External Cardiac Massage is a lifesaving treatment that a client can refuse. The most appropriate initial nursing action is to notify the physician, because written do not Resuscitate (DNR) order from the physician is needed. The DNR order must be reviewed or renewed on a regular basis per agency policy. Question 36 A nurse in a surgical unit receives a postoperative client form the post anesthesia care unit. After the initial assessment of the client, the nurse plans to monitor and continue with post operative assessment activities. Which of the following would be appropriate? A client returns to his room following heart surgery. The nurse is aware that Thrombus formation is a danger of all postoperative clients. The nurse should act independently to prevent this complication by: Massaging the clients extremities gently with lotion Massaging the clients extremities Assisting the client to exercise in bed Urging the client to drink adequate fluids Question 39 Explanation: ANSWER: Assisting the client to exercise in bed ; RATIONALE: Inactivity causes venous stasis hyper Question 37 Explanation: ANSWER: More accurate ; RATIONALE: A blood glucose testing is a one direct accurate measure. Question 38 A client diagnosed with multiple myeloma asks the nurse how the disease may progress. In providing information to this client, the nurse should discuss the possibility that: Blood Transfusion may be necessary Frequent Urinary Tract Infection may result Intravenous therapy may be administered at home The disease is exacerbated by exposure to ultra violet rays Question 38 Explanation: ANSWER: Blood Transfusion may be necessary ; RATIONALE: Blood products (packed RBC or platelet) are administered when warranted.

coagulability, and arterial pressure against the vein, all of which lead to thrombus formation, early ambulation in exercise of the lower extremities reduce the occurrence of this phenomenon Question 40

stated that he/she should report which of the following early symptoms of compartment syndrome? Cold, bluish-colored fingers Pain that is relieved only by oxycodone and aspirin

A nurse is caring to a client admitted in the labor room. The nurse performs an assessment and monitors the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. Document the findings and tell the mother that the monitor indicates fetal well-being. Notify the physician or nurse-midwife of the findings. Reposition the mother and check the monitor for changes in the fetal tracing. Question 40 Explanation: ANSWER: Document the findings and tell the mother that the monitor indicates fetal well-being. ; RATIONALE: Acceleration are transient increase in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well being and adequate oxygen reserve. Question 41 When preparing a client for discharge after a thyroidectomy, the nurse should teach a client to observe for sign of hyperthyroidism. The nurse would be aware that the client understands the teaching when the client says, I should call my physician if I develop: Muscle cramping and sluggishness Tachycardia and an increase in weight Fatigue and an increased pulse rate Dry hair and an intolerance to cold Question 41 Explanation: ANSWER: Dry hair and an intolerance to cold ; RATIONALE: Dry, sparse hair and cold intolerance are characteristics adaptations to low serum thyroxine. Question 42 A nurse provides a home care instruction to the parents of a child diagnosed with celiac disease. The nurse teaches the parents of the child to include which of the following food items in the childs diet? Rice Oatmeal Rye Toast Wheat Bread Question 42 Explanation: ANSWER: Rice ; RATIONALE: Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, oats should be eliminated from the diet. Question 43

Numbness and tingling in the fingers Pain that increases when the arm is dependent Question 43 Explanation: ANSWER: Numbness and tingling in the fingers ; RATIONALE: The earliest symptoms of compartment syndrome is paresthesia (numbness and tingling) Question 44 A nurse caring for the child with Kawasaki disease who just admitted to the hospital is reviewing the order of the physician. The nurse expects to note an order which of the following as part of the treatment plan for the child? Immune globulin Heparin infusion Morphine sulfate Digoxin Question 44 Explanation: ANSWER: Immune globulin ; RATIONALE: Immune globulin is administered intravenously to the child with Kawasaki Disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation. Question 45 A nurse enters the female client room to administer medication. Inside the room, the client is in manic state. She is naked and making sexual remarks and gestures toward the nurse. The best initial nursing action is to: Confront the client on the inappropriateness of her behavior and offer her a time-out Ask the other nurse to calm the client Approach the client and insist that she has to put on her clothes Quietly approach the client and assist her in getting dressed Question 45 Explanation: ANSWER: Quietly approach the client and assist her in getting dressed ; RATIONALE: A person who is experiencing mania lacks insight and judgment, has poor impulse control and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client. Question 46 The nurse provided the client all the information needed about the upcoming endoscopic retrograde cholangiospancreatography procedure. The nurse determines that the client needs additional information if the client makes which of the following statements? I hope the throat spray keeps me from gagging Im glad I dont have to lie still for this procedure I know I must sign the consent form

The nurse is providing information to the client in an arm cast about signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client

Im glad some IV medication will be given to relax me

Question 46 Explanation: ANSWER: Im glad I dont have to lie still for this procedure ; RATIONALE: The client doest not have to lie still for ERCP, which takes about an hour to perform. Question 47

tongue cannot be moved back because it would occlude the airway. Swallowing can not be done with the mirror in place. The procedure takes longer that the time the client would be able to hold the breath, and this action is ineffective. Question 50

A charge nurse assigned a nursing assistant to care to a client with delirium. While the nurse is on her way to the other clients room, she happens to hear the nursing assistant talking in an unusually loud voice to the client. The charge nurse takes which appropriate action? Explains to the nursing assistant that yelling in the clients room is tolerated only If the client is talking loudly. Informs the client that everything is all right. Speaks to the nursing assistant immediately while in the clients room to solve the problem. Ascertains the clients safety, calmly asks the nursing assistant to join the nurse outside the room, and informs the nursing assistant that her voice was unusually loud. Question 47 Explanation: ANSWER: Ascertains the clients safety, calmly asks the nursing assistant to join the nurse outside the room, and informs the nursing assistant that her voice was unusually loud. ; RATIONALE: The nurse must ascertain the client is safe, and then discuss the matter with the nursing assistant in an area away from the hearing of the client. If the client heard the conversation, the client may become more confused or agitated. Question 48 The nurse is assigned to monitor the client with a diagnosis of chronic gastritis. The nurse is aware that this client is at risk for which of the following vitamin deficiencies? Vitamin E Vitamin C Vitamin A Vitamin B12 Question 48 Explanation: ANSWER: Vitamin B12 ; RATIONALE: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of the intrinsic factor is lost which results inability to absorb vitamin B12. Question 49 A client is scheduled for indirect visualization of the larynx to assess the function of the vocal cords. As the physician is performing the procedure, the nurse instructed the client to do which of the following? Roll the tongue to the back of the mouth Hold the breath Try to swallow

The nurse inserted a Foley catheter to a hospitalized client with head injury. The client has begun urinating copious amount of dilute urine through the catheter. The urine output is 3000ml. The nurse implements which of the following new physician order to administer? Desmopressin ( DDAVP, Stimate) Dexamethasone (Decadron) Ethacrynic acid (Edecrin) Mannitol (Osmotri) Question 50 Explanation: ANSWER: Desmopressin ( DDAVP, Stimate) ; RATIONALE: A complication of head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9L per day generally requires treatment with Desmopressin. Question 51 A nurse is teaching a mother who has been diagnosed with mastitis. Which of the following statements if made by the client indicates a need for further teaching? I can use analgesics to assess in alleviating some of the discomfort " I need to wear a supportive bra to relieve the discomfort I need to stop breast feeding until this condition resolves I need to take antibiotics, and I should begin to feel better in 24-48 hours Question 51 Explanation: ANSWER: I need to stop breast feeding until this condition resolves ; RATIONALE: In most cases, the mother can continue to breast-feed with both breast. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 48 hours. Additional supporting measures include ice packs, breast supports, and analgesics. Question 52 A nurse is assigned to a client scheduled for a colonoscopy and the physician has provided detailed information to the client about the procedure. After confirming if the client clearly understands the procedure, the nurse prepares the informed consent for the client to sign it. Then the client informs the nurse that he does not know how to write. What is the nurse appropriate action? Contact a family member to represent for the client and sign the inform consent form Send the client for the procedure without a signed informed consent

Breathe normally Contact the physician and inform that the client cannot write Question 49 Explanation: ANSWER: Breathe normally ; RATIONALE: Indirect laryngoscopy is done to assess the function of the vocal cords or to obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. The Obtain a second nurse to also act as a witness and ask the client to sign the form with an X Question 52 Explanation: ANSWER: Obtain a second nurse to also act as a witness and ask the client to sign the form with an X ;

RATIONALE: Clients who cannot write may sign an informed consent with an X. This is witnessed by two nurses. Nurses serve as a witness to the clients signature and not to the fact that the client is informed. It is the physicians responsibility to inform the client about a procedure. The nurse clarifies facts presented by the physician. There is no useful reason to contact the physician at this time. A client is not send to a procedure without a signed informed consent Question 53 The nurse in the nursery is caring for a newborn infant. A new employee will be assign to the unit and the nurse needs to provide a teaching session regarding sudden infant syndrome to her colleague. The nurse tells the new employee that SIDS usually occurs during sleep and Most frequently occurs in toddlers Most frequently occurs during the summer months Most frequently occurs in girls Most frequently occurs from 2-4 months of life Question 53 Explanation: ANSWER: Most frequently occurs from 2-4 months of life ; RATIONALE: Sudden infant death syndrome usually occurs during sleep and during the winter months and most frequently occurs between the second and the forth month of life. The syndrome is more common in boys. Question 54 Female client with schizophrenia has been prescribed Chlorpromazine ( Thorazine). The client was alarmed with the color of her urine that becomes dark. The client has no other urinary symptoms. The nurse tells the client: That this medication indicates toxicity That this is an expected side effect of the medication To increase intake of acid-ash foods and liquids To seek treatment for urinary tract infection

A nurse in charge observes that the staff nurse is not providing quality care to the client, not able to meet Clients needs in a reasonable time frame, does not solve any problems in the nursing unit and does not prioritize nursing care. Which of the following is the responsibility of the charge nurse? Report the staff nurse to the supervisor so that something is done to resolve the problem Provide support and identify the underlying cause of the staff nurses problems Supervise the staff nurse more closely so tasks are completed Ask other staff members to help the staff nurse get the work done Question 56 Explanation: ANSWER: Provide support and identify the underlying cause of the staff nurses problems ; RATIONALE: Option c empowers the charge nurse to assist the staff nurse while trying to identify and reduce the behaviors that make it difficult for the staff nurse to function. Question 57 A nurse is in charge to care for a young female client, a victim of sexual assault. The nurse completed the physical assessment and important evidence was gathered. The nurse notes that the client is withdrawn, confused, and at times physically immobile. This behavior are interpreted by the nurse as: Evidence that the client is a high suicide risk Indicative of the need for hospital admission Normal reaction to a devastating event Signs of depression Question 57 Explanation: ANSWER: Normal reaction to a devastating event ; RATIONALE: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction to an intensely difficult crisis event. Question 58

Question 54 Explanation: ANSWER: That this is an expected side effect of the medication ; RATIONALE: Chlorpromazine is an antipsychotic medication. A side effect of this medication is that the color of the urine may darken. The client should be aware that this effect is harmless. Question 55

A severely depressed client is admitted in the mental health unit for 8 weeks. The nurse observes that the client has not responded to any of the antidepressant medication, the physician decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should: Limit the clients intake to a light breakfast on the day of the treatment

A nurse enters the medication room and finds another nurse inside that is about to insert a needle attached to the syringe containing a clear fluid into the antecubital area. The nurse appropriate initial action is: Lock the nurse inside the medication room until help is obtained

Have the client speak with other clients receiving ECT Provide a simple explanation of the procedure and continue to reassure the client Give the client a detailed explanation of the entire procedure

Call the secure All the nursing supervisor Call the police Question 55 Explanation: ANSWER: All the nursing supervisor ; RATIONALE: Nurse Practice acts require reporting impaired nurses. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and authorities. Question 56 WRONG Question 58 Explanation: ANSWER: Provide a simple explanation of the procedure and continue to reassure the client ; RATIONALE: The nurse should offer support and use clear, simple terms to allay the clients anxiety. Question 59 The nurse on the day shift is scheduled to care for three clients. One client is scheduled for a cardiac catheterization at 10AM; the other has a tracheostomy and is on a mechanical ventilator. And the other client was newly diagnosed with diabetes mellitus and is scheduled

for discharged to home. How would the nurse plan the order of care of the clients for the day? A client with tracheostomy and is on mechanical ventilator, client scheduled for a cardiac catheterization followed by the client with diabetes mellitus scheduled for discharged. A client with tracheostomy and scheduled for cardiac catheterization would at the same time be given the highest priority in the plan of care, client for discharge does not need much attention A client scheduled for a cardiac catheterization, client with diabetes mellitus and for discharged to home, client with tracheostomy A client with diabetes mellitus, client scheduled for a cardiac catheterization, client with tracheostomy Question 59 Explanation: ANSWER: A client with tracheostomy and is on mechanical ventilator, client scheduled for a cardiac catheterization followed by the client with diabetes mellitus scheduled for discharged. ; RATIONALE: Airway is always a high priority and the nurse would assess the client who has a tracheostomy and is on a mechanical ventilator first. The nurse next step of care would assess the client scheduled for cardiac catheterization, followed by the client scheduled for discharge. Question 60 The physician advised the client to take senna (Senokot) to treat constipation. The client is curious to know the effect of the medication. The client asks the nurse how this medication works. The nurse would incorporate which of the following when formulating a response to the client? Senna stimulates the vagus nerve to improve the bowel tone Senna accumulates water and increases peristalsis Senna coats the bowel wall and makes it slippery Senna adds fiber and bulk to the stool Question 60 Explanation: ANSWER: Senna accumulates water and increases peristalsis ; RATIONALE: Senna works by changing the transport of water in the large intestine which causes accumulation of water in the mass of stool and increase peristalsis. Question 61 The mother of the child who had a myringotomy with insertion of tympanostomy was so worried when the tubes have fallen out. The mother calls the nurse and asks for an immediate action. Which of the following is the most appropriate response of the nurse to the mother? Place the tubes in hydrogen peroxide for 1 hour before replacing them in the childs ears "Replace the tube immediately so that the created opening does not close This is an emergency and requires immediate intervention. Bring the child to the emergency room This is NOT an emergency; I will speak to the physician and call you right back Question 61 Explanation: ANSWER: This is NOT an emergency; I will speak to the physician and call you right back ; RATIONALE: The size and appearance of the tympanostomy tube should be described to the parents after surgery. They should be reassured that

if the tube fall out, it is not an emergency, but the physician should be notified Question 62 A newly admitted client with an acute myocardial infarction asks the nurse what are the complications accompany this disease. The question of the client makes the nurse is aware that there is a possibility of death from complications. The nurse should monitor the client during the first 48 hours is: Ventricular tachycardia Failure of the Right ventricle Pulmonary edema Pulmonary embolism Question 62 Explanation: ANSWER: Ventricular tachycardia ; RATIONALE: At least of all deaths occur from the life-threatening dysrhythmias of ventricular tachycardia. Question 63 A client is taking Amitriptyline hydrochloride (Elavil). The nurse evaluates that the medication is most effective for this client if the client reports which of the following? Having difficulty concentrating on an activity Sleeping 14-16 hours a day Ability to get to work on time each day Decrease in appetite Question 63 Explanation: ANSWER: Ability to get to work on time each day ; RATIONALE: Amitriptyline is a tricyclic antidepressant. Depressed individuals sleep for extended periods, have a change in appetite, unable to go to work, and have difficulty concentrating. They also may experience increased fatigue, feeling of guilt, worthlessness, loss of interest in activities and possible suicidal tendencies. Question 64 A client is to receive an IV solution. When evaluating a clients response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs would be: Blood pressure of 50/30 and 90/40 mmHg Pulse rate of 120 and 110 in a 15minute period Central venous pressure reading 2 cm water Urinary output of 30ml per hour Question 64 Explanation: ANSWER: Urinary output of 30ml per hour ; RATIONALE: A rate of 30ml/hr is considered adequate perfusion of the kidney, heart and brain. Question 65 A male client arrives at the health care clinic and tells the nurse that he would like to be tested for Lyme disease. The client tells the nurse that he was bitten by a tick and removes the tick and flushed it down the toilet. Which of the following nursing actions is best in this client? Refer the client for a blood test immediately

Inform the client to return in 4-6 weeks to be tested because testing before this time is not reliable Inform the client that there is not a test available for Lyme disease Tell the client that testing is not necessary unless arthralgia Question 65 Explanation: ANSWER: Inform the client to return in 4-6 weeks to be tested because testing before this time is not reliable ; RATIONALE: A blood test is available to detect Lyme disease however the test is not reliable if performed before 4-6 weeks following the tick bite. Question 66 A nurse is completing the assessment to a client who is 4 hours postpartum. Following assessment, the nurse notes that the client has cool, clammy skin and observed that the client is also restless and excessively thirsty. The nurse prepares immediately to: Begin fundal massage and start oxygen by mask Elevate the head of the bed and assess vital signs Begin hourly pad counts and reassure the client

Question 69 After a vehicle accident, client is scheduled for below-the-knee amputation. Following the surgery, the client tells the nurse, I think Im going to be crazy. I can feel my left foot itching. The nurse interprets the clients statement to be: An abnormal response that indicates the presence of phantom limb pain A normal response that indicates that the client needs more psychological support A normal response that indicates the presence of phantom limb sensation An abnormal response that indicates the client is in denial about the limb loss Question 69 Explanation: ANSWER: A normal response that indicates the presence of phantom limb sensation ; RATIONALE: Phantom limb sensation are felt in the area of the amputated limb. These sensations can include itching, warmth and cold. The sensations are due to intact peripheral nerves in the area amputated. Question 70

Assess for hypovolemia and notify the healthcare provider Question 66 Explanation: ANSWER: Assess for hypovolemia and notify the healthcare provider ; RATIONALE: Symptoms of hypovolemia include cool clammy pale skin, sensation of anxiety or impending doom, restlessness and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the healthcare provider. Question 67 The nurse assigned a nursing student to formulate a post procedure plan of care to a client who undergone bone biopsy. The nurse determines that the student needs to research further about post procedure care if which inaccurate intervention is documented? Monitoring Vital signs every 4 hours Administering Narcotic Analgesic intramuscularly Monitoring Site for swelling, bleeding or hematoma Question 71 Elevating the limb for 24 hours Question 67 Explanation: ANSWER: Administering Narcotic Analgesic intramuscularly. ; RATIONALE: After biopsy the client usually requires mild analgesic. Question 68 The nurse is planning an intervention to help a client with bipolar I disorder, manic episode meet needs for rest and sleep, the nurse must remember that the manic client: Experiences few sleep pattern disturbances Is easily stimulated by the environment Needs to expend energy to be tired enough to sleep Requires less sleep than the average person Question 68 Explanation: ANSWER: Is easily stimulated by the environment ; RATIONALE: These individuals readily respond to environmental cues; increased stimulation increases activity; decreased stimulation decreases activity. The nurse is assigned to care for client with phobia. The nurse exposes the client to a short period of time to the phobic object while in a calm state. The nurse understands that this form of behavior modification can best described as A behavioral approach to changing behavior A form of behavior modification therapy A cognitive approach to changing behavior A living, learning or working environment Question 71 Explanation: ANSWER: A form of behavior modification therapy ; RATIONALE: Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually exposure is increased until the anxiety about or fear of the objects or situation has ceased. A nurse is providing health teaching to a client with Addisons disease regarding diet therapy. The nurse is aware that which of the following diets most likely the physician will prescribe for this client? High fat intake Low carbohydrate intake Low protein intake Normal sodium intake Question 70 Explanation: ANSWER: Normal sodium intake ; RATIONALE: A high-complex carbohydrate and high protein diet will be prescribed for the client with Addisons disease. To prevent excess fluid and sodium loss, the client will be taught to maintain a normal salt intake daily (3g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting or diarrhea.

Question 72 A mother brought her child to the emergency room after the ingestion of about one half bottle of acetylsalicylic acid (aspirin). The nurse in charge in the emergency room anticipates that the most likely first treatment will be: Dialysis Administration of syrup of ipecac Administration of sodium bicarbonate Administration of vitamin K Question 72 Explanation: ANSWER: Administration of syrup of ipecac ; RATIONALE: Initial treatment of salicylate overdose includes inducing vomiting with syrup of ipecac. Question 73 A post partum client with a diagnosis of deep vein thrombosis is receiving a continuous intravenous infusion of heparin sodium. The nurse reviews the laboratory results and wants to know if the client is given an appropriate dose of heparin. Which of the following laboratory results the nurse would check to determine if an effective dose of the heparin is being delivered? Platelet count International normalized ratio Activated partial thromboplastin time

Sternal rub Pressure on the orbital rim Nail bed pressure Squeezing of the sternocleidomastoid muscle Question 75 Explanation: ANSWER: Nail bed pressure ; RATIONALE: Motor testing of the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle. Question 76 The nurse is conducting a lecture session regarding cast care to a client that will be discharged in the next two hour. The nurse would evaluate that the client understands proper care of the cast if the client states that he or she should: Use the padded coat hanger end to scratch under the cast Avoid getting the cast wet Use the fingertips to lift and move the leg Cover the casted leg with warm blanket Question 76 Explanation: ANSWER: Avoid getting the cast wet ; RATIONALE: A plaster cast must remain dry to keep its strength. Question 77

Prothrombin time Question 73 Explanation: ANSWER: Activated partial thromboplastin time ; RATIONALE: Anticoagulation therapy maybe used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and the heparin dose should be adjusted to maintain a therapeutic level of 1.5 2.5 times the control. The prothrombin time and the international normalized ratio are used to monitor coagulation time when warfarin (coumadin) is used. The platelet count cannot be used to determine an adequate dosage for the heparin infusion. Question 74 A client comes to the clinic for a check up and suspected of having Tuberculosis. The nurse understands the most accurate method for confirming the diagnosis is: a positive Purified Protein Derivative Test (PPD) Question 78 a chest X-ray positive for lung lesion a sputum culture positive for Mycobacterium Tuberculosis obtaining clients health history Question 74 Explanation: ANSWER: A sputum culture positive for Mycobacterium Tuberculosis ; RATIONALE: The most accurate means of confirming the diagnosis of Tuberculosis is by sputum culture. Question 75 The client is unconscious and the physician assigned the nurse to do an assessment. The nurse is assessing the motor function of the client. The nurse would plan to use which of the following to test the clients peripheral response to pain? A nurse was hired to be a home care nurse to assist the family in caring for a newborn with congenital tracheoesopahgeal fistula who is receiving enteral feedings. The nurse receives a telephone call and a woman introduced herself to the nurse as a family friend and wishes to know the condition of the client and inquire if there is anything she can do to assist the parents. The best nursing action is to: Report the friends telephone call to the nurse manager for referral to the clients social worker Request that the friend come to the clients home, where she can be taught to administer the feedings Inform the friend to directly contact the family and offer her assistance to them Question 77 Explanation: ANSWER: Maintaining the supine position for a minimum of 4 hours. ; RATIONALE: The supine position prevents hip flexion limiting injury and promoting healing of the catheter insertion site; if the head of the bed is elevated, it should not exceed 20 degrees. A nurse is developing a plan of care for a client who has had a cardiac catheterization, which of the following would the nurse include? maintaining the supine position for a minimum of 4 hours ambulating the client 2 hours after the procedure keeping the client NPO for 4 hours after the procedure checking the vital signs every 15 minutes for 8 hours

Inform the friend that the family has no need for assistance at this time because the nurse is making daily visits Question 78 Explanation: ANSWER: Inform the friend to directly contact the family and offer her assistance to them. ; RATIONALE: A nurse must uphold the clients rights and does not give any information regarding a clients care needs to anyone who is not directly involved in the clients care. To request that the friend come for teaching is a direct violation of the clients right to privacy. There is no information in the question to indicate that the family desires assistance form the friend. To refer the call to the nurse manager and social worker again assumes that the friends assistance and involvement is desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential. Question 79 The nurse is reviewing the prescribed medication of a newly admitted client. The nurse reviewed the order and notes that the physician has ordered the dose that is twice the amount the client is taking before admission. The nurse verifies the medication dosage before the administration. What is the next most appropriate nursing action? Verify the prescribed medication by calling the nurse supervisor Contact the physician and verifies the order Carry out the order because there is no question about it Administer the drug even the dosage is twice the amount because that is the order of the physician Question 79 Explanation: ANSWER: Contact the physician and verifies the order ; RATIONALE: If the nurse determines that a physicians order is unclear, or if the nurse has a question about an order, the nurse should contact the physician, before implementing the order. Under no circumstances should the nurse carry out the order unless the physician has clarified the order. Question 80

Strain Contusion Sprain Fracture Question 81 Explanation: ANSWER: Fracture ; RATIONALE: Typical sign and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling and ecchymosis. Question 82 A nurse assigned a nursing student to perform a cardiovascular assessment on a postpartum woman. The nurse asks the student about the procedure to elicit Homans sign. Which response by the nursing student would indicate an understanding of this assessment technique? I will ask the woman to raise the legs and to try to lower them against pressure from my hand. I will ask the woman to extend her legs flat on the bed, and I will grasp the foot and gently dorsiflex it forward. I will ask the woman to raise the legs up to the waist and then lower the legs slowly. I will ask the woman to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward. Question 82 Explanation: ANSWER: I will ask the woman to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward. ; RATIONALE: To elicit homans sign, the nurse asks the woman to extend her legs on the bed. The nurse grasps the foot and dorsiflexes it forward. If this cause any discomfort or resistance, the nurse should notify the physician or midwife that Homans sign is present. Question 83

A nurse is caring for a client admitted in the labor room. The nurse is completing an assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? Place the client in Trendelenburg position Call the delivery room to notify the staff that the client will be transported immediately. Find the closest telephone and stat page the physician.

The nurse in-charge placed the manic client in a seclusion room following an outburst of violent behavior that involved a physical assault on another client. As the client is in the seclusion room, the nurse in charge would: Tells the client that she will be allowed to rejoin the others when she can behave Asks the client if she understands why the seclusion is necessary Remains silent because verbal interaction would be too stimulating

Gently push the cord into the vagina Informs the client that he is being secluded to help regain self-control Question 80 Explanation: ANSWER: Place the client in Trendelenburg position ; RATIONALE: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the 105 hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and the others staff members should call the physician and notify the delivery room. Question 81 The client is admitted in the emergency room for a lower leg injury. The deformity of the leg of the client is visible, and the affected leg is shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced a Question 83 Explanation: ANSWER: Informs the client that he is being secluded to help regain self-control ; RATIONALE: The client is removed to a nonstimulating environment as a result of behavior. It is best to inform the client the purpose of the seclusion. Question 84 The nurse is performing a follow-up assessment with a client that was discharged a month ago. The client is taking Flouxetine (Prozac). What would be the important information that the nurse need to obtain regarding the side effects related to the medication? Problems with mouth dryness Cardiovascular symptoms

Problems with excessive sweating Gastrointestinal dysfunctions

parents need to be instructed that if the child vomits after the digoxin is administered they are not to repeat the dose. Question 88

Question 84 Explanation: ANSWER: Gastrointestinal dysfunctions ; RATIONALE: The most common side effects related to the medication includes central nervous system and gastrointestinal system by causing nausea, vomiting, cramping and diarrhea. Question 85 Following an abdominal surgery, the client develops internal hemorrhage, The nurse performs further assessment, the nurse should expect the client to exhibit: Bradypnea Polyuria Tachycardia Hypertension

The nurse is developing a plan of care to a child scheduled for a tonsillectomy. A nurse is aware which of the following would present the highest risk of aspiration during surgery. Exudate in the throat area Bleeding during surgery The presence of loose teeth Difficulty in swallowing Question 88 Explanation: ANSWER: The presence of loose teeth ; RATIONALE: In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Question 89

Question 85 Explanation: ANSWER: Tachycardia ; RATIONALE: With shock the heart rate accelerates to increase blood flow and oxygen to body tissue Question 86

A client is admitted in the mental health unit complaining of loose, watery stool, and difficulty walking. The nurse would expect the serum lithium level to be which of the following? 1.8 mEq/L

A nurse receives a telephone call from a female client who states that she wants to kill herself and holding a bottle of a poisonous substance. The best nursing action is to: Insist that the client give you her name and address so that you can get the police there immediately Keep the client talking and allow the client to ventilate feelings Keep the client talking and signal another staff member to trace the call so that appropriate help can be sent Use therapeutic communication techniques, especially the reflection of feelings Question 86 Explanation: ANSWER: Keep the client talking and signal another staff member to trace the call so that appropriate help can be sent. ; RATIONALE: In a crisis the nurse must take an authoritative, active role to promote the clients safety. A bottle of poisonous substance that will be used to kill her is the crisis. The clients safety is the prime concern. Keeping the client on the phone and getting help to the client is the best intervention. Question 87 The home health nurse is conducting a home care instruction to the parents of the child with congestive heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement if made by the parents indicates the need for further instructions? If the child vomits after medication administration, I will repeat the dose. "I will take the childs pulse before administering the medication. If more than 1 dose is missed I will call the physician. I will not mix the medication with food. Question 87 Explanation: ANSWER: If the child vomits after medication administration, I will repeat the dose. ; RATIONALE: The

1.0 mEq/L 1.3 mEq/L 0.7 mEq/L Question 89 Explanation: ANSWER: 1.8 mEq/L ; RATIONALE: The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A serum lithium level of 1.8 mEq/L indicates moderate toxicity. Serum lithium concentration of 1.5 2.5 mEq/L may produce vomiting, diarrhea, ataxia, incoordination, muscle twitching,and slurred speech. Question 90 A physicians order reads Potassium chloride 30mEq to be added to 1L ml normal saline and to be given over 10-hour period. The available potassium chloride is 40mEq per 20ml. A nurse prepares how many milliliters of Potassium Chloride to administer the correct dose of medication? 15ml 20ml 10ml 50ml Question 90 Explanation: ANSWER: 15ml ; RATIONALE: Desire Available x ml = 30mEq/ 40mEq x 20ml = 15ml Question 91 A physician ordered to transfuse a unit of packed RBC for an assigned client. In planning coverage for the client, the nurse just looked for another available nurse to check the blood to be transfused. Once the blood was double checked, how long will the assigned nurse stay with the client? 30 minutes 15 minutes

45 minutes 5 minutes Question 91 Explanation: ANSWER: 15 minutes ; RATIONALE: The nurse must remain with the client for the first 15 minutes of transfusion which is the most frequent period of danger of transfusion reaction. This enables the nurse to detect reactions and intervene quickly. Question 92

Question 95 An older client is admitted for hypertension and serum electrolytes studies have abnormal results. The physician scheduled the client for an Aldosteronoma scan. The nurse recognizes that this scan is ordered to rule out disease of the: Pituitary gland Kidney cortex Thyroid gland

On the day shift, the registered nurse has just received an assignment. While making initial rounds and checking all the assigned clients, which clients will the registered nurse give first priority of care? A client scheduled for physical therapy at 1 PM

Adrenal cortex Question 95 Explanation: ANSWER: Adrenal cortex ; RATIONALE: An Aldosteronoma is an aldosterone secreting adrenal cortex Question 96

A client who is ambulatory A client with a fever who is diaphoretic and restless A post operative client who has just received pain medication Question 92 Explanation: ANSWER: A client with a fever who is diaphoretic and restless ; RATIONALE: A nurse would plan to care first a client who had a fever and restless because the clients needs are the priority. Waiting for pain medication to take effect before providing care to the post operative client is best. Question 93 The client is displaying an aggressive behavior in the mental health unit. The nurse is visit the unit and observes that the client aggressive behavior is escalating. Which nursing intervention is least helpful to this client at this time? Maintain a safe distance with the client Acknowledge the clients behavior Initiate confinement measures Assist the client to an area that is quiet Question 93 Explanation: ANSWER: Initiate confinement measures ; RATIONALE: During the escalation period, the clients behavior is moving toward loss of control. Nursing actions include taking control, maintaining safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is not appropriate. Question 94 Mr. Cruz, 40 year old client was diagnosed with chronic pancreatitis. The nurse checks the laboratory results, anticipating a laboratory report that indicates a serum amylase level of 500 units/L 300 units/L 45 units/L 100 units/L Question 94 Explanation: ANSWER: 300 units/L ; RATIONALE: The normal serum amylase is 25 to 151 IU/L. In client with chronic pancreatitis, the increase in serum amylase does not exceed 3 times the normal value. A physician scheduled the client for pulmonary angiography. The client is fearful about the procedure and asks the nurse if it is painful and if there is radiation exposure. The nurse provides reassurance to the client based on the understanding that: The procedure is somewhat painful, but there is minimal exposure to radiation Discomfort my occur with needle insertion and there is minimal exposure to radiation There is very mild pain throughout the procedure and the exposure to radiation is negligible There is absolutely no pain, although a moderate amount of radiation must be used to get accurate result. Question 96 Explanation: ANSWER: Discomfort my occur with needle insertion and there is minimal exposure to radiation ; RATIONALE: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. Question 97 A nurse is caring for a client diagnosed with Pheochromocytoma. The client is hungry and asks the nurse of something to eat and drink. The most appropriate choice of food and drinks for the client to meet nutritional needs would be which of the following? Graham crackers and warm milk Crackers with cheese and tea Toast with peanut butter and cocoa Vanilla wagers and coffee with cream and sugar Question 97 Explanation: ANSWER: Graham crackers and warm milk ; RATIONALE: The client with pheochromocytoma needs to be provided with a diet high in vitamins, minerals and calories. Beverages that contain caffeine, tea, cola, cocoa, are prohibited because they can precipitate hypertensive crisis. Question 98 A client comes to the emergency department for check up. While waiting for the physician the client starts complaining of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of:

Glomerulonephritis Pyelonephritis Blow or trauma to the bladder or abdomen Renal cancer in the clients family Question 98 Explanation: ANSWER: Blow or trauma to the bladder or abdomen ; RATIONALE: Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Question 99 A client is admitted in a short stay unit after the myelogram. A waterbased contrast agent was used. The nurse would give information to the client regarding activity restrictions. Which of the following activity would the client avoid? Bedrest for 6-8 hours, with head of bed flat Bedrest for 2-4 hours, with head of bed flat Bedrest for 2-4 hours, with the head of the bed elevated 15-30 degrees Bedrest for 6-8 hours, with the head of the bed elevated 15-30 degrees Question 99 Explanation: ANSWER: Bedrest for 6-8 hours, with the head of the bed elevated 15-30 degrees ; RATIONALE: Following a myelogram, the client is placed on bedrest for 6-8 hours after the procedure. When a water based contrast medium is used, the client is position with the head of bed elevated 15-30 degrees. Question 100 A nurse is performing tracheostomy care to the client and replaced the tracheostomy tube holder. The nurse ensures that the tube holder is not too tight by checking if: The client nods that he or she feels comfortable Two fingers can be slid comfortably under the holder Four fingers can be slid comfortably under the holder The tracheostomy does not move more than inch when the client is coughing Question 100 Explanation: ANSWER: Two fingers can be slid comfortably under the holder ; RATIONALE: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to present tracheostomy dislocation, while preventing excessive constriction around the neck.