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Kaplan Q Trainer 1

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1. 65-year-old man scheduled colon resection Strategy: 3. A 14-year-old girl is brought to the Strategy: Answers
this morning. Last night he had polyethylene Think about hospital for treatment of second- and are
glycolelectrolyte solution (GoLytely) and a each answer. third-degree burns sustained in house implementation.
soapsuds enema. This morning he passes (1) Correct- fire. Intravenous infusion is started in Determine the
medium amount of soft, brown stool. The Colon should patient's left forearm. The nurse knows outcome of each
nurse should know that this: not have that the primary purpose of the IV is to: answer. Is it
1. Indicates that the bowel preparation is remaining 1. Provide a route for pain medications. desired?
incomplete. soft stool 2. Maintain fluid balance. (1) Route used for
2. Is evidence that the patient ate something (2) Anything 3. Prevent gastrointestinal upset. pain medication to
after midnight. eaten after 4. Obtain blood specimens for analysis ensure absorption,
3. Is an expected finding before this type of midnight but not primary
surgery. would not purpose of IV
4. Is the last stool that was left in the colon. appear as (2) Correct- Loss
stool by the of fluid occurs
next morning from open burn
(3) Not surfaces;
expected; maintaining
need to clean circulation is life-
GI tract for saving
surgery requirement.
(4) (3) Threat GI
Assumption, upset not primary
not importance; IV
substantiated primary purpose
2. A 7-year-old girl is seen in clinic with Strategy: to maintain fluid &
diagnosis of pituitary dwarfism. Which of Determine electrolyte
following clinical manifestations is the nurse how each balance
MOST likely to observe? answer (4) Peripheral IV
1. Abnormal body proportions. relates to not used for this
2. Early sexual maturation. dwarfism. purpose
3. Delicate features. (1) You will 4. A 20-year-old woman arrives at the trategy: Think
4. Coarse, dry skin. see small size hospital in active labor. The admitting about each
but normal nurse attaches an internal fetal monitor. answer.
body Nurse knows the MOST important (1) Clinical
proportions reason for fetal monitor is: assessments
(2) Usually 1. To evaluate the progress of the client's provide
have delayed labor. information about
sexual 2. To assess the strength & duration of progress of labor
maturity the client's contractions. (dilation &
(3) Correct- 3. To monitor the oxygen status of the effacement)
appear fetus during labor. (2) Not most
younger than 4. To decide if an oxytocin drip is important reason
chronological necessary. for monitoring
age (3) Correct-goal
(4) Usually is early detection
see fine, of mild fetal
smooth skin hypoxia
(4) Fetal well-
being is most
important reason
for fetal
5. A 47-year-old woman Strategy: Think about each answer. 6. A 48-year-old man with an Strategy: All answers are
comes into outpatient (1) correct-projection (attributing endotracheal tube needs implementation. Determine
psychiatric clinic for one's thoughts or impulses to suctioning. Which of the the outcome of each
treatment of a fear of another) & displacement (shifting following statements is an answer. Is it desired?
heights. The nurse of emotion concerning person or accurate description of how the (1) catheter is inserted until
knows that phobias object to another neutral or less nurse should perform the resistance met; never
involve. dangerous object or person) procedure? suction longer than 10-15
1. projection & (2) sublimation (diversion 1. Insert the suction catheter sec
displacement. unacceptable drives into socially four inches into the tube. Apply (2) use twirling motion
2. sublimation & acceptable channels) & suction for 30 seconds, using a when withdrawing catheter
internalization. internalization (incorporation of twirling motion as the catheter (3) suction is never applied
3. rationalization & someone else's opinion as one's is withdrawn. when catheter is inserted
intellectualization own) 2. Hyperoxygenate the client (4) Correct-insert suction
4 reaction formation & (3) rationalization (attempt make and then insert the suction catheter until resistance is
symbolization behavior appear be result of logical catheter into the tube. Suction met without applying
thinking), intellectualization while you remove the catheter suction, withdraw 0.4-0.8 in
(excessive reasoning or logic used using a back and forth motion. (1-2 cm), apply intermittent
avoid experiencing disturbing 3. Explain the procedure to the suction with twirling
feelings) patient. Insert the catheter motion
(4) reaction formation while gently applying suction,
(development of conscious attitudes & withdraw using a twisting
& behavior patterns into opposite of motion.
what one really wants to do), 4. Insert the suction catheter
symbolization (something until resistance is met, then
represents something else); withdraw it slightly. Apply
symbolization is involved in phobias suction intermittently as the
catheter is withdrawn.
7. A 54-year-old client has Strategy: Answer choices
developed postoperative indicate that you are
infection & received looking for a complication.
ceftriaxone sodium (Rocephin) (1) Correct-long-term use
IV every day. MOST important of Rocephin can cause
for nurse to monitor which of overgrowth of organisms;
the following? monitoring of tongue &
1. The surface of the tongue. oral cavity is
2. Hemoglobin & hematocrit. recommended
3. Skin surfaces in skin folds. (2) Does not reflect a
4. Changes in urine problem with this
characteristics medication
(3) Does not reflect a
problem with this
(4) Does not reflect a
problem with this
8. A client, gravida 2 para 1, is Strategy: Determine how 10. A middle-aged man is Strategy: Think about each
admitted with hypertension & each answer relates to pre- admitted to an inpatient answer.
complains that her wedding eclampsia. psychiatric unit. Over the (1) Correct-client has
band is tight. The nurse should (1) Only partially correct; last several months he has delusions of persecution;
expect to assess which of the blurred vision appears later, become convinced that his delusion is a strongly held
following with early pre- with eclampsia brother is trying to steal belief that is not validated by
eclampsia? (2) Contains signs of his property. He is reality; the idea that his
1. Blurred vision and eclampsia before a seizure diagnosed with paranoid brother is trying to steal his
proteinuria. (3) Correct-represents the disorder. The nurse knows property is a belief not
2. Epigastric pain and complete triad seen with that this client is validated by reality
headache. pre-eclampsia demonstrating which of the (2) Hallucination sensory
3. Facial swelling and (4) Oliguria is seen later following? perception that takes place
proteinuria. with eclampsia 1. Delusions of persecution. without external stimuli; most
4. Polyuria and hypertonic 2. Command hallucinations. common are auditory, hearing
reflexes. 3. Delusions of reference. voices; other types
9. A mentally retarded client is to Strategy: Answers are a mix 4. Persecution hallucinations are tactile, visual,
be discharged home on of assessment and hallucinations. gustatory, olfactory; command
warfarin sodium (Coumadin), 5 implementation. Does this hallucinations involve
mg each day. To maintain situation require experiencing auditory
client safety, which of the assessment? Yes. hallucinations that are telling
following would be an (1) Implementation; might him/her to do something; for
appropriate FIRST nursing be done after assessment of example, to kill someone.
action? the comprehension level (3) Delusions reference are
1. Instruct significant other (2) Correct-assessment; false belief that public events
about medication regimen. mentally retarded client or people are directly related
2. Evaluate client should be carefully to individual.
comprehension of medication evaluated to ensure (4) Is not a hallucination
administration. complete comprehension 11. An 18-month-old is Strategy: Determine how each
3. Prepackage medication to of the dosage regimen to admitted to the unit with a answer relates to croup.
encourage correct prevent overdosage & diagnosis of (1) Kussmaul respirations are
administration. underdosage laryngotracheobronchitis associated with diabetic
4. Encourage return (3) Implementation; might (LTB). During the initial ketoacidosis; hypoxia & anxiety
demonstration of medication be done after assessment of assessment, the nurse are associated with tachycardia
self-administration. the comprehension level should expect to find which (2) Respiratory rate would be
(4) Implementation; might of the following early increased
be done after evaluation of symptoms? (3) More often noted with
the comprehension level 1. Kussmaul respirations & respiratory distress of the
Bradycardia. newborn
2. Elevated temperature (4) Correct-this condition
and Slow respiratory rate. characterized by edema &
3. Expiratory wheezing and inflammation of upper airways
Substernal retractions.
4. Inspiratory stridor and
12. An 80-year-old admitted Strategy: Think about each 15. At 32-weeks gestation, client has an Strategy: Think about
with possible fractured right symptom and how it relates order for ultrasound. Client each answer.
hip. During the initial nursing to hip fracture. indicates understanding of this (1) Correct-
assessment, which of the (1) Correct- Accurate procedure if she makes which of the ultrasound detects
following observations of the assessments of position of following statements to the nurse? the gestational age
right leg would validate or fractured hip prior to repair. 1. "The results will inform us of the (2) Determined
support this diagnosis? (2) Plantar flexion occurs gestational age." lecithin/sphingomyelin
1. The leg appears to be with foot drop 2. "This test will evaluate the baby's (L/S) ratio via an
shortened & is abducted & (3) Leg would not appear to lungs." amniocentesis
externally rotated. be longer 3. "The test will show us if there is (3) Determined with
2. Plantar flexion is observed (4) Occurs with injury to the any problem in the spinal cord." amniocentesis
with sciatic pain radiating lumbar disc area 4. "Early problems with the baby's (4) Determined with
down the leg. blood can be identified with this amniocentesis
3. From the hip, the leg test."
appears to be longer & is 16. A woman is being evaluated for Strategy: Think about
externally rotated. infertility. The doctor gives each answer.
4. There is evidence of clomiphene citrate (Clomid) 50 mg (1) Correct-
paresis with decreased daily for five days. The client says clomiphene citrate
sensation & limited to nurse, "What is purpose of this (Clomid) induces
movement medicine?" The nurse should ovulation by altering
13. A new mother is taking her Strategy: All answers are instruct her that the action of estrogen &
infant home. Client asks the implementation. Determine medication is to: stimulating follicular
nurse when she should start the outcome of each answer. 1. Induce ovulation changing growth to produce a
giving her child solid foods. Is it desired? hormonal effect on the ovary. mature ovum
The nurse's response should (1) Correct-Infants less 2. Change uterine lining to be more (2) Infertility problem,
be based on which of the likely to be allergic to rice conducive to implantation. but Clomid does not
following statements? cereal than to other solid 3. Alter vaginal pH to increase affect it
1. Rice cereal is usually the food; usually started sperm motility. (3) Infertility problem,
first solid food & is started between four & five months 4. Produce multiple pregnancy for but Clomid does not
around four to five months. of age; breast-fed infants those who desire twins. affect it
2. Strained fruits are well may be started on solids (4) not desired effect
tolerated as the first solid even later.
food, & infants like them. (2) Inaccurate
3. Introduction of solid foods (3) Does not answer the
is not important at this time. mother's question
4. Solid foods are usually not (4) Usually started between
started until the infant is four & five months of age
around six months old.
14. A six-month-old is brought to Strategy: Think about each
clinic for well-baby check- answer.
up. During the exam, the 1. A pincer grasp.; present at
nurse should expect to 9 mos of age
assess which of the 2. Sitting with support.;
following? CORRECT- 6 month old
1. A pincer grasp. should sit with help
2. Sitting with support. 3. Tripling of the birth
3. Tripling of the birth weight. weight.; present at 1 year
4. Presence of the posterior 4. Presence of the posterior
fontanelle. fontanelle.; fontanelle is
closed by 2-3 months
17. Child has pediculosis capitis Strategy: Answers are 20. Client has been receiving Strategy: Determine how
(head lice) & is being treated implementation. Determine chlorpromazine hydrochloride each answer relates to
with 1% gamma benzene the outcome of each (Thorazine). When the nurse Thorazine.
hexachloride (Kwell) shampoo. answer. Is it desired? checks on the patient, the (1) Untrue statement;
Nurse should explain to the (1) Too frequent an patient is restless, unable to sit dosage may need to be
child's parents that: application of the shampoo still, & complains of insomnia & decreased due to side
1. Treatment continued every (2) Very hot water & special fine tremors of her hands. effect medication;
other day for 1 week. detergent (RID) need to be Nurse knows that these antiparkinsonian drug such
2. Clothing & personal used cleansing clothing & symptoms are: as Cogentin may be
belongings require normal personal belongings 1. Side effect of medication that ordered
cleansing with soap & water. (3) Correct-Kwell is she will tolerate better as time (2) Not accurate,
3. Application of the shampoo organic solvent, can be passes. antipsychotic medication
is repeated in 7 to 10 days. toxic, absorbed through 2. The reason she is receiving (3)Correct-Side effects
4. One treatment with Kwell scalp; may be repeated this medication. include akathisia (motor
kills both lice & nits. five to seven days after 3. Extrapyramidal side effects restlessness), dystonias
first application resulting from this medication. (protrusion of tongue,
(4) Must be repeated after 4. Indication that the dosage of abnormal posturing),
eggs hatch; permethrin 1% the medication needs to be pseudoparkinsonism
creme rinse (Nix) kills both increased. (tremors, rigidity),
lice & nits after one dyskinesia (stiff neck,
application difficulty swallowing)
18. Client admitted with Strategy: Think about each (4) Dosage may be
cerebrovascular accident answer. decreased &
(CVA) & has facial paralysis. (1) May occur, but nursing antiparkinsonian drug such
The nursing care should be care cannot prevent it as Cogentin may be
planned to prevent which of (2) May occur, but nursing ordered
the following complications? care cannot prevent it 21. Client is ordered to take aspirin Strategy: All answers are
1. Inability to talk. (3) May occur, but nursing gr. X, PO. The drug label reads: implementation.
2. Inability to swallow caused care cannot prevent it "Aspirin 325 mg per tablet." Determine the outcome of
by loss of the gag reflex. (4) Correct-client will be Which of the following actions each answer. Is it desired?
3. Inability to open the unable close eye should the nurse take? (1) Unnecessary
affected eye. voluntarily; when facial 1. Request that the pharmacy (2) Unnecessary
4. Corneal abrasion. nerve (cranial nerve VII) send a correctly labeled (3) Inaccurate
affected, the lacrimal medication. (4) Correct-ten grains =
gland will no longer 2. Notify the doctor regarding 600 mg, give two tablets;
supply secretions that the dosage. slight difference in
protect eye. 3. Give one tablet. conversion of grains to
19. Client has an order for IV fluid Strategy: Remember the 4. Give two tablets. milligrams is because
of D5 0.45% normal saline formula. differences between
1,000 cc to run from 9 AM to 9 (1) Incorrect metric & apothecary
PM. The drip factor on the (2) Correct-IV is to run in systems.
delivery tubing is 15 gtts/min. 12 hours, or 720 minutes. 21 22. During the fourth stage of labor, Strategy: Think about
The nurse should adjust the IV gtts/min nurse should palpate the each answer.
to infuse at: (3) Incorrect fundus: (1) Is unusual to palpate
1. 12 gtts/min. (4) Incorrect 1. Three cm below the umbilicus. the fundus below the
2. 21 gtts/min. 2. At the umbilicus. umbilicus during this stage
3. 25 gtts/min. 3. Two cm above the umbilicus. (2) Correct-The uterus is
4. 31 gtts/min. 4. To the right of the umbilicus. normally contracted and
palpable at the umbilicus
(3) Is unusual to palpate
the fundus above the
umbilicus during this stage
(4) May indicate a
problem with a distended
23. Elderly client has been Strategy: Think about each 26. In preparing a teaching plan Strategy: All answers
recently immobilized ordered answer. regarding colostomy implementation. Need
begin passive range-of- (1) inaccurate statement irrigations, the nurse should Determine outcome of
motion (ROM) exercises. Nurse (2) ROM may be limited include which of the following? each answer. Is it desired?
the understand what about (3) should not be done to 1. Colostomy needs to be (1) Correct- Colostomy
ROM before initiating this point of discomfort irrigated at the same time every irrigation should be done
order? (4) Correct-Full range day. at same time each day.
1. Passive range-of-motion motion may not be needed 2. Irrigate colostomy after Establishing a normal
exercises increase muscle or accomplished without meals to increase peristalsis. pattern of elimination.
strength. discomfort for elderly 3. Insert the catheter about 10 (2) Colostomy should be
2. A full range of motion must client; emphasis should be inches into the stoma. irrigated only once a day
be completed for the elderly on ROMs that support 4. The solution should be very (3) Catheter should never
client. ADLs warm to increase dilation and be inserted more than 4
3. Exercises should be flow. inches
completed to the point of (4) Solution should be at
discomfort. body temperature;
4. A sufficient range of motion increasing temperature
assists the elderly to carry out does not make irrigation
activities of daily living (ADLs). more efficient
24. If a client has ataxia, the MOST Strategy: Think about each 27. In the process of a normal Strategy: Think about each
important nursing action answer. adjustment to a terminal illness, answer.
would be to: (1) Correct- Client's the nurse knows that client's (1) This is the fifth stage
1. Supervise ambulation. coordination is poor; only initial denial & isolation will (2) This is the third stage
2. Measure the intake and relevant nursing action is give way to the second stage, (3) Correct- Second stage
output accurately. to supervise ambulation. which is characterized by: characterized by anger.
3. Consult the speech (2) Unnecessary 1. acceptance. (4) This is the fourth stage
therapist. (3) Unnecessary 2. bargaining.
4. Elevate the foot of the bed. (4) Unnecessary 3. anger.
25. In planning diet teaching for a Strategy: Think about each 4. depression
child in the early stages of answer. 28. Nurse administering oral Strategy: Think about the
nephrotic syndrome, the nurse (1) Correct- If child can verapamil (Isoptin) to a client. action of the drug.
should discuss with the parents tolerate protein intake, Before administering the (1) Unnecessary action
which of the following dietary then it is encouraged to verapamil the nurse should (2) Unnecessary action
changes? speed healing; sodium is check the client's: (3) Unnecessary action
1. Adequate protein intake, low usually restricted 1. electrolytes. (4) Correct-Verapamil
sodium. (2) Low protein & high 2. urine output. indicated for treatment of
2. Low-protein, low-potassium potassium contraindicated 3. weight. supraventricular
intake. in renal clients 4. heart rate. tachycardias, so client's
3. Low-potassium, low-calorie (3) Does not address heart rate should be
intake. protein need at all checked prior to
4. Limited-protein, high- (4) May be appropriate administration.
carbohydrate intake only if child cannot tolerate
protein intake
29. Nurse cares for a newborn Strategy: All answers are 32. Nurse recognizes which of the Strategy: Think about each
infant with fetal alcohol assessment. Determine following as early signs of answer.
syndrome. The nurse would how each assessment lithium toxicity? (1) Indicative of side effects
expect to see which of the relates to fetal alcohol 1. Restlessness, shuffling gait, associated with
following physical syndrome. involuntary muscle antipsychotic agents, not
characteristics? (1) Usually small for movements. lithium
1. An infant that is large for gestational age 2. Ataxia, confusion, seizures. (2) Indicative of severe
gestational age (LGA) with (2) Correct- Seen with 3. Fine tremors, nausea, lithium toxicity, which
craniofacial abnormalities & fetal alcohol syndrome vomiting, diarrhea. requires prompt medical
hydrocephalus. (3) May have feeding 4. Elevated white blood cell management
2. An infant with a small head difficulties and poor count, orthostatic hypotension (3) Correct-nurse should
circumference, low birth sucking ability be alert early
weight, & undeveloped (4) Head circumference signs/symptoms of lithium
cheekbones. usually small, respiratory toxicity; include fine
3. An infant with a small head distress related to preterm tremors of fingers, wrists,
circumference, low birth birth, neurologic damage, & hands, & nausea,
weight, & excessive rooting & small trachea, floppy vomiting, & diarrhea
sucking behaviors. epiglottis (4) Indicative of side effects
4. An infant with normal head associated with
circumference, low birth antipsychotic agents, not
weight, & respiratory distress lithium
syndrome. 33. Physician orders mannitol Strategy: Think about each
30. Nurse caring for a client with Strategy: Think about each (Osmitrol) for a client with a answer.
tracheostomy. An appropriate answer. closed head injury. Which of (1) Increase in blood
nursing diagnosis for this client (1) Diagnosis acceptable; the following should the nurse pressure is not desired
is: however, 2 is priority recognize as desired (2) Correct-Mannitol
1. Impaired verbal (2) Correct- ineffective response to this medication? (Osmitrol) is an osmotic
communication related to airway clearance top 1. The blood pressure diuretic; increases urinary
absence of speaking ability. priority with increases to 150/90. output & decreases
2. Ineffective airway clearance tracheostomy since loss 2. Urinary output increases to intracranial pressure
related to increased of upper airway increases 175 cc/hour. (3) Does not indicate
tracheobronchial secretions. the amount & viscosity of 3. There is decrease in level of desired effect of
3. Risk for impaired skin secretions. activity. medication
integrity related to (3) Diagnosis acceptable; 4. There is absence of fine (4) Does not indicate
tracheostomy incision. however, 2 is a priority tremors of the fingers desired effect of
4. Alteration in comfort: pain (4) Tracheostomy is not medication
related to tracheostomy. usually painful
31. Nurse is caring for a three- Strategy: All answers are
month-old infant that is implementation.
scheduled for a barium swallow Determine the outcome of
in the morning. Prior to the each answer. Is it desired?
procedure, the MOST (1) Inappropriate
appropriate nursing action (2) Correct- Infant should
would be to: be NPO three hours prior
1. offer the infant only clear to the procedure.
liquids. (3) Inappropriate
2. make the infant NPO for (4) Unnecessary for an
three hours. infant to be NPO for six
3. feed the infant regular hours
4. maintain the infant NPO for
six hours
34. Physician writes an order for a Strategy: Think about 36. Prenatal client eight-weeks Strategy: Think "Maslow."
STAT dose of Demerol 50 mg IM each answer. gestation has a positive (1) Physical, true to some
for pain. Three hours later the (1) Does not address VDRL. In preparing teaching extent with regard to
client again complains of pain, & fact there was no plan, which following would pregnant client not taking
the nurse administers a second order for the Demerol be MOST appropriate for medication over-the-counter.
injection of Demerol. Which of the to be repeated nurse to include? unless prescribed by a
following describes the nurse's (2) Correct-Order for 1. The importance of not doctor, but not highest
liability? STAT dose does not taking any medications so as priority
1. The nurse administered the state PRN; nurse had not to damage the fetus. (2) Correct-Physical, Vitally
medication appropriately; there is an order for only the 2. Instructing the client on important to complete all
no liability. first injection, not the the importance of taking the the penicillin
2. The nurse violated narcotic law second one. penicillin for the prescribed (3) Physical, more important
in not having an order to (3) Does not address time. to be treated for disease
administer the Demerol a second fact there was no 3. Instructing the client to (4) Psychosocial,
time. order for Demerol to refrain from sexual activity. communicable diseases are
3. The client was not injured; if be repeated 4. Maintaining the reportable; partners or
injury did not occur, then the nurse (4) Does not address confidentiality of sexual contacts need to be found &
is not liable. fact there was no partners or contacts. notified so they may be
4. The nurse should have waited at order for Demerol to treated
least four hours; then there would be repeated 37. Prior to sending client for Strategy: Think about
be no liability. cardiac catheterization, significance of each answer &
35. Postoperative cataract client Strategy: Think about MOST important for nurse to how it relates to a cardiac
cautioned about not making each answer. report which of following? catheterization.
sudden movements or bending (1) Not relevant to this 1. The client has an allergy to (1) Correct-allergies to
over. The nurse understands that situation shellfish. iodine &/or seafood must be
rationale for this recommendation (2) Not relevant to this 2. The client has diminished reported immediately
is to prevent which of the situation palpable peripheral pulses. before a cardiac
following? (3) Correct-Sudden 3. The client has cool lower catheterization to avoid
1. Impairment of cerebral blood changes in position, extremities bilaterally. anaphylactic shock during
flow and headaches. constipation, 4. Client is anxious about the procedure.
2. Increased intracranial pressure. vomiting, stooping, pending procedure. (2) May be normal finding
3. Pressure on the ocular suture bending over increase before the test
line. the intraocular (3) May be normal finding
4. Displacement of the lens pressure & put before the test
implant. pressure on the (4) May be normal finding
suture line before the tes
(4) Occurs because of
pressure on suture
area; not all clients
have lens implants; 3 is
a more comprehensive
38. Several days after the delivery of a Strategy: Answers 40. The client has been receiving a blood Strategy: Think
stillborn, the parents say, "We wish implementation. Need transfusion for approximately 30 about each answer.
we could talk with other couples to determine outcome minutes. Which of these assessments, (1) Indicative of a
who have gone through this of each answer. Is it if made by the nurse, would indicate hemolytic
trauma." Which of the following desired? an allergic reaction? transfusion reaction
nursing responses would be BEST? (1) Support group for 1. Hypotension. (2) Indicative of a
1. "SIDS will provide you with this parents who have had 2. Chills. hemolytic
opportunity." an infant die from 3. Respiratory wheezing. transfusion reaction
2. "SHARE will provide you with this sudden infant death 4. Lower back discomfort. (3) Correct-allergic
opportunity." syndrome reaction is
3. "RESOLVE will provide you with (2) Correct-SHARE is characterized by
this opportunity." a support group for wheezing, urticaria
4. "CANDLELIGHTERS will provide parents who have lost (hives), facial
you with this opportunity a newborn or have flushing, &
experienced a epiglottal edema
miscarriage. (4) Indicative of a
(3) Support group for hemolytic
infertile clients transfusion reaction
(4) Support group for 41. The mother of a child with Strategy: Think
families who have lost chickenpox asks the physician's office about each answer.
a child to cancer nurse why her child will not come (1) Cccurs when
39. The client had a kidney transplant Strategy: All answers down with chickenpox again if antibodies are
yesterday. The client's son has implementation. exposed to the virus at school at a passed from mother
come to visit. The nurse should Determine outcome of later date. The nurse's response to fetus via
instruct the son to do which of the each answer. Is it should be based on the information placenta, colostrum,
following? desired? that: and breast milk
1. No special isolation techniques (1) Inaccurate 1. Natural passive immunity occurs (2) Small amounts of
are necessary. (2) Inaccurate, masks because the child receives antibodies specific antigens are
2. Wear a double mask and gloves. are unnecessary for from outside the body. used for
3. Perform good hand washing. this patient 2. Artificial active immunity occurs vaccination; body
4. Wear a gown and a mask. (3) Correct- Good because the child receives specific responds actively
hand washing is the antigens against the chickenpox virus. making antibodies
most effective 3. Natural active immunity occurs (3) Correct-
method of reducing because the child's body actively Antigen enters the
infection; very makes antibodies against the body without
important with chickenpox virus. human assistance;
immunosuppressed 4. Artificial passive immunity occurs body responds
clients. because of the inflammatory process actively making
(4) Inaccurate, masks of chickenpox. antibodies
are unnecessary for (4) Involves injection
this patient with antibodies that
were produced in
another person or
animal; used to
protect person
exposed to serious
42. The nurse has collected the following Strategy: Think 44. The nurse is caring for a Strategy: Think about
data: client anger directed toward about each answer. postoperative client whose each answer.
staff in form of frequent sarcastic or (1) Not warranted diabetes has been controlled (1) Inaccurate
crude comments, increased wringing with the data with oral antihyperglycemic (2) Inaccurate
of hands, purposeless pacing, indicated agents in the past. Client asks (3) Correct-inability
particularly after client has used (2) Not warranted why the physician ordered control diabetes mellitus
telephone. Based on this data, nurse with the data subcutaneous insulin injections by diet & oral agents,
should make which nursing diagnosis? indicated after surgery. The nurse's coupled with surgically
1. Impaired social interaction related (3) Not warranted response should be based on induced metabolic
to conversion reaction. with the data which of the following changes, being NPO
2. Risk for potential activity indicated statements? both before & after
intolerance as evidenced by (4) Correct- 1. Tissue injury after surgery surgery, infusion
purposeless pacing. Displaying decreases blood sugar. intravenous fluids
3. Powerlessness in hospital situation. evidence of anger 2. Anesthesia acts to increase necessitates temporary
4. Ineffective individual coping and anxiety and an glycogen stores. control by insulin.
related to recent anger and anxiety inability to directly 3. Being NPO inhibits normal (4) Inaccurate
deal with concerns, blood sugar control.
which is ineffective 4. Surgery often leads to insulin
coping dependency.
43. The nurse is caring for a patient with Strategy: Determine 45. The nurse is caring for clients in Strategy: Determine how
a pneumothorax resulting from an how each a drug rehabilitation facility. each answer relates to IV
auto accident three days ago. He has observation relates Which of the following drug abuse.
chest tube connected to three- to a chest tube. complications of IV drug abuse (1) Jaundice can develop
chamber water-seal drainage system (1) Doesn't indicate is the nurse MOST likely to due to hepatitis B &
(Pleur-evac) with 20 cm suction. How re-expansion observe? cirrhosis, which may
would the nurse know if the lung had (2) Correct- 1. Jaundice. occur in narcotic abusers
re-expanded? Indicates no more 2. Rash. who use intravenous
1. There is no drainage in the air leaking into 3. Bruising. drugs
collection chamber for three hours. pleural space 4. Cellulitis. (2) May occur due to
2. Fluid in water-seal chamber does (3) Indicates air chemicals that are used
not fluctuate with respirations. leak; need check in cutting the drugs by
3. There is continuous bubbling in the for location of leak; the client or the drug
water-seal chamber. clamp tubing close dealer.
4. There is gentle bubbling in the to chest & check for (3) May occur due to the
suction-control chamber. bubbling, then chemicals that are used
clamp tubing close in cutting the drugs by
to container & the client or drug dealer
check for bubbling (4) Correct-most
(4) Normal finding narcotic addicts do not
inject sterile purified
material with aseptic
techniques; cellulitis
common complication
due to skin popping or
using an infected drug
46. The nurse is caring for clients in Strategy: Determine 49. The nurse is teaching a parenting class to Strategy: Think
the outpatient clinic. Which of the the significance of a group of expectant mothers. The nurse about each
following messages should the each assessment and should advise that the breastfeeding answer.
nurse return FIRST? how it relates to a mother should increase her daily caloric (1) Inadequate
1. A mother reports that the newborn. intake by how many calories? amount
umbilical cord of her five-day-old (1) expected outcome; 1. 200. (2) Inadequate
infant is dry and hard to the touch. falls off within 1-2 2. 300. amount
2. Mother reports that the "soft weeks; no tub baths 3. 400. (3) Inadequate
spot" on the head of her four-day- until the cord falls off 4. 500 amount
old infant feels slightly elevated (2) correct-fontanelle (4) Correct-
when the baby sleeps. should feel soft& flat; milk
3. Mother reports that the fullness or bulging production
circumcision of her 3-day-old indicates increased requires an
infant is covered with yellowish intracranial pressure increase of
exudate. (3) normal healing, 500 calories
4. Father reports that he bumped don't remove exudate; per day.
the crib of his two-day-old infant clean with warm water 50. The nurse knows that according to Strategy: Think
and she violently extended her (4) motor reflex is Erikson's stages of psychosocial about each
extremities & returned to them normal; disappears development, which of the following best answer.
their previous position. after 3-4 months represents a 50-year-old client? (1) Appropriate
47. The nurse is discussing growth and Strategy: Picture a 1. Integrity versus despair & disgust. for ages 65 and
development with the parents of a four-year-old. 2. Generativity versus stagnation. older
four-year-old child. The nurse (1) Describes play for 3. Intimacy versus isolation. (2) Correct-
should identify which of the an infant 4. Identity versus role diffusion. Stage of
following as the type of play (2) Describes play for development
characteristic of this age group? a toddler is appropriate
1. Solitary play. (3) Correct-this is play for 45-64
2. Parallel play. characterizes four- years of age
3. Associative play. year-olds (3) Appropriate
4. Aggressive play. (4) Is not play but a for the young
behavior adult
48. The nurse is supervising an Strategy: Answers are (4) Appropriate
LPN/LVN who is administering an all implementation. for the
enema to a patient. During Determine outcome of adolescent
administration, MOST important for each answer. Is it 51. The nurse knows that Cortisol is Strategy: Think
LPN/LVN to take which of the desired? responsible for: about each
following actions? (1) Could cause rapid 1. Preparing the body for "flight or fight." answer.
1. Place the solution 20 inches infusion & possible 2. Regulating the calcium metabolism. (1) Action of
above the anus. painful distention of 3. Converting proteins and fat into epinephrine
2. Adjust the temperature of the colon glucose. (2) Action of
solution. (2) Is not feasible 4. Enhancing musculoskeletal activity. parathyroid
3. Insert the tube six inches. during the hormone
4. Position the patient left side- administrative phase parathormone
lying (Sim's) with knee flexed. (3) Tube should be (3) Correct-
inserted no more than action Cortisol;
four inches also an anti-
(4) Correct-Allows inflammatory
solution flow agent
downward along (4) action of
natural curve of norepinephrine
sigmoid colon &
rectum, which
improves retention of
52. The nurse knows which of Strategy: Think about how each 54. The nurse on a psychiatric unit of the Strategy: Think
the following mood- drug is administered. hospital refuses to agree to a 32- about each answer.
altering drugs is most (1) Not commonly used year-old patient's request to organize (1) Inaccurate,
often associated with an intravenously a party on the unit with his friends. doesn't undermine
increased risk for HIV (2) Not commonly used The patient becomes angry and uses authority of staff
infection related to intravenously abusive language with the nurse. (2) Shows lack of
intravenous drug use? (3) Not commonly used Which of the following statements understanding of
1. Benzodiazepines. intravenously indicates that the nurse has an cause for patient's
2. Marijuana. (4) Correct-narcotics are most understanding of the patient's behavior
3. Barbiturates. often used intravenously behavior? (3) Correct-
4. Narcotics. 1. Allowing the patient to use abusive Symptoms will
53. The nurse knows which of Strategy: Think about each language will undermine the authority respond to
the following would have answer. of the nurse. treatment
the greatest impact on an (1) Speech disturbance, would 2. Responding in kind to a patient who (4) Suggests that
elderly client's ability to have greatest impact on uses abusive language will using acceptable
complete activities of daily communication ability perpetuate the behavior. language will
living (ADLs)? (2) Speech disturbance, would 3. Abusive language is one of the change patient's
1. Perseveration. have greatest impact on behaviors that is a symptom of the behavior; shows
2. Aphasia. communication ability patient's illness. lack of
3. Mnemonic disturbance. (3) Speech disturbance, would 4. The nurse should model acceptable understanding of
4. Apraxia. have greatest impact on behavior & language for all patients. patient's behavior
communication ability 55. *The nurse performs the Rinne tests Strategy: Think
(4) Correct- Apraxia is loss on a 6-year-old girl. Which of the about each answer.
purposeful movement in following is an accurate (1) Inaccurate
absence of motor or sensory statement of how this test should be (2) Correct-child
impairment; when it affects an performed?* should hear sound
ADL, such as dressing, client 1. The stem of vibrating tuning fork is again when tuning
may not be able to put clothes held against the auditory canal until fork is moved from
on properly the child indicates that she can no mastoid bone to
longer hear the sound. Then the the front of the
tuning fork is moved away from the auditory canal
canal. because air
2. The stem of vibrating tuning fork is conduction is
held against the mastoid bone until better than bone
the child indicates that she can no conduction.
longer hear the sound. Then tuning (3) Is the Weber test
fork is moved in front of the auditory (4) Inaccurate
3. The stem of vibrating tuning fork is
held in middle of the forehead & the
girl's hearing is assessed in both ears.
4. The stem of vibrating tuning fork is
positioned two inches behind the
girl's head, & the length of time she
hears the sound is documented.
56. The nurse prepares a 67-year-old man for Strategy: Think 58. The nurse suggests that Strategy: Think about each
an intravenous pyelogram (IVP). The client about each the client not eat or drink answer.
asks nurse to explain reason why the answer. anything just before (1) Correct-Full stomach is
procedure is performed. The nurse's (1) Would going to bed. The more likely to slide (reflux)
response should be based on the involve appropriateness of this through the hernia, causing
knowledge that the primary purpose of an invasive comment is based on regurgitation & heartburn
IVP is to: procedure, which of these (2) Vomiting, decreased
1. observe the renal pelvis directly. such as understandings about a respirations, and fluid overload
2. assess glomerulofiltration rate. cystoscopy sliding Hiatal hernia? are not related to hiatal hernia
3. examine the urinary tract by x-ray. (2) Not primary 1. The client is less likely (3) Vomiting, decreased
4. inject medication into the urinary purpose to awaken during the respirations, and fluid overload
system (3) Correct-x- night with heartburn if the are not related to hiatal hernia
rays of entire stomach is empty. (4) Vomiting, decreased
urinary tract 2. Early morning vomiting respirations, and fluid overload
taken, will be less of a problem are not related to hiatal hernia
evaluates if the stomach is empty.
kidney 3. Drinking or eating
function before lying down causes
(4) Not primary decreased respirations
purpose due to increased pressure
57. The nurse should caution the client with Strategy: Think on the lungs.
hypothyroidism to avoid: about each 4. The client may develop
1. Warm environmental temperatures. answer. fluid overload if fluids
2. Narcotic sedatives. (1) Client with are taken just before
3. Increased physical exercise. hypothyroidism going to bed.
4. A diet high in fiber cannot tolerate 59. The nurse understands Strategy: Think about each
cold that the primary reason answer.
temperatures. elderly adults have (1) Decreased intake high-fiber
(2) Correct- problems with foods due to chewing difficulties
Client is very constipation is that they: is seen but is not major cause of
sensitive to 1. Eat a small volume of constipation
narcotics, food with decreased bulk. (2) Correct-Reduced GI motility
barbiturates, & 2. Have less activity and due decreased muscle tone,
anesthetics. decreased muscle tone. decreased exercise. Other
(3) Should not 3. Have neurological factors: prolonged laxative use,
be avoided changes in the ignoring urge defecate, side
(4) Requires gastrointestinal tract. effect from medications,
high fiber, high 4. Have decreased emotional problems,
cellulose foods sensation in the insufficient fluid intake, &
to prevent gastrointestinal tract. excessive dietary fat.
constipation. (3) Decreased response to
stretch receptors in rectum &
anal canal occurs but is not
major cause constipation
(4) Decreased response to
stretch receptors in rectum &
anal canal occurs but is not
major cause constipation
60. The nurse would explain to the diabetic Strategy: Think 62. The outpatient clinic nurse is caring for Strategy: Think
client that the decreased vision he has about each a 66-year-old woman with insulin- about each
experienced is due to which of following? answer. dependent diabetes mellitus (IDDM). answer.
1. Bleeding into the inner ocular chamber of (1) Because client is unwilling perform (1) Correct-The
the eye. Complication blood glucose monitoring, she tests her level at which
2. Gradual separation of the retina from the of urine for sugar & acetone. Nurse knows glucose starts to
base of the eye. postoperative that blood glucose monitoring appear in the
3. An increase in the size of the vessels in eye surgery or preferred over urine testing glucose urine increases,
the back of the eye. traumatic because: leading to false
4. Gradual destruction and degeneration of injury 1. The renal threshold for glucose is negative
the retina (hyphema) elevated in the elderly. readings, results
(2) Describes 2. Blood glucose monitoring is easier in elevated
a retinal and less costly for clients to perform. glucose levels
detachment 3. Urine testing for glucose provides (2) More
(3) false-positive readings. expensive
Destruction of 4. Determination of the color on a procedure
the vessels, as reagent strip varies from person to (3) Provides false-
well as person. negative readings,
edema, occurs may be negative
(4) Correct- from 0-180 mg/dL
gradual (4) Results are
destruction expressed as a
occurs due to percentage
deterioration according to
of the retinal color change
61. The nursing team consists of a RN who has Strategy: The
been practicing for six months, a LPN/LVN RN cares for
who has been practicing for 15 years, & clients that
nursing assistant who has been caring for require
clients for three years. The RN should care assessment,
for which of the following clients? teaching, and
1. A client 1 day postop after an internal nursing
fixation of a fractured left femur. judgment.
2. A client receiving diltiazem (Cardizem) (1) Care can
and phenytoin (Dilantin). be assigned to
3. A client who is to receive 2 units of the nursing
packed cells prior to an upper endoscopy assistant;
procedure. standard,
4. A client admitted yesterday with unchanging
exhaustion and a diagnosis of acute bipolar procedure
disorder. (2) Medication
can be given
by the LPN
(3) Correct-
Requires the
and teaching
skills of RN.
(4) Offer food
and fluids,
assign to LPN
63. The parents of a child with Strategy: Think about 66. The physician orders Strategy: Determine how
hemophilia want to know the each statement. Is it true? naproxen sodium each answer relates to
cause of the disease. Which of 1. "The father transmits the (Naprosyn) for a 77-year- Naprosyn.
the following would be the BEST gene to his son."; affected old man. The nurse should (1) Not side effects seen with
response by the nurse? male inherits gene from assess the patient for: this medication; may see
1. "The father transmits the gene his mother and can 1. stomatitis and headache, nausea
to his son." transmit it only to his photosensitivity. (2) Not side effects seen with
2. "Both the mother and the daughters 2. brachycardia and dry this medication; may see
father carry a recessive trait." 2. "Both the mother and mouth. epigastric distress and rash
3. "The mother transmits the the father carry a 3. fluid retention and (3) Correct-NSAID
gene to her son." recessive trait."; it is not an dizziness. (nonsteroidal
4. "There is 50% chance that the autosomal recessive trait 4. gynecomastia and antiinflammatory drug) used
mother will pass the trait to 3. "The mother transmits impotence as analgesic; side effects
each of her daughters." the gene to her son."; include headache, dizziness,
CORRECT- hemophilia is GI distress, pruritus, & rash.
a sex linked disorder (4) Not side effects seen with
4. "There is 50% chance this medication; may see
that mother will pass the nephrotoxicity & pruritus
trait to each of her 67. Toddler with lead poisoning Strategy: Determine how
daughters."; there is 50% admitted to the pediatric each answer relates to lead
chance that mother will unit. There is an order to poisoning.
pass the trait to each of encourage fluids. Which of (1) Correct- Milk providea an
the children following fluids would be large amount of vitamin D;
64. The physician inserts a Strategy: Think about the best for the nurse to vitamin D optimizes
temporary pacemaker 45-year- each answer. offer to the child? deposition of lead in the
old man following a myocardial (1) Action of cardiac 1. Milk. long bones; purpose
infarction. The nurse knows that glycosides such as 2. Water. treatment is to remove lead
the primary purpose of the Digoxin 3. Orange juice. from the blood & soft tissues
pacemaker is to: (2) Correct- Acts to 4. Fruit punch (2) Good for fluid
1. Increase the force of regulate cardiac rhythm replacement; does not relate
myocardial contraction. (3) Action of to the lead poisoning
2. Increase the cardiac output. antiarrhythmics such as (3) Good for fluid
3. Prevent premature Quinidine replacement; does not relate
ventricular contractions (PVCs). (4) Action of diuretics to the lead poisoning
4. Prevent systemic overload such as Lasix (4) Good for fluid
65. The physician orders Strategy: Recall replacement; does not relate
hydromorphone hydrochloride classification of drug. to the lead poisoning
(Dilaudid) 15 mg IM for a 56- (1) These side effects are 68. Which information should Strategy: Think about each
year-old woman. Side effects of not seen with this nurse recognize as being answer.
this medication that the nurse medication MOST pertinent to the (1) Indicates other
should observe the patient for (2) Correct-narcotic diagnosis of cholecystitis? gastrointestinal problem
include: analgesic used for 1. Flatulence. (2) Indicate other
1. Photosensitivity & moderate to severe pain, 2. Nausea & vomiting. gastrointestinal problem
constipation. Monitor vital signs 3. Right upper abdominal (3) Correct-will experience
2. Hypotension/Respiratory frequently pain. pain in the upper-right
depression (3) These side effects are 4. Dyspepsia. abdominal quadrant
3. Tardive dyskinesia & diplopia. not seen with this (4) Indicates other
4. Dry mouth & tinnitus. medication gastrointestinal problem
(4) These side effects are
not seen with this
69. Which nursing observation Strategy: Determine how 72. Which of the Strategy: Remember the "comma, comma,
would suggest that a client each answer relates to following and" rule.
has developed an Addisonian Addison's. might alert (1) Is more indicative of a dysphoric or
crisis? (1) Signs and symptoms of the nurse to depressed client
1. Muscular weakness and Addison's disease, but do consider an (2) Could warrant further exploration of
fatigue. not indicate a crisis alcohol alcohol use, but is not best indication
2. Restlessness and rapid, (2) Correct-may be signs of problem in a (3) Correct-when admitted for another
weak pulse. shock related to an client physical problem to general medical,
3. Dark pigmentation of the Addisonian crisis hospitalized surgical, or critical care unit, nurse many
skin. (3) Signs and symptoms of for a physical times becomes case finder; must be alert
4. Gastrointestinal Addison's disease, but do illness? for subtle symptoms of alcohol-related
disturbances and anorexia. not indicate a crisis 1. Depression, problem; client who has several complaints
(4) Signs and symptoms of difficulty of pain that do not appear to be correlated
Addison's disease, but do falling asleep, to admissions problem requires further
not indicate a crisis decreased investigation; tremors, elevated
70. Which of the following Strategy: Answers are concentration. temperature, & pain symptoms are
instructions should be given implementation. Determine 2. Elevated indicative of alcohol-related problem
by the nurse to an adult client the outcome of each liver enzymes, (4) More indicative of withdrawal from
in preparation for a plasma answer. Is it desired? cirrhosis, narcotics or infective problem such as
cholesterol screening? (1) Normal diet should be decreased tuberculosis
1. Eat a vegetarian diet for one eaten the week before the platelets.
week before the test. test 3. Tremors,
2. Limit alcohol intake to two (2) Alcohol intake will elevated
glasses of wine the day interfere with test results temperature,
before the test. (3) Normal diet should be complaints of
3. Abstain from dairy products eaten the week before the nocturnal leg
for 48 hours before the test. test cramps,
4. Only sips of water should (4) Correct- Only sips of complaints of
be taken for 12 hours before water are permitted for 12 pain
the test. hours before plasma symptoms.
cholesterol screening to 4. Flulike
achieve accurate results. symptoms,
71. Which of the following is the Strategy: Determine how night sweats,
BEST way for a nurse to each answer relates to elevated
assess the fluid balance of a hydration. temperature,
70-year-old man? (1) May be elevated due to decreased
1. Assess the client's blood age-related hypertension deep tendon
pressure. (2) Not accurate due to reflexes.
2. Check the client's tissue changes in skin elasticity
turgor. from the aging process
3. Ask the client if he is thirsty. (3) Not reliable indicator;
4. Maintain an accurate intake may have diminished
and output sensation of thirst
(4) Correct- Best indicator
fluid status.
73. Which of the following should be charted by the nurse to reflect a Strategy: Good charting is objective.
client's emotional adjustment to being hospitalized in the intensive (1) Does not describe emotional adjustment
care unit? (2) Draws conclusions without supporting data
1. "The client is unable to complete activities of daily living without (3) Correct-gives an objective description of the client's
assistance." behavior & affect
2. "The client appears to be depressed and anxious regarding his/her (4) Describes the client's family, not the client
3. "The client constantly calls for nurses, pleads for them to stay at
the bedside, & cries uncontrollably."
4. "The family is unable to visit more often than once a week because
they live far away."
74. Which of the following types of foods should the nurse encourage in Strategy: Think about each answer.
the diet of a client with hypoparathyroidism? (1) Diet should be low in phosphorus
1. High in phosphorus. (2) Correct-diet should provide high calcium & low
2. High in calcium. phosphorus because parathyroid controls calcium
3. Low in sodium. balance
4. Low in potassium. (3) Not regulated by the parathyroid
(4) Not regulated by the parathyroid
75. Which of the following would be MOST important for the Strategy: Determine the outcome & how it relates to
rehabilitation nurse to assess during a new client's admission? rehabilitation.
1. The client's expectations of family members. (1) Important to assess but is not as crucial for future
2. Client's understanding of available supportive services. success as the client's goals
3. Client's personal goals for rehabilitation. (2) Important to assess but is not as crucial for future
4. The client's past experiences in the hospital. success as the client's goals
(3) Correct- Important for the nurse to understand what
client expects from rehabilitation program for future
(4) Important to assess but is not as crucial for future
success as the client's goals