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PN Comprehensive Review CD Questions 901-1000 {No alternative format questions} 901. A nurse in a prenatal clinic is teaching a group of pregnant women about physiological adaptations during pregnancy. The nurse provides information to the clients, knowing that a normal cardiovascular symptom experienced by most pregnant women is a(n): 1. Decrease in cardiac output 2. Increase in pulse 3. Increase in blood pressure 4. Decrease in blood volume Answer: 2 Rationale: Between 14 and 20 weeks the pulse increases slowly, up 10 to 15 beats/min, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy, returning to baseline in the second half. Test-Taking Strategy: Use the process of elimination and knowledge regarding the normal physiological changes that occur in pregnancy. Eliminate options 1 and 4 because cardiac output and blood volume increase. Recalling that the blood pressure decreases in the first half of pregnancy will direct you to option 2 from the remaining options. Review the normal physiological changes that occur in pregnancy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 42. 902. A nurse in a prenatal clinic is teaching a group of pregnant women about anemia. The nurse provides information to the clients, knowing that physiological anemia of pregnancy or hemodilution is a result of a(n): 1. Increased blood volume of the mother 2. Decreased metabolism of iron 3. Increased demand for iron 4. Decreased maternal hemoglobin formation Answer: 1 Rationale: During the later part of the first trimester, the blood volume of the mother increases rapidly, more rapidly than blood cell production, leading to a decrease in the concentration of hemoglobin and erythrocytes. This is a normal process that causes a physiological anemia of pregnancy or hemodilution. There is an increased metabolism of iron and maternal hemoglobin formation. The increased demand for iron is not a factor in the development of physiological anemia. Test-Taking Strategy: Use the process of elimination and note the key word hemodilution in the question. This word and knowledge regarding physiological anemia will assist in directing you to option 1. Also note the relation between the key word and

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option 1. Review the physiology associated with this type of anemia in pregnancy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 225. 903. When examining the umbilical cord immediately after birth, the nurse expects to observe: 1. Two arteries 2. Two veins 3. One artery 4. A musty odor Answer: 1 Rationale: The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi, and one vein that returns blood to the embryo. There should be no odor. Test-Taking Strategy: Use the process of elimination and knowledge regarding the anatomy of the umbilical cord to answer the question. Remember the umbilical cord is made up of two arteries and one vein. If you had difficulty with this question review this anatomy. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 125. 904. A client who is 8 weeks’ pregnant calls the clinic and speaks to the nurse about complaints of nausea and vomiting every morning. To promote relief, the nurse suggests: 1. Eating three large meals per day 2. Eating a high-fat diet 3. Eating crackers before arising 4. Increasing fluids with meals Answer: 3 Rationale: Some measures for decreasing morning nausea are keeping crackers, Melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats in the diet; and consuming adequate fluid between meals, but not with meals. Test-Taking Strategy: Use the process of elimination and knowledge regarding the measures that will relieve morning nausea. Note the relationship between “every morning” in the question and “before arising” in the correct option. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 275. 905. A nurse is reviewing the results of an eye examination on a client and notes that results from the tonometry test indicate an intraocular pressure of 20 mm Hg. The nurse interprets these findings as: 1. Elevated intraocular pressure 2. Low intraocular pressure 3. Inconclusive findings 4. Normal intraocular pressure Answer: 4 Rationale: Tonometry is an effective screening test for early detection of glaucoma. The normal intraocular pressure is 12 to 22 mm Hg. An intraocular pressure of 20 mm Hg is a normal finding. Test-Taking Strategy: Knowledge regarding the normal intraocular pressure is required to answer this question. Remember that the normal intraocular pressure is 12 to 22 mm Hg. If you are unfamiliar with this finding, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 562. 906. A client has impetigo, and the nurse reviews the home care instructions with the client. Which statement indicates that the client does not understand the measures that will prevent the spread of the infection? 1. “I need to take the full course of the antibiotics.” 2. “I need to wash my dishes and eating utensils separate from other household members.” 3. “My clothes can be laundered with other household members’ clothes.” 4. “I must wash my hands thoroughly and frequently throughout the day.” Answer: 3 Rationale: It is necessary to separate laundry from other household members. Thorough hand washing, separating laundry, and separate washing of the client’s dishes are required because the infection is contagious as long as skin lesions are present. Antibiotics are administered and should be continued as prescribed. Test-Taking Strategy: Note the key words does not understand in the stem of the question. These words indicate a false-response question and that you need to select the incorrect client statement. General principles related to the administration of antibiotics will assist in eliminating option 1. Knowledge of the principles related to asepsis will assist in eliminating option 4. From the remaining options, recalling that impetigo is contagious will direct you to option 3. Review home care instructions related to this

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infection if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Integumentary Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 70. 907. The emergency services team brings a client to the emergency department. The client was found lying in an alley near a trash bin by a policeman who reports that the client is a homeless victim. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding should the nurse note in this condition? 1. White skin that is insensitive to touch 2. A pink edematous hand 3. Black fingertips surrounded by an erythematous rash 4. Red skin with edema in the nail beds Answer: 1 Rationale: Findings in frostbite include white or blue skin that is hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, blisters or blebs, or tissue edema appears. Gangrene develops in 9 to 15 days. Test-Taking Strategy: Focus on the issue, the characteristics of frostbite. The words “insensitive to touch” in option 1 should assist in directing you to this option. Review the characteristics of frostbite if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 199. 908. A nurse is inspecting the skin on a client who is immobile and notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as a: 1. Stage 1pressure ulcer 2. Stage 2 pressure ulcer 3. Stage 3 pressure ulcer 4. Stage 4 pressure ulcer Answer: 2 Rationale: In a stage 2 pressure ulcer, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and may characterize as an abrasion, blister, or shallow crater. The skin is intact in stage 1. A deep craterlike appearance occurs in stage 3, and sinus tracts develop in stage 4. Test-Taking Strategy: Use the process of elimination and knowledge of the characteristics associated with each stage of pressure ulcers. Focusing on the description in the question will assist in directing you to option 2. Review the characteristics of these stages if you had difficulty with this question.

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Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Integumentary Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 278. 909. A client is receiving radiation therapy to the brain because of a diagnosis of a brain tumor. Which side effect does the nurse expect the client to most likely experience? 1. Pneumonitis 2. Esophagitis 3. Nausea and vomiting 4. Diarrhea Answer: 3 Rationale: Radiation therapy to the brain can cause cerebral edema. Clients may also experience nausea and vomiting because of the effects of the radiation on the brain’s chemoreceptor trigger zone. Because hair follicles are destroyed by radiation, clients receiving radiation to the head may also experience hair loss. Pneumonitis and esophagitis relate to radiation to the respiratory system and upper gastrointestinal tract. Diarrhea is related to radiation to the lower gastrointestinal tract. Test-Taking Strategy: Focus on the area of the body being radiated as addressed in the question to direct you to the correct option. Eliminate option 1 because it relates to the respiratory system. Next, eliminate options 2 and 4 because they relate to the upper and lower gastrointestinal tracts. Review the effects of radiation therapy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Oncology Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 330. 910. A nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note on data collection of the client? 1. Complaints of diarrhea 2. Petechiae on the upper extremities 3. Chills and night sweats 4. High fever Answer: 3 Rationale: The client with tuberculosis usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first as unrelated to a respiratory disorder. From the remaining options, it is necessary to know that a low-grade fever is characteristic of tuberculosis. This will direct you to option 3. Review the clinical manifestations associated with TB if you had difficulty with this

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question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 505. 911. A pregnant woman who visits a health care clinic for the first prenatal visit hears the physician discuss the fetal period of development with the nurse. The woman asks the nurse what this means. The nurse tells the woman that the fetal period is the: 1. First 3 days of fetal development following conception 2. First 2 weeks of fetal development following conception 3. Beginning of the third week through the eighth week after conception 4. Is the longest period of fetal development Answer: 4 Rationale: The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form. The preembryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period. Test-Taking Strategy: Use the process of elimination and knowledge regarding the process of fetal development. Focusing on the key words fetal period of development will assist in directing you to option 4. If you are unfamiliar with fetal development, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 28-31. 912. A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse tells the woman that estrogen: 1. Maintains the uterine lining for implantation 2. Stimulates metabolism of glucose and converts the glucose to fat 3. Prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed 4. Stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation Answer: 4 Rationale: Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the

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uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Test-Taking Strategy: Use the process of elimination. Focusing on the issue of the question, the purpose of estrogen, and recalling the physiology related to the reproductive system will direct you to option 4. Review the function and purpose of estrogen if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 42. 913. A nursing instructor asks a nursing student to describe Montgomery’s tubercles of the breast. Which response by the student indicates an understanding of this anatomical structure? 1. “These are sebaceous glands that are located in the areola.” 2. “These are lobes of glandular tissue that secrete milk.” 3. “These are small sacs that contain acinar cells to secrete milk.” 4. “These are ducts containing milk from all areas of the breast.” Answer: 1 Rationale: Montgomery’s tubercles are sebaceous glands in the areola. They are inactive and not obvious except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft. Within each breast are lobes of glandular tissue that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk. The alveoli drain into lactiferous ducts that connect to drain milk from all areas of the breast. Test-Taking Strategy: Knowledge regarding the anatomy and physiology of the breast is required to answer this question. Focus on the issue, Montgomery’s tubercles, to assist in directing you to option 1. Remember Montgomery’s tubercles are sebaceous glands in the areola. If you are unfamiliar with the structures of the female breast, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 28. 914. A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response by the student indicates an understanding of the anatomy of this structure? 1. “The uterus has a capacity of about 50 ml.” 2. “The uterus weighs about 2.2 lb.” 3. “The uterus weighs about 2 oz.”

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4. “The uterus is round and weighs approximately 1000 g.” Answer: 3 Rationale: Before conception the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. Before pregnancy the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 ml (0.3 oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb) and has a sufficient capacity for the fetus, placenta, and amniotic fluid. Test-Taking Strategy: Note the key word nonpregnant and visualize each of the items identified in the options. Eliminate options 2 and 4 first because they are similar in regard to the weight of the uterus. From the remaining options, focusing on the key word will direct you to option 3. Review the anatomical structure of the uterus if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 25. 915. A pregnant client has a positive test result for the hepatitis B virus (HBV), and the client asks the nurse if she will be able to breast-feed the baby as planned after delivery. The nurse makes which response to the client? 1. “You will not be able to breast-feed the baby until 6 months after delivery.” 2. “Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery.” 3. “Breast-feeding is allowed once the baby has been vaccinated.” 4. “Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby.” Answer: 3 Rationale: Although HBV is transmitted in breast milk, once the first dose of hepatitis B vaccine and the serum immune globulin has been administered to the newborn, the woman may breast-feed without risk to the newborn. Options 1, 2, and 4 are incorrect responses. Test-Taking Strategy: Use knowledge regarding the pathophysiology associated with hepatitis B virus and its effects on the fetus and newborn to answer this question. Recalling that the mother will be able to continue to breast-feed once the infant has been vaccinated will assist in directing you to the correct option. Review therapeutic management of the mother and newborn born to the mother with HBV if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 422.

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916. A nurse is collecting data from a client during her first prenatal visit to the clinic. The nurse takes the client’s temperature and notes that the temperature is 99.2º F. Which nursing action is appropriate? 1. Document the temperature 2. Retake the temperature by the rectal route 3. Notify the physician 4. Inform the client that the temperature is elevated, and antibiotics may be required Answer: 1 Rationale: The normal temperature during pregnancy is 36.2º C to 37.6º C (98º F to 99.6º F). A temperature above this level suggests an infection that might require medical management. Options 2, 3, and 4 are unnecessary. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because this option may cause fear in the mother. From the remaining options, recalling the normal temperature during pregnancy will direct you to option 1. Review the normal vital signs during pregnancy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 146. 917. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which of the following does the nurse anticipate to be prescribed? 1. Repeat hepatitis screen 2. Retesting the mother in 1 week 3. The administration of immune globulin and vaccine in the infant soon after birth 4. The administration of antibiotics during pregnancy Answer: 3 Rationale: A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive a hepatitis immune globulin and a vaccine soon after birth. Options 1, 2, and 4 are incorrect actions or treatment measures. Test-Taking Strategy: Use the process of elimination. Option 4 can be eliminated first, knowing that antibiotics are not used to treat hepatitis. Eliminate options 1 and 2 next because they are similar. Additionally, recalling that the concern is the effect on the fetus will assist in directing you to the correct option. Review the purpose and the significance of the hepatitis B screen if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 160. Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia:

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W.B. Saunders, pp. 49, 109. 918. A nursing instructor is lecturing on the reproductive cycle of the female and asks a nursing student to identify the anatomical structure that is the female organ of coitus. The student correctly responds by identifying which structure? 1. Ovaries 2. Pelvis 3. Vagina 4. Fallopian tube Answer: 3 Rationale: The vagina allows discharge of the menstrual flow, is the female organ of coitus, and allows the passage of the fetus from the uterus to outside the mother’s body during childbirth. The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle. The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs. The fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward the uterine cavity to propel the ovum through the tube. Test-Taking Strategy: Use knowledge regarding the function of the anatomical structures of the female reproductive system. Focusing on the key words female organ of coitus will direct you to option 3. If you had difficulty with this question, review the function and structure of the vagina. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 12. 919. A nursing student is asked to identify the location of the isthmus of the uterus. The student correctly states that the isthmus is the: 1. Body of the uterus 2. Uppermost part of the uterus 3. Area between the corpus of the uterus and the cervix 4. Tubular neck of the lower uterus Answer: 3 Rationale: The uterus has three divisions, the corpus, isthmus, and cervix. The isthmus is located between the corpus of the uterus and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus. The cervix is the tubular “neck” of the lower uterus. Test-Taking Strategy: Focus on the issue “location of the isthmus of the uterus.” Visualize the anatomical structures of the female reproductive system to direct you to option 3. If you had difficulty with this question, review the anatomical structure of the uterus. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity

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Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 26. 920. A nurse is conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is: 1. Testosterone 2. Oxytocin 3. Prolactin 4. Progesterone Answer: 3 Rationale: Prolactin stimulates the secretion of milk. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. Test-Taking Strategy: Use the process of elimination. Focusing on the key words stimulates the secretion of milk will assist in directing you to option 3. If you had difficulty with this question, review the functions of the various hormones of the female reproductive system. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 16. 921. A nursing student is reviewing the anatomy and physiology of the female reproductive system. The student reads that the follicle-stimulating hormone is produced by the: 1. Ovaries 2. Anterior pituitary gland 3. Posterior pituitary gland 4. Pancreas Answer: 2 Rationale: The follicle-stimulating hormone and luteinizing hormone are produced by the anterior pituitary gland. The ovaries are the endocrine glands that produce estrogen and progesterone. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions during birth. The pancreas produces insulin and other enzymes that aid in digestion. Test-Taking Strategy: Knowledge regarding the various hormones and the production and secretion of the hormones is required to answer this question. Focus on the issue “the follicle-stimulating hormone” to direct you to option 2. If you had difficulty with this question or are unfamiliar with these hormones, review this content.

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Level of Cognitive Ability: Knowledge Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 461. 922. A nurse is reading the physician’s documentation regarding a pregnant client and notes that the physician has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is: 1. Rounded and most favorable for a vaginal birth 2. Narrow, oval, and not the most favorable for a vaginal birth 3. Wedge shaped, narrow, and nonfavorable for a vaginal birth 4. Flat and nonfavorable for a vaginal birth Answer: 3 Rationale: The android pelvis is wedge shaped and narrow and is nonfavorable for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable shape for a vaginal birth. An anthropoid pelvis is long, narrow, and oval. It is not as favorable a shape for a vaginal birth as the gynecoid pelvis; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvis is flattened with a wide, short, oval shape and is also a nonfavorable shape for a vaginal birth. Test-Taking Strategy: Use knowledge regarding the characteristics of the various pelvic shapes to answer the question. Recalling the characteristics of an android pelvic shape will direct you to option 3. Remember that the android pelvis is wedge shaped and narrow and is nonfavorable for a vaginal birth. If you had difficulty with this question, review the characteristics of the various pelvic shapes. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 14. 923. A nurse is collecting data on a client with anorexia nervosa. The nurse understands that objective findings may indicate: 1. Elevated potassium levels 2. Low blood urea nitrogen 3. Weight loss of at least 4% of original weight over a short period 4. That the client has extensive knowledge of nutrition Answer: 4 Rationale: The potassium level is usually low, and the blood urea nitrogen is usually elevated in clients with anorexia nervosa. Clients lose at least 15% of their original body weight in a short period. These clients are very knowledgeable about nutrition and the caloric value of food. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 first because

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this small amount of weight loss may not be a cause for concern. Next eliminate options 1 and 2 because these are not noted in starvation or a fluid or electrolyte deficiency typical of anorexia nervosa. Review the clinical manifestations associated with anorexia nervosa if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 236. 924. A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission the client states, “There’s nothing wrong with me. I shouldn’t even be here. I am taking up a room, and there is probably someone else who really needs it.” The nurse interprets this client’s statement as: 1. Projection 2. Denial 3. Regression 4. Rationalization Answer: 2 Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression the client returns to an earlier, more comforting, although less mature way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener. Test-Taking Strategy: Use the process of elimination. Noting the key words There’s nothing wrong with me will direct you to option 2. Remember that defense mechanisms are used by clients who are dealing with threats to their self-esteem. Review these defense mechanisms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 182. 925. A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) is analyzed for protein. The nurse reviews the protein values and notes that the value that most supports the diagnosis of Guillain-Barré syndrome is: 1. 5 mg/dl 2. 15 mg/dl 3. 45 mg/dl 4. 75 mg/dl Answer: 4

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Rationale: Normal CSF protein is 15 to 45 mg/dl. Seven to 10 days following the onset of symptoms of Guillain-Barré, the spinal fluid protein levels become extremely high. Test-Taking Strategy: Focus on the issue, the protein value that most supports the diagnosis of Guillain-Barré syndrome. If you are unsure about the normal level of CSF protein, select the option that is similar to the issue of the question and select the highest value. Review the diagnostic findings in this syndrome if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 645. Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 741. 926. Atropine sulfate is prescribed for a client with gastrointestinal hypermotility, and the nurse reviews the client’s record before administering the medication. Which of the following if noted on the client’s record indicates the need to contact the physician before administering the medication? 1. History of peptic ulcer disease 2. Sinus bradycardia 3. Biliary colic 4. Narrow-angle glaucoma Answer: 4 Rationale: Atropine sulfate can cause mydriasis (dilation of the pupil) and cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma. Options 1, 2, and 3 are all therapeutic reasons for using the medication. Test-Taking Strategy: Use the process of elimination. Recalling that atropine sulfate is an anticholinergic medication will assist in directing you to the correct option. Remember that atropine sulfate is contraindicated in clients with narrow-angle glaucoma. Review the contraindications associated with this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 96. 927. A nurse is caring for client with myasthenia gravis. The physician plans to perform a Tensilon test on the client to determine the presence of cholinergic crisis. In addition to planning care for the client during this testing, which of the following will the nurse ensure is at the bedside? 1. Vial of protamine sulfate and a syringe 2. Oxygen equipment 3. Cardiac monitor

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4. Potassium injection and 1 L of normal saline solution Answer: 2 Rationale: A Tensilon test is performed to distinguish between myasthenic and cholinergic crisis. Following administration of the edrophonium chloride (Tensilon), if symptoms intensify, the crisis is cholinergic. Because the symptoms of cholinergic crisis will worsen with the administration of edrophonium chloride, atropine sulfate and oxygen should be immediately available whenever edrophonium chloride is used. Test-Taking Strategy: Note the key words ensure is at the bedside. Use the ABCs— airway, breathing, and circulation—to direct you to option 2. Review the Tensilon test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1035. 928. A client arrives at the health care clinic for follow-up care and evaluation of the effectiveness of prazosin (Minipress). Which finding indicates a therapeutic effect related to the use of this medication? 1. Decrease in blood glucose level 2. Decrease in blood pressure 3. Increased red blood cell count 4. Increased platelet count Answer: 2 Rationale: Prazosin is an antihypertensive medication. The principal indication for its use is hypertension. A decrease in blood pressure indicates a therapeutic effect of the medication. Options 1, 3, and 4 are unrelated to the use of this medication. Test-Taking Strategy: Use the process of elimination. Note the name of this medication Minipress. This name should provide a guide that it is related to lowering blood pressure. Review the action and uses of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 880. Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 710. 929. A nurse reviews the phenytoin level of a client who is taking phenytoin (Dilantin). The nurse notes that the plasma drug level is 9 mcg/ml. Which of the following does the nurse anticipate to be prescribed for the client? 1. Maintenance of the prescribed present dosage 2. An increase in the present dosage 3. A decrease in the present dosage

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4. The addition of a second anticonvulsant medication Answer: 2 Rationale: The dosing objective is to produce phenytoin levels between 10 and 20 mcg/ml Levels below 10 mcg/ml are too low to control seizures. At levels above 20 mcg/ml, signs of toxicity begin to appear. Test-Taking Strategy: Focus on the data in the question. Recalling that the dosage objective is to produce levels between 10 and 20 mcg/ml will assist in directing you to the correct option. Review the therapeutic phenytoin level if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 690. 930. A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The nurse is told that the client’s prothrombin time is 18 seconds with a control of 11 seconds. The nurse plans to: 1. Administer the next dose of warfarin sodium 2. Withhold the next dose of warfarin sodium 3. Double the next dose of warfarin sodium 4. Cut the next dose of warfarin sodium in half Answer: 1 Rationale: The therapeutic range for prothrombin time (PT) is 1.5 to 2 times the control for clients at high risk for a thrombus. Based on the client’s control value, the therapeutic range for this individual is 16.5 to 22.0 seconds. The nurse should administer the next dose as usual. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 3 and 4 because the question does not mention standing orders, whereby the usual dose could be altered by the nurse. To choose correctly between the remaining options, you must know the significance of the client’s PT value and that the therapeutic range for prothrombin time (PT) is 1.5 to 2 times the control. Review the significance of this test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 906. 931. A nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous (IV) infusion. The nurse ensures that which medication is readily available should a morphine overdose occur? 1. Nalmefene (Revex) 2. Atropine sulfate

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3. Promethazine (Phenergan) 4. Protamine sulfate Answer: 1 Rationale: Nalmefene (Revex) is a long-acting antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic used in the treatment of cholinergic crisis. Protamine sulfate is the antidote for heparin therapy, and promethazine is an antiemetic. Test-Taking Strategy: Knowledge regarding the antidote for various medication therapies is required to answer the question. Remember that nalmefene (Revex) is a long-acting antagonist that is used to treat opioid overdose. If you had difficulty with this question and are unfamiliar with the actions and uses of the medications identified in the options, review these medications. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 236. 932. A nurse employed in a physician’s office is collecting data on a client who is taking ergotamine tartrate (Cafergot). The nurse evaluates the effectiveness of therapy by asking which question? 1. “Do you still have a backache?” 2. “Are the headaches relieved?” 3. “Are you having any diarrhea?” 4. “Is the coughing keeping you awake at night?” Answer: 2 Rationale: Ergotamine tartrate is used to treat migraine or cluster headaches. Options 1, 3, and 4 are unrelated to the use of this medication. Test-Taking Strategy: Knowledge regarding the use of ergotamine tartrate is required to answer this question. Remember that ergotamine tartrate is used to treat migraine or cluster headaches. Review the action and use of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 322. 933. A nurse is providing dietary instructions to a client who is taking spironolactone (Aldactone). The nurse instructs the client to avoid which of the following in the daily diet? 1. Oatmeal 2. Citrus fruits 3. Rice

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4. Salad Answer: 2 Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia is the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas. Options 1, 3, and 4 are appropriate food items to include in the daily diet. Test-Taking Strategy: Note the key word avoid. This word indicates a false-response question and that you need to select the incorrect food item. Recalling that spironolactone is a potassium-sparing diuretic and knowledge of the foods that are high in potassium will direct you to option 2 as the food to avoid. Review this medication and the foods high in potassium if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 986. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 485. 934. A nurse is caring for a client with chronic renal failure who is receiving dialysis. Epoetin alfa (Epogen) has been prescribed for the client. The nurse prepares to administer the medication by: 1. Obtaining the medication from the medication freezer 2. Shaking the vial before drawing up the medication 3. The subcutaneous route 4. Mixing the medication with 0.1 ml of heparin before administration to prevent clotting Answer: 3 Rationale: Epoetin alfa is dispensed for subcutaneous or intravenous injections. Vials should not be shaken because epoetin alfa is a protein that can be denatured by agitation. Epoetin alfa is not to be mixed with other medications. The medication should be refrigerated, but should not be frozen. Test-Taking Strategy: Knowledge regarding the storage and administration of epoetin alfa is required to answer this question. Remember that epoetin alfa is dispensed for subcutaneous or intravenous injections. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 385. 935. A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data suggests to the nurse the presence of concealed bleeding? 1. Increase in fundal height

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2. Heavy vaginal bleeding 3. Early deceleration on the monitor 4. Nausea Answer: 1 Rationale: The signs of concealed bleeding include increase in fundal height, hard boardlike abdomen, persistent abdominal pain, late decelerations in the fetal heart rate or decreasing baseline variability. Options 2, 3, and 4 are not signs of concealed bleeding. Test-Taking Strategy: Focus on the issue of the question, concealed bleeding. The only option that relates to this issue is option 1. Review the signs of concealed bleeding in a pregnant client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 673-673. 936. A pregnant client at 36 weeks’ gestation who has painless bleeding is admitted to the labor room. Which action should the nurse initially include in the plan of care? 1. Maintain complete bed rest, encourage fluids, and reduce stimuli 2. Maintain complete bed rest, monitor intravenous (IV) fluid intake, and monitor for uterine contractions 3. Maintain complete bed rest, assist with the vaginal examination, and restrict food and fluids 4. Maintain complete bed rest, monitor IV fluid intake, and monitor the fetal heart rate (FHR) Answer: 4 Rationale: Initial nursing actions for care of a pregnant client with bleeding include maintaining complete bed rest (to reduce the chance for further bleeding), initiating and monitoring an IV (anticipating the need for fluid replacement), and monitoring the FHR (assessing the status of the fetus). Food and fluid may or may not be restricted. Reducing stimuli is not a priority consideration. A vaginal examination is not appropriate because it may stimulate uterine contractions and increase bleeding. Test-Taking Strategy: Note the key word initially and read each of the options thoroughly. Note that the correct option specifically addresses both the mother and the fetus. Review care for the pregnant client experiencing bleeding if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 674. 937. A nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this

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pregnancy? 1. She has a history of chronic hypertension 2. Her previous two babies were delivered by cesarean section 3. There is a family history of type 1 diabetes mellitus 4. She is 5 feet 2 inches tall and weighs 175 lb Answer: 1 Rationale: Known risk factors that increase the risk of developing gestational diabetes include obesity (more than 198 lb), chronic hypertension, family history of type 2 diabetes mellitus, previous birth of a large infant (more than 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors. Test-Taking Strategy: Knowledge regarding the risk factors associated with gestational diabetes is required to answer this question. Noting the words “chronic hypertension” in option 1 will direct you to this option. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 895. 938. A prenatal client with vaginal bleeding is admitted to the labor unit. Which of the following signs or symptoms indicates placenta previa? 1. Painful vaginal bleeding 2. Abdominal pain 3. Back pain 4. Painless vaginal bleeding Answer: 4 Rationale: The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Options 1, 2, and 3 are signs of abruptio placentae. Test-Taking Strategy: Knowledge regarding the signs of placenta previa is required to answer this question. Recalling that in this condition the client experiences painless bleeding will direct you to option 4. Review the differences between placenta previa and abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 216. 939. A nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse reviews the nursing care plan and notes documentation of a nursing diagnosis of Impaired Gas Exchange. The nurse should monitor for which item as the best indicator of an adequate respiratory status? 1. Moderate amounts of tracheobronchial secretions

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2. Small to moderate amounts of frank blood suctioned from the tube 3. Respiratory rate of 18 breaths per minute 4. Oxygen saturation of 89% Answer: 3 Rationale: Impaired Gas Exchange could occur following tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. The respiratory rate of 18 breaths per minute is well within the normal range of 14 to 20 breaths per minute. Test-Taking Strategy: Focus on the issue, the best indicator of an adequate respiratory status. An oxygen saturation of 89% is suboptimal and is eliminated first. Bloody secretions (option 2) are also abnormal, although secretions may be blood tinged for a few days after tracheostomy insertion. Although tracheobronchial secretions may be expected, they are not the best indicator of an adequate respiratory status, making the respiratory rate of 18 breaths per minute the correct option. Review care to the client at risk for impaired gas exchange if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 500. 940. A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a physician’s visit. The client asks the nurse if a change in the medication to treat the diabetes will occur. The nurse bases the response on which of the following? 1. An increase in intermediate-acting insulin is needed 2. An increase in short-acting insulin is needed 3. An oral hypoglycemic medication will be added to the regimen 4. A steady increase in insulin will be necessary Answer: 4 Rationale: There is little change in insulin requirements during the first trimester of pregnancy. In the second and third trimesters, insulin requirements increase gradually, often doubling toward the end of pregnancy. Oral hypoglycemic medications pass through the placenta and may be teratogenic to the fetus. Intermediate- and short-acting insulins are usually prescribed together. Option 4 is the correct option. Test-Taking Strategy: Use the process of elimination. Remember that oral hypoglycemic medications pass through the placenta and may be teratogenic to the fetus; thus eliminate option 3. From the remaining options, use knowledge regarding the insulin needs of the pregnant client to direct you to option 4. Also note that this option is the umbrella (global) one. Review care to the pregnant client who has diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum

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References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 104. Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 890-891. 941. A nurse in the prenatal clinic is collecting data regarding the client’s nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat: 1. Chicken 2. Rice 3. Cheese 4. Beans Answer: 4 Rationale: Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Cheese is high in calcium, and rice and chicken are good sources of iron. Test-Taking Strategy: Focus on the issue, the food items high in folic acid. Remember that sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Review these foods if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 61. 942. A client who has undergone femoral-popliteal bypass grafting says to the nurse, “I hope I don’t have any more problems that could make me lose my leg. I’m so afraid that I’ll have gone through this for nothing.” The appropriate nursing response is which of the following? 1. “There is nothing to worry about.” 2. “You are concerned about losing your leg?” 3. “You have the best physician in the city, and the physician will not let anything happen to you.” 4. “There are many people with the same problem, and they are doing just fine.” Answer: 2 Rationale: The appropriate response is the one that uses the therapeutic technique of restatement. Option 2 restates the client’s concern and provides an opportunity for the client to further discuss the concern. Options 1, 3, and 4 are inappropriate because they provide false reassurance and do not address the client’s concern. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Remember to always address the client’s feelings and concerns. Option 2 is the only option that addresses the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity

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Integrated Process: Communication and Documentation Content Area: Adult Health/Cardiovascular References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 336-337. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 943. A nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse tells the client to do which of the following? 1. Bend the leg at the hip 2. Place two pillows under the knees 3. Use the knee gatch on the bed controls 4. Keep the ankles uncrossed Answer: 4 Rationale: A graft can become clotted from any form of pressure, which results in impaired blood flow through the graft. Positions and movements to be avoided include bending at the hip or knee, crossing the knees or ankles, or the use of a knee gatch or pillows under the knees. Test-Taking Strategy: Use knowledge of the basic principles of blood flow and the causes of circulatory obstruction to answer this question. Note that options 1, 2, and 3 are similar. The correct option is the only option that does not involve flexion of leg joints or possible blood vessel compression and kinking. Review measures related to aortoiliac bypass grafting if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1521. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 775. 944. A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs or symptoms? 1. Fever and sore throat 2. Vaginal itching 3. Skin scratches 4. Burning on urination Answer: 1 Rationale: Rheumatic heart disease can occur as a result of infection with group A betahemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting for the presence of sore throat and fever. The other options are unrelated to this problem and indicate possible yeast infection, skin lesions, and urinary tract infection, respectively.

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Test-Taking Strategy: Use the process of elimination. Remember that streptococcal infections, especially of the upper respiratory system, are largely responsible for rheumatic heart disease. Recalling this concept should help you eliminate each of the incorrect options. Review the findings noted in rheumatic heart disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 324. 945. A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which of the following on an ongoing basis? 1. Crackles, peripheral edema, and weight gain 2. Respiratory distress, chest pain, and the use of accessory muscles 3. Confusion, decreasing level of consciousness, and aphasia 4. Flank pain with radiation to the groin and hematuria Answer: 1 Rationale: The client with infective endocarditis may experience both left- and rightsided heart failure, and thus the nurse monitors the client for both pulmonary and peripheral symptoms, such as crackles, peripheral edema, and weight gain. Option 2 contains symptoms that occur with pulmonary embolism, which is not related to the issue of the question. Options 3 and 4 relate to embolus to the brain and kidney, respectively. Test-Taking Strategy: Use the process of elimination and note the key words at risk for heart failure. Recalling the signs and symptoms of heart failure will direct you to option 1. Review the complications of infective endocarditis and the signs of heart failure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 589-590. 946. A nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade? 1. Distended jugular neck veins 2. Pulse rate of 58 beats/min 3. Systolic blood pressure of 110 mm Hg, dropping to 94 mm Hg on inspiration 4. Muffled and distant heart sounds Answer: 2 Rationale: Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure, accompanied by pulsus paradoxus (a drop in inspiratory blood pressure by greater than 10 mm Hg).

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Bradycardia is the symptom that is unrelated. Test-Taking Strategy: Note the key word unrelated. This word indicates a false-response question and that you need to select the incorrect finding. Remember that in cardiac tamponade, tachycardia rather than bradycardia occurs. Review the signs and symptoms of cardiac tamponade if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 197. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 755. 947. A nurse is listening to the client’s breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. The nurse interprets that this client has: 1. Crackles 2. Wheezes 3. Rhonchi 4. Pleural friction rub Answer: 2 Rationale: Wheezes are musical noises heard on inspiration, expiration, or both. They are the result of narrowed air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together near the ear and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is excessive production of mucus, which accumulates in the air passages. A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating in quality. The sounds are localized over an area of inflammation of the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle. Test-Taking Strategy: Focus on the data in the question. The words musical and whistling are the key words that will direct you to option 2. Review the characteristics of the various breath sounds if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1756. 948. A nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the most accurate indicator of the effectiveness of suctioning? 1. Breath sounds are now clear 2. Oxygen saturation has increased two points 3. Suctioning is required only once a shift

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4. Respiratory rate has gone down by four breaths per minute Answer: 1 Rationale: Clear breath sounds are the most accurate indicator of the effectiveness of a suctioning procedure. Options 2 and 4 are incorrect because they are less precise. Option 3 is incorrect because the need for suctioning may be influenced by factors other than the effectiveness of previous suctioning. These other factors could include improvement of underlying respiratory condition, fluid status, and effectiveness of cough. Test-Taking Strategy: Use the process of elimination. Options 2 and 4 are the least precise indicators and are eliminated first. From the remaining options, select breath sounds as the immediate means of assessing the effectiveness of the procedure. Review suctioning procedure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1099-1100. 949. A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the physician if this process should be delayed temporarily, based on administration of which of the following medications to the client in the last hour? 1. Lorazepam (Ativan) 2. Furosemide (Lasix) 3. Metoclopramide (Reglan) 4. Digoxin (Lanoxin) Answer: 1 Rationale: Antianxiety medications (such as lorazepam) and narcotic analgesics are used cautiously or withheld whenever possible in the client being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The other medications do not interfere with the respiratory drive and so will not affect the weaning process. Test-Taking Strategy: To answer this question accurately you need to identify the items that could interfere with the client’s strength, endurance, and respiratory drive in maintaining independent ventilation. Recalling that lorazepam is an antianxiety medication and recalling the effects of this medication will direct you to option 1. If this question was difficult, review care for the client being weaned from a mechanical ventilator and the medications identified in the options. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1894. Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby,

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p. 510. 950. A client with myxedema has changes in intellectual function, such as impaired memory, decreased attention span, and lethargy. The client’s husband is upset and shares his concerns with the nurse. Which statement by the nurse is most helpful to the client’s husband? 1. “It’s obvious that you are concerned about your wife’s condition, but the symptoms may improve with continued therapy.” 2. “Would you like for me to ask the physician for a prescription for a stimulant?” 3. “I don’t blame you for being frustrated because the symptoms will only get worse.” 4. “Give it time. I’ve seen dozens of clients with this problem that fully recover.” Answer: 1 Rationale: Using therapeutic communication techniques, the nurse acknowledges the husband’s concerns and conveys that the client’s symptoms are common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal. Option 2 is not helpful, and it blocks further communication. Option 3 is pessimistic and untrue. Option 4 is not appropriate and offers false reassurance. Test-Taking Strategy: Use therapeutic communication techniques to direct you to option 1. Therapeutic communication techniques enhance communication because they address the concerns of the client or family. Recall too that symptoms of myxedema usually resolve once medication therapy has been initiated. Review therapeutic communication techniques and treatment measures for myxedema if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Endocrine References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 102-104. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 951. A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which of the following liquids? 1. Fruit juice 2. Iced tea 3. Water 4. Milk Answer: 4 Rationale: Milk products are high in phosphates, which should be avoided by a client with hypoparathyroidism. Otherwise, calcium products are best absorbed with milk because the vitamin D in the milk promotes calcium absorption. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis. Recalling that the client with hypoparathyroidism should avoid food items high in phosphates will direct you to option 4. Review the pathophysiology associated with hypoparathyroidism and the foods high in phosphates if you had difficulty with this

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question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 470. 952. A client has hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which of the following foods in the diet? 1. Bananas 2. Chicken breast 3. Ice cream 4. Oatmeal Answer: 3 Rationale: The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products, such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods. Test-Taking Strategy: Focus on the client’s diagnosis and note the key word limit. Recalling that the client with hyperparathyroidism is likely to have elevated calcium levels will direct you to option 3. If this question was difficult, review the dietary measures associated with hyperparathyroidism and food items that are high and low in calcium. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 894. 953. A nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which of the following will the nurse include in the plan of care? 1. Get out of bed to ambulate with assistance 2. Place an eye patch over the affected eye 3. Maintain high Fowler’s position 4. Restrict visitors Answer: 2 Rationale: The nurse places an eye patch over the client’s affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the physician. Visitors do not need to be restricted. Test-Taking Strategy: Use the process of elimination and note the client’s diagnosis.

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Eliminate options that suggest activity, such as in option 1. Remembering that the eye needs to be protected and rested will assist in eliminating options 3 and 4 and direct you to option 2. Review care to the client with retinal detachment if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 575. 954. A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has a nursing diagnosis of Impaired Gas Exchange. Which action is contraindicated as the nurse delivers care to this client? 1. Suctioning the airway on an as-needed basis 2. Encouraging regular use of an incentive spirometer 3. Repositioning side to side every 2 hours 4. Keeping the client in a supine position Answer: 4 Rationale: The client with a thoracic burn and smoke inhalation requires aggressive pulmonary measures to prevent atelectasis and pneumonia. These include turning and repositioning, using humidified oxygen, providing incentive spirometry, and suctioning the client on an as-needed basis. The client should not be left lying in a single position and should not have the head of the bed flat. These could promote development of complications by limiting chest expansion. Test-Taking Strategy: Use the process of elimination and note the key word contraindicated. This word indicates a false-response question and that you need to select the incorrect action. Use basic nursing knowledge about respiratory interventions to eliminate each of the incorrect options. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 515. 955. A nurse looks at the clock and notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to do which of the following next in the care of this client? 1. Immediately place the client on NPO status 2. Administer a narcotic analgesic last taken 6 hours ago 3. Gather dressing supplies to send with the client to hydrotherapy 4. Get out a robe and slippers for the client

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Answer: 2 Rationale: The client should receive pain medication approximately 20 minutes before a burn dressing change. This will help the client to tolerate a painful procedure. The client does not need to be NPO for this procedure. Dressing supplies are not sent with the client because they are available in the hydrotherapy area. A robe and slippers are given to the client for transport, but are not indicated 30 minutes ahead of time. Test-Taking Strategy: Use the process of elimination and note the key word next. This tells you that more than one or all of the options may be partially or totally correct. Use Maslow’s Hierarchy of Needs theory to answer this question and the ability to sequence nursing activities in terms of time. Recalling that this procedure can be painful for the burn client will direct you to option 2. Review care to the burn client receiving hydrotherapy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Integumentary Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1451. 956. A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dl on an otherwise healthy client. The nurse tells the client to do which of the following as a next step? 1. Begin blood glucose monitoring three times a day 2. Call the physician to have the value rechecked as soon as able 3. Seek treatment for diabetes mellitus 4. Ask the pharmacist about staring insulin therapy Answer: 2 Rationale: Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia, polyuria, and polyphagia),or by laboratory values. Diabetes is diagnosed by an abnormal glucose tolerance test, when random plasma glucose levels are greater than 200 mg/dl, or fasting plasma glucose levels are greater than 140 mg/dl on two separate occasions. Further confirmation of this result is necessary to ensure appropriate diagnosis and therapy. Test-Taking Strategy: Use the process of elimination and note the key words next step. Eliminate options 3 and 4 first because the nurse does not diagnose disease or recommend treatment. Choose correctly between the remaining options by recalling that a single value does not absolutely indicate diabetes mellitus. Review the diagnostic measures for diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 476-477.

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957. A client with Addison’s disease asks the nurse how a newly prescribed medication, fludrocortisone acetate (Florinef), will improve the condition. When formulating a response, the nurse should incorporate that a key action of this medication is to: 1. Replace insufficient circulating estrogens 2. Make the body produce more cortisol 3. Alter the body’s immune system functioning 4. Help restore electrolyte balance Answer: 4 Rationale: Fludrocortisone acetate is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the long-term management of Addison’s disease. Mineralocorticoids cause renal reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. These actions help restore electrolyte balance in the body. The other options are incorrect. Test-Taking Strategy: Knowledge regarding the pathophysiology associated with Addison’s disease and the action of this medication is necessary to answer this question. Remember fludrocortisone acetate helps restore electrolyte balance. Review the action of this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 444-445. 958. A nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities caused by type 2 diabetes mellitus. The nurse plans care, knowing that which nursing diagnosis noted in the plan has the highest priority for this client? 1. Situational low self-esteem related to perceived loss of abilities 2. Risk for Injury related to decreased sensation in the legs and feet 3. Disturbed Body Image related to impaired ability to walk 4. Chronic pain related to intermittent claudication Answer: 2 Rationale: The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Thus the highest priority nursing diagnosis using Maslow’s Hierarchy of Needs theory is option 2. Options 1 and 3 represent nursing diagnoses that are more psychosocial in nature and as such are secondary needs using Maslow’s theory. Option 4 is incorrect because the client may not have intermittent claudication. Test-Taking Strategy: Use the process of elimination and Maslow’s Hierarchy of Needs theory to answer the question. Note the relationship between the words “neuropathy” in the question and “decreased sensation in the legs and feet” in the correct option. Review care to the client with diabetic neuropathy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning

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Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1284. 959. An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client reviews the plan of care and plans to address which nursing diagnosis noted in the plan first? 1. Risk for Injury 2. Impaired Urinary Elimination 3. Risk for Constipation 4. Ineffective Health Maintenance Answer: 1 Rationale: The client with severe osteoporosis as a result of hyperparathyroidism is at risk for injury as a result of pathological fractures that can occur from bone demineralization. The client may or may not have a risk for impaired urinary elimination, depending on other factors in the client’s history. The client may also have a risk for constipation from the disease process, but this is a lesser priority than client safety. There is no information in the question to support whether the client has ineffective health maintenance. Test-Taking Strategy: Use the process of elimination and note the key word first. Use Maslow’s Hierarchy of Needs theory and focus on the data in the question. Remember that severe osteoporosis places the client at risk for pathological fractures. This will direct you to option 1. Review care to the client with hyperparathyroidism and severe osteoporosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 894, 897. 960. A client has hypoparathyroidism. The nurse teaches the client to include foods in the diet that are: 1. High in phosphorus and low in calcium 2. Low in phosphorus and low in calcium 3. Low in phosphorus and high in calcium 4. High in phosphorus and high in calcium Answer: 3 Rationale: Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder then is one that is high in calcium but low in phosphorus because these two electrolytes have inverse proportions in the body. All of the other options are unrelated to this disorder and are incorrect. Test-Taking Strategy: To answer this question correctly, you must have an understanding of hypoparathyroidism and its effects on the body. Recalling that hypoparathyroidism results in hypocalcemia will assist in eliminating options 1 and 2. From the remaining

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options, recalling that calcium and phosphorus have inverse proportions in the body will direct you to option 3. Review the dietary measures for hypoparathyroidism if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 470. 961. Diabetes mellitus has been newly diagnosed in a hospitalized client. The client must take both NPH and regular insulin for glucose control. The nurse develops a teaching plan to help the client meet which outcome as a first step in managing the disease? 1. Lose 40 lb to achieve ideal body weight 2. Adjust insulin according to capillary blood glucose levels 3. Maintain health at an optimal level 4. Avoid all strenuous exercise Answer: 2 Rationale: There are many learning goals for the client who is newly diagnosed with diabetes mellitus. The client must learn dietary control, medication management, and proper exercise to control the disease. As a first step, the client learns to adjust medication (insulin) according to blood glucose results as ordered by the physician. The client should then focus on long-term dietary control and weight loss, which will often lead to a decreased need for insulin. At the same time that diet is being controlled, the client should begin a regular exercise program to aid in weight loss. Option 4 is incorrect. Test-Taking Strategy: The key words in this question are first step. This tells you that more than one option is likely to be correct. Eliminate option 4 first because of the absolute word “all.” From the remaining options, focusing on the diagnosis of the client and the treatment measures as identified in the question will assist in directing you to option 2. Review care to the client newly diagnosed with diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 481. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 900. 962. A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7 A.M. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client states to look for which of the following in the late afternoon?

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1. Hunger, shakiness, and cool, clammy skin 2. Increased urination, thirst, and rapid deep breathing 3. Nausea and vomiting, and abdominal pain 4. Drowsiness; red, dry skin; and fruity breath odor Answer: 1 Rationale: The client taking NPH insulin obtains peak medication effects approximately 6 to 12 hours after administration. At the time that the medication peaks, the client is at risk for hypoglycemia if food intake is insufficient. The nurse should teach the client to watch for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness, and hunger. The other options list various signs and symptoms of hyperglycemia. Test-Taking Strategy: Use the process of elimination and focus on the issue, the signs and symptoms of hypoglycemia. Remember that when an option has more than one part, all of the parts must be correct for the option to be correct. Recalling the signs and symptoms of hypoglycemia will direct you to option 1. Review these signs and symptoms if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 921. 963. A client newly diagnosed with diabetes mellitus is having difficulty learning the technique of blood glucose measurement. The nurse should teach the client to do which of the following to perform the procedure properly? 1. Puncture the center of the finger pad 2. Puncture the finger as deeply as possible 3. Wash the hands first using cold water 4. Let the arm hang dependently and milk the digit Answer: 4 Rationale: Before doing a fingerstick for blood glucose measurement, the client should first wash the hands. Warm water should be used to stimulate the circulation to the area. The finger is punctured near the side, not the center, because there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequate size drop of blood; excessively deep punctures may lead to pain and bruising. The arm should be allowed to hang dependently, and the finger may be milked to promote obtaining a good size blood drop. Test-Taking Strategy: Use the process of elimination and note the key word properly. This tells you that one option is clearly better than the others. Use knowledge of asepsis and blood glucose measurement procedures to eliminate each of the incorrect options. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine

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Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 395. 964. A nurse is planning to instruct a client with diabetes mellitus who has hypertension about “sick day management.” Which of the following does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally? 1. Ginger ale 2. Apple juice 3. Regular cola 4. Mineral water Answer: 4 Rationale: Diabetic clients should take in approximately 15 g of carbohydrate every 1 to 2 hours when unable to tolerate food because of illness. Each of the beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of carbohydrate in a half-cup serving. Mineral water is incorrect for two reasons. First, it contains sodium and should not be used by the client with hypertension. Second, it is not a source of carbohydrates. Test-Taking Strategy: Use the process of elimination and note the key words hypertension and avoid. This tells you that the question is looking for an item that should not be used by the hypertensive client. Because hypertension is aggravated by excess sodium intake, select the option that is highest in sodium. This will direct you to option 4. Review food items that are high in sodium and carbohydrates if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1286. 965. A nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis (DKA) receiving an insulin infusion. The nurse determines that which of the following values needs to be reported? 1. Potassium 3.1 mEq/L 2. Serum osmolality 288 mOsm/kg H2O 3. Calcium 9.2 mg/dl 4. Sodium 137 mEq/L Answer: 1 Rationale: The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin and because potassium is excreted in the urine once rehydration has occurred. Thus the nurse carefully monitors the results of serum potassium levels and reports hypokalemia (option 1) promptly. The other laboratory values are within the normal ranges.

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Test-Taking Strategy: To answer this question correctly, it is necessary to understand the relationship among glucose, insulin, and potassium in the treatment of DKA. An understanding of normal reference ranges for the tests listed in the options also allows you to choose correctly. Option 1 is the only abnormal value. Review care to the client with DKA and normal laboratory values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 887. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 487-488. 966. The wife of client with diabetes mellitus who takes insulin calls the nurse in a physician’s office about her husband. She states that her husband is sleepy and that his skin is warm and flushed. She adds that his breathing is faster than normal, and his pulse rate seems fast. Which of the following should the nurse tell the woman to do first? 1. Call an ambulance 2. Drive him to the physician’s office 3. Take his temperature 4. Check the client’s blood glucose level Answer: 4 Rationale: The client’s signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse would then report to the physician. Option 1 or 2 may be done at a later time if required. Option 3 is unrelated to the client’s immediate problem. Test-Taking Strategy: Use the process of elimination and note the key word first in the question. This tells you that more than one option may be partially or totally correct. In this question option 3 is incorrect and unrelated to the situation and is eliminated first. From the remaining options, select option 4 over options 1 and 2, knowing that the blood glucose results may have an impact on the subsequent directions given to the client. Review home care instructions regarding diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 487-488. 967. A male client recently diagnosed with diabetes mellitus requiring insulin tells the clinic nurse that he is traveling by air throughout the next week. The client asks the nurse for any suggestions about managing the disorder while traveling. The nurse tells the client to: 1. Check the blood glucose every 2 hours during the flight

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2. Obtain referrals to physicians in the destination cities 3. Keep snacks in carry-on luggage to prevent hypoglycemia during the flight 4. Pad the insulin and syringes against breakage and place in a suitcase to be stowed Answer: 3 Rationale: A frequent concern of diabetic clients during air travel is the availability of food at times that correspond with the timing and peak action of the client’s insulin. For this reason, the nurse may suggest that the client have carbohydrate snacks on hand. Insulin equipment and supplies should always be placed in carry-on luggage (not stowed). This provides ready access to treat hyperglycemia, if needed, and prevents loss of equipment if luggage is lost. Options 1 and 2 are unnecessary. Test-Taking Strategy: Use the process of elimination. Remember that hyperglycemia or hypoglycemia can occur if mealtimes are disrupted for the client with diabetes mellitus. Look for the option that indicates a measure to prevent or manage these complications. This will direct you to option 3. Review the teaching points for the diabetic client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, pp. 961, 969. 968. A client with a major burn is admitted to the emergency department. The nurse anticipates that which of the following medication routes will be prescribed for analgesics for this client? 1. Intramuscular 2. Intravenous 3. Oral 4. Subcutaneous Answer: 2 Rationale: The client with a major burn should receive medications by the intravenous route whenever possible. Oral medications are not absorbed well because the gastrointestinal tract slows with burn shock or paralytic ileus. The parenteral routes (subcutaneous and intramuscular) are avoided because absorption may be poor or erratic because of fluid shifts as a result of the burn injury. Test-Taking Strategy: Recall the concepts related to fluid shifts and altered gastrointestinal function that occur with a burn injury to answer this question. Eliminate option 3 first, recalling that the client will be placed on NPO status. From the remaining options, remember that options that are similar are not likely to be correct. This enables you to eliminate options 1 and 4 next. Review care to the client following a burn injury if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Integumentary

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Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 91. 969. A client who has a history of chronic ulcerative colitis is anemic. The nurse interprets that which factor is most likely responsible for this laboratory finding? 1. Decreased intake of dietary iron 2. Intestinal malabsorption 3. Blood loss 4. Lack of appetite Answer: 3 Rationale: The client with ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support option 1 or 4. In ulcerative colitis the large intestine is involved, not the small intestine where vitamin B12 and folic acid are absorbed (option 2). Test-Taking Strategy: Use the process of elimination and knowledge of the pathophysiology of ulcerative colitis. Recalling that the client with ulcerative colitis often has bloody stools will direct you to option 3. Review the manifestations associated with ulcerative colitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 818. 970. A nurse is caring for a client following a total hip replacement. The client has iron deficiency anemia. The nurse instructs the client to increase intake of which of the following foods? 1. Lean beef and chicken liver 2. Milk and yogurt 3. Potatoes and carrots 4. Apples and mangos Answer: 1 Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver, and other organ meats; blackstrap molasses and oysters. Milk products are lowest in iron of all the food sources listed. Test-Taking Strategy: Focus on the issue, iron deficiency anemia. Using the process of elimination and knowledge regarding these food items high in iron will direct you to option 1. Review the foods high in iron if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal

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Reference: Nix, S. (2005). Williams’ basic nutrition & diet therapy (11th ed.). St. Louis: Mosby, pp. 142-143. 971. A physician has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which of the following to enhance compliance with therapy? 1. Chew the tablet thoroughly 2. Decrease fluid intake 3. Decrease dietary fiber 4. Take the medication following a meal Answer: 4 Rationale: Iron preparations can be very irritating to the stomach and are best taken after a meal. The tablet is swallowed whole, not chewed. Because the client may experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. Test-Taking Strategy: Focus on the issue, to enhance compliance with therapy. Use the process of elimination and eliminate options 2 and 3 first because these actions will worsen the side effects of iron therapy. General principles related to medication therapy will assist in eliminating option 1. Review client teaching points related to the administration of iron if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 576. 972. A client with Crohn’s disease is seen by the physician and a complete blood count (CBC) has been ordered. The nurse provides instructions to the client who will be reporting to the laboratory in the morning to have the blood test drawn. The nurse gives the client which of the following information about this test? 1. The client must fast after midnight 2. Drink extra liquids for the remainder of the day 3. Avoid red meat for the remainder of the day 4. No special preparation is necessary Answer: 4 Rationale: For most hematological laboratory studies, including a CBC, there is no special care needed either before or after the test. There is no reason to fast after midnight, drink extra liquids, or avoid red meat before the laboratory test is drawn. Test-Taking Strategy: To answer this question accurately, you must be familiar with this laboratory test. Remember that there is no special preparation for this test. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal

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Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 402-403. 973. A bone marrow aspiration is scheduled for a client suspected of having leukemia. The nurse prepares supplies for the procedure and plans to bring which of the following skin cleansing agents to the bedside before this procedure? 1. Soap and water 2. Povidone-iodine (Betadine) 3. Hydrogen peroxide 4. Alcohol swabs Answer: 2 Rationale: Before bone marrow aspiration, the site is cleansed with an antiseptic solution, such as povidone-iodine (Betadine). This helps reduce the number of bacteria on the skin and decreases the risk of infection from the procedure. The other options are incorrect. Test-Taking Strategy: Use the process of elimination to answer the question. Knowledge of general asepsis and topical cleansing agents used before invasive diagnostic procedures will direct you to option 2. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 175. 974. A nurse is providing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. The nurse tells the client: 1. To drink liquids through a straw for the next few weeks 2. That showering is permitted, but swimming is to be avoided 3. To increase fluids and take a stool softener daily 4. That there are no limitations with activities with this type of surgery Answer: 3 Rationale: Following ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, avoid air travel, and avoid coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is also avoided. Clients need to avoid rapidly moving the head, bouncing, and bending over for 3 weeks. Test-Taking Strategy: Use the process of elimination. Consider the anatomical area of the surgical procedure in eliminating options 1 and 2. From the remaining options, recalling general postoperative principles will assist in eliminating option 4. Review home care instructions following a fenestration procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning

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Content Area: Adult Health/Ear References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1988. Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1130. 975. A client with leukemia who had a bone marrow aspiration is thrombocytopenic. The nurse gives which of the following instructions to the family as the client is discharged to home? 1. Do not administer acetaminophen (Tylenol) for discomfort 2. Watch the puncture site for bleeding for the next several days 3. Take the client’s temperature daily for a week 4. Force fluid intake for the next 3 days Answer: 2 Rationale: The client who is thrombocytopenic is at risk for bleeding. The family should observe the puncture site for bleeding for several days after the procedure. Acetaminophen may be given for discomfort, but acetylsalicylic acid (aspirin) should be avoided because it can aggravate bleeding. It is unnecessary to monitor the client’s temperature daily for a week. The client is not at added risk for infection with thrombocytopenia, which is a low platelet count. There is no reason to force fluids following this procedure. In fact the client should not be forced to do anything. Test-Taking Strategy: Use the process of elimination and focus on the key word thrombocytopenic. Recalling that this condition places the client at risk for bleeding will direct you to option 2. Review the priorities of care for a client who is thrombocytopenic if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 176. 976. A client with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is most likely caused by which of the following conditions that is part of the client’s health history? 1. Decreased dietary intake of iron 2. Hemigastrectomy 3. Excessive vitamin C intake 4. Hypothyroidism Answer: 2 Rationale: Pernicious anemia may develop as a complication in the client who has had surgical resection of the stomach or small intestine. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with

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iron supplements. Excessive vitamin C intake and hypothyroidism are unrelated to pernicious anemia. Test-Taking Strategy: Use the process of elimination and knowledge of the risk factors for pernicious anemia to answer this question. Remember that pernicious anemia may develop as a complication in the client who has had surgical resection of the stomach or small intestine. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 190. 977. A nurse is reviewing the health care record of a client suspected of having mastoiditis. Which finding does the nurse expect to note if this disorder is present? 1. Swelling behind the ear 2. A clear tympanic membrane 3. A mobile tympanic membrane 4. A transparent tympanic membrane Answer: 1 Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. Test-Taking Strategy: Knowledge regarding the findings associated with mastoiditis is required to answer this question. Noting that options 2, 3, and 4 are normal findings will assist in directing you to the correct option. Review the clinical manifestations of mastoiditis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Ear Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1983. 978. A nursing student is caring for a client in the health care clinic who has glaucoma. The nursing instructor asks the student to describe the type of medication that will most likely be prescribed for the client to treat the eye disorder. Which statement by the student indicates an accurate understanding of the treatment for glaucoma? 1. “A miotic agent will lower the pressure in the eye and increase the blood flow to the retina.” 2. “A dilating agent will help to dilate the eye to prevent pressure from occurring.” 3. “A cycloplegic agent will relax the muscles of the eyes and prevent blurred vision.” 4. “A mydriatic agent will help to block the responses that are sent to the muscles in the eye.”

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Answer: 1 Rationale: Miotics are used to lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of trabecular meshwork. Options 2, 3, and 4 all describe actions related to mydriatic medications, which primarily dilate the pupils and relax the ciliary muscles. These options are incorrect and are not used in the client with glaucoma. Test-Taking Strategy: Use the process of elimination. Recalling that prevention of increased intraocular pressure is the goal in clients with glaucoma will assist in directing you to the correct option. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 577. 979. A nursing student is preparing to assist with an ear irrigation on an assigned client who has a build-up of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The instructor determines that the student understands this procedure if the student tells the instructor that: 1. The client is positioned with the ear to be irrigated facing upward 2. The irrigating solution is warmed to 100° F 3. A direct and slow, steady stream of irrigation solution is directed toward the eardrum 4. The client is positioned with the affected ear up following the irrigation Answer: 2 Rationale: Irrigation solutions that are not close to the client’s body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward because this allows gravity to assist in the removal of the earwax and solution. Following the irrigation, the client is to lie on the affected side for a short time to finish the drainage of the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the tympanic membrane (ear drum). Too much force could cause the tympanic membrane to rupture. Test-Taking Strategy: Use the process of elimination. Read each option carefully and remember that the concern is to prevent damage to the eardrum. Therefore option 3 can be eliminated. Visualize the procedure to assist in eliminating options 1 and 4. Additionally, remember that the client should be positioned with the affected side downward to allow drainage of the irrigation solution. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Eye Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1081.

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980. A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse provides instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? 1. “I need to have clear fluids only on the morning of the test.” 2. “I need to shower on the morning of the test using povidone-iodine (Betadine).” 3. “I need to stop taking my antihistamine 2 days before I come to the clinic for the test.” 4. “I need to take my prednisone (Deltasone) on the morning of the test.” Answer: 3 Rationale: Client preparation for a patch test includes informing the client to discontinue the administration of systemic corticosteroids or antihistamines for at least 48 hours before the test. Topical steroid therapy may be continued as long as the agent is not applied on the area to be tested. To prevent suppression of the inflammatory response to an allergen, these medications must be discontinued. There are no dietary restrictions, and the client is not instructed to shower on the morning of the test using povidoneiodine, which is very irritating to already irritated skin. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate options 1 and 2 first. There is no reason to maintain dietary restriction, and considering the client’s disorder, it could be harmful to use povidone-iodine on the skin. Focus on the purpose of the test to assist in directing you to option 3. Review client instructions for this test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Integumentary Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1386-1387. 981. A client calls the health care clinic and tells the nurse that he was bitten by a tick. The client is concerned and asks the nurse about the first signs of Lyme disease. The nurse informs the client that stage 1 of Lyme disease is characterized by: 1. Tremors and weakness 2. Painful joints 3. Headaches and blurred vision 4. Skin rash Answer: 4 Rationale: The hallmark of stage 1 is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull’s-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage 1, flulike symptoms that last 7 to 10 days develop in most infected people, and these symptoms may reoccur later. Options 1, 2, and 3 are not the first symptoms related to Lyme disease. Test-Taking Strategy: Note the key words first signs. Because the issue of the question relates to stage 1 of Lyme disease, eliminate options 1 and 2. It is necessary to know that

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a skin rash is characteristic of this stage to answer the question correctly. If you had difficulty with this question, review the stages of Lyme disease. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1737. 982. A client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which of the following questions should the nurse ask next? 1. “Did you save the tick for inspection?” 2. “When were you bitten by the tick?” 3. “Was the tick small or large?” 4. “Did the tick bite anyone else in the family?” Answer: 2 Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are similar. From the remaining options, focus on the issue of the question, the timing of the blood test. This will direct you to option 2. If you had difficulty with this question, review the method of diagnosing Lyme disease. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Integumentary Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 202. 983. A nurse is reviewing the physician’s orders written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which order? 1. Administer antibiotics 2. Apply cold compresses to the affected area 3. Obtain blood cultures 4. Administer acetaminophen (Tylenol) for fever Answer: 2 Rationale: Warm compresses, such as moist heat, may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics are initiated. The nurse should provide supportive care as prescribed to manage symptoms, such as fatigue, fever, chills, headache, and myalgia. Cold compresses are not a component of the treatment measures. Test-Taking Strategy: Use the process of elimination and note the key words question which order. Noting the diagnosis cellulitis will assist in directing you to option 2. Review the treatment measures for cellulitis if you had difficulty with this question.

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Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 494. 984. A clinic nurse has provided home care instructions to a client with glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma? 1. “I need to restrict my fluid intake to four glasses daily.” 2. “I need to take my eye drops for the rest of my life.” 3. “I can use salt only for cooking.” 4. “I need to limit my amount of reading to 2 hours a day.” Answer: 2 Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. Clients need to be instructed that medications will need to be taken for the rest of their life. Limiting fluids and reducing salt intake will not decrease intraocular pressure. Restricting the amount of time reading is not a component of the plan. Test-Taking Strategy: Use the process of elimination. Recalling that medications are an integral component of the treatment plan and are needed for life will direct you to option 2. Review the treatment associated with the care of the client with glaucoma if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Eye Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 580. 985. A client has an order to have radial arterial blood gases drawn. Before drawing the sample, an Allen’s test will be performed. In performing the Allen’s test, the nurse assists to occlude the: 1. Brachial and radial artery, then releases them and observes the circulation to the hand 2. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery 3. Radial artery and observes for color changes in the affected hand 4. Ulnar artery and observes for color changes in the affected hand Answer: 2 Rationale: Before drawing an arterial blood gas, the nurse checks the collateral circulation to the hand with the Allen’s test. This involves compressing both the radial and ulnar arteries and asking the client to close and open the fist. This should cause the hand to become pale. The nurse then releases pressure on one artery and observes if circulation is quickly restored. The process is then repeated, releasing the other artery. The blood sample may be safely taken if there is adequate collateral circulation.

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Test-Taking Strategy: To answer this question correctly, you must first know that collateral circulation to the hand must be ensured before drawing arterial blood gases. Recalling the anatomical location of the arteries that supply the hand with blood will direct you to option 2. Review the procedure for performing the Allen’s test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 248. 986. A client in labor asks the nurse why it is so important to void frequently during labor. The nurse responds using knowledge that the most important reason is to: 1. Ensure comfort and conserve energy 2. Prevent fetal placental complications 3. Ensure labor progress and prevent injury 4. Maintain adequate pain control Answer: 3 Rationale: Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor. The statements contained in the other options are incorrect. Test-Taking Strategy: Use the process of elimination and knowledge about the physiology of labor to answer this question. Recalling the anatomical location of the bladder will assist in directing you to option 3. Review the rationale for nursing interventions during labor if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 110. 987. A nurse is caring for a client in labor. The fetal heart rate (FHR) is 156 beats/min and regular. The client’s contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which of the following at this time? 1. Continue monitoring the client because the data reflect acceptable progress 2. Prepare for imminent delivery of the fetus 3. Report the contractions because they reflect a potential complication 4. Report the FHR immediately Answer: 1 Rationale: The normal FHR ranges from 120 to 160 beats/min. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and an irregular FHR. Based on the data in the question, the nurse should continue to monitor the client.

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Test-Taking Strategy: Use the process of elimination and knowledge of the expected findings during labor. Focusing on the data in the question will assist in eliminating options 2, 3, and 4 because they are unnecessary actions. Review the normal and expected findings during labor if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 110. 988. A nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 ml during the past 2 hours. The nurse should do which of the following at this time? 1. Change the woman to a side-lying position 2. Notify the registered nurse of a possible prolapsed cord 3. Notify the registered nurse of a possible maternal infection 4. Administer oxygen at 8 to 10 L/min by face mask Answer: 3 Rationale: Signs of maternal infection include foul-smelling amniotic fluid, a maternal fever in the presence of adequate hydration (adequate urine output) and fetal tachycardia. The nurse should inform the registered nurse of this data (who will then notify the physician) so that treatment can be initiated. Options 1, 2, and 4 are unrelated to the data in the question. Test-Taking Strategy: Use the process of elimination. Noting the relationship between the data in the question and option 3 will direct you to this option. Review the signs of maternal infection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 231. 989. A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse take first? 1. Place the woman in either a side-lying position or high Fowler’s position 2. Wrap the cord loosely in a sterile towel saturated with warm sterile normal saline 3. Palpate and evaluate contractions while calling the physician 4. Obtain the equipment to insert an intravenous (IV) line Answer: 2 Rationale: When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Nursing actions are directed at reducing cord compression and facilitating delivery of the fetus. The client should be placed in the

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extreme Trendelenburg’s, Sims position, or knee-chest position to reduce cord compression. The physician is notified, and an IV is started after initiating emergency care for the client. Test-Taking Strategy: Use the process of elimination and note the key word first. Note the relationship between the data in the question and option 2. Review emergency measures for a prolapsed cord if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 248. 990. A client has had a midline episiotomy. In relation to a mediolateral episiotomy, the nurse anticipates that this client will generally experience: 1. Greater blood loss 2. No blood loss 3. Greater pain 4. Less pain Answer: 4 Rationale: Midline episiotomies are effective, easily repaired, and generally result in less pain. The blood loss is greater, and the repair is more difficult and painful with the mediolateral episiotomy than the midline episiotomy. Test-Taking Strategy: Use the process of elimination and knowledge concerning the differences between midline and mediolateral episiotomies. Eliminate option 2 first because of the absolute word “no.” Eliminate options 1 and 3 next because of the presence of the word “greater” in both options. Review these types of episiotomies if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 245. 991. The nurse most accurately measures the amount of lochial flow following delivery by using which of the following methods? 1. Weigh each perineal pad after use in relation to the number of pads used 2. Gauge the extent of staining on the perineal pad in relation to the time factor involved 3. Estimate the amount of blood loss by gauging the extent of staining on a perineal pad 4. Weigh the perineal pad before and after use in relation to the time factor involved Answer: 4 Rationale: To gather accurate observable data for objective comparison, the perineal pads must be weighed before and after use. Once these two weights are gathered, the amount of lochial flow can be accurately determined. Each gram increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain an accurate estimate of lochial flow,

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the time factor must be incorporated into the analysis. The other options are incorrect. Test-Taking Strategy: Use the process of elimination and note the key words most accurately. With this in mind, determine that the time factor must be included along with calculation of volume by weight to accurately determine blood loss. This will direct you to option 4. Review assessment of lochial flow if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 206. 992. A hospitalized client is dyspneic and has a left pneumothorax on a chest x-ray. Which of the following signs or symptoms observed by the nurse most clearly indicates that the pneumothorax is rapidly worsening? 1. Pain with respiration 2. Hypertension 3. Tracheal deviation to the right 4. Respiratory rate of 18 breaths per minute Answer: 3 Rationale: A pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis. The client could have pain with respiration even with a milder pneumothorax. The increased intrathoracic pressure causes the blood pressure to fall, not rise. A respiratory rate of 18 breaths per minute is within the normal range. Test-Taking Strategy: Use the process of elimination and note the key words rapidly worsening. Recalling that an extending pneumothorax causes the trachea to be pushed in the opposite direction will direct you to option 3. Review the signs or symptoms associated with complications following pneumothorax if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 387. 993. The nurse is assisting in caring for a client with preeclampsia who is receiving magnesium sulfate. During the administration of this medication, the nurse should particularly check which of the following? 1. Deep tendon reflexes 2. Apical heart rate 3. Degree of edema 4. Presence of pitting peripheral edema Answer: 1

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Rationale: Loss of reflexes is often the first sign of developing toxicity. The nurse should assess the knee jerk (patellar tendon reflex) for evidence of diminished or absent reflexes. Although options 2, 3, and 4 may be components of the assessment, these are not the priority with this medication. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 because they are similar. From the remaining options, note that option 1 is specific to the administration of this medication. Review this medication and the nursing responsibilities associated with its administration if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 661. 994. A client is returned to the nursing unit with chest tubes in place following thoracic surgery. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage and expects to note that it is: 1. Serous 2. Serosanguineous 3. Bloody 4. Bloody with clots Answer: 3 Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing. Test-Taking Strategy: Use the process of elimination. Recall that following thoracic surgery there may be considerable capillary oozing for some hours in the postoperative period. This would lead you to choose the bloody drainage over serous or serosanguineous. Knowing that patent chest tubes do not allow blood to collect in the pleural space eliminates the option of blood with clots. Review the expected findings in the client with a chest tube if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1864-1865. 995. A nurse assists in preparing a care plan for the client who will be returning from surgery following a right wedge resection. Included in the plan is that in the postoperative period the nurse should avoid positioning this client: 1. In low Fowler’s 2. In semi-Fowler position

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3. On the left side 4. Laterally, on the right side Answer: 4 Rationale: Following a wedge resection, the client should not be placed on the operative side. Lying on the operative side hinders expansion of remaining lung tissue and may accentuate perfusion of poorly ventilated tissue. This further impedes normal gas exchange. Test-Taking Strategy: Use the process of elimination and note the key word avoid. This word indicates a false-response question and that you need to select the incorrect position. Eliminate options 1 and 2 first because they are similar. From the remaining options, it is necessary to know that the client should not be positioned on the operative side. If you had difficulty with this question, review postoperative care following this surgical procedure. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, pp. 553-555. 996. Strong iodine solution (Lugol’s solution) is prescribed for a client. The client calls the nurse in the physician’s office and reports symptoms of a brassy taste in the mouth when taking the medication. Which of following instructions does the nurse provide to the client? 1. Continue to take the medication because the symptoms are normal 2. Dilute the medication in 8 oz of juice 3. The physician will need to be notified for further medication instructions 4. Take half of the prescribed dose for the next few days Answer: 3 Rationale: The client should be informed about symptoms of iodism that can occur with the administration of iodine solution. These symptoms include a brassy taste, burning sensation in the mouth, and soreness of gums and teeth. The client should be instructed to withhold the medication and notify the physician if these signs occur. Test-Taking Strategy: Focus on the data in the question. Knowing that a brassy taste is a sign of mild toxicity will direct you to option 3. Review the adverse effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 629. 997. A nurse is assisting in preparing a plan of care for a client who will be receiving oxytocin (Pitocin) The nurse understands that the action of oxytocin is to:

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1. Increase the force of uterine contractions 2. Increase maternal alertness during labor 3. Decrease the frequency of uterine contractions 4. Decrease the duration of uterine contractions Answer: 1 Rationale: Oxytocin is a uterine stimulant that increases the force, frequency, and duration of uterine contractions. Options 2, 3, and 4 are incorrect actions. Test-Taking Strategy: Use the process of elimination. Recalling that oxytocin is a uterine stimulant will direct you to option 1. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 697. 998. A nurse is caring for a woman in the delivery room. The physician prescribes an oxytocic medication for the woman to stimulate uterine contractions and prevent hemorrhage. The nurse understands that this medication will be administered after delivery of the: 1. Infant’s body 2. Placenta 3. Infant’s head 4. Infant’s shoulders Answer: 2 Rationale: Oxytocics are administered because they stimulate the uterus to contract, thereby helping to prevent hemorrhage after the placenta is removed. If an oxytocic medication is ordered, the nurse administers the medication after the placenta has been expelled. If the medication is given before the delivery of the placenta, it can cause the uterus to contract more forcefully and restrict delivery. Test-Taking Strategy: Use the process of elimination. Remember that options that are similar are not likely to be correct. In this case each of the incorrect options addresses a part of the infant’s body, whereas the correct option addresses the placenta. Review the administration of oxytocic medications following delivery if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 597. 999. Following delivery, a client experiences subinvolution of the uterus. The nurse plans care, recalling that which of the following is the primary cause for this occurrence? 1. Maternal hypertension

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2. Increased estrogen levels 3. Increased progesterone levels 4. Retained placental fragments Answer: 4 Rationale: Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination and note the key words primary cause. Focusing on the condition identified in the question will assist in directing you to option 4. Review the causes of subinvolution if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 291-292. 1000. A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago, but has not relieved the discomfort. The nurse should avoid doing which of the following at this time to assist in relieving the back discomfort? 1. Allow the client to sit on the side of the bed 2. Assist the client to ambulate in the room 3. Turn the client to the lateral position 4. Place a pillow under one hip when lying in the supine position Answer: 2 Rationale: Ambulation should be avoided because the client is in active labor and received an analgesic 1 hour ago. Each of the other options identifies measures that are both safe and effective to reduce back discomfort for the client. Test-Taking Strategy: Use the process of elimination and note the key word avoid. This word indicates a false-response question and that you need to select the incorrect action. Focusing on the data in the question and noting that the client received an analgesic will direct you to option 2. Review measures to relieve back discomfort in the client in labor if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1000.

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