Test 2 Haad RN

Question 1
The nurse is assessing an 8-month-old during a wellness checkup. Which action is a normal
development task for an infant this age?
sitting without support
saying two words
feeding himself with a spoon
playing patty-cake
Correct. The answer is
sitting without support
Explanation:
The correct answer is
sitting without support.
According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7
months. A 15-month-old child should be able to say two words. By 17 months, the toddler should be able to feed
himself with a spoon. A 10-month-old should be able to play patty-cake.
Question 2
The nurse is preparing to administer a Vitamin K injection to a newborn. Which site on the body should
the nurse use for the injection?
deltoid muscle in the upper arm
ventrogluteal muscle in the thigh
vastus lateralis muscle in the thigh
quadricep muscle
Explanation:
The correct answer:
Vitamin K is used to prevent a hemorrhagic disease due to a dependence on vitamin K. There are three muscle
sites on the body where medication is administered through an injection. The preferred site for an intramuscular
injection for a newborn is the vastus muscle in the thigh. Further, the nurse administers the vitamin K drug in
the vastus thigh muscle one hour after the baby is born.
Question 3
The nurse is educating a family on violence and assault. The nurse explains what?
assault is a type of nonintentional tort
assault is the act of wounding a person without the intention of causing harm
assault is a form of slander
assault is the mental or physical threat of violence
assault is the mental or physical threat of violence
Explanation:
The correct answer is assault is the mental or physical threat of violence. Further, assault is a type of intentional tort
instead of a nonintentional tort. Next, the act of wounding a person with the intention of causing harm is known as
battery.
Question 4
Which of the following is an Antihypercalcemic?
Dibasic calcium phosphate.
Calcium carbonate.
Pamidronate disodium.
Cinacalcet hydrochloride.
Cinacalcet hydrochloride.
Explanation:
Correct answer:
Cinacalcet hydrochloride
Choices A & B are calcium supplements. Choice C is a calcium regulator.

Question 5
A client admitted for medically monitored detoxification from alcohol was assessed by the nurse with
insomnia, hyperalertness and anorexia. The nurse determines that the symptoms are related to what?
delirium tremens
alcohol withdrawal syndrome
Korsakoff's syndrome
cirrhosis
alcohol withdrawal syndrome
Explanation:
The correct answer is alcohol withdrawal syndrome. Alcohol withdrawal syndrome is seen in individuals who are
heavy drinkers. Alcohol withdrawal is seen 8 hours after the individual has stopped drinking alcohol. This syndrome
is evident by anorexia, irritability, nausea, insomnia, hyperalterness, trachyarida and diaphoresis. Delirium tremens
is another symptom of alcohol withdrawal syndrome. However, it is evident by irregular tremors, delusions,
confusion and hallucinations. Korsakoff's syndrome is not associated with alcohol withdrawal syndrome. However, it
is a result of alcohol dependence that is chronic, irreversible and follows Wernicke's encephalopathy.
Question 6
Which of the following terms is a management system that reduces the length of one’s hospital stay?

Case management.
Variances.
Accountability.
Critical path.
Incorrect. The answer is
Critical path.
Explanation:
Correct answer:
Critical path
Choice A is defined as a health care delivery system that focuses on the most efficient use of personnel and
resources to maximize revenue as well as provide high quality healthcare. Choice B refers to the deviations from
the usual critical paths. Choice C is defined as a nurse taking responsibility for the consequences of an acti
Question 7
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
Cyanosis of the lips.
Bilateral crackles.
Productive cough.
Leg edema.
Leg edema.
Explanation:
Correct answer:
Leg edema
Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, neck vein distention,
and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive
cough.
Question 8
Which of the following is NOT a complication commonly associated with central venous catheters?
Air embolism<./font>
None of these.
Damage to the catheter.
Bleeding.
None of these.
Explanation:
Correct answer:
None of these
In addition to Choices A, C and D, the following possible complications are also to be considered: 1. overload of the
circulatory system 2. phlebitis 3. infection 4. pneumothorax 5. dysrhythmia 6. occlusion
Question 9
A 55-year-old male is scheduled for a Anterior Segment Surgery. What is the goal of this procedure
that the nurse should discuss with the client?
this surgery will remove tissue
this surgery will remove a cataract

this surgery will remove an ulcer
this surgery will remove a tumor
this surgery will remove a cataract
Explanation:
The correct answer is this surgery will remove a cataract. Anterior Segment Surgery involves removing the cloudy
lens which is caused by a cataract and replacing it with an artificial lens. If a cataract is not removed from the lens of
the eye, an individual's vision is impaired and in some cases the client may go blind.
Question 10
The nurse is teaching a group of women to perform a breast self-examination. The nurse should
explain that the purpose of performing the examination is to discover what?
Cancerous lumps.
Areas of thickness or fullness.
Changes from previous self-examinations.
Fibrocystic masses.
Changes from previous self-examinations.
Explanation:
Correct answer:
Changes from previous self-examiniations
Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a
physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a
malignancy, or masses that are fibrocystic as opposed to malignant.
Question 11
When caring for a client who is hypovolemic on the unit, the nurse realizes that plasma expanders
are not available. The nurse anticipates which of the following solutions to be prescribed by the
physician?
0.45% sodium chloride and 5% dextrose.
10% dextrose in water.
0.45% sodium chloride.
5% dextrose in water.
Explanation:
The Correct answer is:
A solution of 0.45% sodium chloride and 5% dextrose is hypertonic and can be used to treat hypovolemia when
plasma expanders are not readily available. 0.45% sodium chloride is hypotonic and 5% and 10% dextrose are
isotonic solutions.
Question 12
Which of the following should the nurse teach the parents of a child diagnosed with bronchiolitis?
encourage the child to engage in moderate activity without taking a nap
spray a steriod nasal spay in the infants nose to clear the passages
report slow shallow breathing to the physician
give fluids
give fluids
Explanation:
The correct answer is give fluids. By giving fluids to the child diagnosed with bronchiolitis, the secretions are
loosened and thinned. Additional teachings the nurse should perform during discharge are instructing the parents
to use a bulb syringe to keep the infant's nares clear, encourage the child to rest and take naps while recovering,
report to the physician immediately if the child's breathing is rapid or difficult.
Question 13
The nurse understands a client diagnosed with chicken pox has what?
A nodule
A pustule
A vesicle
A wheal
A vesicle
Explanation:
The correct answer is A vesicle. A vesicle is a round or oval shaped thin mass that is translucent. Also, the mass
contains blood or serous fluid. Examples of vesicles are chicken pox, a burn blister and herpes simplex.
Question 14
Of the following, which is the normal blood pressure range for a toddler?
110-140/60-90
90-100/50-65
60-80/30-60
110-120/60-80
90-100/50-65
Explanation:
The correct answer is B. Choice A is the normal range for an adult. Choice C is normal for a newborn and Choice D,
for an adolescent.
Question 15
An incident report is part of a legal safeguard for a health care facility. Which of the following is an
accurate statement regarding incident reporting?
The report should be filled out accurately, factually, and completely.
The report form should be copied for the client's record.
The incident should be documented in the client's record.
The report helps identify problem clients who will not be allowed readmission.
Explanation:
The report form should not be copied for the client's record. The incident report form should not be mentioned in the
client's record. The report is used as a means of identifying risk situations and improving client care, not as a tool to
discriminate against clients.
Question 16
The nurse has administered a 13-year-old Demerol for postoperative pain. What intervention should
the nurse perform?
assess the client's pulse every 15 minutes
assess pain control every hour
assess urine output every 30 minutes
assess blood pressure every hour
Explanation:
The correct answer is:
assess pain control every hour.
The nurse should assess the client each hour to ensure the pain is relieved. The reason is to prevent the pain from
becoming severe due to inadequate control of the pain.
Question 16
The nurse has administered a 13-year-old Demerol for postoperative pain. What intervention should
the nurse perform?
assess the client's pulse every 15 minutes
assess urine output every 30 minutes
assess blood pressure every hour
Explanation:
assess pain control every hour.
The nurse should assess the client each hour to ensure the pain is relieved. The reason is to prevent the pain from
becoming severe due to inadequate control of the pain.
Question 17
Which medical diagnosis should the nurse expect while collecting the history from a client who is
scheduled for a gastrectomy?
encephalorrhagia
hyperthyroidism
phatnorrhagia
duodenal ulcer
duodenal ulcer
Explanation:
The correct answer is duodenal ulcer. Clients diagnosed with a duodenal ulcer may have surgical interventions such
as a partial gastrectomy or vagotomy. Encephalorrhagia is not a correct choice as this deals with cerebral
hemorrhage. Further, hyperthyroidism is a condition where there is excessive secretion of the thyroid glands.
Phatnorrhagia is a hemorrhage from the tooth socket.
Question 18
The next day after being admitted with bipolar disorder, a client becomes verbally aggressive during a
group therapy session. Which response by the nurse would be therapeutic?
"You are behaving in an unacceptable manner, and you need to control yourself."
"If you continue to talk like that, no one will want to be around you."
"You are scaring everyone in the group. Leave the room immediately."
"You are disturbing the other clients. I will walk with you around the patio to help you
release some of your energy."
"You are disturbing the other clients. I will walk with you around the patio to help you release some of your
energy."
Explanation:
Correct answer:
"You are disturbing the other clients. I will walk with you around the patio to help you release some of your
energy"
This response shows that the nurse finds the client's behavior unacceptable, yet still regards the client as worthy of
help. The other options give the false impression that the client is in control of the behavior; the client has not been
in treatment long enough to control the behavior.
Question 19
The RN is providing discharge instructions to a mother of a 3-year-old child who has undergone an
orchiopexy to correct cryptorchidism. Which of the following statements made by the mother would
indicate further teaching is necessary?
"I'll give him medication so he'll be comfortable."
"I'll check his voiding to be sure there is no problem."

"I will let him decide when he wants to return to his play activities."
"I will check his temperature."
Explanation:
Vigorous activities should be restricted for 2 weeks following this type of surgery to allow for healing and prevent
injury. Normal 3- year-olds want to be active, therefore, to prevent dislodging of the internal sutures, activity should
be restricted. Monitoring the urine output, providing analgesics, and monitoring temperature are all important for the
mother to be instructed upon.
Question 20
A client with suspected lung cancer is scheduled for a thoracentesis as part of the diagnostic workup.
The nurse reviews the client's history for conditions that might contraindicate this procedure. Which
condition is a contraindication for thoracentesis?
A seizure disorder.
Chronic obstructive pulmonary disease.
Anemia.
A bleeding disorder.
A bleeding disorder.
Explanation:
Correct answer:
A bleeding disorder
A bleeding disorder is a contraindication for thoracentesis because a hemorrhage may occur during or after this
procedure, possibly causing death. Although a history of a seizure disorder, chronic obstructive pulmonary disease,
or anemia calls for caution, it does not contraindicate thoracentesis.
Question 21
The nurse understands which principle is associated with the elimination of unwanted substances as
part of the final urine formation process?
Tubular diffusion.
Tubular reabsorption.
Tubular transport.
Tubular secretion.
Tubular secretion.
Explanation:
Correct answer:
Tubular secretion
In the final stages of urine formation, tubular secretion occurs. This process gets rid of substances, for instance,
medications that have not undergone filtration. Further, tubular secretion gets rid of extra amounts of potassium ions
and regulates the pH of the blood.
Question 22
The nurse is caring for a client diagnosed with Down syndrome. The nurse understands the most
common defect associated with Down Syndrome is what?
Congenital heart disease.
Blurred vision.
Pneumonia.
Loss of muscle tone.
Congenital heart disease.
Explanation:
Correct answer:
Congenital heart disease
Down syndrome is type of mental retardation characterized by a sloping forehead, short broad hands, a flat nose,
and a dwarf- appearing physical build. Further, children born with Down syndrome may also have a congenital
heart disease.
Question 23
Which of the following would include severe abdominal pain and vaginal bleeding?
Abruptio placenta
Prolapsed umbilical cord
Placenta previa
Premature labor
Abruptio placenta
Explanation:
The correct answer is A.
With choice C, there will most likely be painless vaginal bleeding. With choice D, there will be no bleeding.
Question 24
A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish
or iodine, the nurse finds no allergies recorded. The client is unable to provide the information. During
the procedure, the nurse should be alert for which find that may indicate an allergic reaction to the dye
used during the arteriogram?
Increased alertness.
Hypoventilation.
Pruritus.
Unusually smooth skin.
Pruritus.
Explanation:
Correct answer:
Pruritus
The nurse should be alert for urticaria and pruritus, which may indicate a mild anaphylactic reaction to the
arteriogram dye. Decreased alertness may occur as well as dyspnea. Unusually smooth skin is not a sign of
anaphylaxis.
Question 25
To be effective, psychoeducation programs must be in effect for at least how long?

Six months.
One year.
Two years.
Nine months.
Nine months.
Explanation:
The correct answer is nine months. Research shows that psychoeducation programs musts be at least nine
months in duration to be effective. The other answer choices are not appropriate for the situation.
Question 26
The psychiatric-mental health nurse functions from the perspective that clients benefit from an internal
locus of control. Which client behavior demonstrates progress toward the client's goal of operating
from an internal locus of control? The client does what?
Verbalizes that "poor" genetics is the cause of everything.
Asks the nurse what actions should be taken.
Shares feelings and treatment preferences with the nurse.
States the belief that God will take care of everything.
Shares feelings and treatment preferences with the nurse.
Explanation:
The correct answer is shares feelings and treatment preferences with the nurse. An internal locus of control enables
clients to feel empowered rather than victimized and facilitates participation in their own healing process by sharing
feelings and treatment preferences with the nurse. Asking the nurse what actions should be taken, stating that God
will take care of everything, and verbalizing that "poor" genetics is the cause of everything are examples of
behaviors originating from an external locus of control.
Question 27
The nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the
nurse should conduct which test?
Whispered voice test.
Weber's test.
Watch tick test.

Rinne test.
Rinne test.
Explanation:
Correct answer:
Rinne test
The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low
-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. The Weber
test evaluates bone conduction.
Question 28
The nurse is assessing a 47-year-old client who has come to the physician's office for his annual
physical. One of the first physical signs of aging is what?
Having more frequent aches and pains.
Failing eyesight, especially close vision.
Increasing loss of muscle tone.
Accepting limitations while developing assets.
Failing eyesight, especially close vision.
Explanation:
Correct answer:
Failing eyesight, especially close vision
Failing eye sight, especially close vision, is one of the first signs of aging in middle life ages 46 - 64. More frequent
aches and pains begin in the early late years of ages 65 to 79. Increase in loss of muscle tone occurs in later years
of ages 80 and older. Accepting limitations while developing assets is socialization development that occurs in
adulthood ages 31 to 45.
Question 29
The best way for the nurse to assess pain in an 18-month-old child is to do what?
Check the child's pupils.
Observe for behavioral changes.
Ask the child, "Are you feeling any pain?"
Tell the parents to call if the child has pain.
Observe for behavioral changes.
Explanation:
Correct answer:
Observe for behavioral changes
Behavioral changes are common signs of pain and are especially valuable indicators in an 18-month-old child, who
has limited verbal skills. Evaluating pupillary response is not an appropriate technique for assessing pain.
Requesting a parental report of a child's pain is not a reliable assessment technique.
Question 30
Which of the following vitamins is necessary for proper blood clotting?

Vitamin A.
Vitamin C.
Vitamin D.
Vitamin K.
Vitamin K.
Explanation:
Correct answer:
Vitamin K
Vitamin A helps with visual activity. Vitamin C helps with the healing of wounds. Vitamin D helps with the formation
of bones.

Question 31
To assess a client for Trousseau sign, the nurse uses which of the following approaches?
apply a blood pressure cuff to the client's arm and leave it inflated for three minutes
tap the skin located over the facial nerve
monitor the muscles to determine if the corners of the mouth draw up
administer intravenous calcium and monitor for tetany
apply a blood pressure cuff to the client's arm and leave it inflated for three minutes
Explanation:
The correct answer is apply a blood pressure cuff to the client's arm and leave it inflated for three minutes.
Trousseau sign is used to test for conditions such as hypocalcemia. When the nurse places the blood pressure cuff
on the client's arm, leave it inflated for three minutes and if a carpal spasm happens, then there is a positive
indication for Trousseau sign, which may indicate the client has hypocalcemia.
Question 32
When working with the older client in a long-term care facility the professional nurse performs which of
the following activities to foster reminiscence among the clients?
sets up pet therapy sessions
encourages client participation in pottery class
has story telling hour
displays calendars and clocks
Explanation:
Clients like to tell stories about past life events. This phenomenon is called life review or reminiscence where they
are reliving and restructuring life experiences and it is part of ego identity. Answers (a and b) indicate physical
activities and answer (d) indicates reality orientation techniques.
Question 33
Which of the following herb/botanicals has a possible side effect of dermatitis?

Black cohash.
Aloe Vera.
Feverfew.
Garlic.
Aloe Vera.
Explanation:
Correct answer:
Aloe Vera
Due to the fact that aloe vera is generally used to treat skin conditions, the possibility of dermatitis exists. Aloe vera
is not used for deep, surgical wounds.
Question 34
The nurse is creating a risk management plan for the oncology department. This is an example of what
type of management function?
coordinating
planning
organizing
directing
planning
Explanation:
The correct answer is planning. Planning is a process that is continuous and it deals with the assessment of a
situation, creating goals and objectives from the assessment and then creating a plan of action along with deadlines,
and the evaluation of outcomes. Risk management duties fall into the category of planning as the nurse has to
analyze, identify and prioritize risks.
Question 35
The nurse changes the dressing on a wound. The nurse understands the pooling of drainage under an
already soaked dressing causes what?
Swelling.
Skin irritation.
Discoloration.
Bruises.
Skin irritation.
Explanation:
Correct answer:
Skin irritation
A nurse's priority when cleaning a wound site is to keep excessive amounts of wound drainage from saturating
under the dressing covering the wound. The reason for this is the excessive drainage under the wound's dressing
can cause irritation of the skin. Also, this can cause an infection of the wound.
Question 36
A client starts to cry after being informed of her diagnosis of human papilloma virus (HPV). Which of
the following statements by the nurse conveys an attitude of acceptance?
"Don't worry about it. In a few weeks, with treatment, the lesions will disappear."
"You seem upset. I'll get the doctor."
"You seem upset. Can I help answer any questions?"
"I think you need to see a therapist."
"You seem upset. Can I help answer any questions?"
Explanation:
The correct answer is "You seem upset. Can I help answer any questions?" The nurse's attitude of acceptance and
matter-of-factness conveys to the woman that she is still an acceptable person who happens to have an infection.
The other statements are not conveying acceptance, they are ignoring the needs of the client.
Question 37
A child is diagnosed with dehydration and has moist mucous membranes and normal skin turgor during
assessment. Which severity level of dehydration does the child represent?
None of these
mild dehydration
moderate dehydration
severe dehydration
mild dehydration
Explanation:
The correct answer is mild dehydration.
When a child is mildly dehydrated, the child exhibits clinical signs and symptoms on assessment of normal blood
pressure, alertness, consciousness, thirst, moist mucous membranes and normal skin turgor. Also, the child shows
normal urine output, a normal size fontanel, warm extremities and normal respirations.
Question 38
Which of the following client statements indicates the need for further teaching about the prescribed
medication mirtazapine (Remeron)?
"I will take my medication at night to help me sleep."
"I won't drink a glass of wine while taking Remeron."
"My depression will be gone in 7 days."
"I will take my medication with a glass of milk."

"My depression will be gone in 7 days."
Explanation:
The correct answer is "My depression will be gone in 7 days." Although therapeutic results may be seen in some
clients at 7 days, other clients need 2 to 4 weeks in order to see improvement. The client's statement regarding "My
depression will be gone in 7 days" reveals that the nurse will need to provide further teaching on the medication,
Remeron with the client. Additionally, taking Remeron with a glass of milk or a light snack may help reduce
gastrointestinal upset in clients who complain of gastric irritation. Remeron is typically prescribed at bedtime since it
may cause sedation. Also, a glass of wine may provide a depressant effect on the client's nervous system when
taken with Remeron.
Question 39
The nurse is performing a physical examination of a primigravid client who is 8 weeks pregnant. At this
time, the nurse expects to assess:
Hegar's sign
fetal outline
ballottement
quickening
Hegar's sign
Explanation:
Hegar's sign

When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (a softening of the lower
uterine segment) between the 6th and 8th weeks of pregnancy. The fetal outline may be palpated after 24 weeks.
Ballottement is not elicited until the 4th or 5th month of pregnancy. Quickening typically is reported after 16 to 20
weeks.
Question 40
You are preparing to administer medication through a nasogastric tube that is connected to suction. In
order to properly administer the medication, the nurse should:
Aspirate the nasogastric tube after medication administration to maintain patency.
Change the suction setting to low intermittent suction for 30 minutes after medication
administration.
Position the client supine to assist in medication absorption.
Clamp the nasogastric tube for 30 minutes following administration of the medication.
Explanation:
If the nasogastric tube is connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube
to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication that
has been administered. Low intermittent suction will remove the medication just administered. The client should not
be placed in the supine position.
Question 41
The most common household allergen is which of the following?
Scented candles.
Cooking odors.
Hairspray.
Dust mites.
Dust mites.
Explanation:
Correct answer:
Dust mites
Many items, including A, B, and C, can be allergens. Dust mites are by far the most common.
Question 42
The nurse is caring for a client who had an abdominal cholecystectomy. What is the highest priority for
the nurse?
ask the client to take deep breaths
ask the client to bend the legs
assist the client with performing range of motion exercises
irrigate the client's nasogastric tube
ask the client to take deep breaths
Explanation:
The correct answer is ask the client to take deep breaths. Deep breathing helps to clear out mucous in the lungs.
Fluid builds up in the lungs because the anesthesia and pain relieving medication used during the procedure stops
the normal actions of the respiratory tract such as removing mucous out of the lungs through coughing and deep
breathing. Further, deep breathing expands the lungs and keeps the secretions in the lungs from building up. As a
result, the deep breathing exercises prevents pneumonia and atelectasis.
Question 43
The Nursing Assistive Personnel is commonly called which of the following?

Unlicensed Assistive Personnel.
NCLEX-PN.
Nurse Licensure Compact.
National Council of State Boards of Nursing.
Unlicensed Assistive Personnel.
Explanation:
Correct answer:
Unlicensed Assistive Personnel
Choice B is an exam completed by individuals who want to become a Practical Nurse. Choice C is a model that
shows that an individual has completed all requirements in order to be licensed as an RN in one state and
potentially also practice in other states (per the states’ guidelines). Choice D is an umbrella organization in which
separate nursing boards come together and discuss and/or act upon health issues with regard to the nursing field.
Question 44
The nurse is assessing a client's right lower leg, which is wrapped with an elastic (Ace) bandage.
Which signs and symptoms suggest circulatory impairment?
Numbness, cool skin temperature, and pallor.
Swelling, warm skin temperature, and drainage.
Numbness, warm skin temperature, and redness.
Redness, cool skin temperature, and swelling.
Numbness, cool skin temperature, and pallor.
Explanation:
Correct answer:
Numbness, cool skin temperature, and pallor
Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may
include swelling, drainage, redness, and warm skin. Signs of adequate circulation include warm skin with normal
return of skin color after blanching and normal sensation.
Question 45
After the insertion of a nasogatric tube, in what position should the nurse place the client to prevent
aspiration?
Lithomony.
Semi-Fowler.
Supine.
Trendlenburg.
Semi-Fowler.
Explanation:
Correct answer:
Semi-Fowler
In order to promote feeding and medication administration for clients who are unable to help themselves, feeding
tubes are used. With the nasogatric tube, the aspiration of gastric content occurs more with this type of tube than
any other feeding tube utilized. In order to prevent aspiration while inserting the nasogatric, the nurse should place
the client in semi-Fowler's position or turn the client to the side.
Question 46
The nurse is caring for a client in an acute manic state. What is the most effective nursing action for
this client?
Assigning him to group activities.
Reducing his stimulation.
Assisting him with self-care.

Helping him express his feelings.
Reducing his stimulation.
Explanation:
Correct answer:
Reducing his stimulation
Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much
stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these
clients are not able to express their inner feelings in a productive, introspective manner. The focus of treatment for a
client in the manic state is behavior control.
Question 47
A client has a wound with a drain. When cleaning around the drain, the nurse should wipe in which
direction?
laterally, from the center to the opposite side
from top to bottom
in a circle, from the center outward
in a circle, from the outer border to the center
in a circle, from the center outward
Explanation:
The correct answer is in a circle, from the center outward. When cleaning the area around the drain, the nurse
should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center
to the opposite side, when cleaning a large horizontal wound and wipes from top to bottom when cleaning a vertical
incision.
Question 48
Which of the following is NOT a symptom of a neonate born with esophageal atresia?
Cyanosis.
Decreased production of saliva.
Coughing.
Choking.
Decreased production of saliva.
Explanation:
Correct answer:
Decreased production of saliva
Choice B is not relevant to esophageal atresia. Choices A, C, and D occur when fluid is aspirated into the trachea.
Question 49
The professional nurse is caring for a client following enucleation. She notes the presence of bright red
drainage on the dressing. Which of the following nursing actions would be most appropriate?
Document the findings.
Notify the physician.
Mark the drainage on the dressing and monitor for any increase in bleeding.
Continue to monitor the drainage.
Explanation:
Bright red drainage on the dressing should be reported to the physician because it indicates hemorrhage. The
presence of bright red blood means there is active bleeding, a know postoperative complication associated with
enucleation. The other answers (a, c, and d) are inappropriate nursing actions.
Question 50
Which of the following possible blood transfusion reactions is usually due to a patient’s sensitivity to
the plasma proteins of the donor’s blood?
Febrile.
All of these.
Allergic.
Hemolytic.
Allergic.
Explanation:
Correct answer:
Allergic
Choice A is a reaction caused by the incompatibility of leukocytes. Choice D is a rare, severe reaction in which the
donated blood type is not compatible with that of the patient.

Question 51
The proper heart rate for a newborn is which of the following?

60-90 beats per minute
Explanation:
The correct answer is B. 100-180 beats per minute is the correct heart rate for a newborn. This should be
ascertained immediately after birth.
Question 52
A nurse assesses a 76-year-old client. Which of the following should the nurse recognize to determine
the differences in dementia and delirium?
Delirium has an acute onset
Slowed, slurred speech
Short-term memory loss
Auditory hallucinations
Delirium has an acute onset
Explanation:
The correct answer is Delirium has an acute onset. Delirium is mental confusion that is evident by disorientation to
place and time. An individual with delirium has incoherent speech and the individual's mind wonders. Further,
delirium has an acute onset whereas dementia progresses in phases over time.
Question 53
Which of the following is not an associated change during the antepartum period?
Nauseau
Increased sensitivity to smells
Decreased basal metabolic rate
Breast tenderness
Decreased basal metabolic rate
Explanation:
Correct answer:
Decreased basal metabolic rate.
Basal metabolic rate rises during pregnancy. The other changes listed are common during the first trimester.
Question 54
The nurse is assessing a client for a possible diagnosis of a neurological disorder. The nurse assesses
the client's orientation to time, place and person. By assessing the client's cognitive functioning, the
nurse can determine what?
The client's intellect.
The client's mood.
An abnormal finding indicative of a neurological disorder.
The client's current behavioral condition.
An abnormal finding indicative of a neurological disorder.
Explanation:
Correct answer:
An abnormal finding indicative of a neurological disorder
Abnormal findings that are identified during a neurological assessment can help diagnose a neurological disorder.
When the nurse assesses a client's cognitive function, the nurse will note the client's orientation to time, place and
person. Disorientation to time and place can indicate neurological conditions such as a stroke.
Question 55
Which of the following is when an individual forcefully restrains another without privilege or authority?
Libel.
Slander.
False imprisonment.
Assault and battery.
False imprisonment.
Explanation:
Correct answer:
False imprisonment
Libel is defined as intentionally hurting someone’s reputation in writing. Slander is an oral way of intentionally hurting
someone’s reputation. Assault and battery is simply defined as when a patient is touched without his or her consent.
This touching does not necessarily have to result in an injury.
Question 56
What is the definition of nihilistic delusions?

A false belief about the functioning of the body.
Belief that the body is deformed or defective in a specific way.
False ideas about the self, others, or the world.
The inability to carry out motor activities.
False ideas about the self, others, or the world.
Explanation:
Correct answer:
False ideas about the self, others, or the world
Somatic delusions involve a false belief about the functioning of the body. Body dysmorphic disorder is
characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out
motor activities.
Question 57
A client is diagnosed with Tay Sach's disease. The nurse understands what about this condition?
Hereditary.
An autoimmune disorder.
Contagious.
A cognitive disorder.
Hereditary.
Explanation:
Correct answer:
Hereditary
Tay Sach's disease, a rare disorder, causes the inability to create enzymes that are vital for the metabolism of fat.
This disease occurs in the Jewish descent. Further, the remaining answer choices are not considered genetic
disorders.
Question 58
Following fertilization, what hormone does the embryo or blastocyst secrete?

Human Chorionic Gonadotropin
Oxytocin
Human Growth Hormone
Estrogen
Human Chorionic Gonadotropin
Explanation:
The correct answer is A. HCG is secreted by the embryo. The other hormones are not secreted by the embryo.
Question 59
Which of the following is NOT a side effect of steroids?

Acne.
Growth spurts.
Hirsutism.
Mood swings.
Growth spurts.
Explanation:
Correct answer:
Growth spurts
Further side effects include possible osteoporosis and adrenal suppression. Steroids will generally cause delayed
growth, not growth spurts.

Question 60
The nurse is caring for a client who has had a cystoscopy. The nurse teaches the client to expect
what?
Nausea.
Burning on urinating 1-2 days after the cystoscopy.
Rapid heart rate.
Hives.
Burning on urinating 1-2 days after the cystoscopy.
Explanation:
Correct answer:
Burning on urinating 1-2 days after the cystoscopy
A cystoscopy is the visualization of the bladder wall and urethra by using a cystoscope. The nurse should
educate the client to expect burning on urination 1-2 days after the procedure. Also, the nurse should tell the
client to notify the doctor if the urine is bloody after 3 voidings following the procedure. Further, the nurse may
educate the client to increase fluids to reduce the risk of infection, difficulty with voiding and pain.
Question 61
A client with Type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The
nurse explains that these medications are only effective if the client what?
Prefers to take insulin orally.
Has Type 2 diabetes.
Is pregnant and has Type 2 diabetes.
Explanation:
Correct answer:
Has Type 2 diabetes
Oral antidiabetic agents are only effective in adult clients with Type 2 diabetes. Oral antidiabetic agents are not
effective in Type 1 diabetes. Pregnant and lactating women are not prescribed oral antidiabetic agents because
the effect on the fetus or breast-fed infant is uncertain.
Question 62
When should the nurse check a client for rebound tenderness?

Near the beginning of the examination.
Before doing anything else.
Anytime during the examination.
At the end of the examination.
At the end of the examination.
Explanation:
Correct answer:
At the end of the examination
If a client complains of abdominal pain, the nurse should check for rebound tenderness. Because this maneuver can
be painful, the nurse should perform it at the end of the abdominal assessment.
Question 63
Nurse Jones conducts a brachial pulse check of her patient. On what part of the body is this done?
Inner thigh
Inner elbow
Temple
Neck
Inner elbow
Explanation:
Inner elbow
The brachial pulse is palpated at the inner elbow. A pulse check on the inner thigh is a femoral. A pulse check on
the temple is temporal and pulse check on the neck is carotid.
Question 64
How long after the ingestion of the last alcoholic beverage will alcoholic withdrawal begin?
24-48 hours.
2-4 days.
1-10 days.
5-7 days.
24-48 hours.
Explanation:
Correct answer:
24-48 hours
An alcoholic can begin withdrawing as soon as 24 hours of their last drink.

Question 65
A physician has ordered a 24 hour urine collection for a client. The client has a urinary catheter in
place. What is the nurse's first priority?
Explain the procedure to the client.
Clamp the catheter 30 minutes before obtaining the specimen.
Wipe the built in sampling port with alcohol.
Aspirate the urine into the syringe attached to the sampling port. Transfer the urine
specimen into sterile containers.
Explain the procedure to the client.
Explanation:
Correct answer:
Explain the procedure to the client
After explaining the procedure to the client, the nurse will need to clamp the catheter 30 minutes before obtaining
the specimen. This helps urine to accumulate in the bladder. Further, wipe the built in sampling port with alcohol to
prevent infection along with aspirating the urine into the syringe attached to the sampling port. Transfering the urine
specimen into sterile containers is a nursing priority but not the first priority.
Question 66
You are instructing an elderly client on home safety during her discharge process. The client is at high
risk for falls due to her neurological status. Which of the following will NOT be an appropriate measure
to prevent falls?
Teach her to keep all of her personal items within reach.
Encourage her to keep adequate lighting in her bathroom area.
Discuss keeping her bed up high to allow for ease of rising.
Explain to her to avoid clutter in her pathways at home.
Explanation:
The bed position should be low to prevent falls and side rails should be up. Other advice would include maintaining
a toileting schedule, staying oriented to surroundings and having a family member provide wellness checks on the
client frequently. The other answers (a, b, and d) are all correct.
Question 67
Which of the following is a risk factor for the development of aortic dissections?
Diabetes mellitus.
Anemia.
Stroke.
Hypertension.
Hypertension.
Explanation:
Correct answer:
Hypertension
Dissection is a tear in the intima of the aorta that hemorrhages into the media of the aorta. The hemorrhage splits
the vessel wall and blood fills between the wall layers. The major factor for 70% of aortic dissections is hypertension,
followed by cystic medial necrosis, age, congenital defects of the aortic valve.
Question 68
What strategies should be included if the nurse is designing a teaching plan for a 3-year-old in
preparation for a surgical procedure?
Include the child's parents in the teaching to prevent separation anxiety.
Provide anatomy and physiology information.
If the child replies "No" then he is not ready to learn.
The intellectual development moves from abstract to concrete.
Include the child's parents in the teaching to prevent separation anxiety.
Explanation:
Correct answer:
Include the child's parents in the teaching to prevent separation anxiety
Separation anxiety is a stressor for children who are admitted to the hospital, especially during the infancy stages
and preschool age. These children may cry and scream for their parent or even go through a period of withdrawal
while in the hospital. In order to reduce separation anxiety, the nurse should include the parents during any
pediatric teaching.
Question 69
Which of the following medication delivery systems is the most common for patients with a healthy
GI system?
Patient-controlled analgesia (PCA).
Oral.
Transdermal.
Intraspinal.
Oral.
Explanation:
Correct answer:
Oral
PCA’s include a pump that allows a patient to press the button and give him or herself more medication as
needed. The transdermal system is utilized by individuals who cannot physically tolerate the oral system. An
example of this type is a patch that’s affixed to the patient’s body and automatically releases the medication. With
the intraspinal system, a catheter is inserted into the patient. The medicine is then injected into the catheter.
Question 70
A 2 1/2 year old child is being treated for left lower lobe pneumonia. In what position should the nurse
position the toddler to maximize oxygenation?
prone
left lateral
supine
right lateral
right lateral
Explanation:
The correct answer is right lateral. The toddler should be positioned on his right side. Gravity contributes to
increased blood flow to the right lung, thereby allowing for better gas exchange. Positioning the child prone, supine,
or in the left lateral position does not allow for better gas exchange in this child.
Question 71
When assessing a newborn's need for oxygen, which value should the nurse assess as it is the best
indicator of low oxygen levels in the baby?
Arterial p02
Pulse rate
Respiratory rate
Skin color
Arterial p02
Explanation:
The correct answer:
Arterial p02
The best indicator of oxygen levels is Arterial p02. Respiratory rate, skin color, and pulse rate can be affected by
factors other than oxygenation. They are indicators but are not the "most" reliable.
Question 72
Which of the following is the third most common health problem in the United States?
Cancer
Heart disease
Stroke
Bipolar disease
Stroke
Explanation:
Stroke
Stroke is the number three cause of death in women, and the number four cause of death in men. Lifestyle changes
that can reduce your risk of stroke include quitting smoking, losing excess weight, exercising and eating a healthy
diet. Heart disease and cancer are the number one and two health problems, respectively, in the United States.
Bipolar illness is not considered a major illness.
Question 73
You are providing an educational session to new employees and the topic is elder abuse. It is
important to stress which client is the most typical victim of abuse?
A 90 year old woman with advanced Parkinson's disease.
A 70 year old woman with early diagnosed Lyme disease.
An 80 year old man with moderate hypertension.
A 65 year old man with newly diagnosed cataracts.
Explanation:
Elder abuse includes physical and psychological abuse, misuse of property, and violation of rights. This is
widespread and occurs among all subgroups of the population. The typical victim is a female of advanced age with
few social contacts. The typical victim usually has at least one physical or mental impairment that limit her ability to
perform activities of daily living.
Question 74
Management is the accomplishment of tasks by one's self or by directing others. A RN must be an

effective manager. Which of the following is NOT one of the four steps of the management process?
Planning.
Organizing.
Directing.
Surveying.
Surveying.
Explanation:
surveying.
The four steps involved in the functions of management include:
Planning: determining objectives and identifying methods that lead to the achievement of those objectives.
Organizing: using resources (human and material) to achieve predetermined outcomes.
Directing: guiding and motivating others to meet the expected outcomes.
Controlling: using performance standards as criteria for measuring success and taking corrective action.
Question 75
The nurse administers dorzolamide (truspot) to a newly diagnosed glaucoma client. The client asks,
“Will this cure my glaucoma?” Which of the following is the most useful nurse's response?
“No, but it will decrease the twitching in your eye lid.”
“No, but it may help control the pressure in your eye.”
“No, but it will increase your natural tears.”
“No, but it will keep your eyes from burning.”
“No, but it may help control the pressure in your eye.”
Explanation:
Correct answer:
"No, but it may help control the pressure in your eye"
Carbonic anhydrase inhibitors, such as dorzolamide (Truspot) reduces and can control the intraocular pressure in
the eyes. However, there are no medications to cure glaucoma.
Question 76
A client with osteoarithris returns to the hospital for a follow up visit. Which of the following is
characteristic of this condition?
Osteoarthritis is associated with chronic inflammation.
Osteoarthritis requires palpation of the lymph nodes.
Osteoarthritis is a metabolic disease.
Osteoarthritis is a normal immune response.
Osteoarthritis is associated with chronic inflammation.
Explanation:
Correct answer:
Osteoarthritis is associated with chronic inflammation
Osteoarthritis is a chronic condition where the joints contain swelling, redness and soreness. Osteoarthritis is not a
metabolic disorder that is related to metabolism, which makes this an incorrect choice. Additionally, osteoarthritis is
not a normal reaction to the immune process.
Question 77
Which of the following is generally NOT true regarding a 6-year-old child with terminal cancer?
The parents may be at different stages in their grieving.
The dying child may be clingy.
The death of a child may have long-term disruptive effects on the family.
The child is thinking and wondering about the future.
The child is thinking and wondering about the future.
Explanation:
Correct answer:
The child is thinking and wondering about the future
A child this age does not fully understand the concept of death. There is a higher divorce rate for parents who have
lost a child.

Question 78
Which of the following types of violence is defined as "depriving a child of education"?

Educational neglect.
Physical neglect.
Economic exploitation.
Developmental neglect.
Educational neglect.
Explanation:
Correct answer:
Educational neglect
Physical neglect is "failure to provide health care to prevent or treat physical or emotional illnesses. Economic
exploitation is "illegal or improper exploitation of money, funds, or other resources for one's personal gain".
Developmental neglect is "failure to provide physical and cognitive stimulation needed to prevent developmental
deficits".
Question 79
Which of the following is not a sign of left-sided heart failure?

Jugular vein distention.
Crackles.
Tachycardia.
Right upper quadrant pain.
Jugular vein distention.
Explanation:
Correct answer:
Jugular vein distention
Other signs include fatigue, heart sounds and cool, pale skin. Jugular vein distention is not relevant to left-sided
heart failure.
Question 80
A woman in labor does not continue to dilate. The physician decides to perform a cesarean section. A
healthy 7 lb. 12 oz baby boy is delivered. What is the most essential nursing intervention in the
immediate postpartum period?
Assess the episiotomy site for bleeding.
Assist the woman with accepting the necessity of having had a c-section.
Check the fundus for firmness.
Encourage fluid intake.
Check the fundus for firmness.
Explanation:
The correct answer is: Check the fundus for firmness. Checking the fundus for hemorrhage is of highest priority. The
placenta has separated from the uterus in a woman who has had a cesarean delivery, just as it does in a vaginal
delivery. Both types of deliveries have a risk of postpartum hemorrhage. It is essential to keep the fundus firm for
both types of deliveries. The woman who had a cesarean delivery has no episiotomy. Assisting with emotional
adjustment will be part of nursing care but is not the highest priority. Encouraging fluid intake is important but is not
the highest priority.
Question 81
When instructing the mother on umbilical cord care for her newborn, the RN must tell her all of the
following except:
Bring the infant in for the cord to be removed at one week of age.
Monitor the cord for odor, swelling, or discharge.
Keep the diaper from covering the cord.
Keep the cord clean and dry.
Explanation:
The newborn will be cleaned via sponge bath until the cord falls off, approximately 2 weeks after birth. The infant
does not need to be brought in for this. The other answers (b, c, and d) are all appropriate instructions for the
mother.
Question 82
Of the following, who is responsible for ensuring a copy of a patient’s advanced directive is in the
patient’s medical record?
Nurse.
Patient.
Physician.
Health services department.
Nurse.
Explanation:
Correct answer:
Nurse
Nurses are not only in charge of making sure a patient’s medical record has a copy of the directive but must also
send a copy to the health services department. The nurse must also let the physician know this directive exists.

Question 83
Which of the following is NOT characteristic of a manic state?

Drinking six cups of coffee with a friend at a restaurant for four hours
Talking to furniture as though it were alive
Developing a complete business plan from scratch
Failure to eat
Drinking six cups of coffee with a friend at a restaurant for four hours
Explanation:
The correct answer is A. Choices B, C and D are classic “manic” symptoms – mostly characterized by an
overzealousness of activity. Choice A would be a rather calm activity that would not be considered manic.
Question 84
The conscious forgetting of unpleasant memories is called which of the following?

Regression.
Repression.
Suppression.
Sublimation.
Suppression.
Explanation:
Correct answer:
Suppression
Regression is to go back in time. Repression is the unconscious forgetting of unpleasant memories.

Question 85
During the assessment, the nurse palpates the lymph nodes of a 3-year- client. The lymph nodes are
firm, warm, tender to touch and enlarged. This assessment may indicate what?
a thyroid condition
a nodule
webbing of the neck
a local infection
a local infection
Explanation:
The correct answer is a local infection. Typically, a young child's lymph nodes during palpation are firm, clearly
defined, nontender and movable up to 1 cm. A localized infection is possibly present if a young child has enlarged,
warm, firm and tender lymph nodes.
Question 86
Which of the following types of consent is signed as an indication that a patient understands the
surgical procedure and/or diagnostic testing that is going to be performed?
Special.
Admission.
Blood transfusion.
Surgical.
Surgical.
Explanation:
Correct answer:
Surgical
Choice A is signed in order to give permission for special events such as the use of restraints and photographing the
patient. Choice B is obtained at the time of admission to the healthcare institution. Choice C is signed as an
indication that a patient understands the benefits and risks of the blood transfusion.
Question 87
A 10-year-old is experiencing severe pain after having an appendectomy. What is the nurse's top
priority?
Pain management.
Behavior modification.
Nausea management.
Nutritional management.
Pain management.
Explanation:
Correct answer:
Pain management
The intervention priority for the nurse is to reduce or alleviate the pain to a level where the client is comfortable.
Further, nausea management and nutritional management are interventions that are associated with other
conditions such as nausea. Behavior modification is not a priority intervention for a child who has postoperative pain.
Question 88
Symptoms of alcohol withdrawal would include which of the following?

Sleeplessness, dry mouth, vomiting.
Tremors, agitation, hallucinations.
Tremors, sleeplessness, hallucinations.
Dry mouth, agitation, vomiting.
Tremors, agitation, hallucinations.
Explanation:
Correct answer:
Tremors, agitation, hallucinations
Sleeplessness, dry mouth and vomiting may be present; however, these are not primary indicators of alcohol
withdrawal. AW would be indicated by tremors, agitation and hallucinations.

Question 89
Nurses who create a climate of respect and openness tend to be more effective when gathering
information about a client's use of several complementary therapies. Which of the following nursing
actions would not be effective?
telling the client to be cautious about any complementary therapy, because there are
many risks associated with them
asking questions that are direct and nonjudgmental in seeking information about the
client's use of complimentary therapies
asking questions about specific therapies, including the use of herbal therapy and
homeopathy
avoiding negative or disparaging comments about complementary therapies
telling the client to be cautious about any complementary therapy, because there are many risks associated
with them
Explanation:
The correct answer is telling the client to be cautious about any complementary therapy, because there are many
risks associated with them. This would send the message that the therapies are not desirable, and might discourage
the client from disclosing the use of the therapies. Asking questions that are direct and nonjudgmental in seeking
information about client's use of complimentary therapies, asking questions about specific therapies, including the
use of herbal therapy and homeopathy, and avoiding negative or disparaging comments about complementary
therapies help to create a climate of respect and openness.
Question 90
Before undergoing a subtotal thyroidectomy, a client receives potassium iodide (Lugol's solution) and
propylthiouracil (PTU). When would the nurse expect the client's symptoms to subside?
In a few days.
In 3 to 4 months.
Immediately.
In 1 to 2 weeks.
In 1 to 2 weeks.
Explanation:
Correct answer:
In 1 to 2 weeks
Potassium iodide reduces the vascularity of the thyroid gland and is used to prepare the gland for surgery.
Potassium iodide reaches its maximum effect in 1 to 2 weeks. PTU blocks the conversation of thyroxine to
triiodothyronine, the more biologically active thyroid hormone. PTU effects are also seen in 1 to 2 weeks. To relieve
symptoms of hyperthyroidism in the interim, clients are usually given a beta-adrenergic blocker such as propranolol.
Question 91
The nurse is planning to teach couples the factors that influence fertility. What should not be included
in the teaching plan?
Sexual intercourse should occur 4 times a week.
Get up to urinate 1 hour after intercourse.
Do not douche
Stress reduction techniques
Sexual intercourse should occur 4 times a week.
Explanation:
The correct answer is sexual intercourse should occur 4 times a week. Intercourse should occur 1 - 3 times per
week at intervals of no less than 48 hours. Urinating 1 hour after intercourse, not douching, and stress reduction
techniques should be included in the teaching plan.
Question 92
Which of the following is the normal serum electrolyte level for potassium?

135 to 148 mEq/L.
3.5 to 5 mEq/L.
4.5 to 5.3 mEq/L.
98 to 106 mEq/L.
3.5 to 5 mEq/L.
Explanation:
Correct answer:
3.5 to 5 mEq/L
Choice A is the normal value for sodium. Choice C is the value for calcium and choice D, for chloride.
Question 93
Which client is at the highest risk for macular degeneration?

a 66-year-old
a 30-year-old
a five-year-old
a 22-year-old
a 66-year-old
Explanation:
The correct answer is a 66-year-old. Macular degeneration is a cause of blindness and vision problems. This
condition typically develops in individuals over the ages of 65. However, 2% of individual may develop the condition
between ages 40 and 49.
Question 94
The nurse is caring for a premature infant. Immediately after arrival in the nursery, which nursing
action is essential?
Check the airway for patency
Cleanse the skin of vernix
Examine for anomalies
Take the rectal temperature
Check the airway for patency
Explanation:
The correct answer is check the airway for patency. The airway should be checked for patency immediately.
Removing vernix is not a high priority. The temperature will be monitored, but this is not the highest priority. The
nurse will check for anomalies, but this is not the highest priority. When the infant is stable, it will be bathed, and
bloody material will be removed. Vernix is good for the skin.
Question 95
Which of the following is a recommended food for a client with gout?

Liver.
Green leafy vegetables.
Cod.
Sardines.
Green leafy vegetables.
Explanation:
Correct answer:
Green leafy vegetables
Liver, cod and sardines are foods high in purine. It is recommended that people with gout avoid foods with purine.
They should also avoid anchovies, kidneys, sweetbreads and alcohol.
Question 96
The nurse is caring for a client with congestive heart failure. The client is taking a cardiac glycoside.
The nurse should withhold the client's medication and notify the physician if what is true?
The apical pulse rate is 60 beats per minute.
Explanation:
Correct answer:
The apical pulse rate is 40 beats per minute
The nurse should withhold the client's medication and contact the physician immediately if a client who is on a
cardiac glycoside pulse rate drops below 50 beats per minute or rises above 110 beats per minute. A drop in the
blood pressure may indicate a decrease in the blood volume which can lead to serious outcomes such as death.
Question 97
What equipment should be used to test the function of the optic nerve?
A puff of air to test eye response.
A tongue depressor to check peripheral vision.
Snellen’s Chart to test visual acuity.
Eye drops to dilate pupils.
Snellen’s Chart to test visual acuity.
Explanation:
Correct answer:
Snellen’s Chart to test visual acuity
The optic nerve impacts visual clarity and acuity. It should be tested with Snellen’s Chart.
Question 98
The RN working at the health department receives a call from a mother regarding her 6-month-old
infant. He has just taken the diphtheria, tetanus, and acellular pertussis (DTaP) immunization and now
has swelling and redness at the injection site. What should the nurse tell the mother to do?
Apply an ice pack to the injection site.
Monitor the infant for fever.
Apply a warm pack to the injection site.
Bring the infant back to the health department immediately.
Explanation:
Redness, swelling, and tenderness may occur at the injection site of the DTaP immunization. This is often relieved
with ice packs for the first 24 hours, and can be followed with warm or cold compresses if the inflammation persists.
The other answers (b, c, and d) are incorrect.
Question 99
The RN working on a cardiac unit will encounter various cardiac dysrhythmias. Which of the following is
a dysrhythmia that is characterized by multiple rapid impulses from many foci that depolarize in the
atria in a disorganized manner and no P wave is observed?
Atrial fibrillation.
Sinus tachycardia.
Ventricular tachycardia.
Ventricular fibrillation.
Atrial fibrillation.
Explanation:
Atrial fibrillation
With atrial fibrillation, the atrial quiver, often leads to the formation of thrombi. Sinus tachycardia is characterized by
atrial and ventricular rates 100 to 180 beats/minute with regular atrial and ventricular rates and rhythms. The PR
interval and QRS width is normal. Ventricular tachycardia occurs because of a repetitive firing of an irritable
ventricular ectopic focus at a rate of 140 to 250 beats/minute. Ventricular fibrillation is a chaotic rapid rhythm in
which the ventricles quiver and leads to death within 3 to 5 minutes.
Question 100
Systemic lupus erythematosus is a type of lupus that consists of a butterfly rash on a client's face
affects which of the following body systems?
integumentary
hematologic
renal
pulmonary
integumentary
Explanation:
The correct answer is
integumentary.
Systemic lupus erythematosus exhibits a pink or red rash on the face or over the bridge of the nose and is
associated with the integumentary system. Systemic lupus erythematosus has clinical manifestations of hemolytic
anemia, low white blood cells, low platelet count and bleeding disorders associated with the hematologic system.
The condition shows clinical manifestations of glomerulonephritis, renal failure and lupus nephritis in the renal
system. The clinical manifestations of systemic lupus erythematosus in the pulmonary system is exhibited by
pleural effusions and pleuritis.

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Question 1

saying two words

feeding himself with a spoon

ventrogluteal muscle in the thigh

vastus lateralis muscle in the thigh

assault is a form of slander

assault is the mental or physical threat of violence

Which of the following is an Antihypercalcemic?

Dibasic calcium phosphate.

Choices A & B are calcium supplements. Choice C is a calcium regulator.

alcohol withdrawal syndrome

Damage to the catheter.

this surgery will remove a cataract

this surgery will remove a tumor

Areas of thickness or fullness.

Changes from previous self-examinations.

10% dextrose in water.

0.45% sodium chloride.

0.45% sodium chloride and 5% dextrose.

report slow shallow breathing to the physician

The report form should be copied for the client's record.

The incident should be documented in the client's record.

assess pain control every hour

assess urine output every 30 minutes

assess blood pressure every hour

assess pain control every hour

assess urine output every 30 minutes

assess blood pressure every hour

"I'll check his voiding to be sure there is no problem."

"I will check his temperature."

Chronic obstructive pulmonary disease.

Loss of muscle tone.

Prolapsed umbilical cord

Unusually smooth skin.

To be effective, psychoeducation programs must be in effect for at least how long?

Asks the nurse what actions should be taken.

Shares feelings and treatment preferences with the nurse.

States the belief that God will take care of everything.

Watch tick test.

Failing eyesight, especially close vision.

Increasing loss of muscle tone.

Accepting limitations while developing assets.

Observe for behavioral changes.

Ask the child, "Are you feeling any pain?"

Tell the parents to call if the child has pain.

Which of the following vitamins is necessary for proper blood clotting?

tap the skin located over the facial nerve

monitor the muscles to determine if the corners of the mouth draw up

administer intravenous calcium and monitor for tetany

encourages client participation in pottery class

has story telling hour

displays calendars and clocks

Which of the following herb/botanicals has a possible side effect of dermatitis?

"You seem upset. I'll get the doctor."

"You seem upset. Can I help answer any questions?"

"I think you need to see a therapist."

"I won't drink a glass of wine while taking Remeron."

"My depression will be gone in 7 days."

"I will take my medication with a glass of milk."

Position the client supine to assist in medication absorption.

ask the client to bend the legs

assist the client with performing range of motion exercises

irrigate the client's nasogastric tube