Note:
This is a 50-item NLE and NCLEX Practice test. Answer keys and explanation are provided thereafter. Ideally, you have to finish the test after 50 minutes (1min/question). Take a pen and paper and number it 1-50 beforehand to conserve time.
GoodLuck!
-Pinoy Nursing Central
1.Mrs. F. has a fractured right hip with 5 pounds of Buck's traction. The bed that Mrs. F. is in is broken. How should the nurse best direct the team to move Mrs. F. to the new bed?
A. Slowly lift the traction to release the weight, support the right leg, and lift Mrs. F. to the new bed.
B. Slowly lift the 5 pound weight from the traction set up, and apply 10 pounds of manual traction during the move.
C. It is not safe to move Mrs. F. with Buck's traction. Support her position changes with pillows until traction is no longer needed.
D. Decrease the weight of traction over a two-hour period, then discontinue the traction and move Mrs. F. into the new bed.
2. An adult client sustained a fractured tibia three hours ago. A long leg cast was applied. Now, the client is complaining of increasing pain. The pain is more intense with passive flexion of the toes. The nurse suspects the client is developing compartment syndrome. Which initial action should the nurse take?
A. Prepare for emergency fasciotomy.
B. Administer the ordered narcotic IV, then reassess the client's pain in 15 minutes.
C. Raise the casted leg above the heart, apply ice, and notify the physician.
D. Raise the casted leg to the level of the heart, notify the physician, and prepare to split the cast.
3. Andy, two years old, begins to scream, kick, and wave his arms angrily when the nurse lowers his siderails to take his temperature and other vital signs. The child and nurse are alone in the room. What is the best action for the nurse to take?
A. Leave Andy alone until his mother comes to visit and can be there to help hold him on her lap for the procedures.
B. Immediately call another nurse to come and help hold Andy still for the procedures.
C. Hold Andy and talk calmly while showing him something of interest and explain what is going to be done.
D. Tell Andy he will be left alone for two minutes without his toys, and he must quiet down during that time.
.
4. An adult client has had a cataract extraction with a lens implant performed on an outpatient basis. The nurse is discussing his postoperative instructions with him prior to his discharge from the surgery center. Which statement made by the client indicates a need for further instruction before he is discharged?
A. "I need to sleep with this metal eye shield at night, but I can wear my glasses during the day.''
B. "I should avoid coughing, sneezing, and vomiting.''
C. "It's okay to bend over to pick something up from the floor as long as I put the eye shield on.''
D. "I should call the doctor for any bad pain in my eyes that the pain medicine doesn't help, or if I start seeing double or light flashes.''
5. An adult client has a fractured right ankle that was casted in the emergency room. Before the client is discharged, the nurse must teach her crutch walking skills. Which is the correct technique?
A. "Lift both crutches, advance a short distance, and swing through with both legs.''
B. "Advance crutches and the right leg, then swing through and touch down with the left leg.''
C. "Advance left leg, then lift and advance crutches, and swing right leg.''
D. "Hold both crutches under one arm, advance crutches up stairs. Hold onto rail, lift body, and touch down one step with left leg.''
Skip this question for now.
6. A woman who has cystitis is receiving Pyridium 200 mg po tid. Which assessment best indicates to the nurse that the medication is effective?
A. The client's urine is reddish-orange in color.
B. There is a decrease in pain and burning on urination.
C. There is a decrease in the client's temperature.
D. The client's white blood cell count has returned to normal.
Skip this question for now.
7. An adult client is now ready for discharge following a bilateral adrenalectomy for treatment of Cushing's syndrome. Which statement made by the client indicates to the nurse that further discharge teaching is needed?
A. "I will begin to look more normal soon.''
B. "I should not lift heavy objects for six weeks.''
C. "I will gradually discontinue the hormone pills in a few months when I feel better.''
D. "I will not go grocery shopping or run the vacuum cleaner until the doctor says I can.''
Skip this question for now.
8. An adult woman is recovering from a mastectomy for breast cancer. She appears depressed and is frequently tearful when she is alone. The nurse's approach should be based on which of these understandings?
A. Clients need a supportive person to help them grieve for the loss of a body part.
B. The client's family should take the leadership in providing the support she needs.
C. The nurse should explain to the client that breast tissue is not needed by the body.
D. The client should focus on the cure of her cancer rather than the loss of the breast.
Skip this question for now.
9. Mr. L. has been hospitalized for one week for severe depression and suicidal thinking. Last night, his wife visited, and they spent a long time alone in his room. Mr. L. was tearful and withdrawn immediately after the visit, but this morning he is much more relaxed and says, "Now, I have it all figured out. I know exactly what I'm going to do.'' It is important that the nurse act on the understanding that
A. a sudden lifting of depression may indicate that the client has formed a suicide plan.
B. support from his wife may have convinced Mr. L. that life is worth living.
C. antidepressant drugs may require several weeks before an effect is felt.
D. an absence of sadness and the ability to plan may indicate improvement in depression.
Skip this question for now.
10. An adult male is admitted to the psychiatric unit with a diagnosis of obsessive-compulsive disorder. His hands are red and rough, and he tells the nurse that he washes them many times a day. Which would be an appropriate short-term goal for him? The client
A. explains why his hand washing is inappropriate.
B. is prevented from accessing the sink in his room.
C. records the number of times he washes his hands each day.
D. verbalizes the anxiety underlying each episode of hand washing.
Skip this question for now.
11. The nurse is evaluating a new mother who is feeding her newborn. Which observation indicates that the mother understands proper feeding methods for her newborn?
A. Holding the bottle so the nipple is always filled with formula
B. Allowing her seven-pound baby to sleep after taking 1 ounces from the bottle
C. Burping the baby every ten minutes during the feeding
D. Warming the formula bottle in the microwave for 15 seconds and giving it directly to the baby
Skip this question for now.
12. The nurse is assessing a woman admitted for a possible ectopic pregnancy. The nurse should ask the client about the presence of which of the following?
A. Profuse, bright-red vaginal bleeding
B. Right or left colicky abdominal pain
C. Nausea and vomiting
D. Dyspareunia
Skip this question for now.
13. A 19-year old woman is admitted with a diagnosis of anorexia nervosa. Which of the following should the nurse include in the care plan?
A. Allow her as much time as she needs for each meal.
B. Explain the importance of an adequate diet.
C. Observe her during and one hour after each meal.
D. Use a random pattern for surprise weigh-ins
Skip this question for now.
14. A 28-year old client with schizophrenia is sitting alone in his room. He alternates quiet, listening behaviors with agitated talking. The nurse enters his room and observes this behavior. What should the nurse say first?
A. "You need to come out to the day area with the group now.''
B. "Why are you hearing voices again?''
C. "You appear to be listening to something.''
D. "I know you hear something, but there is no one here.''
Skip this question for now.
15. Mr. H. is standing in the day room. His anxiety level has been increasing all morning, and now he is shouting, "I want out of here. I want out right now!'' The initial response by the nurse should be to
A. position him/herself in front of Mr. H. and make eye contact.
B. stand behind Mr. H. and say, "You need to quit shouting now.''
C. approach Mr. H. from the side and say, "You're feeling pretty angry.''
D. obtain sufficient help and escort Mr. H. to the seclusion room.
Skip this question for now.
A 28-year old client with schizophrenia has been taking a phenothiazine drug, chlorpromazine (Thorazine) 50 mg po qid for four days. Which observation by the nurse indicates a desired effect of the drug? The client
A. reports fewer episodes of hallucinations.
B. sleeps ten hours at night plus a two-hour afternoon nap.
C. reports feelings of stiffness in his neck and face.
D. is increasingly responsive to his delusional system.
Skip this question for now.
17. When a male client with chronic schizophrenia and a history of non-compliance with medication programs was first admitted to the hospital, he refused medication and argued with the nurse about his need for it. Which observation by the nurse is the best indication that his goal of compliance with the medication routine has been achieved? The client
A. requests his medication at scheduled times.
B. verbalizes the need for medication while in the hospital.
C. takes his medication when offered by the nurse.
D. describes reasons that compliance is important.
Skip this question for now.
18. The nurse is caring for a client who has just returned to the surgical unit following a femoral arteriogram. Which initial assessment by the nurse is most essential?
A. Auscultating the lungs
B. Obtaining blood pressure
C. Palpating the carotid pulse
D. Inspecting the groin area
Skip this question for now.
19. The nurse is caring for a client who is scheduled for an MRI (magnetic resonance imaging) study. Which statement made by the client warrants further assessment by the nurse?
A. "I am allergic to iodine and seafood.''
B. "I had a total hip replacement five years ago.''
C. "I've been taking a blood thinner and bleed easily.''
D. "My doctor told me never to take laxatives.''
Skip this question for now.
20. The nurse is to give medication to an infant. What is the best way to assess the identity of the infant?
A. Ask the mother what the child's name is.
B. Look at the sign above the bed that states the client's name.
C. Compare the bed number with the bed number of the care plan.
D. Compare the ankle band with the name on the care plan.
21. The nurse is caring for a client who has been placed in cloth wrist restraints. To ensure the client's safety, the nurse should
A. remove the restraints every two hours and inspect the wrists.
B. wrap each wrist with gauze dressing beneath the restraints.
C. keep the head of the bed flat at all times.
D. tie the restraints, using a square knot.
Skip this question for now.
22. An adult client is scheduled for gallbladder x-rays in the morning for suspected cholelithiasis. While preparing the client for the x-rays, it is most important for the nurse to ask the client if she
A. has ever had trouble with uncontrolled bleeding.
B. has any known allergies.
C. received teaching regarding a low-fat diet.
D. understands the procedure for local anesthesia.
Skip this question for now.
23. A client is referred to the outpatient clinic to have a glucose tolerance test (GTT) and glycosylated hemoglobin assay (Hgb A 1c ) to assess for questionable diabetes mellitus. The client requests clarification from the clinic nurse regarding these tests. The nurse differentiates between a glucose tolerance test (GTT) and glycosylated hemoglobin assay (Hgb A 1c ) by explaining that the Hgb A 1c
A. is used to diagnose diabetes mellitus.
B. involves administration of an oral glucose load.
C. measures serum glucose at 30 minute, 1-, 2-, and 3-hour intervals.
D. reflects blood glucose level over a 2-3 month period.
Skip this question for now.
24. An adult male client is admitted with a diagnosis of acute M.I. (myocardial infarct). He is attached to a cardiac monitor and has an IV catheter in place. His cardiac rhythm has been normal sinus rhythm with occasional PVCs. The nurse notes a sudden change on the cardiac monitor screen to a very irregular, chaotic-looking pattern. The client appears to be sleeping. The most appropriate action on the part of the nurse is to
A. administer a precordial thump.
B. obtain the defibrillator.
C. begin cardiopulmonary resuscitation.
D. check the client's ECG electrodes.
Skip this question for now.
25. An adult client presents with the sudden onset of the appearance of "floating black spots'' in her right eye. The client sees a black shadow in her peripheral vision. There is no pain but the client is very frightened. What should the nurse expect to do in the care of this client?
A. Place patches on both eyes and plan for strict bed rest.
B. Patch the right eye and let the client resume activity after 24 hours.
C. Plan for emergency surgery as the client is in danger of losing her eyesight.
D. Administer a cholinergic eye drop (Pilocarpine) to decrease intraocular pressure.
26.The nurse is caring for a woman in labor. When she is 8 cm dilated she tells her support person she wants "to go home for a few hours of sleep.'' The nurse helps the support person realize that this statement reflects the woman's desire to
A. have others tell her what she needs.
B. have a soothing back rub.
C. be rid of this difficult situation.
D. be left alone.
Skip this question for now.
27. A 22-year old woman comes into the obstetrics clinic requesting oral contraceptives. Which item in the nursing history would indicate that she is not a good candidate for this method of contraception?
A. She has a history of heavy menstrual periods.
B. She has diabetes mellitus.
C. The client reports a broken leg when she was ten years old.
D. The client had a baby six months ago.
Skip this question for now.
28. Mrs. G., 25, is hospitalized for depression. One evening after an argument with her husband, Mrs. G. discusses with the evening nurse her intent to cut her wrists. Her husband has threatened to divorce her and retain custody of the children. The most appropriate initial action for the nurse to take is to
A. attempt to convince Mrs. G. of the need to address her husband's threats instead of using self-destructive behavior.
B. place Mrs. G. on suicide precautions, which restrict her from leaving the nursing unit.
C. place Mrs. G. on suicide precautions requiring close observation and one to one monitoring by nursing staff.
D. recognize the suicidal remarks as less serious since Mrs. G. is in a safe environment.
Skip this question for now.
29. Mrs. L. will be administering daily insulin to her 84-year-old blind grandfather. The insulin dose is 15 u NPH, 5 u regular every morning at 0745. Which statement best indicates that Mrs. L. needs further instruction in insulin administration prior to her grandfather's discharge from the hospital?
A. "The regular insulin acts quickly. NPH insulin is milky colored and lasts longer, usually the whole day.''
B. "I need to keep track of where I give his insulin so that I don't use the same site over and over.''
C. "If I can't get to Granddaddy's house until lunch time occasionally, I can give him a little more insulin in case his sugar went up in the morning.''
D. "It's very important to keep insulin shots on schedule and for him to eat at regular times.''
Skip this question for now.
30. An elderly woman received digoxin 0.25 mg for treatment of her congestive heart failure. Which of the following physiological responses indicates that the digoxin is having the desired effect?
A. Increased heart rate.
B. Decreased cardiac output.
C. Increased urine output.
D. Decreased myocardial contraction force.
31. An adult is admitted to the hospital with anorexia, weight loss, and ascites. Serum SGOT (AST), SGPT (ALT), LDH, and total bilirubin are significantly elevated. Based on the lab results, the nurse performing an admission assessment will expect to find
A. pallor.
B. dry mucous membranes.
C. jaundice.
D. peripheral edema.
Skip this question for now.
32. The nurse is preparing a client for an IVP tomorrow. The client tells the nurse that she gets a rash and becomes short of breath after eating lobster. Given this information, the nurse knows that the client
A. should be visited by a dietitian while in the hospital.
B. is not a candidate for IVP.
C. is at risk for an allergic reaction.
D. will require an antihistamine before her IVP.
Skip this question for now.
33. An elderly client requiring abdominal wound packing tid complains about his wound care to the nurse making morning rounds. He states that "everyone does it differently and at any time they feel like it.'' He is angry at being awakened at night for this procedure. The best response for the nurse to make is
A. "The wound care is being done as ordered by your doctor.''
B. "I understand you're upset at losing sleep. You can have medication to help you get back to sleep.''
C. "Tell me what's really bothering you.''
D. "After rounds I'll be back, and we can plan your wound care.''
Skip this question for now.
34. The nurse is planning care for a client with cervical radiation implants. Which nursing intervention will be included in the plan of care?
A. Implement strict isolation protocol.
B. Provide a lead apron for the client.
C. Use only disposable supplies and equipment in the client's room.
D. Limit visitors to 30 minutes per day.
Skip this question for now.
35. The nurse reviews a client's laboratory data and notes the following hematology values: hematocrit (hct) 43%; hemoglobin (Hgb) 15 g/dl; RBCs 5 million; WBCs 7,500; platelet count 30,000. What nursing care is indicated in relation to these lab values?
A. Plan a diet high in iron.
B. Plan for frequent rest periods throughout the day.
C. Avoid invasive procedures and injections.
D. Implement protective isolation precautions.
36. The nurse is planning care for a client who is having a gastroscopy performed. Included in the plan of care for the immediate postgastroscopy period will be
A. maintain nasogastric tube to intermittent suction.
B. assess gag reflex prior to administration of fluids.
C. assess frequently for pain and medicate according to orders.
D. measure abdominal girth every four hours.
Skip this question for now.
37. An elderly client has suffered a cerebrovascular accident (CVA) and, as a result, has left homonymous hemianopia. Based on this fact, what measure will the nurse include in this client's plan of care?
A. Supporting the client's left arm and hand with pillows
B. Applying a patch to the client's left eye
C. Encouraging the client to use his right hand for activities of daily living
D. Placing the client's meal on the right side of the overbed table
Skip this question for now.
38. A toddler is admitted with a history of vomiting and diarrhea for two days, accompanied by abdominal pain. The admitting diagnosis is gastroenteritis. What type of room assignment should the nurse make?
A. A room near the nurses' station so that he can be checked frequently and heard if he vomits
B. A single room with a sink near the doorway for isolation use
C. A double room with another toddler who also has vomiting and diarrhea
D. A bed in the pediatric intensive care unit, in case dehydration develops
Skip this question for now.
39. The nurse is caring for a client who is to have a lumbar puncture (L-P). How should the client be positioned during the procedure?
A. Prone with head turned to the left
B. Side-lying in a fetal position
C. Sitting at the edge of the bed
D. Trendelenburg position
Skip this question for now.
40. The physician has ordered a Schilling's test for a client with possible pernicious anemia. Implementation of the test will require the nurse to
A. administer a mild laxative.
B. initiate a 24-hour urine collection.
C. administer an intramuscular dose of iron.
D. insert an intravenous catheter.
41. The nurse has given discharge instructions on how to care for a newly applied cast to an adult client. Which statement indicates the client understands the instructions?
A. "I should pack the casted leg in ice for 24 hours to help it dry.''
B. "I can use my hair dryer to help the cast dry faster.''
C. "A good way to relieve the itching under the cast is to gently scratch under the cast with a soft knitting needle.''
D. "Putting the casted leg up on fabric-covered pillows is the best way to dry the cast.''
Skip this question for now.
42. The nurse is caring for a client who has just had a bone marrow biopsy. What is essential for the nurse to do at this time?
A. Apply firm pressure over the puncture site.
B. Maintain the client on bed rest for 24 hours.
C. Apply an occlusive dressing to the puncture site.
D. Refrigerate the biopsy specimen.
Skip this question for now.
43. An adult client is one day post subtotal thyroidectomy. The nurse planning care for the day knows that it is most important to
A. carry out range of motion exercises to the neck and shoulders every shift.
B. maintain bed rest with client in supine position at all times.
C. ask client questions every hour or two to assess for hoarseness.
D. provide tracheostomy care every shift and suction PRN to maintain a patent airway.
Skip this question for now.
44. An adult client is four hours post-op abdominal hysterectomy. She has an IV at 125 ml per hour, an indwelling catheter that has drained 100 ml since surgery, and her pain is "3'' out of "10.'' Which would be the priority nursing diagnosis?
A. Alteration in comfort, pain
B. Alterations in patterns of elimination
C. Disturbance in self-concept, body image
D. Fluid volume deficit, actual or risk for
Skip this question for now.
45. An adult client has meperidine HCl (Demerol) 50 mg-100 mg IM every 3-4 hours ordered. He received Demerol 50 mg IM three hours ago but he's still complaining of pain at "8 out of 10.'' The client is asking for pain medication even before it is due and refuses to get out of bed "because of the pain.'' He was heard telling jokes to the cleaning personnel. What is the best action for the nurse to take?
A. Give the client 50 mg of Demerol IM now.
B. Wait one hour and give the client 75 mg of Demerol IM.
C. Give the client 100 mg of Demerol IM now and repeat 100 mg Demerol IM in three hours if the pain is still greater than "5 out of 10.''
D. Do not medicate the client now. Laughing and joking behavior indicate the pain is not as severe as the client claims.
46. An elderly male with undiagnosed respiratory symptoms is to receive a diagnostic test for histoplasmosis. The nurse giving a histoplasmin skin test will
A. apply a patch to the skin on the forearm.
B. make a shallow scratch on the skin surface.
C. use a 25-gauge needle placed parallel to the skin.
D. use a 19-gauge needle and Z track injection.
Skip this question for now.
47. A 35-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment?
A. inability to make decisions
B. feelings of hopelessness
C. family history of depression
D. increased interest in sex
Skip this question for now.
48. An adult male, who appears about 40-years old, is admitted to the psychiatric unit for alcohol detoxification. He is tremulous and irritable, and complains of nervousness and nausea. Which information is most important for the admitting nurse to obtain?
A. The amount of alcohol and other drugs usually taken and the type and amount taken in the last few days.
B. The events prompting the client to seek treatment.
C. The factors that trigger the client's drinking episodes.
D. Any work, legal, or family problems that relate to his alcohol use.
Skip this question for now.
49. A woman who is nine months pregnant is attending a luncheon and fashion show. Suddenly, her membranes rupture and contractions come so rapidly that she yells, "The baby is coming.'' What is the most appropriate action for the nurse to take?
A. Ask for boiled water, towels, string, and scissors.
B. Ask someone to call her doctor.
C. Take her via cab to the nearest hospital.
D. Have her lie on her left side in a less-crowded area and be prepared to help with the delivery.
Skip this question for now.
50. While attending a basketball game, a woman who is nine months pregnant suddenly goes into labor and delivers her baby within five minutes. What is the most appropriate course of action for the nurse to take?
A. Tie the cord with a shoelace and cut the cord with a penknife.
B. Have the mother's friend hold the baby until an ambulance arrives.
C. Place the naked baby on the mother's bare chest, cover both, and encourage breastfeeding.
D. Ask people to clear the area so more air can circulate around the mother and baby.
<----------------------Answer-Key-and-Explanation----------------------->
1.
Mrs. F. has a fractured right hip with 5 pounds of Buck's traction. The bed that Mrs. F. is in is broken. How should the nurse best direct the team to move Mrs. F. to the new bed?
A.
Slowly lift the traction to release the weight, support the right leg, and lift Mrs. F. to the new bed.
B.
Slowly lift the 5 pound weight from the traction set up, and apply 10 pounds of manual traction during the move.
C.
It is not safe to move Mrs. F. with Buck's traction. Support her position changes with pillows until traction is no longer needed.
D.
Decrease the weight of traction over a two-hour period, then discontinue the traction and move Mrs. F. into the new bed.
Explanation:
Choice a is correct: 5-8 pounds of traction is applied temporarily to provide immobilization prior to surgery. Buck's traction should be removed every eight hours to assess the skin under the traction device. Skeletal traction should not be released unless there is a life-threatening emergency.
Choice b is incorrect: It is not necessary to maintain manual traction, especially at twice the weight, to move a person in Buck's traction.
Choice c is incorrect: It is safe to move persons with Buck's traction and would be uncomfortable to use pillow support for position changes.
Choice d is incorrect: Once the weight of traction has been established as effective, the weight should be maintained until it is no longer needed.
Section: Implementation
Subsection: Reduction of Risk Potential
2.
An adult client sustained a fractured tibia three hours ago. A long leg cast was applied. Now, the client is complaining of increasing pain. The pain is more intense with passive flexion of the toes. The nurse suspects the client is developing compartment syndrome. Which initial action should the nurse take?
A.
Prepare for emergency fasciotomy.
B.
Administer the ordered narcotic IV, then reassess the client's pain in 15 minutes.
C.
Raise the casted leg above the heart, apply ice, and notify the physician.
D.
Raise the casted leg to the level of the heart, notify the physician, and prepare to split the cast.
Explanation:
Choice d is correct: To decrease the pressure within the compartment, raise the affected extremity only to the level of the heart and remove any constrictive dressing or cast. If this does not work to decrease the pressure, a fasciotomy may be necessary.
Choice a is incorrect: Fasiotomy is performed if compartment pressure cannot be relieved.
Choice b is incorrect: Pain from compartment syndrome does not respond well to pain medicine.
Choice c is incorrect: Placing the extremity above the level of the heart increases compartment pressure and should be avoided.
Section: Implementation
Subsection: Physiological Adaptation
3.
Andy, two years old, begins to scream, kick, and wave his arms angrily when the nurse lowers his siderails to take his temperature and other vital signs. The child and nurse are alone in the room. What is the best action for the nurse to take?
A.
Leave Andy alone until his mother comes to visit and can be there to help hold him on her lap for the procedures.
B.
Immediately call another nurse to come and help hold Andy still for the procedures.
C.
Hold Andy and talk calmly while showing him something of interest and explain what is going to be done.
D.
Tell Andy he will be left alone for two minutes without his toys, and he must quiet down during that time.
Explanation:
Choice c is correct: A two year old may respond to distraction to regain some sense of control before he is calm enough to listen to the explanation of what the nurse wants him to do. Even if he cannot listen, he will sense that the nurse cares and understands the emotion he's trying to communicate and that he will be comforted after the procedure.
Choice a is incorrect: Toddlers tolerate nursing procedures much more easily if not threatened with separation from the parent. Having the mother assist as part of the team gives control to both the child and parent. However, vital signs often need to be done in the parent's absence, as in this case.
Choice b is incorrect: Getting the help of another nurse may get the procedure done quickly and efficiently but may produce more unreleased anger in the child. It may also give the child a sense of having been abused and misunderstood.
Choice d is incorrect: Time-out should be set for one minute per year of age. Time-out discipline requires that the child understand what behavior is incorrect and what is desired. There is no evidence in the question that Andy is aware of this. Leaving the room could be a way of ignoring the temper tantrum. Discipline that the child is able to understand should be initiated as soon as the child misbehaves. Telling him "I'm sorry you don't like this, but I have to see what your temperature is now'' would start to inform him of what is expected.
Section: Implementation
Subsection: Growth/Development Through Life Span
4.
An adult client has had a cataract extraction with a lens implant performed on an outpatient basis. The nurse is discussing his postoperative instructions with him prior to his discharge from the surgery center. Which statement made by the client indicates a need for further instruction before he is discharged?
A.
"I need to sleep with this metal eye shield at night, but I can wear my glasses during the day.''
B.
"I should avoid coughing, sneezing, and vomiting.''
C.
"It's okay to bend over to pick something up from the floor as long as I put the eye shield on.''
D.
"I should call the doctor for any bad pain in my eyes that the pain medicine doesn't help, or if I start seeing double or light flashes.''
Explanation:
Choice c is correct: Bending over should be avoided as it increases intraocular pressure.
Choice a is incorrect: The client understands the need to sleep with the eye shield at night to protect the eye from accidental injury during sleep.
Choice b is incorrect: The client indicates an understanding of the need to avoid coughing, sneezing, or vomiting, which may increase intraocular pressure.
Choice d is incorrect: The physician should be notified of severe pain in the eyes not relieved by pain medication, any visual changes, headaches, inflammation, or discharge.
Section: Evaluation
Subsection: Reduction of Risk Potential
5.
An adult client has a fractured right ankle that was casted in the emergency room. Before the client is discharged, the nurse must teach her crutch walking skills. Which is the correct technique?
A.
"Lift both crutches, advance a short distance, and swing through with both legs.''
B.
"Advance crutches and the right leg, then swing through and touch down with the left leg.''
C.
"Advance left leg, then lift and advance crutches, and swing right leg.''
D.
"Hold both crutches under one arm, advance crutches up stairs. Hold onto rail, lift body, and touch down one step with left leg.''
Explanation:
Choice b is correct: The three-point gait is used when one leg cannot bear weight. The body weight is supported by the hands on the crutches and on the unaffected extremity (three points).
Choice a is incorrect: Walking as described could only be achieved with a walker.
Choice c is incorrect: This is not a correct gait.
Choice d is incorrect: This describes the technique for stair climbing, which the client may need to know but is not what the question asked.
Section: Implementation
Subsection: Basic Care and Comfort
6.
A woman who has cystitis is receiving Pyridium 200 mg po tid. Which assessment best indicates to the nurse that the medication is effective?
A.
The client's urine is reddish-orange in color.
B.
There is a decrease in pain and burning on urination.
C.
There is a decrease in the client's temperature.
D.
The client's white blood cell count has returned to normal.
Explanation:
Choice b is correct: Pyridium acts locally on the urinary tract mucosa to produce analgesia or local anesthetic effects. If the medication is effective there should be a decrease in the pain and burning the client has been experiencing when urinating.
Choice a is incorrect: Pyridium will turn the client's urine reddish-orange. This is a side effect, not a therapeutic effect.
Choice c is incorrect: Pyridium is a non-narcotic analgesic acting directly on the urinary tract. It has no antimicrobial effects and will not decrease the client's temperature. The client will also have an antimicrobial prescribed.
Choice d is incorrect: Pyridium is a non-narcotic analgesic acting directly on the urinary tract. It has no antimicrobial effects and will not decrease the white blood cell count. The client will also have an antimicrobial prescribed.
Section: Evaluation
Subsection: Pharmacological and Parental Therapies
7.
An adult client is now ready for discharge following a bilateral adrenalectomy for treatment of Cushing's syndrome. Which statement made by the client indicates to the nurse that further discharge teaching is needed?
A.
"I will begin to look more normal soon.''
B.
"I should not lift heavy objects for six weeks.''
C.
"I will gradually discontinue the hormone pills in a few months when I feel better.''
D.
"I will not go grocery shopping or run the vacuum cleaner until the doctor says I can.''
Explanation:
Choice c is correct: Clients undergoing a bilateral adrenalectomy require lifelong glucocorticoid and mineralocorticoid replacement. The client's statement that hormones will be gradually discontinued after a few months indicates a need for further discharge instructions.
Choice a is incorrect: The client should gradually lose the Cushing syndrome features following surgery and adjustment of her hormone replacement.
Choice b is incorrect: The client, like all who have had major abdominal surgery, should not lift heavy objects for six weeks following surgery.
Choice d is incorrect: The client, like all who have had major abdominal surgery, should not engage in strenuous activities until given approval to do so by the physician.
Section: Evaluation
Subsection: Reduction of Risk Potential
8.
An adult woman is recovering from a mastectomy for breast cancer. She appears depressed and is frequently tearful when she is alone. The nurse's approach should be based on which of these understandings?
A.
Clients need a supportive person to help them grieve for the loss of a body part.
B.
The client's family should take the leadership in providing the support she needs.
C.
The nurse should explain to the client that breast tissue is not needed by the body.
D.
The client should focus on the cure of her cancer rather than the loss of the breast.
Explanation:
Choice a is correct: The nurse must support the client through the steps of grief by encouraging discussion of the loss, its meaning to the client, the reactions of others, and the ways of compensating.
Choice b is incorrect: The family will need support in working through their feelings before they can support the client.
Choice c is incorrect: Breasts symbolize femininity and sexual attractiveness, and the loss of that image is threatening to self-esteem.
Choice d is incorrect: Minimizing the importance of a loss hinders grief work.
Section: Analysis
Subsection: Coping and Adaptation
9.
Mr. L. has been hospitalized for one week for severe depression and suicidal thinking. Last night, his wife visited, and they spent a long time alone in his room. Mr. L. was tearful and withdrawn immediately after the visit, but this morning he is much more relaxed and says, "Now, I have it all figured out. I know exactly what I'm going to do.'' It is important that the nurse act on the understanding that
A.
a sudden lifting of depression may indicate that the client has formed a suicide plan.
B.
support from his wife may have convinced Mr. L. that life is worth living.
C.
antidepressant drugs may require several weeks before an effect is felt.
D.
an absence of sadness and the ability to plan may indicate improvement in depression.
Explanation:
Choice a is correct: Reassessment for suicide risk is essential when depression suddenly improves, as the client may appear to feel better once the decision to commit suicide has been made. The words "Now, I have it all figured out'' sound like he may be considering suicide as the answer.
Choice b is incorrect: It is possible that the wife's visit may have significantly decreased the depression, but not likely. Reassessment of suicide risk is vital.
Choice c is incorrect: It is true that the action of antidepressant drugs may be delayed but the priority is reassessment of suicide risk when depression improves and verbal clues are given.
Choice d is incorrect: These characteristics may occur when depression lifts, but suicide is also a possibility and requires assessment.
Section: Analysis
Subsection: Coping and Adaptation
10.
An adult male is admitted to the psychiatric unit with a diagnosis of obsessive-compulsive disorder. His hands are red and rough, and he tells the nurse that he washes them many times a day. Which would be an appropriate short-term goal for him? The client
A.
explains why his hand washing is inappropriate.
B.
is prevented from accessing the sink in his room.
C.
records the number of times he washes his hands each day.
D.
verbalizes the anxiety underlying each episode of hand washing.
Explanation:
Choice c is correct: The client's participation in obtaining baseline data is the first step to decreasing that behavior.
Choice a is incorrect: Clients with compulsive behavior usually know that the behavior is inappropriate but cannot stop it without an increase in anxiety.
Choice b is incorrect: When compulsive behavior is physically prevented, the client may experience a panic attack or resort to other methods to carry out the compulsion. It is not uncommon for a client who is denied access to the sink to use water from the toilet to wash.
Choice d is incorrect: Identifying and dealing with the underlying anxiety are long-term goals in obsessive-compulsive behavior and are usually reached through psychotherapy.
Section: Planning
Subsection: Psychosocial Adaptation
11.
The nurse is evaluating a new mother who is feeding her newborn. Which observation indicates that the mother understands proper feeding methods for her newborn?
A.
Holding the bottle so the nipple is always filled with formula
B.
Allowing her seven-pound baby to sleep after taking 1 ounces from the bottle
C.
Burping the baby every ten minutes during the feeding
D.
Warming the formula bottle in the microwave for 15 seconds and giving it directly to the baby
Explanation:
Choice a is correct: Holding the bottle so the nipple is always filled with formula prevents the baby from sucking air. Sucking air can cause gastric distention and intestinal gas pains.
Choice b is incorrect: A seven-pound baby should be getting 50 calories per pound, which amounts to 350 calories per day. Standardized formulas have 20 calories per ounce. This seven-pound baby needs 17.5 ounces per day. 17.5 ounces per day divided by 6–8 feedings equals 2–3 ounces per feeding.
Choice c is incorrect: A normal newborn without feeding problems should be burped halfway through the feeding and again at the end. If burping needs to be at intervals, it should be done by ounces or half ounces, not minutes.
Choice d is incorrect: Microwaving is not recommended as a method for warming due to the uneven heating of the formula. If used, the formula should be shaken after warming and the temperature then checked with a drop on the wrist. The recommended method for warming is to place the bottle in a pan of hot water then check the temperature on the wrist before feeding.
Section: Evaluation
Subsection: Growth/Development Through Life Span
12.
The nurse is assessing a woman admitted for a possible ectopic pregnancy. The nurse should ask the client about the presence of which of the following?
A.
Profuse, bright-red vaginal bleeding
B.
Right or left colicky abdominal pain
C.
Nausea and vomiting
D.
Dyspareunia
Explanation:
Choice b is correct: In ectopic pregnancy, the abdominal pain is usually on one side, is vague, cramping, or colicky from tubal distention, and lasts from one day to a week or longer.
Choice a is incorrect: In ectopic pregnancy, there is only intermittent vaginal spotting and it is dark red as the uterine decidua is sloughed off.
Choice c is incorrect: Nausea and vomiting occur, especially if rupture has occurred, but this is not a first complaint.
Choice d is incorrect: The stress of intercourse can weaken the site in the fallopian tube, but dyspareunia is not a complaint.
Section: Assessment
Subsection: Growth/Development Through Life Span
13.
A 19-year old woman is admitted with a diagnosis of anorexia nervosa. Which of the following should the nurse include in the care plan?
A.
Allow her as much time as she needs for each meal.
B.
Explain the importance of an adequate diet.
C.
Observe her during and one hour after each meal.
D.
Use a random pattern for surprise weigh-ins
Explanation:
Choice c is correct: Left alone at meal time, clients with anorexia nervosa may hide or discard food, or induce vomiting after a meal. The client should be watched during and one hour after each meal.
Choice a is incorrect: Without a time limit, meals for clients with anorexia nervosa may become lengthy sessions providing attention for maladaptive behaviors.
Choice b is incorrect: The problem is not a knowledge deficit. In fact, clients with eating disorders may be knowledgeable about nutrition. Discussions of food may provide reinforcement for maladaptive behaviors.
Choice d is incorrect: To be accurate, weigh-ins must be done at the same time each day. Manipulation of weight is avoided by having the client wear a hospital gown and void prior to weighing.
Section: Planning
Subsection: Coping and Adaptation
14.
A 28-year old client with schizophrenia is sitting alone in his room. He alternates quiet, listening behaviors with agitated talking. The nurse enters his room and observes this behavior. What should the nurse say first?
A.
"You need to come out to the day area with the group now.''
B.
"Why are you hearing voices again?''
C.
"You appear to be listening to something.''
D.
"I know you hear something, but there is no one here.''
Explanation:
Choice c is correct: This response shares the nurse's observation and allows for validation by the client. This should be the initial response.
Choice a is incorrect: Initially, the nurse needs to validate what is happening to the client. Directing the client to another activity avoids dealing with his symptoms. This client may be too ill for group participation at this time.
Choice b is incorrect: Why questions should not be used. Why implies blame. The inference that the client is hallucinating needs validation before any exploration takes place.
Choice d is incorrect: The inference that the client is hallucinating should be validated and the content of the hallucination determined before confronting the client with reality.
Section: Implementation
Subsection: Psychosocial Adaptation
15.
Mr. H. is standing in the day room. His anxiety level has been increasing all morning, and now he is shouting, "I want out of here. I want out right now!'' The initial response by the nurse should be to
A.
position him/herself in front of Mr. H. and make eye contact.
B.
stand behind Mr. H. and say, "You need to quit shouting now.''
C.
approach Mr. H. from the side and say, "You're feeling pretty angry.''
D.
obtain sufficient help and escort Mr. H. to the seclusion room.
Explanation:
Choice c is correct: A sidewise approach is less threatening than approaching in front or behind the client. An empathetic statement that acknowledges the angry feelings may allow the client to discuss his anger more calmly.
Choice a is incorrect: A frontal approach and direct eye contact may be perceived as threatening and make the nurse the target of the client's anger.
Choice b is incorrect: Standing behind the client and making direct commands increase his feelings of being out of control and may escalate the situation.
Choice d is incorrect: Seclusion may be required but verbal intervention should be tried first. There is no evidence that anyone is in immediate danger.
Section: Implementation
Subsection: Psychosocial Adaptation
16.
A 28-year old client with schizophrenia has been taking a phenothiazine drug, chlorpromazine (Thorazine) 50 mg po qid for four days. Which observation by the nurse indicates a desired effect of the drug? The client
A.
reports fewer episodes of hallucinations.
B.
sleeps ten hours at night plus a two-hour afternoon nap.
C.
reports feelings of stiffness in his neck and face.
D.
is increasingly responsive to his delusional system.
Explanation:
Choice a is correct: Phenothiazine drugs, like chlorpromazine, are antipsychotic drugs. The desired action is to reduce the symptoms of psychosis such as hallucinations.
Choice b is incorrect: Drowsiness is a common side effect of phenothiazine drugs early in the course of treatment and should diminish with time.
Choice c is incorrect: Stiffness in the neck and face may be signs of a dystonic reaction, one of the extrapyramidal side effects of phenothiazine drugs. If a dystonic reaction is developing, treatment with an antiparkinson drug such as Cogentin will be needed.
Choice d is incorrect: Increased response to delusions indicates that the psychosis may be worsening in spite of the drug.
Section: Evaluation
Subsection: Psychosocial Adaptation
17.
When a male client with chronic schizophrenia and a history of non-compliance with medication programs was first admitted to the hospital, he refused medication and argued with the nurse about his need for it. Which observation by the nurse is the best indication that his goal of compliance with the medication routine has been achieved? The client
A.
requests his medication at scheduled times.
B.
verbalizes the need for medication while in the hospital.
C.
takes his medication when offered by the nurse.
D.
describes reasons that compliance is important.
Explanation:
Choice a is correct: Requesting the medication when it is due is good evidence of understanding and participating in the medication program. The nurse must also be sure he actually takes the medication.
Choice b is incorrect: Talking about the need for medication is not as good evidence of compliance as actually requesting the medication.
Choice c is incorrect: Requesting the medication before it is offered is better evidence of compliance than simply taking it when offered by the nurse.
Choice d is incorrect: Talking about reasons for compliance is not as good evidence of actual compliance as requesting his medication.
Section: Evaluation
Subsection: Psychosocial Adaptation
18.
The nurse is caring for a client who has just returned to the surgical unit following a femoral arteriogram. Which initial assessment by the nurse is most essential?
A.
Auscultating the lungs
B.
Obtaining blood pressure
C.
Palpating the carotid pulse
D.
Inspecting the groin area
Explanation:
Choice d is correct: Bleeding at the site of arterial puncture is a serious potential problem for several hours following femoral arteriogram.
Choice a is incorrect: The arteriogram procedure does not increase the client's risk for pulmonary complications. A general anesthetic is not given during this procedure.
Choice b is incorrect: Hypotension could occur with significant bleeding, but obvious bleeding would be the initial assessment finding.
Choice c is incorrect: Changes in the pulse are not complications associated with an arteriogram except in the case of thrombus formation at the puncture site, in which case the femoral, not carotid pulse, would be affected.
Section: Assessment
Subsection: Reduction of Risk Potential
19.
The nurse is caring for a client who is scheduled for an MRI (magnetic resonance imaging) study. Which statement made by the client warrants further assessment by the nurse?
A.
"I am allergic to iodine and seafood.''
B.
"I had a total hip replacement five years ago.''
C.
"I've been taking a blood thinner and bleed easily.''
D.
"My doctor told me never to take laxatives.''
Explanation:
Choice b is correct: Implanted medical devices (pacemaker, screws, pins, etc.) may render the client unsuitable for the MRI procedure. Metal devices may heat up from absorption of energy.
Choice a is incorrect: No contrast media is utilized for MRI, so there is no possibility of allergic reaction.
Choice c is incorrect: No puncture of vessels or skin is necessary with MRI; therefore, there is no bleeding risk.
Choice d is incorrect: A bowel prep is not required for MRI imaging.
Section: Assessment
Subsection: Reduction of Risk Potential
20.
The nurse is to give medication to an infant. What is the best way to assess the identity of the infant?
A.
Ask the mother what the child's name is.
B.
Look at the sign above the bed that states the client's name.
C.
Compare the bed number with the bed number of the care plan.
D.
Compare the ankle band with the name on the care plan.
Explanation:
Choice d is correct: Making sure that the client's name is the same as the name on the medication plan is the only safe way to administer medications.
Choice a is incorrect: Asking the parent could be appropriate if the identification band could not be found and the medication had to be given immediately. Ask the parent to state the child's name, rather than asking them whether a certain name is the name of the child. This eliminates misunderstandings from hearing deficits. As soon as possible, a new identification band should be put on the infant's ankle or wrist.
Choice b is incorrect: There should be a sign above the bed, but it could be from the last client who occupied the bed. This is not as safe a method as comparing the name on the ankle band with the name on the care plan.
Choice c is incorrect: Mistakes in bed numbers can be made in admitting, on the unit, and in writing care plans or medication cards.
Section: Assessment
Subsection: Management of Care
21.
The nurse is caring for a client who has been placed in cloth wrist restraints. To ensure the client's safety, the nurse should
A.
remove the restraints every two hours and inspect the wrists.
B.
wrap each wrist with gauze dressing beneath the restraints.
C.
keep the head of the bed flat at all times.
D.
tie the restraints, using a square knot.
Explanation:
Choice a is correct: Wrists must be inspected for signs of skin breakdown or trauma.
Choice b is incorrect: Wrist restraints are soft and padded already; no further padding is necessary.
Choice c is incorrect: The position of the head of the bed has no relationship to safety with use of restraints.
Choice d is incorrect: The method for tying restraints is important for ease of removal, but does not, in itself, affect safety.
Section: Assessment
Subsection: Safety and Infection Control
22.
An adult client is scheduled for gallbladder x-rays in the morning for suspected cholelithiasis. While preparing the client for the x-rays, it is most important for the nurse to ask the client if she
A.
has ever had trouble with uncontrolled bleeding.
B.
has any known allergies.
C.
received teaching regarding a low-fat diet.
D.
understands the procedure for local anesthesia.
Explanation:
Choice b is correct: Iodine contrast media is used for gallbladder x-rays. The client must be assessed for history of allergy to iodine.
Choice a is incorrect: This is not an invasive study and will not precipitate bleeding.
Choice c is incorrect: Although the client will receive a low-fat diet the evening before the study, this is not a priority assessment.
Choice d is incorrect: Local anesthesia is not used during gallbladder x-rays.
Section: Assessment
Subsection: Safety and Infection Control
23.
A client is referred to the outpatient clinic to have a glucose tolerance test (GTT) and glycosylated hemoglobin assay (Hgb A 1c ) to assess for questionable diabetes mellitus. The client requests clarification from the clinic nurse regarding these tests. The nurse differentiates between a glucose tolerance test (GTT) and glycosylated hemoglobin assay (Hgb A 1c ) by explaining that the Hgb A 1c
A.
is used to diagnose diabetes mellitus.
B.
involves administration of an oral glucose load.
C.
measures serum glucose at 30 minute, 1-, 2-, and 3-hour intervals.
D.
reflects blood glucose level over a 2-3 month period.
Explanation:
Choice d is correct: The Hgb A1c assay provides information about long-term control of diabetes mellitus. The assay reflects glucose level within erythrocytes, providing an average level over the 2-3 months preceding the test.
Choice a is incorrect: The assay is used to evaluate control of diabetes; GTT is used to diagnose diabetes.
Choice b is incorrect: Oral glucose load is administered for the GTT.
Choice c is incorrect: The GTT measures serum glucose at various time intervals.
Section: Analysis
Subsection: Reduction of Risk Potential
24.
An adult male client is admitted with a diagnosis of acute M.I. (myocardial infarct). He is attached to a cardiac monitor and has an IV catheter in place. His cardiac rhythm has been normal sinus rhythm with occasional PVCs. The nurse notes a sudden change on the cardiac monitor screen to a very irregular, chaotic-looking pattern. The client appears to be sleeping. The most appropriate action on the part of the nurse is to
A.
administer a precordial thump.
B.
obtain the defibrillator.
C.
begin cardiopulmonary resuscitation.
D.
check the client's ECG electrodes.
Explanation:
Choice d is correct: Sudden bizarre-looking ECG patterns may be a result of loose electrodes (artifact) rather than a lethal arrhythmia. The client and electrodes should be checked as the safest initial intervention.
Choice a is incorrect: A precordial thump can cause injury and would not be utilized until it has been determined that the client had a lethal dysrhythmia.
Choice b is incorrect: Defibrillation can cause injury and would not be utilized until it has been determined that the client had a lethal dysrhythmia.
Choice c is incorrect: Cardiopulmonary resuscitation can cause injury and would not be utilized until it has been determined that the client had a lethal dysrhythmia.
Section: Analysis
Subsection: Physiological Adaptation
25.
An adult client presents with the sudden onset of the appearance of "floating black spots'' in her right eye. The client sees a black shadow in her peripheral vision. There is no pain but the client is very frightened. What should the nurse expect to do in the care of this client?
A.
Place patches on both eyes and plan for strict bed rest.
B.
Patch the right eye and let the client resume activity after 24 hours.
C.
Plan for emergency surgery as the client is in danger of losing her eyesight.
D.
Administer a cholinergic eye drop (Pilocarpine) to decrease intraocular pressure.
Explanation:
Choice a is correct: The client is displaying signs of a detached retina, which requires patching of both eyes to minimize eye movement and bed rest with a flat or slightly raised head of the bed to prevent separation of the retina and choroid layers.
Choice b is incorrect: Both eyes need to be patched to prevent tracking (movement of one eye when the other one moves), and activity must be curtailed to prevent complete detachment.
Choice c is incorrect: Emergency surgery is not the initial plan of care but scleral buckling or laser reattachment surgery are options for treatment.
Choice d is incorrect: Cholinergic eye drops (Pilocarpine) are for treating narrow angle glaucoma.
Section: Planning
Subsection: Physiological Adaptation
26.
The nurse is caring for a woman in labor. When she is 8 cm dilated she tells her support person she wants "to go home for a few hours of sleep.'' The nurse helps the support person realize that this statement reflects the woman's desire to
A.
have others tell her what she needs.
B.
have a soothing back rub.
C.
be rid of this difficult situation.
D.
be left alone.
Explanation:
Choice c is correct: The pain may be unbearable at this time, and she wishes to get away from it.
Choice a is incorrect: She does not want to have others tell her what she needs. She wishes to remain in control.
Choice b is incorrect: Back rubs are good in early labor, but not in transition when she does not wish to be touched.
Choice d is incorrect: She wants help but turns inward and shuts out extraneous stimuli. She does not wish to be left alone.
Section: Analysis
Subsection: Growth/Development Through Life Span
27.
A 22-year old woman comes into the obstetrics clinic requesting oral contraceptives. Which item in the nursing history would indicate that she is not a good candidate for this method of contraception?
A.
She has a history of heavy menstrual periods.
B.
She has diabetes mellitus.
C.
The client reports a broken leg when she was ten years old.
D.
The client had a baby six months ago.
Explanation:
Choice b is correct: Diabetes is a contraindication for taking oral contraceptives. Diabetics have a high incidence of cardiovascular disease.
Choice a is incorrect: Oral contraceptives decrease menstrual flow and may help to regulate periods and reduce chances of anemia.
Choice c is incorrect: The broken leg was too long ago to pose a problem. A long leg cast at the present time or a major injury to the lower leg would be a concern because of the danger of thrombus formation.
Choice d is incorrect: There is a concern if the baby is only a few days old because the pills may predispose the baby to cardiovascular problems, but her baby is six months old.
Section: Assessment
Subsection: Pharmacological and Parental Therapies
28.
Mrs. G., 25, is hospitalized for depression. One evening after an argument with her husband, Mrs. G. discusses with the evening nurse her intent to cut her wrists. Her husband has threatened to divorce her and retain custody of the children. The most appropriate initial action for the nurse to take is to
A.
attempt to convince Mrs. G. of the need to address her husband's threats instead of using self-destructive behavior.
B.
place Mrs. G. on suicide precautions, which restrict her from leaving the nursing unit.
C.
place Mrs. G. on suicide precautions requiring close observation and one to one monitoring by nursing staff.
D.
recognize the suicidal remarks as less serious since Mrs. G. is in a safe environment.
Explanation:
Choice c is correct: Suicide attempts are more common on evenings or night shifts and weekends when unit structure is lessened. Mrs. G. is at high risk because of her husband's threats to cut off financial resources and access to her children. She is depressed and is experiencing "tunnel vision" in regards to her situation. Mrs. G.'s safety needs must be met. The suicidal intent must be taken seriously. She has an intent to follow through with a plan and needs close observation, preferably one on one with the nurse.
Choice a is incorrect: Safety is the nurse's first concern. Therapeutic sessions will address the marital relationship, coping strategies, and problem solving at a later time.
Choice b is incorrect: Mrs. G.'s safety may not be secure as she could possibly find some object with which to cut herself.
Choice d is incorrect: All suicidal remarks and gestures must be taken seriously. Clients can find a multitude of ways to commit or attempt to commit suicide while hospitalized.
Section: Implementation
Subsection: Physiological Adaptation
29.
Mrs. L. will be administering daily insulin to her 84-year-old blind grandfather. The insulin dose is 15 u NPH, 5 u regular every morning at 0745. Which statement best indicates that Mrs. L. needs further instruction in insulin administration prior to her grandfather's discharge from the hospital?
A.
"The regular insulin acts quickly. NPH insulin is milky colored and lasts longer, usually the whole day.''
B.
"I need to keep track of where I give his insulin so that I don't use the same site over and over.''
C.
"If I can't get to Granddaddy's house until lunch time occasionally, I can give him a little more insulin in case his sugar went up in the morning.''
D.
"It's very important to keep insulin shots on schedule and for him to eat at regular times.''
Explanation:
Choice c is correct: It is important not to change the insulin dosage or time without consulting the physician. This statement indicates that the client needs further instruction before her grandfather leaves the hospital.
Choice a is incorrect: The client is correct. Regular insulin onset is usually to 1 hour while NPH onset is 3 to 4 hours with a duration of 20–24 hours.
Choice b is incorrect: The client understands that site rotation is important. This will prevent localized changes in fatty tissue.
Choice d is incorrect: The client understands the importance of keeping her grandfather's insulin administration on schedule and having him eat regularly scheduled meals to keep his blood sugar controlled.
Section: Evaluation
Subsection: Pharmacological and Parental Therapies
30.
An elderly woman received digoxin 0.25 mg for treatment of her congestive heart failure. Which of the following physiological responses indicates that the digoxin is having the desired effect?
A.
Increased heart rate.
B.
Decreased cardiac output.
C.
Increased urine output.
D.
Decreased myocardial contraction force.
Explanation:
Choice c is correct: Urine output increases due to the increased cardiac output and myocardial contraction force, increasing perfusion of the kidney. Increase in urine output helps to decrease edema.
Choice a is incorrect: Digoxin decreases the heart rate and makes it more effective.
Choice b is incorrect: Cardiac output is increased, not decreased.
Choice d is incorrect: Digoxin increases myocardial contraction force. This increases the effectiveness of the pumping action.
Section: Evaluation
Subsection: Pharmacological and Parental Therapies
31.
An adult is admitted to the hospital with anorexia, weight loss, and ascites. Serum SGOT (AST), SGPT (ALT), LDH, and total bilirubin are significantly elevated. Based on the lab results, the nurse performing an admission assessment will expect to find
A.
pallor.
B.
dry mucous membranes.
C.
jaundice.
D.
peripheral edema.
Explanation:
Choice c is correct: The lab values, elevated liver enzymes and total bilirubin, along with the symptoms, anorexia, weight loss and ascites, all suggest liver disease. Jaundice occurs with liver disease because of the inability of diseased liver cells to clear bilirubin from the blood. Bile is deposited in the skin and sclera, producing the yellow discoloration.
Choice a is incorrect: Pallor is an indication of anemia, which does not correspond to the lab work results. The client will be jaundiced, not pale.
Choice b is incorrect: Dry mucous membranes are found with dehydration. The lab results given reflect liver function, not hydration status.
Choice d is incorrect: Ascites, rather than peripheral edema, is a common finding with hepatic failure. The lab results indicate hepatic dysfunction.
Section: Analysis
Subsection: Reduction of Risk Potential
32.
The nurse is preparing a client for an IVP tomorrow. The client tells the nurse that she gets a rash and becomes short of breath after eating lobster. Given this information, the nurse knows that the client
A.
should be visited by a dietitian while in the hospital.
B.
is not a candidate for IVP.
C.
is at risk for an allergic reaction.
D.
will require an antihistamine before her IVP.
Explanation:
Choice c is correct: People who are allergic to shellfish (iodine) are at risk for allergic reactions to the contrast material (iodine) used for an IVP.
Choice a is incorrect: An allergic response to shellfish suggests an allergic reaction to iodine, the contrast material used for an IVP. The primary concern is the client's safety during the procedure.
Choice b is incorrect: The test probably won't be canceled, but a substitute, less allergenic contrast material will be used or the client will be given steroids and/or antihistamines before the test.
Choice d is incorrect: The nurse does not make the decision about administering antihistamines. The data in the question only tells us that the client is at risk for an allergic reaction.
Section: Analysis
Subsection: Reduction of Risk Potential
33.
An elderly client requiring abdominal wound packing tid complains about his wound care to the nurse making morning rounds. He states that "everyone does it differently and at any time they feel like it.'' He is angry at being awakened at night for this procedure. The best response for the nurse to make is
A.
"The wound care is being done as ordered by your doctor.''
B.
"I understand you're upset at losing sleep. You can have medication to help you get back to sleep.''
C.
"Tell me what's really bothering you.''
D.
"After rounds I'll be back, and we can plan your wound care.''
Explanation:
Choice d is correct: The nurse arranges to plan wound care with the client, thereby allowing him to participate in his own care and addressing the source of his anger.
Choice a is incorrect: This reply discounts the client's feelings and concerns.
Choice b is incorrect: This response only addresses part of the problem with the suggestion of an inappropriate solution.
Choice c is incorrect: This response reflects a misunderstanding of the client's complaints as a symptom of another problem.
Section: Analysis
Subsection: Management of Care
34.
The nurse is planning care for a client with cervical radiation implants. Which nursing intervention will be included in the plan of care?
A.
Implement strict isolation protocol.
B.
Provide a lead apron for the client.
C.
Use only disposable supplies and equipment in the client's room.
D.
Limit visitors to 30 minutes per day.
Explanation:
Choice d is correct: Limited time in the client's room reduces exposure to radiation for nursing staff and visitors.
Choice a is incorrect: Strict isolation is not appropriate. Only time and distance limits need to be instituted.
Choice b is incorrect: A lead apron may be worn by visitors or healthcare workers, not by the client.
Choice c is incorrect: Disposable supplies and equipment are not necessary. Bed linens and dressings will be handled according to radiation protocol.
Section: Planning
Subsection: Safety and Infection Control
35.
The nurse reviews a client's laboratory data and notes the following hematology values: hematocrit (hct) 43%; hemoglobin (Hgb) 15 g/dl; RBCs 5 million; WBCs 7,500; platelet count 30,000. What nursing care is indicated in relation to these lab values?
A.
Plan a diet high in iron.
B.
Plan for frequent rest periods throughout the day.
C.
Avoid invasive procedures and injections.
D.
Implement protective isolation precautions.
Explanation:
Choice c is correct: The platelet count is low. Normal platelet count is 150,000-500,000. A low platelet count places the client at risk for bleeding. Trauma, injections, and invasive procedures should be avoided.
Choice a is incorrect: The hct, Hgb, and RBCs are all within normal limits so the client is not anemic and will not require supplemental iron.
Choice b is incorrect: The hct, Hgb, and RBCs are all within normal limits so the client is not anemic and will not require rest periods for fatigue.
Choice d is incorrect: The WBC is normal so the client is not at risk for infection.
Section: Planning
Subsection: Reduction of Risk Potential
36.
The nurse is planning care for a client who is having a gastroscopy performed. Included in the plan of care for the immediate postgastroscopy period will be
A.
maintain nasogastric tube to intermittent suction.
B.
assess gag reflex prior to administration of fluids.
C.
assess frequently for pain and medicate according to orders.
D.
measure abdominal girth every four hours.
Explanation:
Choice b is correct: Because a local anesthetic is used to numb the pharyngeal area for gastroscopy, the nurse must be certain the client is able to swallow before giving food or fluids. It may take two to four hours for the gag reflex and swallowing ability to return.
Choice a is incorrect: Clients will not have a nasogastric tube in place following a gastroscopy.
Choice c is incorrect: The client should have no pain following this procedure. Pain is an indication of a complication.
Choice d is incorrect: Measuring abdominal girth is not included in the plan of care immediately following a gastroscopy.
Section: Planning
Subsection: Reduction of Risk Potential
37.
An elderly client has suffered a cerebrovascular accident (CVA) and, as a result, has left homonymous hemianopia. Based on this fact, what measure will the nurse include in this client's plan of care?
A.
Supporting the client's left arm and hand with pillows
B.
Applying a patch to the client's left eye
C.
Encouraging the client to use his right hand for activities of daily living
D.
Placing the client's meal on the right side of the overbed table
Explanation:
Choice d is correct: This disorder includes blindness involving the left half of the visual field of both eyes. Therefore, the client can only see objects placed within the right visual field.
Choice a is incorrect: Supporting the client's left arm and hand with pillows is appropriate for a client who has left hemiplegia. This client may have left hemiplegia but we are not given this information. The question asks the action related to left homonymous hemianopia.
Choice b is incorrect: Applying a patch to one eye is an appropriate intervention for diplopia (double vision) but this is not the condition this client has.
Choice c is incorrect: Encouraging the client to use his right hand for activities of daily living may be an appropriate intervention for the CVA client but is not related to hemianopia.
Section: Planning
Subsection: Reduction of Risk Potential
38.
A toddler is admitted with a history of vomiting and diarrhea for two days, accompanied by abdominal pain. The admitting diagnosis is gastroenteritis. What type of room assignment should the nurse make?
A.
A room near the nurses' station so that he can be checked frequently and heard if he vomits
B.
A single room with a sink near the doorway for isolation use
C.
A double room with another toddler who also has vomiting and diarrhea
D.
A bed in the pediatric intensive care unit, in case dehydration develops
Explanation:
Choice b is correct: The child should be placed on enteric isolation until the lab reports no contagious organisms in the stool. If the stool is infected, isolation is continued after the antibiotics are completed until three consecutive daily stool specimens are negative.
Choice a is incorrect: A room near the nurses' station is a good idea, but does not address the problem of communicability.
Choice c is incorrect: Another child with the same clinical manifestations may be afflicted with an entirely different organism. Placing these two together would facilitate the exchange of organisms from poor hand washing by caregivers and use of the same equipment in the room.
Choice d is incorrect: Even if dehydration develops, it can be handled on the regular pediatric unit without the psychologic and financial stressors of an intensive care unit. Only severe dehydration is treated in the pediatric intensive care unit.
Section: Planning
Subsection: Safety and Infection Control
39.
The nurse is caring for a client who is to have a lumbar puncture (L-P). How should the client be positioned during the procedure?
A.
Prone with head turned to the left
B.
Side-lying in a fetal position
C.
Sitting at the edge of the bed
D.
Trendelenburg position
Explanation:
Choice b is correct: The fetal position (flexion) increases space between lumbar vertebrae facilitating easier entry of the needle into the subarachnoid space.
Choice a is incorrect: The prone position would make access to intervertebral spaces difficult.
Choice c is incorrect: Sitting at the edge of the bed is used for thoracentesis. Sometimes epidural anesthesia is started in this position. However, cerebrospinal fluid is not withdrawn. An upright position might cause spinal headache if utilized for L-P.
Choice d is incorrect: Trendelenburg position is used for insertion of central catheters and sometimes for shock states.
Section: Implementation
Subsection: Reduction of Risk Potential
40.
The physician has ordered a Schilling's test for a client with possible pernicious anemia. Implementation of the test will require the nurse to
A.
administer a mild laxative.
B.
initiate a 24-hour urine collection.
C.
administer an intramuscular dose of iron.
D.
insert an intravenous catheter.
Explanation:
Choice b is correct: A Schilling's test measures the percent of vitamin B12 excreted in a 24-hour urine sample following an intramuscular "loading'' dose of vitamin B12 and a radioactive oral dose of vitamin B12.
Choice a is incorrect: Laxatives should not be administered during the test, since increased gastrointestinal motility may interfere with oral B12 absorption.
Choice c is incorrect: An intramuscular dose of vitamin B12, not iron, is given. Iron is given to treat iron deficiency anemia.
Choice d is incorrect: An intravenous catheter is not required for this test.
Section: Implementation
Subsection: Reduction of Risk Potential
41.
The nurse has given discharge instructions on how to care for a newly applied cast to an adult client. Which statement indicates the client understands the instructions?
A.
"I should pack the casted leg in ice for 24 hours to help it dry.''
B.
"I can use my hair dryer to help the cast dry faster.''
C.
"A good way to relieve the itching under the cast is to gently scratch under the cast with a soft knitting needle.''
D.
"Putting the casted leg up on fabric-covered pillows is the best way to dry the cast.''
Explanation:
Choice d is correct: Cloth-covered pillows or blankets are breathable materials that allow the cast to air dry. No plastic should be used.
Choice a is incorrect: Ice should be applied for 20 minutes, then removed for 20 minutes, to help prevent edema of the casted extremity.
Choice b is incorrect: Hair dryers, fans, and heat lamps should not be used to dry a cast. The inside of the cast would remain damp while the outside would dry.
Choice c is incorrect: No objects of any kind should be inserted under the cast.
Section: Planning
Subsection: Reduction of Risk Potential
42.
The nurse is caring for a client who has just had a bone marrow biopsy. What is essential for the nurse to do at this time?
A.
Apply firm pressure over the puncture site.
B.
Maintain the client on bed rest for 24 hours.
C.
Apply an occlusive dressing to the puncture site.
D.
Refrigerate the biopsy specimen.
Explanation:
Choice a is correct: Bleeding may occur from the puncture site. Firm pressure is required for several minutes to prevent this.
Choice b is incorrect: The client can resume normal activity once sedation has worn off.
Choice c is incorrect: An occlusive dressing is not required for the puncture site.
Choice d is incorrect: The biopsy specimen is sent to the lab immediately after the procedure.
Section: Implementation
Subsection: Reduction of Risk Potential
43.
An adult client is one day post subtotal thyroidectomy. The nurse planning care for the day knows that it is most important to
A.
carry out range of motion exercises to the neck and shoulders every shift.
B.
maintain bed rest with client in supine position at all times.
C.
ask client questions every hour or two to assess for hoarseness.
D.
provide tracheostomy care every shift and suction PRN to maintain a patent airway.
Explanation:
Choice c is correct: Damage to the recurrent laryngeal nerve is a major complication of thyroid surgery. Hoarseness immediately following surgery is often related to intubation during surgery. However, persistent or worsening hoarseness must be reported immediately to the physician because it may be the first sign of nerve injury.
Choice a is incorrect: Tension on the suture line should be avoided. Teach the client to support the head and neck when turning or changing position.
Choice b is incorrect: Semi-Fowler's position should be maintained to promote respiratory function, and the head should be supported in a neutral position with pillows.
Choice d is incorrect: A tracheostomy is not routinely performed during a thyroidectomy. An emergency tracheostomy set should be available on the unit for use if the client develops respiratory impairment and obstruction due to laryngeal edema.
Section: Planning
Subsection: Reduction of Risk Potential
44.
An adult client is four hours post-op abdominal hysterectomy. She has an IV at 125 ml per hour, an indwelling catheter that has drained 100 ml since surgery, and her pain is "3'' out of "10.'' Which would be the priority nursing diagnosis?
A.
Alteration in comfort, pain
B.
Alterations in patterns of elimination
C.
Disturbance in self-concept, body image
D.
Fluid volume deficit, actual or risk for
Explanation:
Choice d is correct: All abdominal surgery clients have a potential for third-spacing of fluids, causing a fluid volume deficit. Post-op urine output should be maintained at least 30 ml per hour. 100 ml in four hours indicates a beginning deficit.
Choice a is incorrect: Alteration in comfort, pain is a working diagnosis. However, fluid volume deficit is the highest priority.
Choice b is incorrect: Alterations in patterns of elimination is a working diagnosis. However, fluid volume deficit is the highest priority.
Choice c is incorrect: Disturbance in self-concept, body image is a working diagnosis. However, fluid volume deficit is the highest priority.
Section: Planning
Subsection: Physiological Adaptation
45.
An adult client has meperidine HCl (Demerol) 50 mg-100 mg IM every 3-4 hours ordered. He received Demerol 50 mg IM three hours ago but he's still complaining of pain at "8 out of 10.'' The client is asking for pain medication even before it is due and refuses to get out of bed "because of the pain.'' He was heard telling jokes to the cleaning personnel. What is the best action for the nurse to take?
A.
Give the client 50 mg of Demerol IM now.
B.
Wait one hour and give the client 75 mg of Demerol IM.
C.
Give the client 100 mg of Demerol IM now and repeat 100 mg Demerol IM in three hours if the pain is still greater than "5 out of 10.''
D.
Do not medicate the client now. Laughing and joking behavior indicate the pain is not as severe as the client claims.
Explanation:
Choice c is correct: Pain research has validated the need for nurses to adequately medicate clients in pain. Pain is what the person says it is and occurs when the person says it does. Nurses often undermedicate persons in pain and look for obvious signs of pain, i.e., grimacing, clenched teeth, crying, etc. The client said the pain was "8 out of 10,'' which validates the nurse giving 100 mg Demerol IM.
Choice a is incorrect: 50 mg Demerol IM did not adequately control the client's pain. The nurse should increase the dose since the order allows the nurse to make this judgment.
Choice b is incorrect: The client is in pain now and needs to be medicated now. The order allows pain medication in three hours.
Choice d is incorrect: People use various forms of coping mechanisms to deal with pain including laughing, joking, sleeping, or even exercising.
Section: Planning
Subsection: Pharmacological and Parental Therapies
46.
An elderly male with undiagnosed respiratory symptoms is to receive a diagnostic test for histoplasmosis. The nurse giving a histoplasmin skin test will
A.
apply a patch to the skin on the forearm.
B.
make a shallow scratch on the skin surface.
C.
use a 25-gauge needle placed parallel to the skin.
D.
use a 19-gauge needle and Z track injection.
Explanation:
Choice c is correct: Intradermal injections are given using a small-gauge needle inserted between skin layers by angling the needle parallel to the skin of the forearm.
Choice a is incorrect: Histoplasmin antigen is administered by intradermal injection, not by means of a patch. Drugs such as nitroglycerin may be given by transcutaneous patch.
Choice b is incorrect: Shallow scratches on the skin are used for administration of antigen for allergy testing.
Choice d is incorrect: Histoplasmin antigen is administered by intradermal injection, not by Z track IM injection. Imferon (iron) is given by Z track injection.
Section: Implementation
Subsection: Reduction of Risk Potential
47.
A 35-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment?
A.
inability to make decisions
B.
feelings of hopelessness
C.
family history of depression
D.
increased interest in sex
Explanation:
Choice d is correct: Interest in sex is markedly decreased in depression.
Choice a is incorrect: Indecisiveness and fear of being wrong are common in depression.
Choice b is incorrect: Depression creates feelings of hopelessness.
Choice c is incorrect: The risk of depression is increased when there is a family history.
Section: Assessment
Subsection: Psychosocial Adaptation
48.
An adult male, who appears about 40-years old, is admitted to the psychiatric unit for alcohol detoxification. He is tremulous and irritable, and complains of nervousness and nausea. Which information is most important for the admitting nurse to obtain?
A.
The amount of alcohol and other drugs usually taken and the type and amount taken in the last few days.
B.
The events prompting the client to seek treatment.
C.
The factors that trigger the client's drinking episodes.
D.
Any work, legal, or family problems that relate to his alcohol use.
Explanation:
Choice a is correct: Knowledge of the type and amounts of alcohol and other drugs consumed is necessary to plan the program of detoxification and anticipate physical complications.
Choice b is incorrect: The client's motivation for treatment will become more important as treatment progresses and he passes the detoxification stage.
Choice c is incorrect: Several weeks of therapy may be necessary before the client can successfully identify the factors that precipitate drinking bouts.
Choice d is incorrect: The social problems created by the client's drinking are not a priority during detoxification but will require consideration as later treatment is planned.
Section: Assessment
Subsection: Psychosocial Adaptation
49.
A woman who is nine months pregnant is attending a luncheon and fashion show. Suddenly, her membranes rupture and contractions come so rapidly that she yells, "The baby is coming.'' What is the most appropriate action for the nurse to take?
A.
Ask for boiled water, towels, string, and scissors.
B.
Ask someone to call her doctor.
C.
Take her via cab to the nearest hospital.
D.
Have her lie on her left side in a less-crowded area and be prepared to help with the delivery.
Explanation:
Choice d is correct: Lying on the left side provides the best perfusion to the uterus and the infant while waiting for delivery. The nurse should have the mother in as clean and uncrowded a place as possible.
Choice a is incorrect: The cord can be tied with clean cloths, but not cut if hospital care is likely within one hour.
Choice b is incorrect: Asking someone to call the doctor is appropriate but not of highest priority. The highest priority is to be prepared to assist the woman with the baby while waiting for the ambulance.
Choice c is incorrect: It is safer for her to stay where she is and wait for the ambulance than to be in transit during the delivery.
Section: Implementation
Subsection: Growth/Development Through Life Span
50.
While attending a basketball game, a woman who is nine months pregnant suddenly goes into labor and delivers her baby within five minutes. What is the most appropriate course of action for the nurse to take?
A.
Tie the cord with a shoelace and cut the cord with a penknife.
B.
Have the mother's friend hold the baby until an ambulance arrives.
C.
Place the naked baby on the mother's bare chest, cover both, and encourage breastfeeding.
D.
Ask people to clear the area so more air can circulate around the mother and baby.
Explanation:
Choice c is correct: Skin-to-skin contact is recommended so that the mother's warm body will warm the infant. Covering both will help keep them warm. Breastfeeding will help contract the mother's uterus and reduce bleeding.
Choice a is incorrect: The cord should only be tied with a clean or sterile item and the cord cut only with a sterile implement. If the mother will get to a hospital within the next hour, cutting the cord is not necessary.
Choice b is incorrect: Mother and baby should be together for warmth, safety, and breastfeeding.
Choice d is incorrect: The area should be kept warm to prevent hypothermia in the mother and baby. Clearing the area may be appropriate to provide privacy and reduce germs but is not the highest priority.
Section: Implementation
Subsection: Growth/Development Through Life Span
source:learnatest.com
