100 item Comprehensive Exam with Answers and Rationale 1.

The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? A) Clear the area of any hazards B) lace the child on the side C) !estrain the child ") #ive the $rescri%ed anticonvulsant The correct answer is B& lace the child on the side rotecting the air'ay is the to$ $riority in a seizure. (f a child is actively convulsing) a $atent air'ay and o*ygenation must %e assured. +. A client has ,ust returned to the medical-surgical unit follo'ing a segmental lung resection. After assessing the client) the first nursing action 'ould %e to A) Administer $ain medication B) -uction e*cessive tracheo%ronchial secretions C) Assist client to turn) dee$ %reathe and cought ") .onitor o*ygen saturation The correct answer is B& -uction e*cessive tracheo%ronchial secretions -uctioning the co$ious tracheo%ronchial secretions $resent in $ost-thoracic surgery clients maintains an o$en air'ay 'hich is al'ays the $riority nursing intervention. 3. A nurse from the surgical de$artment is reassigned to the $ediatric unit. The charge nurse should recognize that the child at highest ris/ for cardiac arrest and is the least li/ely to %e assiged to this nurse is 'hich child? A) Congenital cardiac defects B) An acute fe%rile illness C) rolonged hy$o*emia ") -evere multi$le trauma The correct answer is C& rolonged hy$o*emia .ost often) the cause of cardiac arrest in the $ediatric $o$ulation is $rolonged hy$o*emia. Children usually have %oth cardiac and res$iratory arrest. 0. Which of the follo'ing 'ould %e the %est strategy for the nurse to use 'hen teaching insulin in,ection techni1ues to a ne'ly diagnosed client 'ith dia%etes? A) #ive 'ritten $re and $ost tests B) As/ 1uestions during $ractice C) Allo' another dia%etic to assist ") 2%serve a return demonstration The correct answer is D& 2%serve a return demonstration -ince this is a $sychomotor s/ill) this is the %est 'ay to /no' if the client has learned the $ro$er techni1ue.

3. The nurse is assessing a + year-old client 'ith a $ossi%le diagnosis of congenital heart disease. Which of these is most li/ely to %e seen 'ith this diagnosis? A) -everal otitis media e$isodes in the last year B) Weight and height in 14th $ercentile since %irth C) Ta/es fre1uent rest $eriods 'hile $laying ") Changing food $references and disli/es The correct answer is C& Ta/es fre1uent rest $eriods 'hile $laying Children 'ith heart disease tend to have e*ercise intolerance. The child self-limits activity) 'hich is consistent 'ith manifestations of congenital heart disease in children. 5. The nurse is reassigned to 'or/ at the oison Control Center tele$hone hotline. (n 'hich of these cases of childhood $oisoning 'ould the nurse suggest that $arents have the child drin/ orange ,uice? A) An 16 month-old 'ho ate an undetermined amount of crystal drain cleaner B) A 10 month-old 'ho che'ed + leaves of a $hilodendron $lant C) A +4 month-old 'ho is found sitting on the %athroom floor %eside an em$ty %ottle of diaze$am 78alium) ") A 34 month-old 'ho has s'allo'ed a mouthful of charcoal lighter fluid The correct answer is A: An 16 month-old 'ho ate an undetermined amount of crystal drain cleaner. "rain cleaner is very al/aline. The orange ,uice is acidic and 'ill hel$ to neutralize this su%stance. 9. A +3 year-old single client is in the 33rd 'ee/ of her first $regnancy. -he tells the nurse that she has everything ready for the %a%y and has made $lans for the first 'ee/s together at home. Which normal emotional reaction does the nurse recognize? A) Acce$tance of the $regnancy B) :ocus on fetal develo$ment C) Antici$ation of the %irth ") Am%ivalence a%out $regnancy The correct answer is C: Antici$ation of the %irth "irecting activities to'ard $re$aration for the ne'%orn;;s needs and $ersonal ad,ustment are indicators of a$$ro$riate emotional res$onse in the third trimester. 6. <$on e*amining the mouth of a 3 year-old child) the nurse discovers that the teeth have chal/y 'hite-to-yello'ish staining 'ith $itting of the enamel. Which of the follo'ing conditions 'ould most li/ely e*$lain these findings? A) (ngestion of tetracycline B) =*cessive fluoride inta/e C) 2ral iron thera$y ") oor dental hygiene The correct answer is B: =*cessive fluoride inta/e The descri%ed findings are indicative of fluorosis) a condition characterized %y an increase in the e*tent and degree of the enamel;;s $orosity. This $ro%lem can %e

associated 'ith re$eated s'allo'ing of tooth$aste 'ith fluoride or drin/ing 'ater 'ith high levels of fluoride. >. Which of the follo'ing should the nurse teach the client to avoid 'hen ta/ing chlor$romazine ?C@ 7Thorazine)? A) "irect sunlight B) :oods containing tyramine C) :oods fermented 'ith yeast ") Canned citrus fruit drin/s The correct answer is A& Avoid direct sunlight henothiazine increases sensitivity to the sun) ma/ing clients es$ecially susce$ti%le to sun%urn. 14. The nurse is discussing dietary inta/e 'ith an adolescent 'ho has acne. The most a$$ro$riate statement for the nurse is A) A=at a %alanced diet for your age.A B) A(ncrease your inta/e of $rotein and 8itamin A.A C) A"ecrease fatty foods from your diet.A ") A"o not use caffeine in any form) including chocolate.A The correct answer is A& A=at a %alanced diet for your age.A A diet for a teenager 'ith acne should %e a 'ell %alanced diet for their age. There are no recommended additions and su%tractions from the diet. 11. The nurse is caring for a child 'ho has ,ust returned from surgery follo'ing a tonsillectomy and adenoidectomy. Which action %y the nurse is a$$ro$riate? A) 2ffer ice cream every + hours B) lace the child in a su$ine $osition C) Allo' the child to drin/ through a stra' ") 2%serve s'allo'ing $atterns The correct answer is D: 2%serve s'allo'ing $atterns The nurse should o%serve for increased s'allo'ing fre1uency to chec/ for hemorrhage. 1+. The nurse is caring for a client 'ith acute $ancreatitis. After $ain management) 'hich intervention should %e included in the $lan of care? A) Cough and dee$ %reathe every + hours B) lace the client in contact isolation C) rovide a diet high in $rotein ") (nstitute seizure $recautions The correct answer is A: Cough and dee$ %reathe every + hours !es$iratory infections are common %ecause of fluid in the retro $eritoneum $ushing u$ against the dia$hragm causing shallo' res$irations. =ncouraging the client to cough and dee$ %reathe every + hours 'ill diminish the occurrence of this com$lication.

13. The nurse is caring for a client 'ith trigeminal neuralgia 7tic douloureau*). To assist the client 'ith nutrition needs) the nurse should A) 2ffer small meals of high calorie soft food B) Assist the client to sit in a chair for meals C) rovide additional servings of fruits and ra' vegeta%les ") =ncourage the client to eat fish) liver and chic/en The correct answer is A: 2ffer small meals of high calorie soft food (f the client is losing 'eight %ecause of $oor a$$etite due to the $ain) assist in selecting foods that are high in calories and nutrients) to $rovide more nourishment 'ith less che'ing. -uggest that fre1uent) small meals %e eaten instead of three large ones. To minimize ,a' movements 'hen eating) suggest that foods %e $ureed. 10. A client treated for de$ression tells the nurse at the mental health clinic that he recently $urchased a handgun %ecause he is thin/ing a%out suicide. The first nursing action should %e to A) Botify the health care $rovider immediately B) -uggest in-$atient $sychiatric care C) !es$ect the client;s confidential disclosure ") hone the family to 'arn them of the ris/ The correct answer is A& Botify the health care $rovider immediately The health care $rovider must %e contacted immediately as the client is a danger to self and others. ?os$italization is indicated. 13. The initial res$onse %y the nurse to a delusional client 'ho refuses to eat %ecause of a %elief that the food is $oisoned is A) ACou thin/ that someone 'ants to $oison you?A B) AWhy do you thin/ the food is $oisoned?A C) AThese feelings are a sym$tom of your illness.A ") ACouDre safe here. ( 'onDt let anyone $oison you.A The correct answer is A: ACou thin/ that someone 'ants to $oison you?A This res$onse ac/no'ledges $erce$tion through a reflective 1uestion 'hich $resents o$$ortunity for discussion) clarification of meaning) and e*$ressing dou%t. 15. A client has ,ust %een admitted 'ith $ortal hy$ertension. Which nursing diagnosis 'ould %e a $riority in $lanning care? A) Altered nutrition& less than %ody re1uirements B) otential com$lication hemorrhage C) (neffective individual co$ing ") :luid volume e*cess The correct answer is B& otential com$lication hemorrhage =so$hageal varices are dilated and tortuous vessels of the eso$hagus that are at high ris/ for ru$ture if $ortal circulation $ressures rise.

19. The nurse in a 'ell-child clinic e*amines many children on a daily %asis. Which of the follo'ing toddlers re1uires further follo' u$? A) A 13 month-old una%le to 'al/ B) A +4 month-old only using + and 3 'ord sentences C) A +0 month-old 'ho cries during e*amination ") A 34 month-old only drin/ing from a si$$y cu$ The correct answer is D: A 34 month-old only drin/ing from a si$$y cu$ A 34 month-old should %e a%le to drin/ from a cu$ 'ithout a cover. 16. Which of the follo'ing conditions assessed %y the nurse 'ould contraindicate the use of %enztro$ine 7Cogentin)? A) Beuromalignant syndrome B) Acute e*tra$yramidal syndrome C) #laucoma) $rostatic hy$ertro$hy ") ar/inson;s disease) aty$ical tremors The correct answer is C: #laucoma) $rostatic hy$ertro$hy #laucoma and $rostatic hy$ertro$hy are contraindications to the use of %enztro$ine 7Cogentin) as the drug is an anticholinergic agent. 1>. A 13 year-old client 'ith a lengthy confining illness is at ris/ for altered gro'th and develo$ment of 'hich tas/? A) @oss of control B) (nsecurity C) "e$endence ") @ac/ of trust The correct answer is C: "e$endence The client role fosters de$endency. Adolescents may react to de$endency 'ith re,ection) uncoo$erativeness) or 'ithdra'al. +4. The nurse is caring for a client 'ith cirrhosis of the liver 'ith ascites. When instructing nursing assistants in the care of the client) the nurse should em$hasize that A) The client should remain on %ed rest in a semi-:o'ler;s $osition B) The client should alternate am%ulation 'ith %ed rest 'ith legs elevated C) The client may am%ulate and sit in chair as tolerated ") The client may am%ulate as tolerated and remain in semi-:o'lers $osition in %ed The correct answer is B& The client should alternate am%ulation 'ith %ed rest 'ith legs elevated. =ncourage alternating $eriods am%ulation and %ed rest 'ith legs elevated to mo%ilize edema and ascites. =ncourage and assist the client 'ith gradually increasing $eriods of am%ulation. +1. (n $roviding care to a 10 year-old adolescent 'ith scoliosis) 'hich of the follo'ing 'ill %e most difficult for this client? A) Com$liance 'ith treatment regimens B) @oo/ing different from their $eers

C) @ac/ing inde$endence in activities ") !eliance on family for their social su$$ort The correct answer is B& @oo/ing different from their $eers Conformity to $eer influences $ea/s at around age 10. -ince many $ersons vie' any disa%ility as deviant) the client 'ill need hel$ in learning ho' to deal 'ith reactions of others. Treatment of scoliosis is long-term and involves %racing andEor surgery. ++. The nurse is $re$aring to $erform a $hysical e*amination on an 6 month-old 'ho is sitting contentedly on his mother;s la$. Which of the follo'ing should the nurse do first? A) =licit refle*es B) .easure height and 'eight C) Auscultate heart and lungs ") =*amine the ears The correct answer is C: Auscultate heart and lungs The nurse should auscultate the heart and lungs during the first 1uiet moment 'ith the infant so as to %e a%le to hear sounds clearly. 2ther assessments may follo' in any order. +3. Which of these $rinci$les should the nurse a$$ly 'hen $erforming a nutritional assessment on a + year-old client? A) An accurate measurement of inta/e is not relia%le B) The food $yramid is not used in this age grou$ C) A serving size at this age is a%out + ta%les$oons ") Total inta/e varies greatly each day The correct answer is C: A serving size at this age is a%out + ta%les$oons (n children) a general guide to serving sizes is 1 ta%les$oon of solid food $er year of age. <nderstanding this) the nurse can assess ade1uacy of inta/e. +0. The nurse is assessing a client 'ith delayed 'ound healing. Which of the follo'ing ris/ factors is most im$ortant in this situation? A) #lucose level of 1+4 B) ?istory of myocardial infarction C) @ong term steroid usage ") "iet high in car%ohydrates The correct answer is C: @ong term steroid usage -teroid de$endency tends to delay 'ound healing. (f the client also smo/es) the ris/ is increased. +3. Which of the follo'ing nursing assessments indicate immediate discontinuance of an anti$sychotic medication? A) (nvoluntary rhythmic stereoty$ic movements and tongue $rotrusion B) Chee/ $uffing) involuntary movements of e*tremities and trun/ C) Agitation) constant state of motion ") ?y$er$yre*ia) severe muscle rigidity) malignant hy$ertension

The correct answer is D: ?y$er$yre*ia) severe muscle rigidity) malignant hy$ertension) hy$er$yre*ia) sever muscle rigidity) and malignant hy$ertension are assessment signs indicative of B.- 7neurole$tic malignant syndrome). +5. A client 'ith ?(8 infection has a secondary her$es sim$le* ty$e 1 7?-8-1) infection. The nurse /no's that the most li/ely cause of the ?-8-1 infection in this client is A) (mmunosu$$ression B) =motional stress C) <n$rotected se*ual activities ") Contact 'ith saliva The correct answer is A: (mmunosu$$ression The decreased immunity leads to fre1uent secondary infections. ?er$es sim$le* virus ty$e 1 is an o$$ortunistic infection. The other o$tions may result in ?-8-1. ?o'ever they are not the most li/ely cause in clients 'ith ?(8. +9. The nurse measures the head and chest circumferences of a +4 month-old infant. After com$aring the measurements) the nurse finds that they are a$$ro*imately the same. What action should the nurse ta/e? A) Botify the health care $rovider B) al$ate the anterior fontanel C) :eel the $osterior fontanel ") !ecord these normal findings The correct answer is D: !ecord these normal findings The 1uestion is ". The rate of increase in head circumference slo's %y the end of infancy) and the head circumference is usually e1ual to chest circumference at 1 to + years of age. +6. At a routine clinic visit) $arents e*$ress concern that their 0 year-old is 'etting the %ed several times a month. What is the nurse;s %est res$onse? A) AThis is normal at this time of day.A B) A?o' long has this %een occurring?A C) A"o you offer fluids at night?A ") A?ave you tried 'a/ing her to urinate?A The correct answer is B& A?o' long has this %een occurring?A Bighttime control should %e $resent %y this age) %ut may not occur until age 3. (nvoluntary voiding may occur due to infectious) anatomical andEor $hysiological reasons. +>. A client 'as admitted to the $sychiatric unit after refusing to get out of %ed. (n the hos$ital the client tal/s to unseen $eo$le and voids on the floor. The nurse could %est handle the $ro%lem of voiding on the floor %y A) !e1uiring the client to mo$ the floor B) !estricting the clientDs fluids throughout the day C) Withholding $rivileges each time the voiding occurs ") Toileting the client more fre1uently 'ith su$ervision

The correct answer is D: Toileting the client more fre1uently 'ith su$ervision With altered thought $rocesses the most a$$ro$riate nursing a$$roach to alter the %ehavior is %y attending to the $hysical need. 34. The nurse is caring for a client 'ith a sigmoid colostomy 'ho re1uests assistance in removing the flatus from a 1 $iece draina%le ostomy $ouch. Which is the correct intervention? A) iercing the $lastic of the ostomy $ouch 'ith a $in to vent the flatus B) 2$ening the %ottom of the $ouch) allo'ing the flatus to %e e*$elled C) ulling the adhesive seal around the ostomy $ouch to allo' the flatus to esca$e ") Assisting the client to am%ulate to reduce the flatus in the $ouch The correct answer is B& 2$ening the %ottom of the $ouch) allo'ing the flatus to %e e*$elled. The only correct 'ay to vent the flatus from a 1 $iece draina%le ostomy $ouch is to instruct the client to o%tain $rivacy 7the release of the flatus 'ill cause odor)) and to o$en the %ottom of the $ouch) release the flatus and dose the %ottom of the $ouch. 31. The nurse is teaching $arents of an infant a%out introduction of solid food to their %a%y. What is the first food they can add to the diet? A) 8egeta%les B) Cereal C) :ruit ") .eats The correct answer is B: Cereal Cereal is usually introduced first %ecause it is 'ell tolerated) easy to digest) and contains iron. 3+. When counseling $arents of a child 'ho has recently %een diagnosed 'ith hemo$hilia) 'hat must the nurse /no' a%out the offs$ring of a normal father and a carrier mother? A) (t is li/ely that all sons are affected B) There is a 34F $ro%a%ility that sons 'ill have the disease C) =very daughter is li/ely to %e a carrier ") There is a +3F chance a daughter 'ill %e a carrier The correct answer is D: There is a +3F chance a daughter 'ill %e a carrier ?emo$hilia A is a se*-lin/ed recessive trait seen almost e*clusively in males. With a normal father and carrier mother) affected individuals are male. There is a +3F chance of having an affected male) +3F chance of having a carrier female) +3F chance of having a normal female and +3F chance of having a normal male. 33. When teaching a client 'ith chronic o%structive $ulmonary disease a%out o*ygen %y cannula) the nurse should also instruct the client;s family to A) Avoid smo/ing near the client B) Turn off o*ygen during meals C) Ad,ust the liter flo' to 14 as needed

") !emind the client to /ee$ mouth closed The correct answer is A& Avoid smo/ing near the client -ince o*ygen su$$orts com%ustion) there is a ris/ of fire if anyone smo/es near the o*ygen e1ui$ment. 30. The nurse is caring for a $ost-o$ colostomy client. The client %egins to cry saying) A(;ll never %e attractive again 'ith this ugly red thing.A What should %e the first action %y the nurse? A) Arrange a consultation 'ith a se* thera$ist B) -uggest se*ual $ositions that hide the colostomy C) (nvite the $artner to $artici$ate in colostomy care ") "etermine the client;s understanding of her colostomy The correct answer is D: "etermine the client;;s understanding of her colostomy. 2ne of the greatest fears of colostomy clients is the fear that se*ual intimacy is no longer $ossi%le. ?o'ever) the s$ecific concern of the client needs to %e assessed %efore s$ecific suggestions for dealing 'ith the se*ual concerns are given. 33. A schizo$hrenic client tal/s animatedly %ut the staff are una%le to understand 'hat the client is communicating. The client is o%served mum%ling to herself and s$ea/ing to the radio. A desira%le outcome for this clientDs care 'ill %e A) =*$resses feelings a$$ro$riately through ver%al interactions B) Accurately inter$rets events and %ehaviors of others C) "emonstrates im$roved social relationshi$s ") =ngages in meaningful and understanda%le ver%al communication The correct answer is D: =ngages in meaningful and understanda%le ver%al communication. "ata su$$ort im$aired ver%al communication deficit. The outcome must %e related to the diagnosis and su$$orting data. Bo data is $resented related to feelings or to thin/ing $rocesses. 35. A 9 year-old child is hos$italized follo'ing a ma,or %urn to the lo'er e*tremities. A diet high in $rotein and car%ohydrates is recommended. The nurse informs the child and family that the most im$ortant reason for this diet is to A) romote healing and strengthen the immune system B) rovide a 'ell %alanced nutritional inta/e C) -timulate increased $eristalsis a%sor$tion ") -$are $rotein cata%olism to meet meta%olic needs The correct answer is D& -$are $rotein cata%olism to meet meta%olic needs Because of the %urn in,ury) the child has increased meta%olism and cata%olism. By $roviding a high car%ohydrate diet) the %rea/do'n of $rotein for energy is avoided. roteins are then used to restore tissue.

39. The $arents of a 9 year-old tell the nurse their child has started to AtattleA on si%lings. (n inter$reting this ne' %ehavior) ho' should the nurse e*$lain the child;s actions to the $arents? A) The ethical sense and feelings of ,ustice are develo$ing B) Attem$ts to control the family use ne' co$ing styles C) (nsecurity and attention getting are common motives ") Com$le* thought $rocesses hel$ to resolve conflicts The correct answer is A: The ethical sense and feelings of ,ustice are develo$ing. The child is develo$ing a sense of ,ustice and a desire to do 'hat is right. At seven) the child is increasingly a'are of family roles and res$onsi%ilities. They also do 'hat is right %ecause of $arental direction or to avoid $unishment. 36. A school nurse is advising a class of un'ed $regnant high school students. What is the most im$ortant action they can $erform to deliver a healthy child? A) .aintain good nutrition B) -tay in school C) Gee$ in contact 'ith the child;s father ") #et ade1uate slee$ The correct answer is A& .aintaining good nutrition Burses can serve a $ivotal role in $roviding nutritional education and case management interventions. Weight gain during $regnancy is one of the strongest $redictors of infant %irth 'eight. -$ecifically) teens need to increase their inta/e of $rotein) vitamins) and minerals including iron. regnant teens 'ho gain %et'een +5 and 33 $ounds have the lo'est incidence of lo'-%irth-'eight %a%ies. 3>. A client continually re$eats $hrases that others have ,ust said. The nurse recognizes this %ehavior as A) Autistic B) =co$ra*ic C) =cholalic ") Catatonic The correct answer is C& =cholalic =cholalic - re$eating 'ords heard. 04. A client is admitted for hemodialysis. Which a%normal la% value 'ould the nurse antici$ate not %eing im$roved %y hemodialysis? A) @o' hemoglo%in B) ?y$ernatremia C) ?igh serum creatinine ") ?y$er/alemia The correct answer is A: @o' hemoglo%in Although hemodialysis im$roves or corrects electrolyte im%alances it has not effect on im$roving anemia.

01. The nurse is caring for a 9 year-old child 'ho is %eing discharged follo'ing a tonsillectomy. Which of the follo'ing instructions is a$$ro$riate for the nurse to teach the $arents? A) !e$ort a $ersistent cough to the health care $rovider B) The child can return to school in 0 days C) Administer che'a%le as$irin for $ain ") The child may gargle 'ith saline as necessary for discomfort The correct answer is A& !e$ort a $ersistent cough to the health care $rovider. ersistent coughing should %e re$orted to the health care $rovider as this may indicate %leeding. 0+. The nurse is caring for a 10 month-old ,ust diagnosed 'ith Cystic :i%rosis. The $arents state this is the first child in either family 'ith this disease) and as/ a%out the ris/ to future children. What is the %est res$onse %y the nurse? A) 1in 0 chance for each child to carry that trait B) 1in 0 ris/ for each child to have the disease C) 1in + chance of avoiding the trait and disease ") 1in + chance that each child 'ill have the disease The correct answer is B: 1 in 0 ris/ for each child to have the disease Cystic :i%rosis is an autosomal recessive transmission $attern. (n this situation) %oth $arents must %e carriers of the trait for the disease since neither one of them has the disease. Therefore) for each $regnancy) there is a +3F chance of the child having the disease) 34F chance of carrying the trait and a +3F chance of having neither the trait or the disease. 03. The nurse is $erforming an assessment on a client 'ith $neumococcal $neumonia. Which finding 'ould the nurse antici$ate? A) Bronchial %reath sounds in outer lung fields B) "ecreased tactile fremitus C) ?ac/ing) non$roductive cough ") ?y$erresonance of areas of consolidation The correct answer is A: Bronchial %reath sounds in outer lung fields neumonia causes a mar/ed increase in interstitial and alveolar fluid. Consolidated lung tissue transmits %ronchial %reath sounds to outer lung fields. 00. "uring seizure activity 'hich o%servation is the $riority to enhance further direction of treatment? A) 2%serve the se1uence or ty$es of movement B) Bote the time from %eginning to end C) (dentify the $attern of %reathing ") "etermine if loss of %o'el or %ladder control occurs The correct answer is A& rotect the client from in,ury

(t is a $riority to note) and then record) 'hat movements are seen during a seizure %ecause the diagnosis and su%se1uent treatment often rests solely on the seizure descri$tion. 03. Which of the follo'ing statements descri%es 'hat the nurse must /no' in order to $rovide antici$atory guidance to $arents of a toddler a%out readiness for toilet training? A) The child learns voluntary s$hincter control through re$etition B) .yelination of the s$inal cord is com$leted %y this age C) Beuronal im$ulses are interru$ted at the %ase of the ganglia ") The toddler can understand cause and effect The correct answer is B& .yelination of the s$inal cord is com$leted %y this age. 8oluntary control of the s$hincter muscles can %e gradually achieved due to the com$lete myelination of the s$inal cord) sometime %et'een the ages of 16 to +0 months of age. 05. A client com$laining of severe shortness of %reath is diagnosed 'ith congestive heart failure. The nurse o%serves a falling $ulse o*imetry. The client;s color changes to gray and she e*$ectorates large amounts of $in/ frothy s$utum. The first action of the nurse 'ould %e 'hich of the follo'ing? A) Call the health care $rovider B) Chec/ vital signs C) osition in high :o'ler;s ") Administer o*ygen The correct answer is D& Administer o*ygen When dealing 'ith a medical emergency) the rule is air'ay first) then %reathing) and then circulation. -tarting o*ygen is a $riority. 09. The nurse is caring for a client 'ith %enign $rostatic hy$ertro$hy. Which of the follo'ing assessments 'ould the nurse antici$ate finding? A) @arge volume of urinary out$ut 'ith each voiding B) (nvoluntary voiding 'ith coughing and sneezing C) :re1uent urination ") <rine is dar/ and concentrated The correct answer is C: :re1uent urination Clients 'ith Benign rostatic ?y$ertro$hy have overflo' incontinence 'ith fre1uent urination in small amounts day and night. 06. An an*ious $arent of a 0 year-old consults the nurse for guidance in ho' to ans'er the child;s 1uestion) AWhere do %a%ies come from?A What is the nurse;s %est res$onse to the $arent? A) AWhen a child as/s a 1uestion) give a sim$le ans'er.A B) AChildren as/ many 1uestions) %ut are not loo/ing for ans'ers.A C) AThis 1uestion indicates interest in se* %eyond this age.A ") A:ull and detailed ans'ers should %e given to all 1uestions.A

The correct answer is A: AWhen a child as/s a 1uestion) give a sim$le ans'er.A "uring discussions related to se*uality) honesty is very im$ortant. ?o'ever) honesty does not mean im$arting every fact of life associated 'ith the 1uestion. When children as/ 1 1uestion) they are loo/ing for 1 ans'er. When they are ready) they 'ill as/ a%out the other $ieces. 0>. A 3 year-old child is treated in the emergency de$artment after ingestion of 1ounce of a li1uid narcotic. What action should the nurse do first? A) rovide the ordered humidified o*ygen via mas/ B) -uction the mouth and the nose C) Chec/ the mouth and radial $ulse ") -tart the ordered intravenous fluids The correct answer is C: Chec/ the mouth and radial $ulse The first ste$ in treatment of a to*ic e*$osure or ingestion is to assess the air'ay) %reathing and circulationH then sta%ilize the client. The other nursing actions 'ill follo'. 34. The charge nurse on the eating disorder unit instructs a ne' staff mem%er to 'eigh each client in his or her hos$ital go'n only. What is the rationale for this nursing intervention? A) To reduce the ris/ of the client feeling cold due to decreased fat and su%cutaneous tissue B) To cover the %ony $rominence and areas 'here there is s/in %rea/do'n C) -o the client /no's 'hat ty$e of clothing to 'ear 'hen 'eighed ") To reduce the tendency of the client to hide o%,ects under his or her clothing The correct answer is D& To reduce the tendency of the client to hide o%,ects under his or her clothing. The client may conceal 'eights on their %ody to increase 'eight gain. 31. (n teaching $arents to associate $revention 'ith the lifestyle of their child 'ith sic/le cell disease) the nurse should em$hasize that a $riority for their child is to A) Avoid overheating during $hysical activities B) .aintain normal activity 'ith some restrictions C) Be cautious of others 'ith viruses or tem$eratures ") .aintain routine immunizations The correct answer is A: Avoid overheating :luid loss caused %y overheating and dehydration can trigger a crisis. 3+. The nurse understands that during the Atension %uildingA $hase of a violent relationshi$) 'hen the %atterer ma/es unreasona%le demands) the %attered victim may e*$erience feelings of A) Anger B) ?el$lessness C) Calm ") =*$losive The correct answer is B: ?el$lessness

The %attered individual internalizes a$$ro$riate anger at the %attererDs unfairness and instead feels de$ressed 'ith a sense of hel$lessness) 'hen the $artner e*$lodes in s$ite of %est efforts to $lease the %atterer. 33. A $arent has numerous 1uestions regarding normal gro'th and develo$ment of a 14 month-old infant. Which of the follo'ing $arameters is of most concern to the nurse? A) 34F increase in %irth 'eight B) ?ead circumference greater than chest C) Crying 'hen the $arents leave ") A%le to stand u$ %riefly in $lay $en The correct answer is A: 34F increase in %irth 'eight Birth 'eight should %e dou%led at 5 months of age) tri$led at 1 year) and 1uadru$led %y 16 months. 30. The nurse has %een assigned to these clients in the emergency room. Which client 'ould the nurse go chec/ first? A) 8iral $neumonia 'ith atelectasis B) -$ontaneous $neumothora* 'ith a res$iratory rate of 36 C) Tension $neumothora* 'ith slight tracheal deviation to the right ") Acute asthma 'ith e$isodes of %ronchos$asm The correct answer is C& Tension $neumothora* 'ith slight tracheal deviation to the right. Tracheal deviation indicates a significant volume of air %eing tra$$ed in the chest cavity 'ith a mediastinal shift. (n tension $neumothora* the tracheal deviation is a'ay from the affected side. The affected side is the side 'here the air lea/ is in the lung. This situation also results in sudden air hunger) agitation) hy$otension) $ain in the affected side) and cyanosis 'ith a high ris/ of cardiac tam$onade and cardiac arrest. 33. The nurse is assessing a 0 year-old for $ossi%le develo$mental dys$lasia of the right hi$. Which finding 'ould the nurse e*$ect? A) elvic ti$ do'n'ard B) !ight leg lengthening C) 2rtolani sign ") Characteristic lim$ The correct answer is D& Characteristic lim$ "evelo$mental dys$lasia $roduces a characteristic lim$ in children 'ho are 'al/ing. 35. A + year-old child has recently %een diagnosed 'ith cystic fi%rosis. The nurse is teaching the $arents a%out home care for the child. Which of the follo'ing information is a$$ro$riate for the nurse to include? A) Allo' the child to continue normal activities B) -chedule fre1uent rest $eriods C) @imit e*$osure to other children ") !estrict activities to inside the house

The correct answer is A& Allo' the child to continue their normal activities hysical activity is im$ortant in a t'o year-old 'ho is develo$ing autonomy. hysical activity is a valua%le ad,unct to chest $hysical thera$y. =*ercise tends to stimulate mucous secretion and hel$ develo$ normal %reathing $atterns. 39. The nurses on a unit are $lanning for stoma care for clients 'ho have a stoma for fecal diversion. Which stomal diversion $oses the highest ris/ for s/in %rea/do'n A) (leostomy B) Transverse colostomy C) (leal conduit ") -igmoid colostomy The correct answer is A& (leostomy (leostomy out$ut contains gastric and enzymatic agents that 'hen $resent on s/in can denuded s/in in several hours. Because of the caustic nature of this stoma out$ut ade1uate $eristomal s/in $rotection must %e delivered to $revent s/in %rea/do'n. 36. A client is unconscious follo'ing a tonic-clonic seizure. What should the nurse do first? A) Chec/ the $ulse B) Administer 8alium C) lace the client in a side-lying $osition ") lace a tongue %lade in the mouth The correct answer is C& lace the client in a side-lying $osition lace the client in a side-lying $osition to maintain an o$en air'ay) drain secretions) and $revent as$iration if vomiting occurs. 3>. The nurse is teaching a client 'ho has a hi$ $rostheses follo'ing total hi$ re$lacement. Which of the follo'ing should %e included in the instructions for home care? A) Avoid clim%ing stairs for 3 months B) Am%ulate using crutches only C) -lee$ only on your %ac/ ") "o not cross legs The correct answer is D& "o not cross legs ?i$ fle*ion should not e*ceed 54 degrees. 54. A nurse 'ho travels 'ith an agency is uncertain a%out 'hat tas/s can %e $erformed 'hen 'or/ing in a different state. (t 'ould %e %est for the nurse to chec/ 'hich resource? A) The state nurse $ractice act in 'hich the assignment is made B) With a nurse colleague 'ho has 'or/ed in that state + years ago ") The Bursing -ocial olicy -tatement 'ithin the <nited -tates C) The $olicies and $rocedures of the assigned agency in that state

The correct answer is A& The state nurse $ractice act in 'hich the assignment is made. The state nurse $ractice act is the governing document of 'hat can %e done in the assigned state. 51. arents of a 9 year-old child call the clinic nurse %ecause their daughter 'as sent home from school %ecause of a rash. The child had %een seen the day %efore %y the health care $rovider and diagnosed 'ith :ifth "isease 7erythema infectiosum). What is the most a$$ro$riate action %y the nurse? A) Tell the $arents to %ring the child to the clinic for further evaluation B) !efer the school officials to $rinted materials a%out this viral illness C) (nform the teacher that the child is receiving anti%iotics for the rash ") =*$lain that this rash is not contagious and does not re1uire isolation The correct answer is D& =*$lain that this rash is not contagious and does not re1uire isolation. :ifth "isease is a viral illness 'ith an uncertain $eriod of communica%ility 7$erha$s 1 'ee/ $rior to and 1 'ee/ after onset). (solation of the child 'ith :ifth "isease is not necessary e*ce$t in cases of hos$italized children 'ho are immunosu$$ressed or having a$lastic crises. The $arents may need 'ritten confirmation of this from the health care $rovider. 5+. What $rinci$le of ?(8 disease should the nurse /ee$ in mind 'hen $lanning care for a ne'%orn 'ho 'as infected in utero? A) The disease 'ill incu%ate longer and $rogress more slo'ly in this infant B) The infant is very susce$ti%le to infections C) #ro'th and develo$ment $atterns 'ill $roceed at a normal rate ") Careful monitoring of renal function is indicated The correct answer is B& The infant is very susce$ti%le to infections ?(8 infected children are susce$ti%le to o$$ortunistic infections due to a com$romised immune system. 53. While teaching a client a%out their medications) the client as/s ho' long it 'ill ta/e %efore the effects of lithium ta/e $lace. What is the %est res$onse of the nurse? A) (mmediately B) -everal days C) + 'ee/s ") 1 month The correct answer is C& + 'ee/s @ithium is started immediately to treat %i$olar disorder %ecause it is 1uite effective in controlling mania. @ithium ta/es a$$ro*imately + 'ee/s to effect change in a clientDs sym$toms. 50. The nurse is caring for a 1+ year-old 'ith an acute illness. Which of the follo'ing indicates the nurse understands common si%ling reactions to hos$italization? A) Counger si%lings ada$t very 'ell B) 8isitation is hel$ful for %oth C) The si%lings may en,oy $rivacy

") Those cared for at home co$e %etter The correct answer is B& 8isitation is hel$ful for %oth Contact 'ith the ill child hel$s si%lings understand the reasons for hos$italization and maintains the relationshi$. 53. :ollo'ing a cocaine high) the user commonly e*$eriences an e*tremely un$leasant feeling called A) Craving B) Crashing C) 2ut'ard %ound ") Bodding out The correct answer is B: Crashing :ollo'ing cocaine use) the intense $leasure is re$laced %y an e1ually un$leasant feeling referred to as crashing. 55. 2ne reason that domestic violence remains e*tensively undetected is A) :e' %attered victims see/ medical care B) There is ty$ically a series of minor) vague com$laints C) =*$enses due to $olice and court costs are $rohi%itive ") 8ery little /no'ledge is currently /no'n a%out %atterers and %attering relationshi$s The correct answer is B: There is ty$ically a series of minor) vague com$laints. -igns of a%use may not %e clearly manifested and a series a minor com$laints such as headache) a%dominal $ain) insomnia) %ac/ $ain) and dizziness may %e covert indications of a%use undetected. Com$laints may %e vague. 59. When ma/ing a home visit to a client 'ith chronic $yelone$hritis) 'hich nursing action has the highest $riority? A) :ollo'-u$ on la% values %efore the visit B) 2%serve client findings for the effectiveness of anti%iotics C) As/ for a log of urinary out$ut ") As for the log of the oral inta/e The correct answer is C& As/ for a log of urinary out$ut The nurse must monitor the urine out$ut as a $riority %ecause it is the %est indictor of renal function. The other o$tions 'ould %e done after an evaluation of the urine out$ut. 56. When a client is having a general tonic clonic seizure) the nurse should A) ?old the client;s arms at their side B) lace the client on their side C) (nsert a $added tongue %lade in client;s mouth ") =levate the head of the %ed The correct answer is B& lace the client on their side This $osition /ee$s the air'ay $atent and $revents as$iration.

5>. The nurse is teaching a client 'ith dysrhythmia a%out the electrical $ath'ay of an im$ulse as it travels through the heart. Which of these demonstrates the normal $ath'ay? A) A8 node) -A node) Bundle of ?is) ur/in,e fi%ers B) ur/in,e fi%ers) -A node) A8 node) Bundle of ?is C) Bundle of ?is) ur/in,e fi%ers) -A node ) A8 node ") -A node) A8 node) Bundle of ?is) ur/in,e fi%ers The correct answer is D& -A node) A8 node) Bundle of ?is) ur/in,e fi%ers The $ath'ay of a normal electrical im$ulse through the heart is& -A node) A8 node) Bundle of ?is) ur/in,e fi%ers. 94. Clients 'ith mitral stenosis 'ould li/ely manifest findings associated 'ith congestion in the A) ulmonary circulation B) "escending aorta C) -u$erior vena cava ") Bundle of ?is The correct answer is A: ulmonary circulation Congestion occurs in the $ulmonary circulation due to the inefficient em$tying of the left ventricle and the lac/ of a com$etent valve to $revent %ac/ flo' into the $ulmonary vein. 91. (n assessing the healing of a client;s 'ound during a home visit) 'hich of the follo'ing is the %est indicator of good healing? A) White $atches B) #reen drainage C) !eddened tissue ") =schar develo$ment The correct answer is C: !eddened tissue As the 'ound granulates) redness indicates healing. 9+. The nursing intervention that %est descri%es treatment to deal 'ith the %ehaviors of clients 'ith $ersonality disorders include A) ointing out inconsistencies in s$eech $atterns to correct thought disorders B) Acce$ting client and the client;s %ehavior unconditionally C) =ncouraging de$endency in order to develo$ ego controls ") Consistent limit-setting enforced +0 hours $er day The correct answer is D& Consistent limit-setting enforced +0 hours $er day Treatment a$$roaches that include restructuring the $ersonality) assisting the $erson 'ith develo$mental level and setting limits for malada$tive %ehavior such as acting out. 93. A client has received her first dose of flu$henazine 7 roli*in) + hours ago. -he suddenly e*$eriences torticollis and involuntary s$astic muscle movement. (n addition to administering the ordered anticholinergic drug) 'hat other measure should the nurse im$lement? A) ?ave res$iratory su$$ort e1ui$ment availa%le

B) (mmediately $lace her in the seclusion room C) Assess the client for an*iety and agitation ") Administer $rn dose of (. anti$sychotic medication The correct answer is A& ?ave res$iratory su$$ort e1ui$ment availa%le ersons receiving neurole$tic medication e*$eriencing torticollis and involuntary muscle movement are demonstrating side effects that could lead to res$iratory failure. 90. The nurse as/s a client 'ith a history of alcoholism a%out the clientDs drin/ing %ehavior. The client states A( didnDt hurt anyone. ( ,ust li/e to have a good time) and drin/ing hel$s me to rela*.A The client is using 'hich defense mechanism? A) "enial B) ro,ection C) (ntellectualization ") !ationalization The correct answer is D& !ationalization !ationalization is ,ustifying illogical or unreasona%le ideas) actions) or feelings %y develo$ing acce$ta%le e*$lanations that satisfies the teller as 'ell as the listener. 93. The nurse is teaching a smo/ing cessation class and notices there are + $regnant 'omen in the grou$. Which information is a $riority for these 'omen? A) @o' tar cigarettes are less harmful during $regnancy B) There is a relationshi$ %et'een smo/ing and lo' %irth 'eight C) The $lacenta serves as a %arrier to nicotine ") .oderate smo/ing is effective in 'eight control The correct answer is B& There is a relationshi$ %et'een smo/ing and lo' %irth 'eight. Bicotine reduces $lacental %lood flo') and may contri%ute to fetal hy$o*ia or $lacenta $revia) decreasing the gro'th $otential of the fetus. 95. The nurse is caring for a client 'ith end stage renal disease. What action should the nurse ta/e to assess for $atency in a fistula used for hemodialysis? A) 2%serve for edema $ro*imal to the site B) (rrigate 'ith 3 mls of 4.>F Bormal -aline C) al$ate for a thrill over the fistula ") Chec/ color and 'armth in the e*tremity The correct answer is C& al$ate for a thrill over the fistula To assess for $atency in a fistula or graft) the nurse auscultates for a %ruit and $al$ates for a thrill. 2ther o$tions are not related to evaluation for $atency. 99. Which thera$eutic communication s/ill is most li/ely to encourage a de$ressed client to vent feelings? A) "irect confrontation B) !eality orientation C) ro,ective identification ") Active listening

The correct answer is D& Active listening <se of thera$eutic communication s/ills such as silence and active listening encourages ver%alization of feelings. 96. The nurse 'al/s into a client;s room and finds the client lying still and silent on the floor. The nurse should first A) Assess the client;s air'ay B) Call for hel$ C) =sta%lish that the client is unres$onsive ") -ee if anyone sa' the client fall The correct answer is C& =sta%lish that the client is unres$onsive The first ste$ in C ! is to esta%lish unres$onsiveness. -econd is to call for hel$. Third is o$ening the air'ay. 9>. What is the %est 'ay for the nurse to accom$lish a health history on a 10 year-old client? A) ?ave the mother $resent to verify information B) Allo' an o$$ortunity for the teen to e*$ress feelings C) <se the same ty$e of language as the adolescent ") :ocus the discussion of ris/ factors in the $eer grou$ The correct answer is B& Allo' an o$$ortunity for the teen to e*$ress feelings Adolescents need to e*$ress their feelings. #enerally) they tal/ freely 'hen given an o$$ortunity and some $rivacy to do so. 64. A ne' nurse on the unit notes that the nurse manager seems to %e highly res$ected %y the nursing staff. The ne' nurse is sur$rised 'hen one of the nurses states& AThe manager ma/es all decisions and rarely as/s for our in$ut.A The %est descri$tion of the nurse manager;s management style is A) artici$ative or democratic B) <ltrali%eral or communicative C) Autocratic or authoritarian ") @aissez faire or $ermissive The correct answer is C& Autocratic or authoritarian Autocratic leadershi$ style is suggested in this situation. (t is a$$ro$riate for grou$s 'ith little education and e*$erience and 'ho need strong direction) 'hile $artici$ative or democratic style is usually more successful on nursing units. 61. A + year-old child is %eing treated 'ith Amo*icillin sus$ension) +44 milligrams $er dose) for acute otitis media. The child 'eighs 34 l%. 713 /g) and the daily dose range is +4-04 mgE/g of %ody 'eight) in three divided doses every 6 hours. <sing $rinci$les of safe drug administration) 'hat should the nurse do ne*t? A) #ive the medication as ordered B) Call the health care $rovider to clarify the dose C) !ecognize that anti%iotics are over-$rescri%ed

") ?old the medication as the dosage is too lo' The correct answer is A: #ive the medication as ordered Amo*icillin continues to %e the drug of choice in the treatment of acute otitis media. The dose range is +4-04 mgE/gEday divided every 6 hours. 13/g * 04mg I 544mg) divided %y 3 I +44 mg $er dose. The $rescri%ed dose is correct and should %e given as ordered. 6+. The nurse is $erforming a develo$mental assessment on an 6 month-old. Which finding should %e re$orted to the health care $rovider? A) @ifts head from the $rone $osition B) !olls from a%domen to %ac/ C) !es$onds to $arents; voices ") :alls for'ard 'hen sitting The correct answer is D& :alls for'ard 'hen sitting -itting 'ithout su$$ort is e*$ected at this age. 63. The nurse is $artici$ating in a community health fair. As $art of the assessments) the nurse should conduct a mental status e*amination 'hen A) An individual dis$lays restlessness B) There are o%vious signs of de$ression C) Conducting any health assessment ") The resident re$orts memory la$ses The correct answer is C& Conducting any health assessment A mental status assessment is a critical $art of %aseline information) and should %e a $art of every e*amination. 60. The nurse caring for a 10 year-old %oy 'ith severe ?emo$hilia A) 'ho 'as admitted after a fall 'hile $laying %as/et%all. (n understanding his %ehavior and in $lanning care for this client) 'hat must the nurse understand a%out adolescents 'ith hemo$hilia? A) .ust have structured activities B) 2ften ta/e $art in active s$orts C) =*$lain limitations to $eer grou$s ") Avoid ris/s after %leeding e$isodes The correct answer is B& 2ften ta/e $art in active s$orts =sta%lish an age-a$$ro$riate safe environment. Adolescent hemo$hiliacs should %e a'are that contact s$orts may trigger %leeding. ?o'ever) develo$mental characteristics of this age grou$ such as im$ulsivity) ine*$erience and $eer $ressure) $lace adolescents in unsafe environments. 63. When assessing a client 'ho has ,ust undergone a cardioversion) the nurse finds the res$irations are 1+. Which action should the nurse ta/e first? A) Try to vigorously stimulate normal %reathing B) As/ the !B to assess the vital signs C) .easure the $ulse o*imetry ") Continue to monitor res$irations

The correct answer is D& 0. Continue to monitor res$irations 1+ res$irations $er minute is tolerated $ost-o$eratively. A range from 6 to 14 gives cause for concern. At that $oint $ulse o*imetry is ta/en) as that rate could %e tolerated. 8igorous stimulation is not indicated %eyond dee$ %reathing and coughing. (t is not necessary to as/ the !B to chec/ findings. 65. (n order to enhance a client;s res$onse to medication for chest $ain from acute angina) the nurse should em$hasize A) @earning rela*ation techni1ues B) @imiting alcohol use C) =ating smaller meals ") Avoiding $assive smo/e The correct answer is A& @earning rela*ation techni1ues The only factor that can enhance the client;;s res$onse to $ain medication for angina is reducing an*iety through rela*ation methods. An*iety can %e great enough to ma/e the $ain medication totally ineffective. 69. The $rimary nursing diagnosis for a client 'ith congestive heart failure 'ith $ulmonary edema is A) ain B) (m$aired gas e*change C) Cardiac out$ut altered& decreased ") :luid volume e*cess The correct answer is C& Cardiac out$ut altered& decreased All nursing interventions should %e focused on im$roving cardiac out$ut. (ncreasing cardiac out$ut is the $rimary goal of thera$y. Comfort 'ill im$rove as the client im$roves and the res$iratory status 'ill im$rove as cardiac out$ut increases. 66. After tal/ing 'ith her $artner) a client voluntarily admitted herself to the su%stance a%use unit. After the second day on the unit the client states to the nurse) A.y hus%and told me to get treatment or he 'ould divorce me. ( donDt %elieve ( really need treatment %ut ( donDt 'ant my hus%and to leave me.A Which res$onse %y the nurse 'ould assist the client? A) A(n early recovery) it;s 1uite common to have mi*ed feelings) %ut unmotivated $eo$le canDt get 'ell.A B) A(n early recovery) itDs 1uite common to have mi*ed feelings) %ut ( didnDt /no' you had %een $ressured to come.A C) A(n early recovery itDs 1uite common to have mi*ed feelings) $erha$s it 'ould %e %est to see/ treatment on an outclient %ases.A ") A(n early recovery) itDs 1uite common to have mi*ed feelings. @etDs discuss the %enefits of so%riety for you.A The correct answer is D& A(n early recovery) itDs 1uite common to have mi*ed feelings. @etDs discuss the %enefits of so%riety for you.A This res$onse gives the client the

o$$ortunity to decrease am%ivalent feelings %y focusing on the %enefits of so%riety. "e$endence issues are great for the client fostering am%ivalence. 6>. Clients ta/ing 'hich of the follo'ing drugs are at ris/ for de$ression? A) -teroids B) "iuretics C) :olic acid ") As$irin The correct answer is A: -teroids Adverse medication effects can cause a syndrome that may or may not remit 'hen the medication is discontinued. =*am$les include& $henothiazines) steroids) and reser$ine. >4. The nurse is assessing a client on admission to a community mental health center. The client discloses that she has %een thin/ing a%out ending her life. The nurse;s %est res$onse 'ould %e A) A"o you 'ant to discuss this 'ith your $astor?A B) AWe 'ill hel$ you deal 'ith those thoughts.A C) A(s your life so terri%le that you 'ant to end it?A ") A?ave you thought a%out ho' you 'ould do it?A The correct answer is D& A?ave you thought a%out ho' you 'ould do it?A This res$onse $rovides an o$ening to discuss intent and means of committing suicide. >1. The nurse is caring for a client + hours after a right lo'er lo%ectomy. "uring the evaluation of the 'ater-seal chest drainage system) it is noted that the fluid level %u%%les constantly in the 'ater seal cham%er. 2n ins$ection of the chest dressing and tu%ing) the nurse does not find any air lea/s in the system. The ne*t %est action for the nurse is to A) Chec/ for su%cutaneous em$hysema in the u$$er torso B) !e$osition the client to a $osition of comfort C) Call the health care $rovider as soon as $ossi%le ") Chec/ for any increase in the amount of thoracic drainage The correct answer is A: Chec/ for su%cutaneous em$hysema in the u$$er torso. Continuous %u%%ling in the 'ater seal cham%er is an a%normal finding + hours after a lo%ectomy. :urther assessment of a$$ro$riate factors 'as done %y the nurse to rule out an air lea/ in the sytem. Thus the conclusion is that the $ro%lem is one of an air lea/ in the lung. This client may need to %e returned to surgery to deal 'ith the sustained air lea/. Action %y the health care $rovider is re1uired to $revent further com$lications. >+. The nurse is caring for a ne'%orn 'ho has ,ust %een diagnosed 'ith hy$os$adias. After discussing the defect 'ith the $arents) the nurse should e*$ect that A) Circumcision can %e $erformed at any time B) (nitial re$air is delayed until ages 5-6 C) ost-o$erative a$$earance 'ill %e normal ") -urgery 'ill %e $erformed in stages The correct answer is D& -urgery 'ill %e $erformed in stages

?y$os$adias) a condition in 'hich the urethral o$ening is located on the ventral surface or %elo' the $enis) is corrected in stages as soon as the infant can tolerate surgery. >3. A client has %een receiving lithium 7@ithane) for the $ast t'o 'ee/s for the treatment of %i$olar illness. When $lanning client teaching) 'hat is most im$ortant to em$hasize to the client? A) .aintain a lo' sodium diet B) Ta/e a diuretic 'ith lithium C) Come in for evaluation of serum lithium levels every 1-3 months ") ?ave %lood lithium levels dra'n during the summer months The correct answer is D: ?ave %lood lithium levels dra'n during the summer months. Clients ta/ing lithium thera$y need to %e a'are that hot 'eather may cause e*cessive $ers$iration) a loss of sodium and conse1uently an increase in serum lithium concentration. >0. When an autistic client %egins to eat 'ith her hands) the nurse can %est handle the $ro%lem %y A) lacing the s$oon in the clientDs hand and stating) A<se the s$oon to eat your food.A B) Commenting A( %elieve you /no' %etter than to eat 'ith your hand.A C) Jo/ingly stating) AWell ( guess fingers sometimes 'or/ %etter than s$oons.A ") !emoving the food and stating ACou canDt have anymore food until you use the s$oon.A The correct answer is A& lacing the s$oon in the clientDs hand and stating A<se the s$oon to eat your food.A This res$onse identifies ada$tive %ehavior 'ith instruction and ver%al e*$ectation. >3. A client develo$s volume overload from an (8 that has infused too ra$idly. What assessment 'ould the nurse e*$ect to find? A) -3 heart sound B) Thready $ulse C) :lattened nec/ veins ") ?y$oventilation The correct answer is A: Auscultation of an -3 heart sound Auscultation of an -3 heart sound. This is an early sign of volume overload 7or C?:) %ecause during the first $hase of diastole) 'hen %lood enters the ventricles) an e*tra sound is $roduced due to the $resence of fluid left in the ventricles. >5. A neonate %orn 1+ hours ago to a methadone maintained 'oman is e*hi%iting a hy$eractive .2!2 refle* and slight tremors. The ne'%orn $assed one loose) 'atery stool. Which of these is a nursing $riority? A) ?old the infant at fre1uent intervals. B) Assess for neonatal 'ithdra'l syndrome C) 2ffer fluids to $revent dehydration ") Administer $aregoric to sto$ diarrhea

The correct answer is B& Assess for neonatal 'ithdra'l syndrome Beonatal 'ithdra'l syndrome is a cluster of findings that signal the 'ithdra'al of the infant from the o$iates. The findings seen in methadone 'ithdra'al are often more severe than for other su%stances. (nitial signs are central nervous system hy$er irrita%ility and gastro-intestinal sym$toms. (f 'ithdra'al signs are severe) there is an increased mortality ris/. -coring the infant ensures $ro$er treatment during the $eriod of 'ithdra'al. >9. While $lanning care for a $reschool aged child) the nurse understands develo$mental needs. Which of the follo'ing 'ould %e of the most concern to the nurse? A) laying imaginatively B) =*$ressing shame C) (dentifying 'ith family ") =*$loring the $layroom The correct answer is B& =*$ressing shame =ri/son descri%es the stage of the $reschool child as %eing the time 'hen there is normally an increase in initiative. The child should have resolved the sense of shame and dou%t in the toddler stage. >6. A de$ressed client 'ho has recently %een acting suicidal is no' more social and energetic than usual. -milingly he tells the nurse A(Dve made some decisions a%out my life.A What should %e the nurseDs initial res$onse? A) ACouDve made some decisions.A B) AAre you thin/ing a%out /illing yourself?A C) A(Dm so glad to hear that youDve made some decisions.A ") ACou need to discuss your decisions 'ith your thera$ist.A The correct answer is B& AAre you thin/ing a%out /illing yourself?A -udden mood elevation and energy may signal increased ris/ of suicide. The nurse must validate suicide ideation as a %eginning ste$ in evaluating seriousness of ris/. >>. The nurse is caring for + children 'ho have had surgical re$air of congenital heart defects. :or 'hich defect is it a $riority to assess for findings of heart conduction distur%ance? A) Artrial se$tal defect B) atent ductus arteriosus C) Aortic stenosis ") 8entricular se$tal defect The correct answer is D& 8entricular se$tal defect While assessments for conduction distur%ance should %e included follo'ing re$air of any defect) it is a $riority for this condition. A ventricular se$tal defect is an a%normal o$ening %et'een the right and left ventricles. The atrioventricular %undle 7%undle of ?is)) a $art of the electrical conduction system of the heart) e*tends from the atrioventricular node along each side of the interventricular se$tum and then divides into right and left %undle %ranches. -urgical re$air of a ventricular se$tal defect consists of a $urse-string a$$roach or a $atch se'n over the o$ening. =ither method involves mani$ulation of the

ventricular se$tum) there%y increasing ris/ of interru$ting the conduction $ath'ay. Conse1uently) $osto$erative com$lications include conduction distur%ances. 144. The nurse is caring for a $ost myocardial infarction client in an intensive care unit. (t is noted that urinary out$ut has dro$$ed from 54 -94 ml $er hour to 34 ml $er hour. This change is most li/ely due to A) "ehydration B) "iminished %lood volume C) "ecreased cardiac out$ut ") !enal failure The correct answer is C: "ecreased cardiac out$ut Cardiac out$ut and urinary out$ut are directly correlated. The nurse should sus$ect a dro$ in cardiac out$ut if the urinary out$ut dro$s.