PN COMPREHENSIVE REVIEW QUESTIONS 101-200

{COMP: Equations/formulas in questions 158-160, 162-164}

101. A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. The nurse tells the mother to: 1. Give the child “children’s aspirin” for the discomfort 2. Give the child acetaminophen (Tylenol) for the discomfort 3. Speak to the physician because the child should not be having any discomfort 4. Be sure that the child is resuming normal activities Answer: 2 Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen can be given to relieve the discomfort. Aspirin should not be administered to the child. The child should rest if discomfort is present. Test-Taking Strategy: Use the process of elimination. Options 1 and 4 can be eliminated by knowing that aspirin should not be given to a child and that the child should rest if discomfort is present. It seems reasonable that the child may have some discomfort following this surgical procedure; therefore eliminate option 3. Review home care instructions for the child following this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1199. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 136. 102. A nurse provides discharge instructions to the mother of a child who had a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further instructions? 1. “I need to be sure my child uses soft Kleenex to blow his nose.” 2. “I will put earplugs in my child’s ears during bathing.” 3. “I will not allow my child to swim in deep water.” 4. “I will not allow my child to swim in lake water.” Answer: 1 Rationale: Parents need to be instructed that the child should not blow their nose for 7 to 10 days. Bath water and lake water are potential sources of bacterial contamination. Diving into water and swimming deeply under water are prohibited. The child’s ears need to be kept dry. Options 2, 3, and 4 are appropriate statements. Test-Taking Strategy: Use the process of elimination and note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Options 2, 3, and 4 are similar, and all relate to the concept of keeping the ears dry. Option 1 may cause disruption of the surgical site.

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Review parent instructions following this procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1199. 103. A nurse is reviewing the laboratory results of a child scheduled for a tonsillectomy. Which laboratory value would be most significant to review? 1. Platelet count 2. Urinalysis results 3. Blood urea nitrogen (BUN) level 4. Creatinine level Answer: 1 Rationale: Before the surgical procedure, the child is assessed for signs of active infection and for redness and exudate of the throat. Because the tonsillar area is extremely vascular, postoperative bleeding is a concern. The prothrombin time (PT), partial thromboplastin time (PTT), platelet count, hemoglobin and hematocrit (H&H) levels, white blood cell (WBC) count, and urinalysis studies are performed preoperatively. The platelet count result would identify a potential for bleeding. The BUN and creatinine values would not determine the potential for bleeding; instead, they would evaluate renal function. Test-Taking Strategy: The issue of the question relates to the potential for bleeding. Options 2, 3, and 4 can be eliminated because they are similar and relate to kidney function. Review preoperative care for a tonsillectomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1202. 104. Following a tonsillectomy, which of the following physician orders would the nurse question? 1. Allow clear, cool liquids when awake 2. Allow ice cream when awake 3. Monitor for bleeding 4. Monitor vital signs Answer: 2 Rationale: Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, induce throat clearing, and increase the risk of bleeding. Options 3 and 4 are important nursing interventions following any type of surgery.

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Test-Taking Strategy: Note the key words would the nurse question. These words indicate a false response question and that you need to select the questionable physician’s order. Consider the anatomical location of the surgery to assist in answering the question. This should direct you to option 2. Review postoperative care following a tonsillectomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 599. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1202-1203. 105. A nurse is monitoring a child following a tonsillectomy. Which finding may indicate that the child is bleeding? 1. A decreased pulse rate 2. An elevation in blood pressure (BP) 3. Complaints of discomfort 4. Restlessness Answer: 4 Rationale: Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated BP is not an indication of bleeding. Complaints of discomfort are an expected finding following a tonsillectomy. Test-Taking Strategy: Use the concepts related to the signs of shock to assist in answering the question. These concepts should assist in eliminating options 1 and 2. From the remaining options, knowing that discomfort does not indicate bleeding will direct you to option 4. Review the signs of postoperative bleeding if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1202-1203. 106. Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement, if made by a parent, would indicate that the instructions were understood? 1. “We will administer the antibiotics if the child has a fever.” 2. “We will administer the antibiotics until the child feels better.” 3. “We will administer the antibiotics until they are gone.” 4. “We will begin to taper the antibiotics after 3 days of a full course.” Answer: 3 Rationale: Antibiotics need to be taken as prescribed, and the full course needs to be

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completed. It is important that parents are instructed regarding the administration of antibiotics. Options 1, 2, and 4 are incorrect. Antibiotics are not tapered but administered until they are completed. Test-Taking Strategy: Use the process of elimination. Recalling that antibiotics must be taken for the full course regardless of whether the child is feeling better will direct you to option 3. Review concepts related to the administration of antibiotics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1199. 107. A nurse is collecting data on a 2-year-old child diagnosed with croup. Which of the following findings are not associated with this illness? 1. Symptoms usually worsen at night and are better during the day 2. Symptoms usually worsen during the day and are relieved during sleep 3. The cough is harsh and metallic 4. Inspiratory stridor may be present Answer: 2 Rationale: Croup often begins at night and may be preceded by several days of upper respiratory tract infection symptoms. It is characterized by a sudden onset of a harsh, metallic cough, sore throat, and inspiratory stridor. Symptoms usually worsen at night and are better in the day. Test-Taking Strategy: Use the process of elimination and note the key words not associated. This word indicates a false response question and that you need to select the incorrect clinical manifestation. Remember that with croup symptoms usually worsen at night and are better in the day. This will direct you to option 2. Review the manifestations associated with croup if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 188. 108. A child with croup is being discharged from the hospital. The nurse provides home care instructions to the mother and advises the mother to bring the child to the emergency room if the child: 1. Appears tired 2. Takes fluids poorly 3. Is irritable 4. Develops stridor Answer: 4 Rationale: The mother should be instructed to bring the child to the emergency room if

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the child develops stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions, or is unable to take oral fluids. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. This should direct you to option 4. Review home care instructions related to croup if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health References: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 190. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1209. 109. A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the physician did not prescribe antibiotics. Which of the following is the correct response that the nurse should make to the mother? 1. “The child is too young to receive antibiotics.” 2. “The child still has the maternal antibodies from birth and does not need antibiotics.” 3. “Antibiotics are not indicated unless a bacterial infection is present.” 4. “The child may be allergic to antibiotics.” Answer: 3 Rationale: Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present. Options 1, 2, and 4 are incorrect. Additionally, there are no supporting data in the question to indicate that the child may be allergic to antibiotics. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 because there are no supporting data in the question regarding the potential for allergies. Noting the age of the child will assist in eliminating options 1 and 2. Review the indications for the use of antibiotics if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health References: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 981. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1214. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1363. 110. A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, is consistently crying, and tries to climb out of the tent. The appropriate nursing action would be to: 1. Call the registered nurse to obtain an order for a mild sedative 2. Tell the mother that the child must stay in the tent 3. Place a toy in the tent to make the child feel more comfortable

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4. Let the mother hold the child and direct a cool mist over the child’s face Answer: 4 Rationale: Crying will aggravate laryngospasm and increase hypoxia, which may cause airway obstruction. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child’s face. A mild sedative should not be administered to the child. Options 2 and 3 will not alleviate the child’s fear. Test-Taking Strategy: Use the process of elimination. Options 1, 2, and 3 will not alleviate the child’s fear. Additionally, they are all similar in that they do not address the fear. Option 4 is the option that addresses the issue of the question. Review care to the child in a mist tent if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 188. 111. A child with croup is placed in a cool-mist tent. The mother asks if the child can have his or her security blanket inside the tent. The appropriate response is: 1. “Objects from home are not allowed to be brought to the hospital.” 2. “The child may have the security blanket inside the tent.” 3. “The blanket is not allowed because it will promote the growth of bacteria.” 4. “The blanket is not allowed but the child may have a toy from the hospital play room.” Answer: 2 Rationale: Familiar objects provide a sense of security for children in the strange hospital environment. The child is allowed to have a favorite toy or blanket while in the mist tent. Options 1, 3, and 4 are inappropriate statements. Test-Taking Strategy: Use the process of elimination and note the key words cool-mist tent. Option 1 can be easily eliminated first. Next eliminate options 3 and 4 because they are similar. Also, remember that a warm environment (not cool) promotes the growth of bacteria. Review care to the child in a mist tent if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 188. 112. A mother arrives at the emergency room with her child, and a diagnosis of epiglottitis is documented for the child. Which of the following physician orders would be most important for the nurse to question? 1. Obtain a throat culture 2. Obtain axillary temperatures 3. Administer humidified oxygen 4. Administer antipyretics for fever

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Answer: 1 Rationale: The throat of a child with suspected epiglottitis should not be examined or cultured, because any stimulation with a tongue depressor or culture swab could cause laryngospasm and complete airway obstruction. Humidified oxygen and antipyretics are components of the treatment. Axillary rather than oral temperatures should be taken. Test-Taking Strategy: Use the process of elimination. Recalling the high probability for complete airway obstruction in a child with epiglottitis will direct you to option 1. Review care to the child with epiglottitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 191. 113. An emergency room nurse is gathering initial data on a child suspected of epiglottitis. The nurse’s priority would be to: 1. Prepare the child for an x-ray 2. Assist the physician with intubation 3. Prepare the child for tracheotomy 4. Assess for a patent airway Answer: 4 Rationale: When epiglottitis is suspected, the priorities are to maintain a patent airway and to obtain an x-ray to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate construction of a surgical airway. Although options 1, 2, and 3 may be components of care, they are not the priority. Test-Taking Strategy: Note the key word priority in the question. Use the ABCs— airway, breathing, and circulation—to direct you to option 4. Review care to the child with suspected epiglottitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 190. 114. A nurse caring for an infant with bronchiolitis is monitoring for signs of dehydration. The nurse monitors which of the following as the most reliable method of determining fluid loss? 1. Intake 2. Output 3. Skin turgor 4. Body weight Answer: 4 Rationale: Body weight is the most reliable method of measurement of body fluid loss or

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gain. One kilogram of weight change represents 1 liter of fluid loss or gain. Although options 1, 2, and 3 may be used to determine fluid status, they are not the most reliable determinants. Test-Taking Strategy: Use the process of elimination and note the key words most reliable. Options 1 and 2 can be eliminated first because they both relate to fluid status. Also, it would be very difficult to obtain an accurate output on an infant. From the remaining options, focusing on the key words will direct you to option 4. Review care to the infant with dehydration if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 597, 672. 115. Ribavirin (Virazole) is prescribed for the hospitalized child with respiratory syncytial virus (RSV). The nurse prepares to administer this medication via which of the following routes? 1. Intravenously 2. Intramuscularly 3. Via facemask 4. Orally Answer: 3 Rationale: Ribavirin is an antiviral respiratory medication that is used mainly in hospitalized children with severe RSV and in high-risk children. Administration is via hood, facemask, or oxygen tent. The medication is most effective if administered within the first 3 days of the illness. Test-Taking Strategy: Knowledge regarding the administration of this medication is required to answer this question. Remember, administration of this medication is via hood, facemask, or oxygen tent. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 598. 116. Which of the following precautions will the nurse specifically take during the administration of ribavirin (Virazole) to a child with respiratory syncytial virus (RSV)? 1. Hand washing before administration 2. Wearing goggles 3. Wearing a gown 4. Wearing a gown and a mask Answer: 2 Rationale: Some caregivers experience headaches, burning nasal passages and eyes, and

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crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A mask may be worn. Hand washing is to be performed before and after any child contact. A gown is not necessary. Test-Taking Strategy: Note the key word specifically. Recalling that this medication is administered via hood, facemask, or oxygen tent will direct you to the correct option. Review this medication 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: Child Health References: deWit, S. (2005). Fundamental concepts and skills for nursing, Philadelphia: W.B. Saunders, p. 212. Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 598. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1214. 117. A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening? 1. Increased wheezing 2. Decreased wheezing 3. Warm, dry skin 4. A pulse rate of 90 beats per minute Answer: 2 Rationale: Decreased wheezing in a child who is not improving clinically may be incorrectly interpreted as a positive sign when, in fact, it may signal an inability to move air. A “silent chest” is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child’s condition is improving. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute. Warm, dry skin indicates an improvement in the condition because the child is normally diaphoretic during exacerbation. Test-Taking Strategy: Use the process of elimination. Noting the key word worsening will assist in eliminating options 3 and 4. From the remaining options, it is necessary to know the signs of improvement in a child treated for asthma. Remember, decreased wheezing may signal an inability to move air. Review these clinical manifestations if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1224-1225. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 294. 118. A mother arrives at the clinic with her 3-year-old child. The mother tells the nurse

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that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which of the following would the nurse anticipate to be a component of the treatment plan? 1. Oral antibiotics 2. Hospitalization and antibiotics 3. Supportive treatment 4. Intravenous (IV) fluid administration Answer: 3 Rationale: With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia, however, is treated with antibiotic therapy. Test-Taking Strategy: Use the process of elimination and note the key word viral in the question. Recalling that antibiotics are not effective in treating viruses will assist in eliminating options 1 and 2. There are no data in the question to support the need for IV fluid administration. This leaves option 3 as the correct answer. It is also the umbrella (global) option. Review care to the child with viral pneumonia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1217-1218. 119. A mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child has discomfort on the right side and that the acetaminophen (Tylenol) is not very effective. The appropriate suggestion by the nurse would be to: 1. Increase the dose of acetaminophen 2. Increase the frequency of acetaminophen administration 3. Encourage the child to lie on the right side 4. Encourage the child to lie on the left side Answer: 3 Rationale: Splinting of the affected side by lying on that side may decrease discomfort. It is inappropriate to advise the mother to increase the dose or frequency of the acetaminophen. Lying on the left side will not be helpful in alleviating discomfort. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 can be eliminated first because the nurse would not provide pharmacological instructions. Recalling the principles related to splinting an incision in the postoperative client will assist in directing you to option 3 from the remaining options. Review care to the child with pneumonia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.).

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Philadelphia: W.B. Saunders, p. 192. 120. A nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which clinical manifestation of this disorder would the nurse expect to note documented in the record? 1. Excessive oral secretions 2. Coughing, wheezing, and short periods of apnea 3. Bowel sounds heard over the chest 4. Hiccupping and spitting up after a meal Answer: 4 Rationale: Clinical manifestations of all types of gastroesophageal reflux include vomiting (spitting up) after a meal, hiccupping, and recurrent otitis media related to pooled secretions in the nasopharynx during sleep. Option 1 is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Option 2 is a clinical manifestation of hiatal hernia. Option 3 is a clinical manifestation of congenital diaphragmatic hernia. Test-Taking Strategy: Knowledge of the clinical manifestations associated with gastroesophageal reflux will easily direct you to the correct option. Note the word “reflux” in the question and the relation to “hiccupping and spitting up after a meal.” If you had difficulty with this question, review the manifestations of this disorder. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 665. 121. A mother of a child with cystic fibrosis asks the clinic nurse about the disease. The nurse tells the mother that it is: 1. A disease that causes the formation of multiple cysts in the lungs 2. A chronic multisystem disorder affecting the exocrine glands 3. Transmitted as an autosomal dominant trait 4. A disease that causes dilation of the passageways of many organs Answer: 2 Rationale: Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and the pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. Test-Taking Strategy: Knowledge regarding the physiology associated with cystic fibrosis is required to answer this question. If you knew that it was a multisystem disorder, you would easily be directed to option 2. Additionally, option 2 is the umbrella (global) option. Review the physiology associated with this disorder if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.).

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Philadelphia: W.B. Saunders, p. 144. 122. A sweat test is performed on a child with a suspected diagnosis of cystic fibrosis (CF). Which test result is suggestive of cystic fibrosis and will require further assessment and investigation? 1. Chloride level of 5 mEq/L 2. Chloride level of 10 mEq/L 3. Chloride level of 20 mEq/L 4. Chloride level of 40 mEq/L Answer: 4 Rationale: In a sweat test, sweating is stimulated on the child’s forearm with pilocarpine, the sample is collected on absorbent material, and the amount of sodium and chloride is measured. A sample of at least 50 mg of sweat is required for accurate results. A chloride level greater than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L is suggestive of CF and requires a repeat test. Options 1, 2, and 3 do not identify results that are positive for CF. Test-Taking Strategy: Note the key word suggestive. Based on the issue of this question, it is best to select the highest level. Review the interpretation of these test results if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 609. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 146. 123. A nurse is providing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the mother? 1. “The immunization schedule will need to be altered.” 2. “The child will receive all of the immunizations except for the polio series.” 3. “The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination.” 4. “The child should not receive any hepatitis vaccines.” Answer: 3 Rationale: It is essential that children with cystic fibrosis be adequately protected from communicable diseases by immunization. It is recommended that in addition to the basic series of immunizations, children with cystic fibrosis should also receive yearly influenza vaccines. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are similar. Recalling the importance of protection from communicable diseases, particularly in children with a disorder such as cystic fibrosis, will assist in directing you to option 3. Review the guidelines for the administration of immunizations if you had difficulty with this question.

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Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1244. 124. A nurse teaches a child with cystic fibrosis how to perform the “huff” maneuver and tells the child to take a: 1. Deep breath, hold it for 15 seconds, and then exhale slowly, whispering the word “huff.” 2. Shallow breath and then exhale rapidly, whispering the word “huff.” 3. Deep breath and then exhale rapidly, whispering the word “huff.” 4. Shallow breath, hold it for 10 seconds, and then exhale rapidly, whispering the word “huff.” Answer: 3 Rationale: The “huff” maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath and then exhaling rapidly, whispering the word “huff.” Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first by recalling that shallow breathing is ineffective in promoting the mobilization of secretions. Select option 3 over option 1 based on the knowledge that exhaling rapidly will assist in reducing bronchial collapse and mobilize secretions. Holding the breath will not achieve this physiological function. Recalling that the “huff” maneuver is also known as a forced expiratory technique will direct you to the correct option. Review this technique if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1244. 125. The mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8 AM, noon, and 6 PM. The nurse tells the mother that the postural drainage should be performed at: 1. 10 AM, 2 PM, and 8 PM 2. 9 AM, 1 PM, and 6 PM 3. 8 AM, noon, and 6 PM 4. 8 AM, 2 PM, and 6 PM Answer: 1 Rationale: Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is also important to perform these treatments before bedtime to clear airways and facilitate rest.

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Test-Taking Strategy: Visualize the procedure of postural drainage in answering the question. Recalling that this position may induce vomiting will assist in eliminating options 2, 3, and 4. 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: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 610. 126. A nursing instructor asks a nursing student about the use of the bacille CalmetteGuérin vaccine (BCG). The nursing student responds correctly knowing that the BCG vaccine is used for: 1. Children with a positive Mantoux test 2. Children with both a positive Mantoux test and a positive chest x-ray 3. All children to prevent tuberculosis (TB) 4. Asymptomatic human immunodeficiency virus (HIV) infected children who are at increased risk for developing TB Answer: 4 Rationale: The BCG vaccine is used mainly for children with a negative chest x-ray and skin test results who have had repeated exposures to TB, and for asymptomatic HIVinfected children who are at increased risk for developing TB. Test-Taking Strategy: Use the process of elimination. Recalling that BCG is a preventative vaccine will assist in eliminating options 1 and 2. From the remaining options, eliminate option 3 because of the absolute word “all” in this option. Review the indications for the use of this vaccine if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1246. 127. A client with Parkinson’s disease has been prescribed benztropine (Cogentin). The nurse monitors for which gastrointestinal (GI) side effect of this medication? 1. Diarrhea 2. Dry mouth 3. Increased appetite 4. Hyperactive bowel sounds Answer: 2 Rationale: Common GI side effects of benztropine therapy include constipation and dry mouth. Other GI side effects include nausea and ileus. These effects are the result of the anticholinergic properties of the medication. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are similar. From the remaining options, recalling that the medication is an anticholinergic would help you to choose dry mouth as the side effect. Review this

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medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity 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. 116. 128. A client with a history of simple partial seizures is taking clorazepate (Tranxene) and asks the nurse if there is a risk of addiction. The nurse’s response is based on the understanding that clorazepate: 1. Is not habit forming either physically or psychologically 2. Leads to physical and psychological dependence with prolonged high-dose therapy 3. Leads to physical tolerance, but only after 10 or more years of therapy 4. Can result in psychological dependence only, due to the nature of the medication Answer: 2 Rationale: Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative/hypnotic (benzodiazepine). One of the nursing implications of clorazepate therapy is that the medication can lead to physical or psychological dependence when there is prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because of the absolute word “only” in these options. From the remaining options, recalling that the medication is a benzodiazepine leads you to conclude that this medication can lead to physical as well as psychological dependence. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 213. 129. A client who was started on anticonvulsant therapy with clonazepam (Klonopin) tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse’s response is based on the understanding that these symptoms: 1. Are most severe during initial therapy, and decrease or disappear with long-term use 2. Indicate that the client is experiencing a severe untoward reaction to the medication 3. Are probably the result of an interaction with another medication 4. Usually occur if the client takes the medication with food Answer: 1 Rationale: Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose related, and usually diminish or disappear altogether with continued use of the medication. It does not indicate that a

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severe side effect is occurring. It is also unrelated to interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are similar and because of the word “severe” in option 2. From the remaining options, recalling that drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy will direct you to option 1. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial 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. 245. 130. A hospitalized client is having the dosage of clonazepam (Klonopin) adjusted. The nurse should plan to: 1. Monitor blood glucose levels 2. Institute seizure precautions 3. Weigh the client daily 4. Observe for areas of ecchymosis Answer: 2 Rationale: Clonazepam is a benzodiazepine that is used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client. Options 1, 3, and 4 are not associated with the use of this medication. Test-Taking Strategy: Focus on the name of the medication. Recalling that clonazepam is a benzodiazepine that is used as an anticonvulsant will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 245. 131. A client has an order for valproic acid (Depakene) orally once daily. The nurse plans to: 1. Administer the medication with a carbonated beverage 2. Administer the medication with an antacid 3. Ensure that the medication is administered 2 hours before breakfast only, when the client’s stomach is empty 4. Ensure that the medication is administered at the same time each day Answer: 4 Rationale: Valproic acid is an anticonvulsant, antimanic, and antimigraine medication. It may be administered with or without food. It should not be taken with an antacid or

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carbonated beverage because these products will affect medication absorption. The medication is administered at the same time each day to maintain therapeutic serum levels. Test-Taking Strategy: Use general pharmacology guidelines to assist in eliminating options 1 and 2. Eliminate option 3 because of the absolute word “only.” Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment 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. 885. 132. A client taking carbamazepine (Tegretol) asks the nurse what to do if he misses one dose. The nurse responds that the carbamazepine should be: 1. Withheld until the next scheduled dose, which should then be doubled 2. Withheld until the next scheduled dose 3. Taken as long as it is not immediately before the next dose 4. Contact the physician Answer: 3 Rationale: Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, as long as it is not immediately before the next dose. The medication should not be double dosed. If more than one dose is omitted, the client should call the physician. Test-Taking Strategy: Use general medication guidelines to eliminate option 1; medications are not double dosed if one dose is missed. From the remaining options, recalling that the medication is an anticonvulsant will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 137. 133. A nurse has given medication instructions to a client beginning anticonvulsant therapy with carbamazepine (Tegretol). The nurse determines that the client understands the use of the medication if the client agrees to: 1. Drive only during the daytime 2. Use sunscreen when outside 3. Keep tissues handy due to excess salivation that may occur 4. Discontinue the medication if fever or sore throat occurs Answer: 2 Rationale: Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other

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activities that require mental alertness until the effect on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth (not excessive salivation), and the client should be instructed to provide good oral hygiene, and use sugarless candy or gum as needed. The medication should not be abruptly discontinued, because it could cause return of seizures or status epilepticus. Fever and sore throat should be reported to the physician (leukopenia). Test-Taking Strategy: Use the process of elimination. Begin to answer this question by recalling that this is an anticonvulsant medication with CNS depressant properties. This would help to eliminate option 1 first, because driving in general could be hazardous. Option 4 is eliminated next because an anticonvulsant is not discontinued solely as a result of side effects or an infection. Rather, the physician should be called. To choose between the remaining options, remember that carbamazepine causes dry mouth. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance 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. 137. 134. A client with vascular headaches is taking ergotamine (Ergostat). The nurse would monitor the client for: 1. Hypotension 2. Dependent edema 3. Constipation 4. Cool, numb fingers and toes Answer: 4 Rationale: Ergotamine produces vasoconstriction, which suppresses vascular headaches when given at a therapeutic dose range. The nurse monitors for hypertension, cool, numb fingers and toes, muscle pain, and nausea and vomiting. Options 1, 2, and 3 are not associated with this medication. Test-Taking Strategy: To answer this question, first recall that vascular headaches are due to vasodilatation of the blood vessels in the head. Following this train of thought, you then recall that this medication must cause vasoconstriction. This would help you to eliminate each of the incorrect options. The only side effect consistent with vasoconstriction is option 4, the cool, numb fingers and toes. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity 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. 393. 135. A nurse is caring for a client with myasthenia gravis who has received edrophonium

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(Tensilon) intravenously. The client asks the nurse how long the improvement in muscle strength will last. The nurse’s response is based on the understanding that the effects have a duration of approximately: 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 60 minutes Answer: 3 Rationale: Edrophonium may be given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication and lasts for about 30 minutes. Test-Taking Strategy: This question is difficult to answer as stated without specific knowledge of the medication. You can eliminate options 1 and 2 because they are excessively brief timeframes, but you would need to know that the medication lasts for 30 minutes to choose between options 3 and 4. Review the effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 303. 136. A client with narcolepsy has been prescribed dextroamphetamine (Dexedrine). The client complains to the nurse that he no longer sleeps well at night and that he does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which of the following proper time schedules? 1. At least 6 hours before bedtime 2. Two hours before bedtime 3. After dinner each day 4. Just before going to bed Answer: 1 Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant, which acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Taking the medication at the timeframes indicated in options 2, 3, and 4 will prevent the client from sleeping because of the stimulant properties of the medication. Test-Taking Strategy: Focus on the name of the medication and recall that it causes CNS stimulation. This medication effect interferes with sleep. Knowing this, you would evaluate each of the options in terms of how far removed the scheduled dose is from the client’s bedtime. Evaluating the question in this way helps you to eliminate each of the incorrect options. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection

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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 312-313. 137. A client on the nursing unit has an order for dextroamphetamine (Dexedrine) orally daily. The nurse collaborates with the dietitian to limit the amount of which of the following items on the client’s dietary trays? 1. Starch 2. Caffeine 3. Protein 4. Fat Answer: 2 Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant. Caffeine is a stimulant also, and should be limited in the client taking this medication. The client should be taught to limit their own caffeine intake as well. Test-Taking Strategy: Focus on the name of the medication and recall that it is a CNS stimulant. You would then evaluate each of the options in terms of the additive stimulation provided by the items listed as options. Knowing that caffeine is also a stimulant would help you to choose this as the item to be limited. Review this medication 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: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 254. 138. A client with Parkinson’s disease has begun therapy with carbidopa/levodopa (Sinemet). The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for: 1. 24 hours 2. 2 to 3 days 3. 1 week 4. 2 to 3 weeks Answer: 4 Rationale: Signs and symptoms of Parkinson’s disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. Clients need to understand this concept to aid in compliance with medication therapy. Options 1, 2, and 3 are incorrect because of the short timeframes. Test-Taking Strategy: To answer this question, you need to know when the medication begins to produce the expected effects. Remember, signs and symptoms of Parkinson’s disease usually begin to resolve within 2 to 3 weeks of starting therapy. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance

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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. 491. 139. A client is taking trihexyphenidyl (Artane) for the treatment of Parkinson’s disease. The nurse would monitor for which adverse effect of this medication? 1. Urinary incontinence 2. Urinary retention 3. Diarrhea 4. Excessive perspiration Answer: 2 Rationale: Trihexyphenidyl is an anticholinergic medication. Because of this, it can cause urinary hesitancy and retention, constipation, dry mouth, and decreased sweating as side effects. Test-Taking Strategy: Recall that this medication has an anticholinergic action. By evaluating each of the options in terms of their consistency with anticholinergic effects, you can eliminate each of the incorrect options. Also, because options 1 and 2 directly oppose each other, you may automatically be drawn to choose between one of them as the correct option. Remember, trihexyphenidyl is an anticholinergic medication that can cause urinary hesitancy and retention. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity 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. 1080. 140. A client receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the nurse that his urine has turned a darker color as a result of taking this medication. The client wants to discontinue use of the medication. In formulating a response to the client’s concerns, the nurse interprets that this change is: 1. Indicative of developing toxicity 2. A sign of interaction with another medication 3. A harmless side effect of the medication 4. A result of taking the medication with milk Answer: 3 Rationale: With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are similar. From the remaining options, it is necessary to know that this is a harmless side effect. Review the side effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis

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Client Needs: Psychosocial 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. 167. 141. A client began taking amantadine (Symmetrel) approximately 2 weeks ago. The nurse would conclude that the medication was having a therapeutic effect if the client exhibited decreased: 1. White blood cell count 2. Voiding 3. Rigidity and akinesia 4. Blood pressure Answer: 3 Rationale: Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension are all adverse effects of the medication. Test-Taking Strategy: Note the key words therapeutic effect. Begin to answer this question by recalling that this medication is used to treat Parkinson’s disease. This would lead you to choose option 3 as the expected effects of the medication. Also, knowledge of the medication reinforces that the other options are incorrect, because they are all adverse effects of the medication. Review 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: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 168. 142. A client is receiving anticonvulsant therapy with phenytoin (Dilantin). The nurse plans to monitor the results of which laboratory test closely? 1. Complete blood count 2. Serum sodium level 3. Serum potassium level 4. Blood urea nitrogen level Answer: 1 Rationale: The nurse monitors the client’s complete blood count because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other values that warrant monitoring include serum calcium levels, and the results of urinalysis, hepatic function, and thyroid function tests. Test-Taking Strategy: Focus on the name of the medication. Recalling that phenytoin causes hematological side effects will direct you to option 1. If this question was difficult, review this medication. Level of Cognitive Ability: Analysis

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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. 691. 143. A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the order if the client had concurrent orders to take: 1. Furosemide (Lasix) 2. Valproic acid (Depakene) 3. Ibuprofen (Motrin) 4. Tranylcypromine (Parnate) Answer: 4 Rationale: The client should not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) or phenelzine (Nardil) within the last 14 days. Otherwise, the client could experience hyperpyretic crisis, convulsions, or death. Test-Taking Strategy: Note the key words withhold the medication and question the order. These words indicate a false response question and that you need to select the medication that is contraindicated with the use of cyclobenzaprine. Remember, cyclobenzaprine may not be taken when MAOIs have been administered within the last 14 days. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 224. 144. A nurse is discussing with clients primary prevention measures regarding osteoporosis. The nurse plans to tell the clients that which of the following is a primary prevention measure? 1. Selecting shoes that have firm, nonskid soles 2. Installing telephones in most rooms of the house 3. Applying nonskid strips on areas that get wet 4. Maintaining body weight at or slightly above minimum recommended levels Answer: 4 Rationale: Maintaining body weight at or slightly above minimum recommended levels is a primary prevention measure (thin, lean body build is a risk factor). Additional primary prevention measures include achieving optimal calcium intake, performing regular exercise, avoiding smoking and alcohol consumption, avoiding a high-sodium and high-protein diet, and consuming adequate amounts of vitamin D. Options 1, 2, and 3 include secondary preventive measures. Test-Taking Strategy: Note the key word primary. Use knowledge regarding the differences between primary and secondary prevention measures to direct you to option

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4. Remember, primary prevention measures prevent the condition from occurring. Review the measures that will prevent osteoporosis 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: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 123. 145. A nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1. Uric acid level of 8.0 mg/dl 2. Calcium level of 9.0 mg/dl 3. Phosphorus level of 3.0 mg/dl 4. Uric acid level of 5.0 mg/dl Answer: 1 Rationale: In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia greater than 7.0 mg/dl. Options 2, 3, and 4 all indicate normal laboratory values. Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis. Test-Taking Strategy: Focus on the client’s diagnosis and recall the pathophysiology associated with gout to direct you to option 1. Also note that options 2, 3, and 4 identify normal laboratory values, whereas option 1 indicates an elevated value. Learn this normal laboratory value 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/Musculoskeletal Reference: Linton, A., & Maebius, N. (2003) Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 814. 146. A nurse is caring for a client with osteoarthritis. The nurse monitors the client knowing that which of the following is a clinical manifestation associated with the disorder? 1. Pain that increases with activity and is relieved by rest 2. An elevated platelet count 3. Symmetrical joint discomfort 4. Elevated antinuclear antibody levels Answer: 1 Rationale: The stiffness and joint pain that occur in osteoarthritis increase with activity and are relieved with rest. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Unlike rheumatoid arthritis, joint involvement is usually not symmetrical. Elevated white blood cell counts, platelet counts, and antinuclear antibodies occur in rheumatoid arthritis.

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Test-Taking Strategy: Knowledge regarding the differences between osteoarthritis and rheumatoid arthritis is required to answer this question. Remember, the stiffness and joint pain that occur in osteoarthritis increase with activity and are relieved with rest. Review these differences 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/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 581. 147. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric (NG) tube. The nurse plans to: 1. Ask the registered nurse to notify the physician immediately 2. Continue to monitor the drainage 3. Measure abdominal girth 4. Irrigate the NG tube Answer: 2 Rationale: Following gastrectomy, drainage from the NG tube is normally bloody for 24 hours postoperatively and then changes to brown-tinged, and then to yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. There is no need to notify the physician at this time. Measuring abdominal girth is performed to detect the development of distension. Following gastrectomy, a NG tube should not be irrigated. Test-Taking Strategy: Use the process of elimination and note the key words immediate postoperative period. Recalling that bloody drainage is expected in this time period will direct you to option 2. If you had difficulty with this question, review the postoperative expected findings following gastrectomy. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, pp. 746-747. 148. A nurse is reviewing the medical history of a client admitted to the hospital with a diagnosis of colorectal cancer. The nurse understands that which data documented in the medical history are an unassociated risk factor of this type of cancer? 1. A history of inflammatory bowel disease 2. Family history of colon cancer 3. Regular consumption of a high-fiber diet 4. Regular consumption of a diet high in fats and carbohydrates Answer: 3 Rationale: Colorectal cancer most often occurs in populations with diets low in fiber and

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high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10-years duration. Test-Taking Strategy: Use the process of elimination and note the key word unassociated. Eliminate options 1 and 2 because they are similar and directly relate to the issue of colorectal cancer. From the remaining options, recalling that a high-fiber diet is recommended as a preventative measure will direct you to option 3. Review the risk factors associated with colorectal cancer if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance 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. 705. 149. A nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which of the following symptoms would be noted in determining this finding? 1. Severely depressed fontanels 2. Slightly dry mucous membranes 3. Pale skin color 4. Oliguria Answer: 4 Rationale: In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be very dry, the skin color would be dusky, and oliguria would be present. Options 2 and 3 describe mild dehydration. In mild dehydration, urine output would be decreased but oliguria would not be present. Option 1 describes severe dehydration. Test-Taking Strategy: Note the key word moderately. This key word will assist in eliminating options 1, 2, and 3. Review the manifestations related to mild, moderate, and severe dehydration if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 84. 150. A physician orders intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child would check which highest priority item before administration of the potassium? 1. Temperature 2. Blood pressure 3. Weight 4. Urine output Answer: 4

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Rationale: The priority assessment would be to check the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. Although options 1, 2, and 3 may be a component of the data collected, they are not specifically related to the administration of this medication. Test-Taking Strategy: Knowledge regarding the effects of potassium on various organ systems is required to answer the question. Recalling that the kidneys play a key role in the excretion and reabsorption of potassium will direct you to option 4. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 158. 151. An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn, and the results indicate a glucose level of 60 mg/dl. The appropriate intervention is to: 1. Keep the child NPO 2. Contact the physician 3. Give the child a glass of juice 4. Let the child rest until the dizziness subsides Answer: 3 Rationale: A blood glucose level below 70 mg/dl indicates hypoglycemia. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Options 1, 2, and 4 do not address the hypoglycemic condition. Test-Taking Strategy: Identify the issue of the question—a hypoglycemic condition. Options 1, 2, and 4 do not address treatment of the hypoglycemia. Review the signs and treatment for hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 285. 152. A child with diabetes mellitus is brought to the emergency room by her mother who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting to care for the child checks the intravenous (IV) and medication supply area for which of the following? 1. 5% dextrose IV infusion 2. 0.9% normal saline IV infusion 3. NPH insulin 4. Potassium Answer: 2

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Rationale: Rehydration is the initial step in resolving DKA. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route and is not used to treat DKA. Dextrose solutions are added to the treatment when the blood glucose levels reach an acceptable level. IV potassium may be required depending on the potassium level, but would not be part of the initial treatment. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 by knowing that dextrose would not be administered in a hyperglycemic state. Eliminate option 3 next by knowing that NPH insulin is never administered by the IV route and is not used to treat DKA. From the remaining options, recalling that hydration is the initial treatment in DKA will direct you to option 2. Review the treatment for DKA if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1480. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 282. 153. A physician has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. The nurse responds by telling the mother that surgery will probably be performed: 1. Immediately 2. Shortly before the child starts school 3. Before the child is 2 years old 4. Just before the child begins to learn to read Answer: 3 Rationale: In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. It is most often indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 2 years old. Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated first because of the word immediately. Options 2 and 4 can be eliminated next because they address a similar time frame. Review the treatment for strabismus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229. 154. A physician prescribes “eye patching” for a child with strabismus of the right eye. The nurse instructs the mother regarding this procedure and tells the mother to: 1. Place the patch on the right eye

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2. Place the patch on both eyes 3. Place the patch on the left eye 4. Alternate the patch from the right to left eye hourly Answer: 3 Rationale: Eye patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the “good” eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist. Test-Taking Strategy: Use the process of elimination. Remembering that this condition is a “lazy eye” will direct you to the correct option. It makes sense to patch the unaffected eye in order to strengthen the muscles in the affected eye. Review the procedure for patching if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 541. 155. The mother of a 6-year-old child arrives at the clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and a culture is sent to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, which of the following would require further investigation? 1. The presence of an allergy 2. Possible trauma 3. Possible sexual abuse 4. The presence of a respiratory tract infection Answer: 3 Rationale: A diagnosis of chlamydial conjunctivitis in a non–sexually-active child should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis but not in chlamydial form. Test-Taking Strategy: Note the age of the child and the organism that is identified in the question. This will assist in directing you to option 3. Options 1, 2, and 4 should be recognized as the common causes of conjunctivitis. These options are similar in that they all relate to a physiological problem. Review content related to chlamydial conjunctivitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1041. 156. A 7-year-old child is diagnosed with viral conjunctivitis, and antibiotic eye drops are prescribed for the child. The mother asks the nurse when the child can return to

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school. The nurse makes which response to the mother? 1. “The child can return to school immediately.” 2. “The child should be kept home until the antibiotic eye drops have been administered for 24 hours.” 3. “The child should be kept home until the antibiotic eye drops have been administered for 1 week.” 4. “The child cannot return to school until seen by the physician in 1 week.” Answer: 2 Rationale: Viral conjunctivitis is extremely contagious. The child should be kept home from school or day care until the child has received antibiotic eye drops for 24 hours. Options 1, 3, and 4 are incorrect instructions. Test-Taking Strategy: Use the process of elimination. Recalling that viral conjunctivitis is highly contagious will assist in eliminating option 1. Next eliminate options 3 and 4 because they are similar and because the time frames are lengthy. Also, recalling the action of antibiotics will assist in directing you to option 2. Review infection control measures related to viral conjunctivitis 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: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1588. 157. A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds knowing that which of the following is an unassociated risk factor related to otitis media? 1. Household smoking 2. Bottle-feeding 3. Exposure to illness in other children 4. A history of urinary tract infections Answer: 4 Rationale: Factors that increase the risk of otitis media include exposure to illness in other children in day care centers, household smoking, bottle-feeding, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has also been identified as a risk factor. Allergies are also thought to precipitate otitis media. Urinary tract infections are not associated with otitis media. Test-Taking Strategy: Note the key word unassociated in the stem of the question. Careful reading of each of the options will direct you to option 4. Review the causes of otitis media if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 536.

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<AQ>158. Penicillin V potassium (Pen Vee K) 250 mg orally every 8 hours is prescribed for a child with a respiratory tract infection. The medication label reads: Penicillin, 125 mg per 5 mL. The nurse has determined that the dosage prescribed is safe for the child. How many milliliters (mL) will the nurse administer to the child per dose? Answer: 10 Rationale: Use the following formula for calculating the appropriate medication dose: Desired 250 mg _________ x Volume = _______ x 5 mL = 10 mL per dose Available 125 mg Test-Taking Strategy: Follow the formula for calculating the correct dose. Recheck your calculation with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 80. 159. A physician has prescribed phenobarbital sodium (Luminal sodium) 25 mg orally twice daily for a child with febrile seizures. The child’s weight is 7.2 kg. The safe pediatric dosage is 1 to 6 mg/kg/day. The nurse determines that: 1. The dosage is too low 2. The dosage is too high 3. The dosage is within the safe range 4. There is not enough information to determine the safe dosage Answer: 2 Rationale: Calculate the dosage parameters, using the safe dose range identified in the question and the child’s weight in kilograms. Next, determine the total daily dose. Dosage parameters: 1 mg/kg/day x 7.2 kg = 7.2 mg/day 6 mg/kg/day x 7.2 kg = 43.2 mg/day Dosage frequency: 25 mg x 2 doses = 50 mg/day The dosage is too high. Test-Taking Strategy: Identify the key components of the question and what the question is asking. In this case, the question asks for the safe dosage range of the medication. Follow the formula steps. Calculate the dosage parameters using the safe dose range identified in the question and the child’s weight in kilograms. Remember to determine the total daily dosage before selecting an option. Review this formula if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, pp. 235-236.

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160. Diphenhydramine hydrochloride (Benadryl) 25 mg orally every 6 hours is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. The nurse determines that: 1. The physician needs to prescribe a lower dosage 2. The dosage is too high 3. The dosage is safe 4. There is not enough information to determine the safe dosage Answer: 3 Rationale: Calculate the dosage parameters, using the safe dose range identified in the question and the child’s weight in kilograms. Next, determine the total daily dose. Dosage parameters: 5 mg/kg x 25 kg = 125 mg/day Dosage frequency: 25 mg x 4 doses = 100 mg/day The dosage is safe. Test-Taking Strategy: Identify the key components of the question and what the question is asking. In this case, the question asks for the safe dosage range of the medication. Follow the formula steps. Calculate the dosage parameters, using the safe dose range identified in the question and the child’s weight in kilograms. Remember to determine the total daily dosage before selecting an option. Review this formula if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, pp. 235-236. 161. Penicillin G procaine (Wycillin) 1,000,000 U intramuscularly has been prescribed for the child with a throat infection. The child’s weight is 62 lb. The safe pediatric dosage is greater than 60 lb: 600,000 to 1,200,000 U daily. The nurse determines that: 1. The dosage is too low 2. The dosage is too high 3. The dosage is within the safe range 4. There is not enough information to determine the safe dosage Answer: 3 Rationale: The child’s weight is 62 lb, which falls within the safe pediatric dosage range. The dosage is safe. Test-Taking Strategy: Identify the key components of the question and what the question is asking. In this case, the question asks for the safe dosage range of the medication. Calculation is not required because the information needed to answer the question is identified in the question. Review information related to pediatric medications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to

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general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, pp. 235-236. 162. A nurse is checking postoperative orders and planning care for a 110-lb child after spinal fusion. Morphine sulfate 8 mg subcutaneously every 4 hours PRN for pain is ordered. The pediatric drug reference states that the safe dosage is 0.1 to 0.2 mg/kg every 2 to 4 hours. From this information, the nurse determines that: 1. The dosage is too low 2. The dosage is too high 3. The dosage is within the safe range 4. There is not enough information to determine the safe dosage Answer: 3 Rationale: Convert pounds to kilograms by dividing by 2.2, because 1 kg = 2.2 lb. Therefore, 110 lb divided by 2.2 = 50 kg. Then determine the dosage parameters. Dosage parameters: 0.1 mg/kg x 50 kg = 5 mg 0.2 mg/kg x 50 kg = 10 mg The dosage is safe. Test-Taking Strategy: The question provides you with a medication order, a child’s weight, and safe dose information. The safe dose is given in milligrams per kilogram and the child’s weight is given in pounds. You should know that the conversion factor is 2.2. Because pounds are smaller than kilograms, you divide the number of pounds by the conversion factor. Calculate the dosage parameters using the safe dose range identified in the question and the child’s weight in kilograms. Review these formulas if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, pp. 235-236. <AQ>163. A physician’s order reads: tobramycin sulfate (Nebcin) 7.5 mg intramuscularly twice daily. The medication label states: tobramycin sulfate, 10 mg/mL. How many milliliters (mL) will the nurse give to administer one dose? Answer: 0.75 Rationale: Use the following formula for calculating the appropriate medication dose: Desired 7.5 mg _______ = _______ x 1.0 mL = 0.75 mL Available 10 mg Test-Taking Strategy: Follow the formula for calculating the correct dose. Recheck your work with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to

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general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 80. <AQ>164. A physician’s order reads: theophylline timed-release capsules (Slo-bid) 100 mg orally every 6 hours. The medication label reads: Theophylline timed-release capsules, 50-mg capsules. How many capsules will the nurse give to administer one dose? Answer: 2 Rationale: Use the following formula for calculating the appropriate medication dose: Desired 100 mg _______ = _______ x 1 Capsule = 2 Capsules Available 50 mg Test-Taking Strategy: Follow the formula for calculating the correct dose. Recheck your work with a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 80. 165. A nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which of the following is the priority concern in caring for the client? 1. Fear 2. Acute pain 3. Impaired gas exchange 4. Grieving Answer: 3 Rationale: The priority should always deal with airway. Although options 1, 2, and 4 are also appropriate concerns for this client, they are not the priority and assume a lesser priority than impaired gas exchange. Test-Taking Strategy: Note the key word priority. Use the ABCs—airway, breathing, and circulation. This will direct you to option 3. Review care to the client with uterine rupture if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 698. 166. A nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. The nurse monitors the client frequently, knowing that the client is at risk for: 1. Postpartum hemorrhage

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2. Chronic hypertension 3. Postpartum infection 4. Coagulopathy Answer: 1 Rationale: Because the placenta is implanted in the lower uterine segment that does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse monitors the client frequently for signs of postpartum hemorrhage. Options 2, 3, and 4 are not directly associated with placenta previa. Test-Taking Strategy: Use the process of elimination and knowledge regarding the complications associated with placenta previa. Also, recalling the pathophysiology associated with placenta previa will direct you to option 1. Review the complications associated with placenta previa 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/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 216. 167. A nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which of the following as the priority goal for the client? 1. Client exhibits no signs of fetal distress 2. Client expresses an understanding of her condition 3. Client identifies and uses available support systems 4. Client demonstrates compliance with activity limitations Answer: 1 Rationale: Option 1 clearly identifies a physiological need. Options 2, 3, and 4 may be a component of the plan of care, but the physiological integrity and safety of the mother/newborn dyad is the priority. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Options 2, 3, and 4 deal with the psychosocial aspects of care while option 1 deals with physiological and safety issues. Review care to the client with placenta previa if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 216. 168. A client had a cesarean delivery with a low transverse uterine incision. The nurse explains the benefits of this type of incision to the client knowing that this type of incision: 1. Allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy 2. Can be extended if a larger incision is needed

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3. Is the best choice with a placenta previa on the lower anterior uterine wall 4. Requires that a vertical skin incision be made Answer: 1 Rationale: A low transverse uterine incision is unlikely to rupture during a subsequent labor and is the only type of uterine incision considered safe for a subsequent VBAC delivery. It cannot be extended laterally because of the location of the major uterine blood vessels in the lower uterine segment. In the presence of a placenta previa, a classic incision into the body of the uterus would be needed to prevent incising into the placental area. A suprapubic skin incision can be made with a lower uterine transverse incision. Test-Taking Strategy: Knowledge regarding the different types of skin and uterine incisions is needed to answer the question. Noting the key words low transverse will assist in directing you to option 1. Review the types of uterine incisions if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 456-457. 169. A nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client’s health record knowing that which finding needs to be further investigated before delivery? 1. Hemoglobin level of 11.5 g/dl 2. White blood cell count of 35,000 mm3 3. Maternal pulse rate of 90 beats per minute 4. Fetal heart rate of 154 beats per minute Answer: 2 Rationale: White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 to 15,000 mm3 up to 18,000 mm3. A count of 35,000 mm3 before delivery is abnormal and may indicate infection, which can complicate the delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dl because of hemodilution caused by an increase in plasma volume during pregnancy. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. A normal fetal heart rate is 120 to 160 beats per minute. Test-Taking Strategy: Note the key words needs to be further investigated. Use the process of elimination, noting that option 2 indicates an abnormal value. Review these laboratory values and the normal findings in pregnancy 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: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child

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nursing (2nd ed.). St. Louis: Elsevier, p. 255. 170. A client is scheduled to have an elective cesarean delivery. The nurse preparing the client for the procedure plans to allay the client’s feelings of anxiety by: 1. Emphasizing the technical aspects of this type of delivery 2. Deciding how soon the client should see the baby after delivery 3. Decreasing the partner’s anxiety by keeping him or her in the waiting area 4. Encouraging the client to discuss her concerns and desires regarding anesthesia options Answer: 4 Rationale: Emotional needs of the client and family are best met by assessing their feelings and allowing for verbalization of concerns. Options 1, 2, and 3 involve actions by the nurse, which do not involve client input. Those undergoing cesarean delivery often feel disappointment and guilt, even if the procedure is elective. Providing the opportunity for discussion and input into decisions can help to alleviate these feelings. Too much technical information may increase the client’s anxiety. The presence of a support person is helpful. Test-Taking Strategy: Use the steps of the clinical problem-solving process (nursing process) to assist in answering the question. Remember that data collection is the first step. Additionally, option 4 focuses on the client’s feelings. Review the psychosocial aspects related to a cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 250. 171. A nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which of the following is noted? 1. Contractions occurring every 3 minutes 2. Fetal tachycardia 3. Soft uterine tone palpated between contractions 4. Increased urinary output Answer: 2 Rationale: Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia from excessive uterine activity. The nurse should also assure that the uterus maintains an adequate resting tone between contractions. Options 1, 3, and 4 are not indications of a problem. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Option 2 is the only option that indicates a problem with circulation. Review care to the client receiving an infusion of oxytocin if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity

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Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 245. 172. A nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse suggests including which of the following in the plan of care? 1. Maintain complete bed rest 2. Notify the neonatal resuscitation team 3. Administer antibiotics 4. Maintain continuous electronic fetal monitoring Answer: 4 Rationale: Maternal and fetal well-being is monitored before and during oxytocin administration including fetal heart rate, uterine contractions and tone, and maternal blood pressure. There are no data in the question that indicate the presence of maternal or fetal complications that would require antibiotics, complete bed rest, or notifying the neonatal resuscitation team. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. This will direct you to option 4. Review care to the client receiving an infusion of oxytocin 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: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 245. 173. A client arrives at the birthing center in active labor. Her membranes are still intact, and the nurse-midwife performs an amniotomy. The nurse explains to the client that after this procedure, she will most likely have: 1. Less pressure on her cervix 2. Increased efficiency of contractions 3. Decreased number of contractions 4. The need for increased blood pressure (BP) monitoring Answer: 2 Rationale: Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not require the need for increased monitoring of the BP. Test-Taking Strategy: Note the key words most likely. Recalling the purpose and effects of amniotomy will direct you to the correct option. If you had difficulty with this question, review the purpose of this procedure. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum

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Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 176-177. 174. A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs: 1. General anesthesia 2. To push with her contractions 3. To be left totally alone 4. To regain her breathing pattern Answer: 4 Rationale: When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated. The client may be terrified of being left alone during this phase of labor. Test-Taking Strategy: Focus on the issue of the question. Note the relation between the words “hyperventilates” in the question and “breathing pattern” in the correct option. Review care to the client in the transition stage of labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 145. 175. A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, “I don’t need the cesarean section after all because I think my baby has moved around.” The appropriate response by the nurse is which of the following? 1. “Tell me what you mean when you say that your baby has moved.” 2. “That would be impossible because babies don’t move around this late.” 3. “The physician is all set to go and cannot change plans now.” 4. “You need to listen to your obstetrician; the physician knows what he is doing.” Answer: 1 Rationale: Anxiety is an expected and normal reaction to surgery and within limits is functional. The nurse should remain with the client and let the client express her fears and concerns. Option 1 encourages the client to express concerns because it uses the therapeutic communication tool of paraphrasing that validates and clarifies. Options 2, 3, and 4 do not, and are blocks to communication. Test-Taking Strategy: Use therapeutic communication techniques. Option 1 most directly relates to the comment made by the client. Always select a response that encourages the client to express concerns. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Intrapartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 30-31. 176. A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure? 1. “I’m getting tired of lying flat on my back.” 2. “How many volts of electricity are going through my body?” 3. “What an efficient way to record my baby’s heart rate.” 4. “I shut the machine off when I talk on the telephone.” Answer: 3 Rationale: EFM is a method of recording the fetal heart rate. The woman is asked to assume a semi-sitting position or a lateral position when undergoing this procedure. The ultrasound transducer acts through the reflection of high-frequency sound waves from a moving interface, in this case, the fetal heart and valves. No electricity or voltage passes through the body. Test-Taking Strategy: Use the process of elimination. Note the relation of the words “fetal monitoring” in the question and “baby’s heart rate” in the correct option. Review electronic fetal monitoring (EFM) if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 74-75. 177. A nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which of the following are the most important data for the nurse to document on the strip? 1. A temporary interruption in recording 2. Maternal vital signs 3. Last menstrual period 4. Age of client Answer: 2 Rationale: Maternal vital signs can influence circulatory exchange with the placenta. Fetal oxygenation depends on a normal flow of oxygenated maternal blood into the placenta and normal uteroplacental exchange. A temporary interruption is noteworthy but not as important as option 2, which is the correct option. Options 3 and 4 are irrelevant data. Test-Taking Strategy: Note the words “most important.” Use the ABCs—airway, breathing, and circulation. Vital signs reflect airway, breathing, and circulation. Review the procedures related to continuous fetal monitoring if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 75. 178. A client tells the nurse that her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, “I can’t take it anymore.” Considering the client’s behavior, the nurse suspects she is dilated: 1. 1 to 2 cm 2. 3 to 4 cm 3. 5 to 7 cm 4. 8 to 10 cm Answer: 4 Rationale: During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment. Test-Taking Strategy: Focus on the data provided in the question. The question asks you to determine the phase of labor (transition) based on characteristic behaviors observed. Remember, the longer labor has progressed, the more likely the behaviors identified in the question will be observed. Therefore the greatest cervical dilation, 8 to 10 cm, is the correct option. Review the transition phase of labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 145. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 91. 179. A nurse is assisting in performing Leopold’s maneuvers. When the client asks what these are for, the nurse’s best response is that these maneuvers help to determine: 1. Duration of contractions 2. Fetal heart rate 3. Fetal position 4. Frequency of contractions Answer: 3 Rationale: Leopold’s maneuvers are a systematic way to evaluate the maternal abdomen using inspection and palpation to determine fetal position and presentation. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Note the similarity between options 1, 2, and 4. These data could all be provided by a fetal monitor. Review Leopold’s maneuvers if you had difficulty with this question. Level of Cognitive Ability: Application

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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, pp. 106-107. 180. A nurse assists the nurse midwife to examine the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation −2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which of the following activity orders for the client? 1. Ambulation 2. Bathroom privileges 3. Complete bed rest 4. Up in chair Answer: 3 Rationale: Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions. Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 4 are similar and promote activity. Option 3 promotes no activity, reduces the risk of prolapsed cord, and is the correct option. Review care to the client in labor 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: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 247-248. 181. A nurse prepares to explain the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage: 1. Is a form of biofeedback to enhance bearing down efforts during delivery 2. Is light stroking of the abdomen to facilitate relaxation during labor 3. Is the application of pressure to the sacrum to relieve a backache 4. Stimulates uterine activity by contracting a specific muscle group while other parts of the body rest Answer: 2 Rationale: Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Options 1, 3, and 4 are incorrect descriptions. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because the focus during delivery is the client. Option 4 focuses on promotion of uterine activity rather than relaxation. Eliminate option 3 because not all labor clients experience backache. Remember, all methods of childbirth preparation promote relaxation and enhance client coping with the event. Review the components of effleurage if you had

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difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 65. 182. A client asks, “What does it mean that the baby is at minus one?” After providing information, the nurse determines client understanding if the client states the fetal presenting part is isolated: 1. 1 cm above the ischial spines 2. 1 finger breadth below the symphysis pubis 3. 1 inch below the coccyx 4. 1 inch below the iliac crest Answer: 1 Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. The question requires you to know that station is measured in centimeters and uses the ischial spines as a reference point. Only option 1 incorporates this information. Also, options 2, 3, and 4 are similar in the use of the word “below,” which would be represented by a positive measurement in determining station. Review station if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 87. 183. A nurse assisting to monitor a client in labor is told that the client’s cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client’s psychological status, the nurse anticipates the client to reflect an attitude of: 1. Excitement 2. Helplessness 3. Irritability 4. Seriousness Answer: 1 Rationale: In the late phase of the second stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth. Options 2, 3, and 4 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced. Test-Taking Strategy: Use the process of elimination. The question requires you to understand the usual psychological state of the client in the second stage of labor. Note

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that option 1 is different from the other options in that it reflects a positive view characteristic of the second stage of labor, when coping is adequate and discomfort is mild. Review the psychosocial responses to labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 145-146. 184. A nurse observes that the client in the second stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as: 1. Exhaustion 2. Fear of losing control 3. Involuntary grunting 4. Valsalva maneuver Answer: 2 Rationale: Pains, helplessness, and fear of losing control are possible client responses in the second stage of labor. Whimpering, high-pitched cries, and crying out in pain are indicative of losing control, while low-pitched grunting sounds usually indicate a woman is working effectively with contractions. Test-Taking Strategy: Use the process of elimination. Note that options 1, 3, and 4 identify similar psychological responses. If you are unfamiliar with the psychological responses that occur in the second stage of labor, review this content. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 146. 185. A pregnant client has been pushing effectively for 1 hour, and the presenting part is at a +2 station. The nurse determines that the client’s primary physiological need at this time is: 1. Change in position 2. Intravenous analgesia 3. Oral food and fluids 4. Rest between contractions Answer: 4 Rationale: The birth process expends a great deal of energy. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion is also enhanced, which enhances fetal tolerance of the stress of labor. There are no data in the question to indicate that option 1 is necessary. Option 2 is incorrect because this action would likely cause central nervous system depression in the infant. Option 3 is incorrect because food and fluids are likely withheld at this time, except for ice chips.

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Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recalling that the need to conserve energy is important will direct you to option 4. Review care to the client in labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 145. Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 584. 186. A nurse tells the client she is now beginning the second stage of labor. The nurse realizes the client understands the developments in this stage when the client says: 1. “I’m having a backache.” 2. “My cervix is completely dilated.” 3. “My membranes just ruptured.” 4. “The contractions are very mild.” Answer: 2 Rationale: The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. Option 1 can occur any time during labor. Options 3 and 4 are characteristics of early labor. Test-Taking Strategy: Knowledge regarding the description related to the second stage of labor is required to answer this question. Remember, the second stage of labor begins when the cervix is completely dilated. If you had difficulty with this question, review this stage of labor. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 583. 187. A client delivers a viable male neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse determines the physical condition of the neonate to be: 1. Critical 2. Poor 3. Fair 4. Good Answer: 4 Rationale: The Apgar scoring system was designed to evaluate the physical condition of the newborn at birth and determine the immediate need for resuscitation. Scores range from 0 to 10. A score of 8 to 10 indicates a newborn in good condition. Test-Taking Strategy: Use the process of elimination and knowledge of the Apgar scoring system. Options 1, 2, and 3 are similar, indicating that additional intervention would be required. Option 4 is different. Review Apgar scoring if you had difficulty

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with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 153. 188. A client has just delivered a viable newborn. The first nursing action to initiate attachment is to: 1. Complete routine newborn care measures quickly 2. Determine the parents’ desires for contact with the newborn 3. Encourage immediate breast-feeding 4. Suggest the mother hold the newborn after the placenta is delivered Answer: 2 Rationale: Although immediate contact may be important for attachment or breastfeeding, the parents’ wishes concerning contact with their newborn need to be supported and determined first. Test-Taking Strategy: Note the key word first. Use the steps of the clinical problemsolving process (nursing process), recalling that data collection is the first step. Option 2 reflects data collection. Review the concepts of parental-newborn attachment if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 207. 189. In providing initial care of the newborn following delivery, the priority action of the nurse is to: 1. Identify gestational age 2. Identify the infant and mother 3. Turn the infant’s head to the side 4. Record the number of umbilical vessels Answer: 3 Rationale: The priority is to maintain an open airway. Turning the infant’s head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later. Test-Taking Strategy: Use the principles of prioritization and the ABCs—airway, breathing, and circulation. Option 3 is correct because this position facilitates drainage of mucus and promotes an open airway and effective breathing. Review initial care of the newborn if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation

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Content Area: Maternity/Intrapartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 555. 190. A nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding may indicate: 1. Bladder distention 2. Endometrial infection 3. Retained placental fragments 4. Uterine atony Answer: 1 Rationale: Immediately following expulsion of the placenta, the fundus is firmly contracted, midline, and located one half to two thirds of the way between the symphysis pubis and umbilicus. Because the uterine ligaments are still stretched, a full bladder can move the uterus. Options 2, 3, and 4 are complications not usually indicated by a firm and displaced uterus. Test-Taking Strategy: Knowledge regarding the physiological findings in the postpartum period is required to answer this question. Visualizing the data in the question and noting the words “displaced to the right” will direct you to the correct option. If you had difficulty with this question, review care to the client in the postpartum period. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 197. Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.) St. Louis: Mosby, p. 631. 191. While a client is holding and talking to her newborn immediately following delivery, she begins to cry. The nurse interprets this behavior as indicating the client is: 1. Disappointed with the baby’s gender 2. Experiencing a normal response to birth 3. Grieving over the loss of the pregnancy 4. Likely to demonstrate malattachment Answer: 2 Rationale: The birth of a baby is an emotionally charged moment for new parents. Crying can be a normal expression of emotions surrounding birth. Holding, eye contact, and touch are signs of healthy maternal-newborn attachment. Options 1, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination. The question requires knowledge of normal attachment behaviors and maternal emotional responses following birth. Options 1, 3, and 4 are similar in that they all represent an abnormal response. Review maternal responses following delivery if you had difficulty with this question. Level of Cognitive Ability: Analysis

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Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 146. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 492. 192. A nurse is caring for a client during the immediate recovery phase or fourth stage of labor. The nurse’s most important action at this time is to: 1. Check the uterine fundus and lochia 2. Assist the client to breast-feed 3. Encourage food and fluid intake 4. Provide privacy for the parents and their newborn Answer: 1 Rationale: A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted, and vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours. Options 2, 3, and 4 are not the most important nursing actions. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Checking uterine position and consistency and the amount and character of lochia provides information about blood loss and circulatory status. Options 2, 3, and 4 are less important at this time. Review care to the client in the immediate postpartum period 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. 497. 193. A nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate (Methergine). The nurse determines the medication is effective when the client says: 1. “At least now I can sleep.” 2. “I feel less nauseated.” 3. “My afterpains are really strong.” 4. “The pain is less intense.” Answer: 3 Rationale: Methylergonovine maleate (Methergine) is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used postpartally to stimulate the uterus to contract and control excessive blood loss. The client statements in options 1, 2, and 4 are not related to this medication. Test-Taking Strategy: Knowledge regarding the action and use of this medication is required to answer this question. Remember, methylergonovine maleate (Methergine) is an ergot alkaloid that stimulates smooth muscles. If you are unfamiliar with this

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medication, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 247. 194. A child is diagnosed with lactose intolerance. The child’s mother asks the nurse about the disease. The appropriate nursing response is which of the following? 1. “It is the inability to fully digest the protein part of wheat, barley, rye, and oats.” 2. “It is the inability to tolerate sugar found in dairy products.” 3. “It results from the absence of ganglion cells in the rectum.” 4. “It results from increased bowel motility that leads to spasm and pain.” Answer: 2 Rationale: Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. It results from absence or deficiency of lactase, an enzyme found in the secretions of the small intestine required for the digestion of lactose. Option 1 describes celiac disease. Option 3 describes Hirschsprung’s disease. Option 4 describes irritable bowel syndrome. Test-Taking Strategy: Use the process of elimination. Note the relation between “lactose intolerance” in the question and the words “inability to tolerate sugar” in option 2. If you are unfamiliar with this disorder, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 65. 195. A nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation would the nurse expect to note documented in the health record? 1. Frothy diarrhea 2. Profuse watery diarrhea and vomiting 3. Foul-smelling ribbon stools 4. Diffuse abdominal pain unrelated to meals or activity Answer: 2 Rationale: Celiac disease causes profuse watery diarrhea and vomiting. Option 1 is a clinical manifestation of lactose intolerance. Option 3 is a clinical manifestation of Hirschsprung’s disease. Option 4 is a clinical manifestation of irritable bowel syndrome. Test-Taking Strategy: Knowledge regarding the clinical manifestations associated with celiac disease is required to answer this question. Remember, celiac disease causes profuse watery diarrhea and vomiting. Review the clinical manifestations associated with this disorder if you had difficulty with this question.

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Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 238. 196. A nurse is providing dietary instructions to the mother of a child with celiac disease. Which statement by the mother indicates a need for further instructions? 1. “I can give my child rice.” 2. “I am so pleased that I won’t have to eliminate oatmeal from my child’s diet.” 3. “My child loves corn. I will be sure to include corn in the diet.” 4. “I will be sure to give my child vitamin supplements every day.” Answer: 2 Rationale: Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. Test-Taking Strategy: Note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Knowledge that wheat, rye, oats, and barley need to be eliminated from the diet will direct you to option 2. Review the diet for the child with celiac disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 238. 197. A nurse is caring for a newborn in the nursery and notes that the physician has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement would the nurse make to the parents? 1. “No treatment is prescribed. It will resolve on its own.” 2. “Surgical repair will be performed if it causes symptoms in the newborn.” 3. “The defect will be closed surgically after all of the contents have been returned to the abdominal cavity.” 4. “Surgical repair will be performed if it persists past age 5.” Answer: 3 Rationale: Gastroschisis is an abdominal wall defect. It involves embryonal weakness in the abdominal wall, causing herniation of the gut on one side of the umbilical cord during development. The defect will be closed surgically after all of the contents have been returned to the abdominal cavity. Even if the defect is small, immediate surgical repair may be done in several stages. Options 1, 2, and 4 describe therapeutic management for an umbilical hernia. Test-Taking Strategy: Use the process of elimination. Recalling that a gastroschisis is an

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abdominal wall defect in which viscera are outside the abdominal cavity and not covered with a sac will direct you to option 3. This is the only option that addresses surgical repair. Review therapeutic management for this disorder if you are unfamiliar with it. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 98. 198. A 2-year-old child is diagnosed with constipation. Which of the following describes a characteristic of this disorder? 1. Incomplete development of the anus 2. Invagination of a section of the intestine into the distal bowel 3. The infrequent and difficult passage of dry stools 4. The presence of fecal incontinence Answer: 3 Rationale: Constipation can affect any child at any time, although its incidence peaks at age 2 to 3 years. Option 4 describes encopresis, which can develop as a result of constipation and is one of the major concerns regarding constipation. Encopresis generally affects preschool and school-age children. Option 1 describes imperforate anus, which is diagnosed in the neonatal period. Option 2 describes intussusception, which is the most common cause of bowel obstruction in children age 3 months to 6 years. Test-Taking Strategy: Use the process of elimination. Noting the child’s age should help you eliminate option 1, because imperforate anus is diagnosed in the neonatal period. Next, focus on the disorder to assist in directing you to option 3. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 666. 199. A newborn who is suspected of having an imperforate anus is admitted to the nursery. While reviewing the health care record of the newborn, the nurse understands that which documented finding is unassociated with this disorder? 1. Stenosis of the anorectal canal 2. Failure to pass meconium stool 3. The presence of stool in the vagina 4. The passage of bloody mucous stool Answer: 4 Rationale: Clinical manifestations of an imperforate anus include failure to pass meconium stool within 24 hours following birth, absence or stenosis of the anorectal canal, an anal membrane, and an external fistula to the perineum. During neonatal

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assessment, the defect should be easily identified on sight. However, a rectal thermometer may be necessary to determine patency if meconium stool is not passed. The presence of stool in the urine, the vagina, or a skin dimple should be reported immediately as an indication of abnormal anorectal development. Option 4 is a clinical manifestation of intussusception. Test-Taking Strategy: Note the key word unassociated. Next, note the name of the disorder identified in the question. Options 1, 2, and 3 relate to the name of this disorder. Review the clinical manifestations associated with imperforate anus 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. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 658. 200. A nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child knowing that generally a 1-year-old child consumes approximately: 1. 90 mL per feeding 2. 125 mL per feeding 3. 175 mL per feeding 4. 300 mL per feeding Answer: 3 Rationale: A 1-year-old child consumes approximately 175 mL (6 oz) of formula per feeding. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Knowledge regarding the pediatric differences in the upper gastrointestinal system is required to answer this question. Note the key words 1-yearold. This should assist you in eliminating options 1 and 2. Attempt to visualize the amount in options 3 and 4 to help you select the correct option. Review these pediatric differences if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 521.

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