Lesson 6: Pharmacological and Parenteral Therapies.

Question 1 A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem Review Information: The correct answer is A: Protamine Protamine binds heparin, making it ineffective.

A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dyspnea, nasal congestion Review Information: The correct answer is B: Sore throat, fever A sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine).

A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin Review Information: The correct answer is B: Potassium If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys.

Question 2 Although nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding Review Information: The correct answer is D: Occult bleeding Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal track.

Question 4 The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication ensure that the entire dose of medication is B) given C) provide more even distribution of the drug D) prevent the drug from causing tissue irritation Review Information: The correct answer is D: prevent the drug from causing tissue irritation Deep injection or Z-track is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the drug.

Question 6 Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics Sudden cessation of alprazolam (Xanax) can cause B) rebound insomnia and nightmares Caffeine beverages can increase the effect of C) sedative hypnotics Avoidance of excessive exercise and high D) temperature is recommended Review Information: The correct answer is B: Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares Sudden cessation of any medication, unless medically necessary, is ill-advised.

Question 5 Question 3 Question 7

A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets Review Information: The correct answer is B: Hemoglobin and hematocrit The post-transfusion hematocrit provides immediate information about red cell replacement and about continued blood loss.

A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the clients comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently Review Information: The correct answer is C: Keep conversations short Keeping conversations short will promote the clients comfort by decreasing demands on the clients breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the clients rest. Monitoring vital signs is an important assessment but not related to promoting the clients comfort.

A) B) C) D)

Bruising at the operative site Elevated heart rate Decreased platelet count No bowel movement for 3 days

Review Information: The correct answer is D: No bowel movement for 3 days With opioid analgesics, observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.

Question 8 The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion Review Information: The correct answer is A: Stop the infusion This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion.

Question 10 An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered check with pharmacy for a liquid form of the D) medication
Review Information: The correct answer is A: administer the medication in 2 separate injections Intramuscular injections should not exceed a volume of 1 ml for small children. Medication doses exceeding this volume should be split into 2 separate injections of 1.0 ml each. In adults the maximum intramuscular injection volume is 5 ml per site

Question 12 Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect Most antipsychotic drugs cause elevated blood B) pressure This provides information on the amount of sodium C) allowed in the diet It will indicate the need to institute antiparkinsonian D) drugs
Review Information: The correct answer is A: Orthostatic hypotension is a common side effect Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after receiving medication. They should be advised to get up slowly, especially from a supine position.

Question 13 Question 9 Question 11 A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides Review Information: The correct answer is D: Application of pediculicides Treatment of head lice consists of application of pediculicides. Pediculicides vary, and the directions must be followed carefully. Question 14 The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? "We will call the health care provider if the child A) develops acne." "Our child should brush and floss carefully after every B) meal." "We will skip the next dose if vomiting or fever C) occur." "When our child is seizure-free for 6 months, we can D) stop the medication." Review Information: The correct answer is B: "Our child should brush and floss carefully after every meal." Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.

A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) Diaphoresis with decreased urinary output B) Increased heart rate with increased respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure Review Information: The correct answer is C: Improved respiratory status and increased urinary output Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI disturbances. Clients being treated with digoxin should have their apical pulse evaluated for 1 full minute prior to the administration of the drug.

The nurse is caring for a client with clinical depression who is receiving a monoamine oxidase inhibitor (MAOI). When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance Review Information: The correct answer is A: Avoid chocolate and cheese Foods high in tryptophan, tyramine and caffeine, such as chocolate, wine and cheese may precipitate hypertensive crisis.

Question 16 The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A) Non-steroidal anti-inflammatory drugs (NSAIDs) B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts Review Information: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs) Medications with NSAIDs may increase the response to Coumadin (warfarin) and increase the risk of bleeding.

Question 18 The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? "I use a sliding scale to adjust regular insulin to my A) sugar level." "Since my eyesight is so bad, I ask the nurse to fill B) several syringes." C) "I keep my regular insulin bottle in the refrigerator." "I always make sure to shake the NPH bottle hard to D) mix it well." Review Information: The correct answer is D: "I always make sure to shake the NPH bottle hard to mix it well." The bottle should by rolled gently, not shaken.

Question 15

Question 17 Question 19

A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition Squeeze the tube before using it to break up stagnant B) liquids Cleanse the skin around the tube daily with C) hydrogen peroxide Flush adequately with water before and after using D) the tube Review Information: The correct answer is D: Flush adequately with water before and after using the tube Flushing the tube before and after use not only provides for good flow and keeps the tube patent, it also provides water to maintain hydration. While medications should be crushed to pass through the tube, it is flushing that moves them through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide

Lesson 7: Reduction of Risk Potential Questions are numbered by the order in which they appeared in the test. * Represents the correct answer.
Question 1 The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post-operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses Review Information: The correct answer is B: Assess for post-operative arrhythmias The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation Review Information: The correct answer is B: Leukopenia Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.

Question 3 A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene Review Information: The correct answer is D: Assist with oral hygiene Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.

Question 20 While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurses best response? "As you urinate more, you will need less medication to A) control fluid." "You will have to take this medication for about a B) year." "The medication must be continued so the fluid C) problem is controlled." "Please talk to your health care provider about D) medications and treatments." Review Information: The correct answer is C: "The medication must be continued so the fluid problem is controlled." This is the most therapeutic response and gives the client accurate information.

Question 2 Question 4

A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs Review Information: The correct answer is C: Lower the oxygen rate A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client''s death.

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) Drowsiness B) Complaint of nausea C) Pulse rate of 82 D) Restlessness eview Information: The correct answer is D: Restlessness Restlessness, increased heart and respiratory rates, and noisy expiration suggest hypoxia and are indications for suctioning.

Question 5 A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes Review Information: The correct answer is A: Notify the health care provider The findings are indicative of circulatory impairment. The health care provider (or practitioner) must be notified immediately.

Question 7 A client has returned from a cardiac catheterization. Which one of the following findings would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output Review Information: The correct answer is C: Loss of pulse in the extremity Loss of the pulse in the extremity would indicate impaired circulation.

The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) wrap the leg with elastic bandages B) apply pressure at the bleeding site C) reinforce the dressing and elevate the leg D) remove the dressings and re-dress the incision Review Information: The correct answer is C: reinforce the dressing and elevate the leg The interventions that must be taken are: reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the provider immediately. This is an emergency post surgical situation.

Question 9 The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to A) maintain adequate hydration B) assist client to turn, deep breathe, and cough C) ambulate client within 12 hours D) splint incision Review Information: The correct answer is B: assist client to turn, deep breathe, and cough Deep air excursion by turning, deep breathing, and coughing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.

Question 6

Question 8

Question 10

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L Review Information: The correct answer is D: Serum potassium 6 mEq/L Although all of these findings are abnormal, the elevated potassium level is a life threatening finding and must be reported immediately.

The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? Disconnect the client from the ventilator and use a manual A) resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator Review Information: The correct answer is B: Perform a quick assessment of the client''s condition A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.

The provider order reads "Aspirate nasogastric (NG) feeding tube every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube Review Information: The correct answer is A: Hold the tube feeding and notify the provider A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal placement.

Question 11 The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurses immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms Review Information: The correct answer is C: Dyspnea Clients having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.

Question 13 A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water Perform Cred's method on the bladder from the bottom to the B) top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again Review Information: The correct answer is C: Assist him to stand by the side of the bed to void When a male is not able to use a urinal unassisted, the client should stand by the side of the bed to void. This is the most desirable position for normal voiding for male clients. Also, given his age, he most likely has some degree of prostate enlargement which may interfere with voiding.

Question 15 When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) relaxation and sleep B) deep breathing and coughing C) incisional healing D) range of motion exercises Review Information: The correct answer is B: deep breathing and coughing The priority is preventing postoperative respiratory complications. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. Client compliance with recommended deep breathing and coughing exercises will only be achieved with the appropriate pain management.

Question 14 Question 12

Question 16

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." "The tube controls the amount of air that enters your C) chest." D) "The tube will seal the hole in your lung." Review Information: The correct answer is B: "The tube will remove excess air from your chest." The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
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A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage Review Information: The correct answer is D: Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.

The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 BPM D) Client is unable to speak Review Information: The correct answer is C: Pulse oximetry of 88 BPM Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings.

Question 17 To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) apply suction for no more than 10 seconds B) maintain sterile technique C) lubricate 3 to 4 inches of the catheter tip D) withdraw catheter in a circular motion Review Information: The correct answer is A: apply suction for no more than 10 seconds Applying suction for more than 10 seconds may result in hypoxia. Although options B, C, and D are important in during suctioning a tracheostomy, hypoxia results from actions that decrease the oxygen supply.

Lesson 8: Physiological Adaptation

Question 1 A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? "What are you taking for pain and does it provide A) total relief?" "Did your provider recommend that you be tested B) for Chlamydia?" C) "Do you have any questions about your care?" "Did you know a consequence of epididymitis is D) infertility?" Review Information: The correct answer is B: "Did your provider recommend that you be tested for Chlamydia?" Epididymitis can result from Chlamydia infection, in which case the clients sexual partners should be tested as well. All of the questions should be asked, however, determining the reason for the clients referral is the most important to start with.

Question 19 The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? "I can't lie in one position for more than thirty A) minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap." Review Information: The correct answer is B: "I am allergic to shrimp." A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could even include seizures.

Question 2 Question 18 Question 20

A client with heart failure has a prescription for Digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) can predispose to dysrhythmias B) may lead to oliguria C) may cause irritability and anxiety D) sometimes alters consciousness Review Information: The correct answer is A: can predispose to dysrhythmias The nurse should be aware of a decrease in the clients potassium levels because low potassium can enhance the effects of digoxin and predispose the client to dysrhythmias. The other options are seen in hyperkalemia. Muscle weakness occurs in both hyperkalemia and hypokalemia.

A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the clients pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive Review Information: The correct answer is C: Participate with the compressions or breathing Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse to leave the room for equipment. The clients advanced directives should have been filed on admission and his choices known prior to the initiation of CPR.

An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation Review Information: The correct answer is A: Stay with client and observe for airway obstruction For the clients safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the clients mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure

Question 3 A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight Review Information: The correct answer is D: weekly weight The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram or 2.2 pounds of weight gain is equal to approximately 1,000 ml of retained fluid. Other options are considered as part of data collection, but they are not the most accurate indicators of fluid balance.

Question 5 Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) hemoglobin level of 12 g/dL B) pale mucosa of the eyelids and lips C) hypoactivity D) a heart rate between 80 and 130 Review Information: The correct answer is B: pale mucosa of the eyelids and lips In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.

Question 4

Question 6

Question 7 Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider? "I started my period and now my urine has turned bright A) red" "I am an diabetic and today I have been going to the B) bathroom every hour" "I was started on medicine yesterday for a urine infection. C) Now my lower belly hurts when I go to the bathroom" "I went to the bathroom and my urine looked very red and D) it didnt hurt when I went" Review Information: The correct answer is D: "I went to the bathroom and my urine looked very red and it didnt hurt when I went" With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone.

Question 8 A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? "I knew this would happen. I've been eating too much A) red meat lately." "I really enjoyed my fishing trip yesterday. I caught two B) fish." "I have really been working hard practicing with the C) debate team at school." "I went to get a cold checked out last week, and I have D) gotten worse." Review Information: The correct answer is D: "I went to get a cold checked out last week, and I have gotten worse." Any condition that increases the body''s need for oxygen or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis.

A) B) C) D)

Decreased urinary output Jugular vein distention Pleural effusion Bibasilar crackles

Review Information: The correct answer is B: Jugular vein distention Signs of right-sided heart failure include jugular vein distention, ascites, nausea, and vomiting.

A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem? A) Chest pain B) Pallor C) Inspiratory crackles D) Heart murmur Review Information: The correct answer is C: Inspiratory crackles In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.

Question 10 The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea Review Information: The correct answer is C: A cold, pale lower leg This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.

Question 12 A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be to A) cover the areas with dry sterile dressings B) assess for dyspnea or stridor C) initiate intravenous therapy D) administer pain medication Review Information: The correct answer is B: assess for dyspnea or stridor Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.

Question 9 The nurse assesses a 72 year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding? Question 11 Question 13

A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurses initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which one would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." "I have been coughing up foul-tasting, brown, thick B) sputum." C) "I have been sweating all day." D) "I feel hot off and on." Review Information: The correct answer is B: "I have been coughing up foul-tasting, brown, thick sputum." Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client is grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.

Question 15 A nurse is providing care to a 17 year-old client in the postoperative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation? A) Abnormal breath sounds B) Cyanosis of the lips C) Increasing pulse rate D) Pulse oximeter reading of 92% Review Information: The correct answer is C: Increasing pulse rate The earliest sign of poor oxygenation is an increasing pulse rate as a part of the bodys compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.

The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem? "When I put my finger in the left hand the baby doesnt A) respond with a grasp." "My baby doesnt seem to follow when I shake toys in B) front of its face." "When it thundered loudly last night the baby didnt C) even jump." "When I put the baby in a back lying position thats how D) I find it hours later." Review Information: The correct answer is D: "When I put the baby in a back lying position thats how I find it hours later." Cerebral palsy is known as a condition whereby motor dysfunction occurs secondary to damage in the motor centers of the brain. Inability to roll over by 8 months of age would illustrate one delay in the infant''s attainment of developmental milestones.

Question 14 Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography? A) Eat a light diet for the rest of the day Rest for the next 24 hours since the preparation and B) the test is tiring During waking hours drink at least 1 8-ounce glass of C) fluid every hour for the next 2 days Measure the urine output for the next day and D) immediately notify the health care provider if it should decrease Review Information: The correct answer is D: Measure the urine output for the next day and immediately notify the health care provider if it should decrease This information would alert to the complication of acute renal failure which may occur as a complication from the dye and the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye injection.

Question 16 A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring? "The client complains of a salty taste in the mouth A) when the dye is injected." B) "The clients entire body turns a bright red color. C) "The client states I have a feeling of getting warm. D) "The client gags and complains I am getting sick. Review Information: The correct answer is B: "The clients entire body turns a bright red color. This observation suggest anaphylaxis which results in massive vasodilation. Other findings would be immediate wheezing and/or respiratory arrest.

Question 18

Question 17

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A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and indicates a wish to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? "Some needles go as deep as 3 inches, depending on where A) they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes." "In traditional Chinese medicine, imbalances in the basic B) energetic flow of life known as qi or chi are thought to cause illness." "The flow of life is believed to flow through major C) pathways called nerve clusters in your body." "By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is D) believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over." Review Information: The correct answer is C: "The flow of life is believed to flow through major pathways called nerve clusters in your body." The major pathways are called meridians, not nerve clusters.

Question 19 A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the clients blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output Review Information: The correct answer is B: Have the client turn to the left side A priority action is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation to the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be monitored every 4 hours or more often if indicated, but no data in the stem supports a check of temperature.

Question 20 A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? Side-lying on the left with the head elevated 10 A) degrees Side-lying on the left with the head elevated 35 B) degrees Side-lying on the right with the head elevated 10 C) degrees Side-lying on the right with the head elevated 35 D) degrees Review Information: The correct answer is A: Side-lying on the left with the head elevated 10 degrees Gravity will draw the most blood flow to the dependent portion of the lung. For unilateral chest disease, it is best to place the healthiest part of the lung in the dependent position to enhance blood flow to the area where gas exchange will be best. Ventilation would be minimally affected in the right dependent lung. This position also enhances the drainage of the infected part of the lung. A head elevation of 35 degrees is counterproductive to therapeutic blood flow and the drainage of secretions.

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) heart rate B) pedal pulses C) lung sounds D) pupil responses Review Information: The correct answer is D: pupil responses The organ most susceptible to damage in hypertensive crisis is the brain due to rupture of the cerebral blood vessels. Neurologic status must be closely monitored.

Question 22 The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) apical click C) systolic murmur D) split S2 Review Information: The correct answer is A: S3 ventricular gallop An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle. This is most common with congestive heart failure.

Question 21 Question 23

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A 2 year-old child is brought to the emergency department at 2:00 in the afternoon. The mother states: My child has not had a wet diaper all day. The nurse finds the child is pale with a heart rate of 132. What assessment data should the nurse obtain next? A) Status of the eyes and the tongue B) Description of play activity C) History of fluid intake D) Dietary patterns Review Information: The correct answer is A: Status of the eyes and the tongue Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110.

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider? A) nausea and vomiting fever of 103 degrees Fahrenheit (39.5 degrees B) Celsius) C) diffuse macular rash D) muscle tenderness Review Information: The correct answer is B: fever of 103 degrees Fahrenheit (39.5 degrees Celsius) Persistent, prolonged fever may be an indication that the antibiotics are not effective and may need to be changed.

Question 24 Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down syndrome B) A teenager who reads at a 4th grade level An elderly client with numerous arthritic nodules on the C) hands D) A preschooler with intermittent episodes of alertness Review Information: The correct answer is D: A preschooler with intermittent episodes of alertness A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump.

Question 26 The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action? A) lower extremity pitting edema B) rales C) jugular vein distension D) weakness in left arm Review Information: The correct answer is D: weakness in left arm In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies.

A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of digoxin to this client? Assess the apical pulse, counting for a full 60 A) seconds B) Take a radial pulse, counting for a full 60 seconds Use the pulse reading from the electronic blood C) pressure device D) Check for a pulse deficit Review Information: The correct answer is A: Assess the apical pulse, counting for a full 60 seconds It is the nurses responsibility to take the clients pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute. A radial pulse, potentially less accurate, or blood pressure are not part of the initial assessment before administering an initial dose of digoxin.

Question 27 Question 25

Question 28 A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce? It is a condition in which one or more tumors called A) gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) It is critical to report promptly to your health care B) provider any findings of peptic ulcers Treatment consists of medications to reduce acid and C) heal any peptic ulcers and, if possible, surgery to remove any tumors With the average age at diagnosis at 50 years the D) peptic ulcers may occur at unusual areas of the stomach or intestine Review Information: The correct answer is B: It is critical to report promptly to your health care provider any findings of peptic ulcers Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite. Abdominal pain, rigidity and

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tenderness can signal perforation of the ulcer and should be reported to the provider immediately. Zollinger-Ellison syndrome can occur in both children and adults.

Question 29 As the nurse is speaking with a group of teens, which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss Review Information: The correct answer is D: Hair loss The major concern for adolescence is body image, so hair loss would be the most disturbing.

The nurse is discussing Kawasaki disease with a group of students. What statement made by a student about Kawasaki disease is incorrect? "It also called mucocutaneous lymph node syndrome A) because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes." "In the second phase of the disease, findings include B) peeling of the skin on the hands and feet with joint and abdominal pain." "Kawasaki disease occurs most often in boys, children C) younger than age 5 and children of Hispanic descent." "Initially findings are a sudden high fever, usually above D) 104 degrees Fahrenheit, which lasts 1 to 2 weeks." Review Information: The correct answer is C: "Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent." Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent, particularly Japanese. Other findings in the initial phase are extremely red eyes (conjunctivitis), a rash on the main part of the body (trunk) and in the genital area, red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands and the soles of the feet; swollen lymph nodes in the neck. Fever reduction signals the second phase, when the findings slowly go away. In the third phase findings, except for abnormal lab values, are gone unless complications associated with the heart develop. The disease lasts from 2 to 12 weeks without treatment. With treatment, the child usually improves within 24 hours. The cause of Kawasaki disease is not known.

The nurse is about to assess a 6 month-old child with nonorganic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be irritable and "colicky," making no attempts to pull to A) standing alert, laughing, playing with a rattle, and sitting with B) support C) dusky in color with poor skin turgor over abdomen pale, have thin arms and legs, and uninterested in D) surroundings Review Information: The correct answer is D: pale, have thin arms and legs, and uninterested in surroundings Diagnosis of NOFTT is made on anthropomorphic findings documenting growth retardation which would lead the nurse to expect muscle-wasting and paleness. In cases of NOFTT, the cause may be a variety of psychosocial factors and these children may be below normal in intellectual development, language and social interactions.

Question 32 A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication? A) acute compartment syndrome B) thromboembolitic complications C) fatty embolism D) osteomyelitis Review Information: The correct answer is A: acute compartment syndrome Increasing pain that is not relieved by narcotic analgesics is an indication of compartment syndrome after a bone fracture and requires immediate action by the nurse. Thromboembolic complications include deep vein thrombosis and pulmonary embolism which are not characterized by increasing pain at the site of injury. Both pulmonary embolism and fat embolism present with respiratory findings. Osteomyelitis is a bone

Question 30 Question 31

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infection which could occur some time after the initial injury, usually at least 48 to 72 hours.

Question 33 Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease? "I have to go at intervals for epoetin (Procrit) A) injections at the health department." "I know I have a high risk of clot formation since B) my blood is thick from too many red cells." "I expect to have periods of little water with voiding C) and then sometimes to have a lot of water." "My bones will be stronger with this disease since I D) will have higher calcium than normal." Review Information: The correct answer is A: "I have to go at intervals for epoetin (Procrit) injections at the health department." Anemia caused by reduced endogenous erythropoietin production, primarily end-stage renal disease is treated with subcutaneous injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells.

While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) call the health care provider immediately administer acetaminophen as ordered as this is B) normal at this time C) send blood, urine and sputum for culture D) increase the client's fluid intake Review Information: The correct answer is B: administer acetaminophen as ordered as this is normal at this time Leukocytosis and fever are common starting on day 2 because of the inflammatory process associated with an acute MI. Nursing interventions should focus on promoting comfort.

Question 35 A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM, the vital signs were T-99.8 degrees Fahrenheit, P-84, R-20, BP130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit C) Cervical dilation of 4 cm D) BP 138/88 Review Information: The correct answer is A: FHT 168 beats/min An increase in FHT may indicate maternal infection. The other assessment findings are normal.

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? "Until the health care provider has determined that A) your ejaculate doesn't contain sperm, continue to use another form of contraception." "This procedure doesn't impede the production of male hormones or the production of sperm in the B) testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate." "After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work C) doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in 7-10 days." "The health care provider at this clinic recommends rest, ice, an athletic supporter or D) over-the-counter pain medication to relieve any discomfort." Review Information: The correct answer is A: "Until the health care provider has determined that your ejaculate doesn''t contain sperm, continue to use another form of contraception." All of these options are correct information. The most important point to reinforce is the continuing need to take additional action for birth control.

Question 34

Question 37

Question 36

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A female client talks to the nurse in the providers office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed? "I am the one out of every 4 women that get A) fibroids, and of women my age between the 30s or 40s, fibroids occur more frequently." "My fibroids are noncancerous tumors that grow B) slowly." "My associated problems I have had are pelvic C) pressure and pain, urinary incontinence, and constipation." "Fibroids that cause no problems still need to be D) taken out." Review Information: The correct answer is D: "Fibroids that cause no problems still need to be taken out." Fibroids that cause no findings may require only "watchful waiting" with no treatment. Only when the clients findings become disturbing to them would surgical interventions be considered.

would be used.

Question 38 A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag reports of the feeling of pulling on the urinary D) catheter Review Information: The correct answer is C: minimal drainage into the urinary collection bag Options A, B, and D are expected complaints after this procedure. Option C needs to be reported immediately since minimal urinary drainage puts the client at risk for bladder rupture. The flow rate of the continuous irrigation would need to be slowed until the provider is notified. If an order to irrigate the system is written, sterile technique

Question 39 Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis (ALS)? Active and passive range of motion exercises twice A) a day B) Use incentive spirometer every 4 hours C) Chest physiotherapy twice a day D) Repositioning every 2 hours around the clock Review Information: The correct answer is C: Chest physiotherapy twice a day These clients have potential inability to have voluntary and involuntary muscle movement or activity. Thus, options A and B may not be feasible for the immobilized client. Option D is not specific for prevention of complications associated with the lung.

A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses Review Information: The correct answer is B: Pupils fixed and dilated Pupils that are fixed and dilated indicate overwhelming injury and intrinsic damage to the upper brain stem. It is a poor prognostic sign.

Question 40

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