1. Answer B.

Immunizing an infant is an example of primary prevention, which aims to

prevent health problems. Administering digoxin to treat heart failure and obtaining a
smear for a screening test are examples for secondary prevention, which promotes early
detection and treatment of disease. Using occupational therapy to help a patient cope
with arthritis is an example of tertiary prevention, which aims to help a patient deal with
the residual consequences of a problem or to prevent the problem from recurring.

2. Answer B. Inspection always comes first when performing a physical examination.

Percussion and palpation of the abdomen may affect bowel motility and therefore should
follow auscultation.

3. Answer D. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It
sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—
is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.

4. Answer B. The nurse identifies human responses to actual or potential health problems
during the nursing diagnosis step of the nursing process. During the assessment step, the
nurse systematically collects data about the patient or family. During the planning step,
the nurse develops strategies to resolve or decrease the patient’s problem. During the
evaluation step, the nurse determines the effectiveness of the plan of care.

5. Answer B. Because furosemide is a potassium-wasting diuretic, the nurse should plan to

teach the patient to increase intake of potassium-rich foods, such as bananas and
oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources
of potassium.

6. Answer D. The most toxic reaction to chloramphenicol is bone marrow suppression.

Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or
status epilepticus.

7. Answer D. Altered peripheral tissue perfusion related to venous congestion” takes

highest priority because venous inflammation and clot formation impede blood flow in a
patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange
is related to decreased, not increased, blood flow. Option B is inappropriate because no
evidence suggest that this patient has a fluid volume excess. Option C may be warranted
but is secondary to altered tissue perfusion.

8. Answer A. When the central venous catheter is positioned correctly, its tip lies in the
superior vena cava, inferior vena cava, or the right atrium—that is, in central venous
circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large
amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are
common insertion sites for central venous catheters.

9. Answer D. During the evaluation step of the nursing process the nurse determines
whether the goals established in the care plan have been achieved, and evaluates the
success of the plan. If a goal is unmet or partially met the nurse reexamines the data and
revises the plan. Assessment involves data collection. Planning involves setting
priorities, establishing goals, and selecting appropriate interventions.
10. Answer C. Wound healing in a client with diabetes will be delayed. Providing the client
with a time frame could give the client false information.

11. Answer B. Although documentation isn’t a step in the nursing process, the nurse is
legally required to document activities related to drug therapy, including the time of
administration, the quantity, and the client’s reaction. Developing a content outline,
establishing outcome criteria, and setting realistic client goals are part of planning rather
than implementation.

12. Answer B. The client shows signs of deep vein thrombosis (DVT). The pelvic area is
rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic
surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the
client’s risk of DVT. In general, diabetes is a contributing factor associated with
peripheral vascular disease.

13. Answer D. The nurse should begin with the simplest interventions, such as pillows or
snacks, before interventions that require greater skill such as relaxation techniques.
Sleep medication should be avoided whenever possible. At some point, the nurse should
do a thorough sleep assessment, especially if common sense interventions fail.

14. Answer C. Moist, sterile saline dressings support would heal and are cost-effective. Dry
sterile dressings adhere to the wound and debride the tissue when removed. Petroleum
supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it
shouldn’t be left on an open wound.

15. Answer C. Upcoding is the practice of using a CPT code that’s reimbursed at a higher
rate than the code for the service actually provided. Unbundling, overbilling, and
misrepresentation aren’t the terms used for this illegal practice.

16. Answer D. The nurse should refer this client to a sex counselor or other professional.
Making appropriate referrals is a valid part of planning the client’s care. The nurse
doesn’t normally provide sex counseling. Therefore, providing time for privacy and
providing support for the spouse or significant other are important, but not as important
as referring the client to a sex counselor.

17. Answer B. According to Maslow, elimination is a first-level or physiological need, and

therefore takes priority over all other needs. Security and safety are second-level needs;
belonging is a third-level need. Second- and third-level needs can be met only after a
client’s first-level needs have been satisfied.

18. Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen
balance. Therefore, inadequate protein intake impairs wound healing. Inadequate
vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A
pressure ulcer should never be massaged.

19. Answer D. Risk for aspiration related to anesthesia takes priority for thins client because
general anesthesia may impair the gag and swallowing reflexes, possibly leading to
aspiration. The other options, although important, are secondary.
20. Answer C. Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid
in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an
excess of urea and other nitrogen products in the blood.

21. Answer B. The Patient’s Bill of Rights addresses the client’s right to information,
informed consent, timely responses to requests for services, and treatment refusal. A
legal document, it serves as a guideline for the nurse’s decision making. Standards of
Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing
practice parameters and primarily describe the use of the nursing process in providing
care.

22. Answer B. Using an undersized blood pressure cuff produces a falsely elevated blood
pressure because the cuff can’t record brachial artery measurements unless it’s
excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the
blood pressure cuff because the sciatic nerve is located in the lower extremity.

23. Answer A. Baked beans, hamburger, and milk are all excellent sources of protein. The
spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice
provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken
provides protein but the chicken-spinach-soda combination provides less protein than
the baked beans-hamburger-milk selection.

24. Answer A. The first priority is to evaluate airway patency before assessing for signs of
obstruction, sternal retraction, stridor, or wheezing. Airway management is always the
nurse’s first priority. Pain management and splinting are important for the client’s
comfort, but would come after airway assessment. Coughing and deep breathing may be
contraindicated if the client has internal bleeding and other injuries.

25. Answer B. The usual or most prevalent reason for lack of productivity in a group of
competent nurses is inadequate communication or a situation in which the nurses have
unexpected feeling and emotions. Although the other options could be contributing to
the problematic situation, they’re less likely to be the cause.

26. Answer B. The client is at risk for infection because WBC count is dangerously low. Hb
level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of
injury are inappropriate.

27. Answer D. Because of lethargy, the post tonsillectomy client is at risk for aspirating
blood from the surgical wound. Therefore, placing the client in the side-lying position
until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t
allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the
risk of blood aspiration.

28. Answer A. Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of
involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double
vision.

29. Answer A. People of Italian heritage tend to verbalize discomfort and pain. The pain
was real to the client, and he may need medication when he wakes up.
30. Answer D. Fluid overload causes the volume of blood within the vascular system to
increase. This increase causes the vein to distend, which can be seen most obviously in
the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An
electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to
jugular vein distention.