1.

A patient is admitted to the same

5. Client lies supine for 15 minutes

day surgery unit for liver biopsy.

following administration.

Which of the following laboratory tests

assesses coagulation? Select all that

4. The nurse is teaching a client with

apply.

polycythemia vera about potential

complications from this disease. Which

1. Partial thromboplastin time.

manifestations would the nurse

2. Prothrombin time.

include in the clients teaching plan?

3. Platelet count.

Select all that apply.

4. Hemoglobin
5. Complete Blood Count

1. Hearing loss

6. White Blood Cell Count

2. Visual disturbance
3. Headache

2. A patient is admitted to the hospital 4. Orthopnea

with suspected polycythemia vera.

5. Gout

Which of the following symptoms is

6. Weight loss

consistent with the diagnosis? Select

all that apply.

5. Which of the following would be

priority assessment data to gather

1. Weight loss.

from a client who has been diagnosed

2. Increased clotting time.

with pneumonia? Select all that apply.

3. Hypertension.
4. Headaches.

1. Auscultation of breath sounds

2. Auscultation of bowel sounds

3. The nurse is teaching the client how 3. Presence of chest pain.

to use a metered dose inhaler (MDI) to 4. Presence of peripheral edema
administer a Corticosteroid drug.

5. Color of nail beds

Which of the following client actions

indicates that he is using the MDI

6. The nurse is teaching a client who

correctly? Select all that apply.

has been diagnosed with TB how to

avoid spreading the disease to family

1. The inhaler is held upright.

members. Which statement(s) by the

2. Head is tilted down while inhaling the

client indicate(s) that he has

medication

understood the nurses instructions?

3. Client waits 5 minutes between puffs.

Select all that apply.

4. Mouth is rinsed with water following

administration

1. I will need to dispose of my old clothing

when I return home.

that apply.

2. I should always cover my mouth and

nose when sneezing.

1. Assessing the clients bowel sounds

3. It is important that I isolate myself from 2. Providing skin care following bowel
family when possible.

movements

4. I should use paper tissues to cough in

3. Evaluating the clients response to

and dispose of them properly.

antidiarrheal medications

5. I can use regular plate and utensils

4. Maintaining intake and output records

whenever I eat.

5. Obtaining the clients weight.

7. The nurse is admitting a client with 10.Which of the following nursing

hypoglycemia. Identify the signs and

diagnoses would be appropriate for a

symptoms the nurse should expect.

client withheart failure? Select all that

Select all that apply.

apply.

1. Thirst

1. Ineffective tissue perfusion related to

2. Palpitations

decreased peripheral blood flow secondary

3. Diaphoresis

to decreased cardiac output.

4. Slurred speech

2. Activity intolerance related to increased

5. Hyperventilation

cardiac output.
3. Decreased cardiac output related to

8. Which adaptations should the nurse structural and functional changes.

caring for a client with diabetic

4. Impaired gas exchange related to

ketoacidosis expect the client to

decreased sympathetic nervous system

exhibit? Select all that apply:

activity.

1. Sweating

11. When caring for a client with a

2. Low PCO2

central venous line, which of the

3. Retinopathy

following nursing actions should be

4. Acetone breath

implemented in the plan of care for

5. Elevated serum bicarbonate

chemotherapy administration? Select

all that apply.

9.When planning care for a client with

ulcerative colitis who is experiencing

1.

Verify patency of the line by the

symptoms, which client care activities presence of a blood return at regular

can the nurse appropriately delegate

intervals.

to a unlicensed assistant? Select all

2. Inspect the insertion site for swelling,

erythema, or drainage.

1.

The client functions well in other

3. Administer a cytotoxic agent to keep the areas of his life.

regimen on schedule even if blood return is 2. The degree of aggressiveness is out of
not present.

proportion to the stressor.

4. If unable to aspirate blood, reposition the 3. The violent behavior is most often
client and encourage the client to cough.

justified by the stressor.

5. Contact the health care provider about

4. The client has a history of parental

verifying placement if the status is

alcoholism and chaotic, abusive family life.

questionable.

5. The client has no remorse about the

inability to control his anger.

12. A 20-year old college student has

been brought to the psychiatric
hospital by her parents. Her admitting
diagnosis is borderline personality

14. Which of the following nursing

disorder. When talking with the

interventions are written correctly?

parents, which information would the (Select all that apply.)

nurse expect to be included in the
clients history? Select all that apply.

1. Apply continuous passive motion

machine during day.

1. Impulsiveness

2. Perform neurovascular checks.

2. Lability of mood

3. Elevate head of bed 30 degrees before

3. Ritualistic behavior

meals.

4. psychomotor retardation

4. Change dressing once a shift.

5. Self-destructive behavior
15. The nurse is monitoring a client
13. When assessing a client diagnosed receiving peritoneal dialysis and nurse
with impulse control disorder, the

notes that a clients outflow is less

nurse observes violent, aggressive,

than the inflow. Select actions that the

and assaultive behavior. Which of the nurse should take.

following assessment data is the nurse
also likely to find? Select all that

1. Place the client in good body alignment

apply.

2. Check the level of the drainage bag

3. Contact the physician

4. Check the peritoneal dialysis system for Upon assessment, the nurse notes
kinks

flushed skin, diaphoresis above the

5. Reposition the client to his or her side.

T5, and a blood pressure of 162/96.

The client reports a severe, pounding

16. The nurse is caring for a

headache. Which of the following

hospitalized client who has chronic

nursing interventions would be

renal failure. Which of the following

appropriate for this client? Select all

nursing diagnoses are most

that apply.

appropriate for this client? Select all

that apply.

1.

Elevate the HOB to 90 degrees

2. Loosen constrictive clothing

1.

Excess Fluid Volume

3. Use a fan to reduce diaphoresis

2. Imbalanced Nutrition; Less than Body

4. Assess for bladder distention and bowel

Requirements

impaction

3. Activity Intolerance

5. Administer antihypertensive medication

4. Impaired Gas Exchange

6. Place the client in a supine position with

5. Pain.

legs elevated

2.

17. The nurse is assessing a child

diagnosed with a brain tumor. Which
of the following signs and symptoms

19. The nurse is evaluating the

would the nurse expect the child to

discharge teaching for a client who

demonstrate? Select all that apply.

has an ileal conduit. Which of the

following statements indicates that

1. Head tilt

the client has correctly understood the

2. Vomiting

teaching? Select all that apply.

3. Polydipsia
4. Lethargy

1. If I limit my fluid intake I will not have to

5. Increased appetite

empty my ostomy pouch as often.

6. Increased pulse

2. I can place an aspirin tablet in my

pouch to decrease odor.

18. The nurse is caring for a client

3. I can usually keep my ostomy pouch on

with a T5 complete spinal cord injury. for 3 to 7 days before changing it.

4. I must use a skin barrier to protect my

4. Increased respirations

skin from urine.

5. I should empty my ostomy pouch of

22. A nurse is caring for a pregnant

urine when it is full.

client with severe preeclampsia who is

receiving IV magnesium sulfate.

20. A nurse is assisting in performing Select all nursing interventions that

an assessment on a client who

apply in the care for the client.

suspects that she is pregnant and is

checking the client for probable signs 1.

Monitor maternal vital signs every 2

of pregnancy. Select all probable signs hours

of pregnancy.

2. Notify the physician if respirations are

less than 18 per minute.

1.

Uterine enlargement

3. Monitor renal function and cardiac

2. Fetal heart rate detected by nonelectric function closely

device

4. Keep calcium gluconate on hand in case

3. Outline of the fetus via radiography or

of a magnesium sulfate overdose

ultrasound

5. Monitor deep tendon reflexes hourly

4. Chadwicks sign

6. Monitor I and Os hourly

5. Braxton Hicks contractions

7. Notify the physician if urinary output is

6. Ballottement

less than 30 ml per hour.

2.

21. A nurse is monitoring a pregnant

client with pregnancy induced
hypertension who is at risk for

23. When interpreting an ECG, the

Preeclampsia. The nurse checks the

nurse would keep in mind which of the

client for which specific signs of

following about the P wave? Select all

Preeclampsia (select all that apply)?

that apply.

1. Elevated blood pressure

1. Reflects electrical impulse beginning at

2. Negative urinary protein

the SA node

3. Facial edema

2. Indicated electrical impulse beginning at

the AV node

better the nurse recommends which of

3. Reflects atrial muscle depolarization

the following? (Select all that apply.)

4. Identifies ventricular muscle

depolarization

1. Drinking a glass of wine just before

5. Has duration of normally 0.11 seconds or retiring to bed

less.

2. Eating a large meal 1 hour before

bedtime

24. When caring for a client with a

3. Consuming a small glass of warm milk at

central venous line, which of the

bedtime

following nursing actions should be

4. Performing mild exercises 30 minutes

implemented in the plan of care for

before going to bed

chemotherapy administration? Select

all that apply.

26. The nurse recognizes that a client

is experiencing insomnia when the

1.

Verify patency of the line by the

client reports (select all that apply):

presence of a blood return at regular

intervals.

1.

Extended time to fall asleep

2. Inspect the insertion site for swelling,

2. Falling asleep at inappropriate times

erythema, or drainage.

3. Difficulty staying asleep

3. Administer a cytotoxic agent to keep the 4. Feeling tired after a nights sleep
regimen on schedule even if blood return is
not present.

27. The nurse teaches the mother of a

4. If unable to aspirate blood, reposition the newborn that in order to prevent

client

sudden infant death syndrome (SIDS)

the best position to place the baby

and encourage the client to cough.

after nursing is (select all that apply):

5. Contact the health care provider about

verifying placement if the status is

1. Prone

questionable.

2. Side-lying
3. Supine
4. Fowlers

25. To assist an adult client to sleep

28. A client has a diagnosis of primary

insomnia. Before assessing this client,
the nurse recalls the numerous causes
of this disorder. Select all that apply:
1. Chronic stress
2. Severe anxiety
3. Generalized pain
4. Excessive caffeine
5. Chronic depression
6. Environmental noise
29. Select all that apply to the use of

Answers and Rationale

1. Answer: 1, 2, and 3
Prothrombin time, partial thromboplastin
time, and platelet count are all included in
coagulation studies. The hemoglobin level,
though important information prior to an
invasive procedure like liver biopsy, does
not assess coagulation.
2. Answer: 2, 3, and 4

barbiturates in treating insomnia:

Polycythemia vera is a condition in which

the bone marrow produces too many red
blood cells. This causes an increase in
1. Barbiturates deprive people of NREM
hematocrit and viscosity of the blood.
sleep
Patients can experience headaches,
2. Barbiturates deprive people of REM sleep dizziness, and visual disturbances.
Cardiovascular effects include increased
3. When the barbiturates are discontinued,
blood pressure and delayed clotting time.
the NREM sleep increases.
Weight loss is not a manifestation of
4. When the barbiturates are discontinued, polycythemia vera.
the REM sleep increases.
5. Nightmares are often an adverse effect
when discontinuing barbiturates.

3. Answer: 1 and 4.
4. Answers: 2, 3, 4 and 5.

Polycythemia vera, a condition in which too

many RBCs are produced in the blood
appropriate when there is a
serum, can lead to an increase in the
benzodiazepine overdose:
hematocrit and hypervolemia,
hyperviscosity, and hypertension.
Subsequently, the client can experience
1.
Administration of syrup of ipecac
dizziness, tinnitus, visual disturbances,
2. Gastric lavage
headaches, or a feeling of fullness in the
3. Activated charcoal and a saline cathartic head. The client may also experience
cardiovascular symptoms such as heart
4. Hemodialysis
failure (shortness of breath and orthopnea)
and increased clotting time or symptoms of
5. Administration of Flumazenil
an increased uric acid level such as painful
swollen joints (usually the big toe). Hearing
loss and weight loss are not manifestations
associated with polycythemia vera.
30. Select all that apply that is

5. Answer: 1, 3, 5.
A respiratory assessment, which includes
auscultation of breath sounds and
assessing the color of the nail beds, is a
priority for clients with pneumonia.
Assessing for the presence of chest pain is
also an important respiratory assessment
as chest pain can interfere with the clients
ability to breathe deeply. Auscultating
bowel sounds and assessing for peripheral
edema may be appropriate assessments,
but these are not priority assessments for
the patient with pneumonia.

Assessing the clients bowel sounds and

evaluating the clients response to
medication are registered nurse activities
that cannot be delegated.
10. Answer: 1 and 3.

HF is a result of structural and functional

abnormalities of the heart tissue muscle.
The heart muscle becomes weak and does
not adequately pump the blood out of the
chambers. As a result, blood pools in the
left ventricle and backs up into the left
atrium, and eventually into the lungs.
Therefore, greater amounts of blood remain
6. Answer: 2, 4, 5.
in the ventricle after contraction thereby
decreasing cardiac output. In addition, this
pooling leads to thrombus formation and
7. Answer: 2, 3, 4.
ineffective tissue perfusion because of the
decrease in blood flow to the other organs
Palpitations, an adrenergic symptom, occur and tissues of the body. Typically, these
as the glucose levels fall; the sympathetic clients have an ejection fraction of less
nervous system is activated and
than 50% and poorly tolerate activity.
epinephrine and norepinephrine are
Activity intolerance is related to a decrease,
secreted causing this response. Diaphoresis not increase, in cardiac output. Gas
is a sympathetic nervous system response exchange is impaired. However, the
that occurs as epinephrine and
decrease in cardiac output triggers
norepinephrine are released. Slurred
compensatory mechanisms, such as an
speech is a neuroglycopenic symptom; as increase in sympathetic nervous system
the brain receives insufficient glucose, the activity.
activity of the CNS becomes depressed.
8. Answer: 2, 4.

11. Answer: 1, 2, 4, 5.

A major concern with intravenous

administration of cytotoxic agents is vessel
irritation or extravasation. The Oncology
Nursing Society and hospital guidelines
require frequent evaluation of blood return
when administering vesicant or non
vesicant chemotherapy due to the risk of
extravasation. These guidelines apply to
peripheral and central venous lines. In
addition, central venous lines may be long9. Answer: 2, 4, and 5.
term venous access devices. Thus, difficulty
drawing or aspirating blood may indicate
The nurse can delegate the following basic
the line is against the vessel wall or may
care activities to the unlicensed assistant:
indicate the line has occlusion. Having the
providing skin care following bowel
client cough or move position may change
movements, maintaining intake and output
the status of the line if it is temporarily
records, and obtaining the clients weight.
against a vessel wall. Occlusion warrants
Metabolic acidosis initiates respiratory
compensation in the form of Kussmaul
respirations to counteract the effects of
ketone buildup, resulting in a lowered
PCO2. A fruity odor to the breath (acetone
breath) occurs when the ketone level is
elevated in ketoacidosis.

more thorough evaluation via x-ray study to intolerance related to fatigue. The nursing
verify placement if the status is
diagnoses of impaired gas exchange and
questionable and may require a declotting pain are not commonly related to chronic
regimen.
renal failure.
12. Answer: 1, 2, 5.

17. Answer: 1, 2, 4.

13. Answer: 1, 2, 4.

Head tilt, vomiting, and lethargy are classic

signs assessed in a child with a brain tumor.
Clinical manifestations are the result of
location and size of the tumor.

A client with an impulse control disorder

who displays violent, aggressive, and
assaultive behavior generally functions well
in other areas of his life. The degree of
18. Answer: 1, 2, 4, 5.
aggressiveness is typically out of proportion
with the stressor. Such a client commonly The client has signs and symptoms of
has a history of parental alcoholism and a autonomic dysreflexia. The potentially lifechaotic family life, and often verbalizes
threatening condition is caused by an
sincere remorse and guilt for the
uninhibited response from the sympathetic
aggressive behavior.
nervous system resulting from a lack of

control over the autonomic nervous

14. Answer: 3.
system. The nurse should immediately
elevate the HOB to 90 degrees and place
extremities dependently to decrease
It is specific in what to do and when.
venous return to the heart and increase
venous return from the brain. Because
15. Answer: 1, 2, 4, 5.
tactile stimuli can trigger autonomic
dysreflexia, any constrictive clothing should
If outflow drainage is inadequate, the nurse be loosened. The nurse should also assess
attempts to stimulate outflow by changing for distended bladder and bowel impaction,
which may trigger autonomic dysreflexia,
the clients position. Turning the client to
and correct any problems. Elevated blood
the other side or making sure that the
client is in good body alignment may assist pressure is the most life-threatening
complication of autonomic dysreflexia
with outflow drainage. The drainage bag
because it can cause stroke, MI, or seizures.
needs to be lower than the clients
abdomen to enhance gravity drainage. The If removing the triggering event doesnt
reduce the clients blood pressure, IV
connecting tubing and the peritoneal
dialysis system is also checked for kinks or antihypertensives should be administered.
twisting and the clamps on the system are A fan shouldnt be used because cold drafts
may trigger autonomic dysreflexia.
checked to ensure that they are open.
There is no reason to contact the physician.
19. Answer: 3, 4.
16. Answer: 1, 2, 3.
The client with an ileal conduit must learn
self-care activities related to care of the
Appropriate nursing diagnoses for clients
stoma and ostomy appliances. The client
with chronic renal failure include excess
should be taught to increase fluid intake to
fluid volume related to fluid and sodium
retention; imbalanced nutrition, less than about 3,000 ml per day and should not limit
intake. Adequate fluid intake helps to flush
body requirements related to anorexia,
mucus from the ileal conduit. The ostomy
nausea, and vomiting; and activity

appliance should be changed

approximately every 3 to 7 days and
whenever a leak develops. A skin barrier is
essential to protecting the skin from the
irritation of the urine. An aspirin should not
be used as a method of odor control
because it can be an irritant to the stoma
and lead to ulceration. The ostomy pouch
should be emptied when it is one-third to
one-half full to prevent the weight from
pulling the appliance away from the skin.
20. Answers: 1, 4, 5, and 6.
The probable signs of pregnancy include:
Uterine Enlargement
Hegars sign or softening and thinning of
the uterine segment that occurs at week 6.
Goodells sign or softening of the cervix
that occurs at the beginning of the 2nd
month
Chadwicks sign or bluish coloration of the
mucous membranes of the cervix, vagina
and vulva. Occurs at week 6.
Ballottement or rebounding of the fetus
against the examiners fingers of palpation
Braxton-Hicks contractions
Positive pregnancy test measuring for hCG.
Positive signs of pregnancy include:

magnesium sulfate therapy, the nurse

would monitor maternal vital signs,
especially respirations, every 30-60
minutes and notify the physician if
respirations are less than 12, because this
would indicate respiratory depression.
Calcium gluconate is kept on hand in case
of magnesium sulfate overdose, because
calcium gluconate is the antidote for
magnesium sulfate toxicity. Deep tendon
reflexes are assessed hourly. Cardiac and
renal function is monitored closely. The
urine output should be maintained at 30 ml
per hour because the medication is
eliminated through the kidneys.
23. Answer: 1, 3, 5.
In a client who has had an ECG, the P wave
represents the activation of the electrical
impulse in the SA node, which is then
transmitted to the AV node. In addition, the
P wave represents atrial muscle
depolarization, not ventricular
depolarization. The normal duration of the P
wave is 0.11 seconds or less in duration
and 2.5 mm or more in height.
24. Answer: 1, 2, 4, 5.

A major concern with intravenous

Fetal Heart Rate detected by electronic
administration of cytotoxic agents is vessel
device (doppler) at 10-12 weeks
irritation or extravasation. The Oncology
Fetal Heart rate detected by nonelectronic Nursing Society and hospital guidelines
device (fetoscope) at 20 weeks AOG
require frequent evaluation of blood return
Active fetal movement palpable by the
when administering vesicant or non
examiners
vesicant chemotherapy due to the risk of
Outline of the fetus via radiography or
extravasation. These guidelines apply to
ultrasound
peripheral and central venous lines. In
21. Answer: 1 and 3.
addition, central venous lines may be longterm venous access devices. Thus, difficulty
The three classic signs of preeclampsia are drawing or aspirating blood may indicate
the line is against the vessel wall or may
hypertension, generalized edema, and
proteinuria. Increased respirations are not a indicate the line has occlusion. Having the
client cough or move position may change
sign of preeclampsia.
the status of the line if it is temporarily
against a vessel wall. Occlusion warrants
22. Answers: 3, 4, 5, 6, and 7.
more thorough evaluation via x-ray study to
verify placement if the status is
questionable and may require a declotting
When caring for a client receiving

regimen.

administration of syrup of ipecac is

contraindicated because of aspiration risks
related to sedation. Gastric lavage is
25. Answer: 3.
generally the best and most effective
means of gastric decontamination.
A small glass of milk relaxes the body and Activated charcoal and a saline cathartic
promotes sleep.
may be administered to remove any
remaining drug. Hemodialysis is not useful
in the treatment of benzodiazepine
26. Answer: 1, 3, and 4.
overdose. Flumazenil can be used to
acutely reverse the sedative effects of
These symptoms are often reported by
benzodiazepines, though this is normally
clients with insomnia. Clients report
done only in cases of extreme overdose or
nonrestorative sleep. Arising once at night
sedation.
to urinate (nocturia) is not in and of itself
insomnia.
27. Answer: 2 and 3.
Research demonstrate that the occurrence
of SIDS is reduced with these two positions.
28. Answer: 1, 4, and 6.
Acute or primary insomnia is caused by
emotional or physical discomfort not
caused by the direct physiologic effects of a
substance or a medical condition. Excessive
caffeine intake is an example of disruptive
sleep hygiene; caffeine is a stimulant that
inhibits sleep. Environmental noise causes
physical and/or emotional and therefore is
related to primary insomnia.
29. Answer: 2, 4, and 5.
Barbiturates deprive people of REM sleep.
When the barbiturate is stopped and REM
sleep once again occurs, a rebound
phenomenon occurs. During this
phenomenon, the persons dream time
constitutes a larger percentage of the total
sleep pattern, and the dreams are often
nightmares.
30. Answer: 2, 3, and 5.
If ingestion is recent, decontamination of
the GI system is indicated. The