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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS
Saunders Comprehensive Review for the NCLEX-RN® Examination, 5Th Ed by Linda Anne Silvestri – Test Bank 
 
Sample  Question       

Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition

 

Adult Health

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse reviews the health record of a client with melasma. The nurse would anticipate that this client will exhibit:
1. Skin that is uniformly dark in color
2. Very pale skin with little pigmentation
3. Patches of skin that have loss of pigmentation
4. Blotchy brown macules across the cheeks and forehead

 

 

  1. The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin?
1. Escherichia coli
2. Candida albicans
3. Staphylococcus aureus
4. Staphylococcus epidermidis

 

 

  1. The client complains of chronic pruritus. Which of the following diagnoses would the nurse expect to support this client’s complaint?
1. Anemia
2. Renal failure
3. Hypothyroidism
4. Diabetes mellitus

 

 

  1. A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?
1. Hyperthyroidism
2. Pernicious anemia
3. Cardiopulmonary disorders
4. Systemic lupus erythematosus (SLE)

 

 

  1. The nurse notes that the older adult client has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as:
1. Purpura
2. Venous star
3. Cherry angioma
4. Spider angioma

 

 

  1. The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the:
1. Nails
2. Hair follicles
3. Pilosebaceous glands
4. Epithelial layer of skin

 

 

  1. The client is diagnosed with a full-thickness burn. The nurse understands that which of the following structural areas of the skin is involved?
1. Epidermis only
2. Epidermis and deeper dermis
3. Epidermis and upper layer of dermis
4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat

 

 

  1. A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse would anticipate observing which sign or symptom?
1. Coma
2. Flushing
3. Dizziness
4. Tachycardia

 

MSC:   Integrated Process: Nursing Process—Assessment

 

  1. A client is admitted to the hospital with cellulitis of the lower leg. The nurse would anticipate which of the following therapies to be prescribed?
1. Intermittent heat lamp treatments
2. Alternating hot and cold compresses
3. Warm compresses to the affected area
4. Cold compresses to the affected area

 

 

  1. The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right breast, the nurse would tell the client to place a pillow:
1. Under the left scapula
2. Under the left shoulder
3. Under the right shoulder
4. Under the small of the back

 

 

  1. The nurse would identify that which of the following foods should be increased in the diet to help decrease the risk of cancer development?
1. Bacon
2. Broccoli
3. Bologna
4. Broiled beef

 

 

  1. The nurse would include which of the following in a list of the most helpful foods for the vegan client wishing to increase foods high in vitamin A?
1. Peas
2. Carrots
3. Potatoes
4. Green beans

 

 

 

  1. According to the American Cancer Society, fecal occult blood testing should be done annually after the age of _____ years.
1. 30
2. 40
3. 50
4. 60

 

 

  1. A 27-year-old female client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask the client whether the breast lumps seem to become more prominent or troublesome at which of the following times?
1. After menses
2. Before menses
3. During menses
4. At any time, regardless of the menstrual cycle

 

 

  1. The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site?
1. Frequent diarrhea
2. Crampy gas pains
3. Flat, ribbon-like stools
4. Dull abdominal pain exacerbated by walking

 

 

  1. A client has undergone abdominal perineal resection for a bowel tumor. The nurse interprets that the client’s colostomy is beginning to function if which of the following signs is noted?
1. Absent bowel sounds
2. The passage of flatus
3. Blood drainage from the colostomy
4. The client’s ability to tolerate food

 

 

  1. A nurse assessing a postoperative ureterostomy client will interpret that the stoma has normal characteristics if the stoma is:
1. Dry
2. Pale
3. Dark-colored
4. Red and moist

 

 

  1. The nurse monitoring the oncological client for early signs of vena cava syndrome would include assessment for which of the following?
1. Cyanosis
2. Arm edema
3. Periorbital edema
4. Mental status changes

 

 

  1. The nurse understands that which of the following hormones is directly responsible for maintaining the free or unbound portion of serum calcium within normal limits?
1. Thyroid hormone
2. Parathyroid hormone
3. Follicle-stimulating hormone
4. Adrenocorticotropic hormone

 

 

  1. The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can “feel his heart beating in his chest.” The nurse interprets that which of the following glands is most likely responsible for these symptoms?
1. Thyroid
2. Pituitary
3. Parathyroid
4. Adrenal cortex

 

 

  1. The client is experiencing an episode of hypoglycemia. The nurse understands that the physiological mechanism that should take place to combat this decrease in the blood glucose level is:
1. Decreased cortisol release
2. Increased insulin secretion
3. Decreased epinephrine release
4. Increased glucagon secretion

 

 

 

  1. The client with diabetes experiences breakdown of fats for conversion to glucose. The nurse determines that this response is occurring if the client has elevated levels of which of the following substances?
1. Glucose
2. Ketones
3. Glucagon
4. Lactic dehydrogenase

 

 

  1. The client with diabetes mellitus is being tested to determine long-term diabetic control. Which of the following results would the nurse expect to see if the client’s long-term control is within acceptable limits?
1. Glycosylated hemoglobin of 6%
2. Fasting blood glucose level of 150 mg/dL
3. Presence of ketones in the urine
4. Presence of albumin in the urine

 

 

 

  1. The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which of the following is an early indicator of this complication?
1. Hyperreflexia
2. Constipation
3. Bradycardia
4. Low-grade temperature

 

 

  1. The client is undergoing an oral glucose tolerance test. The nurse interprets that the client’s results are not compatible with diabetes mellitus if the glucose level is lower than which of the following cutoff values after 120 minutes (2 hours)?
1. 80 mg/dL
2. 110 mg/dL
3. 140 mg/dL
4. 160 mg/dL

 

 

  1. A client who visits the physician’s office for a routine physical reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse continues to assess for which of the following?
1. Weight loss and thinning skin
2. Complaints of weakness and lethargy
3. Increased heart rate and respiratory rate
4. Diaphoresis and increased hair growth

 

 

  1. The nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client’s laboratory results, the nurse determines that which of these findings will support the diagnosis?
1. Elevated serum lipase level
2. Elevated serum bilirubin level
3. Decreased serum trypsin level
4. Decreased serum amylase level

 

 

  1. A nurse is caring for a client postoperatively following creation of a colostomy. Which of the following nursing diagnoses should the nurse include in the plan of care?
1. Sexual dysfunction
2. Disturbed body image
3. Fear
4. Imbalanced nutrition: more than body requirements

 

 

  1. The client is experiencing blockage of the common bile duct. Which of the following food selections made by the client indicates the need to plan for further diet teaching?
1. Rice
2. Whole milk
3. Broiled fish
4. Baked chicken

 

  1. The nurse is reviewing laboratory test results for the client with liver disease and notes that the client’s albumin level is low. Which of the following nursing actions is focused on the consequence of low albumin levels?
1. Evaluating for asterixis
2. Inspecting for petechiae
3. Palpating for peripheral edema
4. Evaluating for decreased level of consciousness

 

 

  1. Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions?
1. Alcohol should be consumed in moderation.
2. Avoid caffeine, because it may aggravate symptoms.
3. Diet should be high in carbohydrates, fats, and proteins.
4. Frothy fatty stools indicate that enzyme replacement is working.

 

 

  1. A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which of the following reflects appropriate intervention by the nurse?
1. Allow the client unassisted bathroom privileges.
2. Keep the client lying flat in bed in the supine position.
3. Withhold oral fluids until the client’s gag reflex has returned.
4. Tell the client to report a sore throat immediately, because it is a serious complication.

 

 

  1. The nurse is assisting the physician during a colonoscopy procedure. The nurse helps the client to assume which of the following positions for the procedure?
1. Left Sims
2. Lithotomy
3. Knee chest
4. Right Sims

 

 

  1. The client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse provides a list of foods from which diet type?
1. Liquid
2. Fat-free
3. Low-protein
4. High-carbohydrate

 

 

  1. In which of the following optimal positions should the nurse plan to place the client after bolus feeding using a nasogastric tube?
1. Head of bed (HOB) flat, with client supine for at least 60 minutes
2. HOB elevated 45 to 60 degrees, with client supine for 15 minutes
3. HOB elevated 10 degrees, with client in the left lateral position for 60 minutes
4. HOB elevated 30 to 45 degrees, with client in the right lateral position for 60 minutes

 

 

  1. The client receiving a cleansing enema complains of pain and cramping. The nurse takes which of the following corrective actions?
1. Discontinue the enema.
2. Reassure the client, and continue the flow.
3. Raise the enema bag so that the solution can be completed quickly.
4. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.

 

 

  1. A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which of the following is the priority action taken by the nurse?
1. Take the client’s vital signs.
2. Perform a complete abdominal assessment.
3. Obtain a thorough history of the recent health status.
4. Prepare to insert a nasogastric tube and test pH and occult blood.

 

 

  1. The client with frequent upper respiratory infections (URIs) asks the nurse why food doesn’t seem to have any taste during illness. The nurse understands that this is because of which of the following?
1. Anorexia is triggered by the infectious organism.
2. Blocked nasal passages impair the senses of smell and taste.
3. The infection blocks sensation from the taste buds of the tongue.
4. The client’s medication therapy has caused changes in the normal flora of the mouth.

 

 

  1. The nurse providing instructions to the client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to:
1. Dilate the major bronchi.
2. Maintain inflation of the alveoli.
3. Increase surfactant production.
4. Enhance ciliary action in the tracheobronchial tree.

 

 

  1. The nurse understands that increasing the flow of oxygen to more than 2 L/min in the client with chronic obstructive pulmonary disease (COPD) could be harmful because it:
1. Is drying to nasal mucosal passages
2. Decreases diaphragmatic excursion and depth
3. Increases the risk of pneumonia and atelectasis
4. Decreases the client’s oxygen-based respiratory drive

 

 

  1. The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The physician states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that the consequence of insufficient surfactant is:
1. Atelectasis and viral infection
2. Bronchoconstriction and stridor
3. Collapse of alveoli and decreased compliance
4. Decreased ciliary action and retained secretions

 

 

  1. The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which of the following arterial blood gas (ABG) findings?
1. pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L
2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L
3. pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L
4. pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

 

 

  1. The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope:
1. Near the lateral 12th rib
2. Just under the left-sided clavicle
3. In the fifth intercostal space
4. Posteriorly, under the left-sided scapula

 

 

 

  1. The nurse would determine that tracheal suctioning is needed if which of the following is noted?
1. Arterial oxygen level of 90 mm Hg
2. Congested breath sounds in the lung fields
3. Two hours elapsed since the last suctioning
4. Respiratory rate of 18 breaths/min, up from 16 breaths/min

 

 

  1. The client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which of the following documented in the client’s record is an expected finding with this client?
1. Increased oxygen saturation with ambulation
2. Hyperinflation of lungs documented by chest x-ray
3. A widened diaphragm documented by chest x-ray
4. A shortened expiratory phase of the respiratory cycle

 

 

  1. The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which of the following assessment findings would be indicative of further fluid volume deficit?
1. Pulse rate increases from 100 beats/min to 136 beats/min
2. +4 edema noted in lower extremities
3. Blood pressure rises from 116/68 to118/74 mm Hg
4. Crackles auscultated from lung bases to apices

 

 

  1. The nurse is preparing to take an apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope at which cardiac site?
1. Aortic area
2. Mitral area
3. Tricuspid area
4. Pulmonic area

 

 

  1. The nurse reading the operative record of a client who had cardiac surgery notes that the client’s cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which of the following conclusions?
1. The cardiac output is above the normal range.
2. The cardiac output is in the high-normal range.
3. The cardiac output is in the low-normal range.
4. The cardiac output is below the normal range.

 

 

  1. The nurse is listening to a 56-year-old client’s apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/min. Which of the following would be an appropriate course of action taken by the nurse?
1. Withhold the digoxin, and reevaluate the heart rate in 4 hours.
2. Administer half the prescribed dose to avoid a further decrease in heart rate.
3. Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity.
4. Administer the digoxin; the heart rate would be considered normal because of the client’s age.

 

 

  1. The nurse is assisting in admitting a client who has a diagnosis of hypothermia. The nurse anticipates that this client will exhibit which of the following vital signs?
1. Increased heart rate and increased blood pressure
2. Increased heart rate and decreased blood pressure
3. Decreased heart rate and increased blood pressure
4. Decreased heart rate and decreased blood pressure

 

 

  1. A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused around reduction of which specific problem associated with this type of heart failure?
1. Ascites
2. Pedal edema
3. Bilateral lung crackles
4. Jugular vein distention

 

 

  1. A client with angina complains that the anginal pain is prolonged, severe, and occurs at the same time each day, most often in the morning. On further assessment, a nurse notes that the pain occurs in the absence of precipitating factors. How would the nurse best describe this type of anginal pain?
1. Stable angina
2. Unstable angina
3. Variant angina
4. Nonanginal pain

 

  1. A client’s total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching?
1. The client should maintain the current dietary regimen but increase activity levels.
2. Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time.
3. The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught.
4. The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen.

 

 

  1. The ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which of the following areas is unnecessary to emphasize when providing client education for blood pressure control?
1. Instruct the client to limit protein intake.
2. Teach the client to avoid adding salt to foods.
3. Discuss the rationale for reducing or maintaining weight.
4. Stress the importance of a regular exercise program.

 

 

  1. The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client’s laboratory results and determines that which of the following results would be consistent with the observation?
1. Serum sodium level of 150 mEq/L
2. Serum chloride level of 95 mEq/L
3. Serum calcium level of 11.5 mg/dL
4. Serum potassium level of 2.8 mEq/L

 

 

  1. The client who has had intracranial surgery is experiencing diabetes insipidus. The nurse understands that the client is experiencing which of the following problems?
1. Water intoxication
2. Excess production of dopamine
3. Excess production of angiotensin II
4. Insufficient production of antidiuretic hormone (ADH)

 

 

  1. The client is admitted to the hospital with a tentative diagnosis of bladder cancer. The nurse expects the client history to reveal which of the following earliest manifestations of the disease?
1. Proteinuria and dysuria
2. Hematuria with no pain
3. Painful urination and hematuria
4. Pyuria and palpable abdominal mass

 

 

  1. The client with glomerulonephritis has developed acute renal failure (ARF) as a complication. The nurse would expect to note which of the following abnormal findings documented on the client’s medical record?
1. Decreased cardiac output
2. Hypertension
3. Bradycardia
4. Decreased central venous pressure

 

  1. The client has been diagnosed with pyelonephritis. The nurse interprets that which of the following health problems has placed the client at risk for this disorder?
1. Diabetes mellitus
2. Intravenous (IV) contrast medium
3. Orthostatic hypotension
4. Coronary artery disease

 

 

  1. The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse should avoid which of the following errors in technique when implementing this procedure?
1. Do not remove urine from the collection container for other specimens.
2. Place the specimen in the appropriate container necessary for the test.
3. Ask the client to save a sample voided at the end of the collection time.
4. Ask the client to void, save the specimen, and note the start time.

 

 

  1. The nurse who is collecting data from the client notes that the client’s left-sided eyelid is drooping. The nurse documents that the client is exhibiting which of the following conditions?
1. Ptosis
2. Arcus senilis
3. Abnormal corneal reflex
4. Blockage of the lacrimal duct

 

  1. The nurse is attempting to inspect the lacrimal apparatus of the client’s eye. Because of its anatomical location, the nurse should do which of the following?
1. Retract the upper eyelid, and ask the client to look down.
2. Retract the upper eyelid, and ask the client to look up.
3. Retract the lower eyelid, and ask the client to look up.
4. Retract the lower eyelid, and ask the client to look down.

 

  1. The nurse conducting an eye examination notes that the client exhibits rapid, involuntary, oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:
1. Nystagmus
2. Photophobia
3. Unequal pupils
4. Impaired consensual response

 

 

  1. The nurse who is assessing the client’s eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as:
1. Myopia
2. Hyperopia
3. Photophobia
4. Accommodation

 

 

  1. The nurse suspects the client may be experiencing dysfunction in the area of the semicircular canals of the ear if the client experiences:
1. Disturbance in balance
2. Conduction hearing loss
3. Tinnitus
4. Sensorineural hearing loss

 

 

  1. A client is experiencing blockage of the eustachian tubes. Which of the following activities by the client may forcibly open the eustachian tube?
1. Performing the Valsalva maneuver
2. Tapping the side of the head lightly
3. Using cotton-tipped applicators in the ears
4. Chewing food using exaggerated mouth movements

 

 

  1. A nurse is caring for a client diagnosed with Ménière’s disease. The nurse plans care, understanding that this disorder is characterized by:
1. Dizziness
2. Blurred vision
3. Hemianopsia
4. Photophobia

 

 

  1. The client has a cerebellar lesion. The nurse would plan to obtain which of the following for use by this client?
1. Walker
2. Slider board
3. Raised toilet seat
4. Adaptive eating utensils

 

TOP:    Content Area: Adult Health/Neurological

MSC:   Integrated Process: Nursing Process—Planning

 

  1. The client has sustained damage to Wernicke’s area in the temporal lobe from a brain attack (stroke). Which of the following should the nurse anticipate when caring for this client?
1. The client will be unable to recall past events.
2. The client will demonstrate difficulty articulating words.
3. The client will have difficulty understanding language.
4. The client will have difficulty moving one side of the body.

 

 

  1. The nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The nurse understands that the selection of an antibiotic to treat meningitis is based on which of the following?
1. It has a long half-life.
2. It acts within minutes to hours.
3. It is able to cross the blood-brain barrier.
4. It can be easily excreted in the urine.

 

  1. The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that these symptoms are because of stimulation of which cranial nerve (CN)?
1. Vagus (CN X)
2. Hypoglossal (CN XII)
3. Spinal accessory (CN XI)
4. Glossopharyngeal (CN IX)

 

 

  1. The client is being scheduled for a positron emission tomography (PET) scan. The nurse provides which of the following explanations to the client?
1. “The test uses magnetic fields to produce images.”
2. “The test provides cross-sectional views of the brain.”
3. “The test detects abnormal glucose metabolism in the brain.”
4. “The test views bones of the skull, nasal sinuses, and vertebrae.”

 

 

  1. The nurse is caring for a client who is scheduled to have electroencephalography. The nurse determines that the client is ready for the procedure after noting which of the following?
1. The client’s hair has been shampooed.
2. The client has not had any breakfast.
3. The client has had two cups of coffee with breakfast.
4. The morning dose of an anticonvulsant has been administered.

 

 

  1. The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)?
1. Swallow a sip of water.
2. Elevate the shoulders.
3. Open the mouth and say “ah.”
4. Vocalize the sounds “la-la,” “mi-mi,” and “kuh-kuh.”

 

 

  1. The nurse is assessing the client’s muscle strength and notes that when asked, the client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. How would the nurse correctly document this finding on the medical record?
1. Client is demonstrating ataxia.
2. Client is exhibiting pronator drift.
3. Client examination reveals hyperreflexia.
4. Client appears to have nystagmus.

 

 

  1. The nurse is testing the client for graphesthesia and asks the client to close his eyes. Which of the following would the nurse have the client do?
1. Identify three objects placed in the hand, one at a time.
2. Identify three numbers or letters traced in the client’s palm.
3. Identify the smallest distance between two skin pricks after pricking the skin with two pins at varying distances.
4. State whether one or two skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client’s skin.

 

 

  1. The nurse plans care for the older adult female client with a diagnosis of osteoporosis knowing that the client is at greatest risk for which of the following?
1. Fractures
2. Phosphatemia
3. Hypocalcemia
4. Muscle atrophy

 

 

  1. The clinical picture of the client with osteitis deformans (Paget’s disease) includes back and leg pain, a crouched forward posture, and legs that bow outward. The nurse plans care, knowing that these manifestations are caused by disturbances of which of the following?
1. Muscle metabolism and growth
2. Bone resorption and regeneration
3. Nervous system impulse transmission
4. Joint integrity and synovial fluid production

 

 

  1. The nurse understands that the most significant rationale for the application of heat to an area of contusion 72 hours after the injury is to:
1. Prevent abscess formation.
2. Promote muscle relaxation.
3. Reabsorb blood from the injured tissue.
4. Reduce the likelihood of strain as a complication.

 

 

  1. The nurse is assisting in performing a physical assessment of a right-handed client’s musculoskeletal system. Which of the following would be an abnormal finding?
1. Presence of fasciculations
2. Muscle strength of normal power
3. Symmetrical movements bilaterally
4. Hypertrophy of right upper arm of 1 cm

 

 

  1. The nurse explaining the procedure of indium imaging to a client with a bone infection would include which of the following?
1. Indium is injected into the bloodstream and outlines the extent of the blood supply to the bone.
2. Indium is injected into the bloodstream and collects in normal bone but not in infected areas.
3. Some of the client’s white blood cells are tagged with indium, which will later accumulate in infected bone.
4. Some of the client’s red blood cells are tagged with indium, which will later accumulate in normal bone.

 

 

 

  1. The client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which of the following changes in vital signs?
1. Fever, bradycardia
2. Fever, hypertension
3. Tachycardia, hypotension
4. Bradycardia, hypertension

 

  1. Which of the following teaching points is the priority when the nurse is teaching the client about caring for a plaster cast?
1. The cast gives off heat as it dries.
2. The client can bear weight on the cast in 1 hour.
3. A stockinette and soft padding are put over the leg area before casting.
4. Immediately report any increase in drainage or interruption in cast integrity.

 

 

  1. The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as a(n):
1. T cell
2. B cell
3. Antibody
4. Foreign antigen

 

 

  1. A client is admitted to the hospital with a diagnosis of parasitic worms. The nurse understands that the primary cell type that will attack these foreign particles is:
1. Basophils
2. Neutrophils
3. Eosinophils
4. Dendritic cells

 

 

  1. Tetanus toxoid is prescribed for a client who has sustained a foot laceration from a piece of metal while walking barefoot on the beach. The nurse understands that the toxoid is a(n):
1. Attenuated bacterium
2. Nonattenuated virus
3. Toxin produced by bacteria that has been altered so that it is no longer toxic
4. Specific antibody that will prevent infection through an antigen-antibody reaction

 

 

  1. The nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer’s cells are located. The student responds correctly by stating that these types of cells are located in the:
1. Liver
2. Tonsils
3. Spleen
4. Bone marrow

 

 

  1. The nursing student understands that the primary purpose of neutrophils in the inflammatory response is to:
1. Dilate the blood vessels.
2. Increase fluids at the site of injury.
3. Phagocytize any potentially harmful agents.
4. Produce permeability of the blood vessels.

 

 

  1. The nursing student correctly describes the process of phagocytosis as:
1. The initial reaction in the inflammatory response
2. A protein produced in response to a viral infection
3. A process required for the production of antibodies
4. A process whereby a particle is ingested and digested by a cell

 

  1. The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. The priority nursing action at this time is which of the following?
1. Elevate the foot of the bed.
2. Position the stump flat on the bed.
3. Put the bed in a reverse Trendelenburg’s position.
4. Keep the stump flat, with the client lying on his or her operative side.

 

 

 

  1. The nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would plan to teach the client which of the following pieces of information about positioning in the postoperative period?
1. Lower the head between the knees 3 times a day.
2. Bend below the waist as often as possible.
3. Avoid sleeping on the left side.
4. Sleep only on the left side.

 

 

  1. The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which of the following positions?
1. Prone position
2. Supine position
3. Semi-Fowler’s position
4. Dorsal recumbent position

 

 

  1. The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching regarding positioning?
1. Sitting up and leaning on a table
2. Standing and leaning against a wall
3. Sitting up with elbows resting on knees
4. Lying on his or her back in a low Fowler’s position

 

 

  1. The nurse is assisting the physician with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse takes which of the following actions?
1. Ensure that suction is turned on.
2. Reinforce the occlusive dressing.
3. Encourage the client to breathe deeply.
4. Document the accurate functioning of the tube.

 

 

  1. The physician is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to:
1. Breathe in and out quickly.
2. Exhale immediately.
3. Take a deep breath.
4. Perform the Valsalva maneuver.

 

MSC:   Integrated Process: Nursing Process—Implementation

 

  1. The nurse is assisting in caring for the client immediately after removal of the endotracheal tube. Which of the following findings should be reported to the health care physician immediately?
1. Stridor
2. Lung congestion
3. Respiratory rate of 26 breaths/min
4. Occasional pink-tinged sputum

 

 

  1. A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to have this taste for the client?
1. Pork
2. Custard
3. Potatoes
4. Cantaloupe

 

 

 

  1. The client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should plan to include which of the following in a list provided to the client?
1. Tomato soup
2. Boiled shrimp
3. Instant oatmeal
4. Summer squash

 

 

  1. The client has been diagnosed with gout. In developing a teaching plan for this client, the nurse should include a list that identifies which of the following foods to be avoided?
1. Chicken liver
2. Carrots
3. Tapioca
4. Chocolate

 

 

  1. The client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid in symptom management that are in which of the following diet types?
1. A low-fat diet
2. A low-fiber diet
3. A high-fiber diet
4. A high-carbohydrate diet

 

 

  1. The nurse is caring for the client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which of the following?
1. Pork
2. Milk
3. Chicken
4. Broccoli

 

 

  1. The client is resuming a diet after hemigastrectomy. To minimize complications, the nurse would tell the client to avoid doing which of the following?
1. Lying down after eating
2. Drinking liquids with meals
3. Eating six small meals per day
4. Excluding concentrated sweets in the diet

 

 

MULTIPLE RESPONSE

 

  1. The older adult client has been lying in a supine position for the last 3 hours. The nurse who is repositioning this client would be most concerned with examining which of the following bony prominences of the client? Select all that apply.
1. Heels
2. Ankles
3. Elbows
4. Sacrum
5. Back of the head
6. Greater trochanter

 

 

  1. The client is having a diagnostic workup for colorectal cancer. Which of the following factors in the client’s history will place the client at increased risk of this type of cancer? Select all that apply.
1. A high-fiber diet
2. A diet high in fats
3. Minimal alcohol intake
4. A diet high in carbohydrates
5. A history of inflammatory bowel disease
6. Maternal grandfather who had a history of heart disease

 

  1. The nurse teaching a group of adults about cancer warning signs presents to the group a list of the seven possible warning signs of cancer that is used by the American Cancer Society. What should this list include? Select all that apply.
1. Areas of alopecia
2. Sores that do not heal
3. Nagging cough or hoarseness
4. Indigestion or difficulty swallowing
5. Change in bowel or bladder habits
6. Absence or decreased frequency of menses

 

 

  1. A client is admitted to the hospital with a diagnosis of Addison’s disease. The nurse would monitor for which of the following problems associated with this disease? Select all that apply.
1. Edema
2. Obesity
3. Syncope
4. Hirsutism
5. Hypotension
6. Muscle weakness

 

 

  1. The client has been diagnosed with Cushing’s syndrome. The nurse would monitor this client for which of the following expected signs of this disorder? Select all that apply.
1. Anorexia
2. Weight loss
3. Hypertension
4. Dizziness
5. Moon facies
6. Truncal obesity

 

 

 

  1. The client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which of the following actions are planned to promote client safety? Select all that apply.
1. Monitor potassium levels.
2. Monitor for symptoms of fluid retention.
3. Provide the client with a soft toothbrush.
4. Instruct the client to use an electric razor.
5. Weigh client daily, and monitor trends.
6. Monitor all secretions for frank or occult blood.

 

 

  1. The nurse is doing volunteer work in a homeless shelter. The nurse monitors the individuals in the shelter for which of the following initial symptoms of tuberculosis (TB)? Select all that apply.
1. Fatigue
2. Lethargy
3. Chest pain
4. Low-grade fever
5. Morning cough
6. Labored breathing

 

 

  1. The nurse notes that the client’s serum calcium level is 6.0 mg/dL. Which of the following assessment findings would be anticipated in this client? Select all that apply.
1. Tetany
2. Constipation
3. Renal calculi
4. Hypotension
5. Prolonged QT interval
6. Positive Chvostek’s sign

 

 

  1. The nurse notes during assessment and history taking that the older client exhibits visual changes. Which of the following are normal age-related changes of the eye? Select all that apply.
1. Ptosis
2. Photophobia
3. Corneal thickening
4. Decreased visual acuity
5. Decreased tolerance of glare
6. Decreased peripheral vision

 

 

  1. The nurse caring for a client admitted to the hospital with acute back pain understands that this problem can be most likely caused by which of the following? Select all that apply.
1. Scoliosis
2. Twisting of the spine
3. Hyperflexion of the spine
4. Sciatic nerve inflammation
5. Herniation of an intervertebral disk
6. Degeneration of the vertebral posterior facet joints

 

 

 

  1. The client who sustained a severe sprain of the ankle is told by the physician that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which of the following interventions should the nurse anticipate will be included in the client’s plan of care? Select all that apply.
1. Ice bags
2. Elevation
3. Heating pad
4. Range-of-motion exercises
5. Compression by an elastic bandage
6. Maintaining the affected extremity in a dependent position

 

 

  1. The nurse collecting data related to the client’s risk factors associated with osteoporosis would include which of the following? Select all that apply.
1. Thin body build
2. Smoking history
3. Postmenopausal age
4. Chronic corticosteroid use
5. Family history of osteoporosis
6. High intake of dairy products

 

 

  1. The student nurse is assisting with an assessment of a client’s level of consciousness using the Glasgow Coma Scale. The student understands that which of the following categories of client functioning are included in this assessment? Select all that apply.
1. Eye opening
2. Best verbal response
3. Best motor response
4. Pupil size and reaction
5. Reflex response

 

 

COMPLETION

 

  1. An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be? (Enter the answer in the space provided.)

 

 

 

Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition

 

Child Health

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse is caring for an infant with a diagnosis of hydrocephalus and is monitoring the infant for signs of increased intracranial pressure (ICP). The nurse suspects increased ICP if which of the following is noted?
1. Proteinuria
2. Bradycardia
3. A drop in blood pressure
4. A bulging anterior fontanel

 

 

 

  1. The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors for the earliest sign of increased ICP by assessing for:
1. Apnea
2. Posturing
3. Tachycardia
4. Changes in level of consciousness (LOC)

 

 

 

  1. The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse includes which of the following instructions?
1. Call the physician if the infant is fussy.
2. Expect an increased urine output from the shunt.
3. Call the physician if the infant has a high-pitched cry.
4. Position the infant on the side of the shunt when the infant is put to bed.

 

 

  1. The nurse reviews the plan of care for a child with Reye’s syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:
1. Signs of hyperglycemia
2. Signs of a bacterial infection
3. The presence of protein in the urine
4. Signs of increased intracranial pressure

 

 

  1. The nurse is providing home care instructions to the mother of a child who is recovering from Reye’s syndrome. Which of the following home instructions should the nurse provide to the mother?
1. Increase the stimuli in the environment.
2. Give the child frequent small meals, if vomiting occurs.
3. Avoid daytime naps so that the child will sleep at night.
4. Check the child’s skin and eyes every day for a yellow discoloration.

 

 

  1. The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child’s needs. The nurse understands that the priority consideration in planning activities for the child is to ensure:
1. Safety with activities
2. Activities providing verbal stimulation
3. Social interactions with other children in the same age group
4. Familiarity with all activities and providing orientation throughout the activities

 

 

  1. The nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the control of seizures. Which of the following statements, if made by the adolescent, indicates a need for further teaching regarding the medication?
1. “The medication may cause oily skin.”
2. “Drinking alcohol may affect the medication.”
3. “If my gums become sore I need to stop the medication.”
4. “Birth control pills may not be effective when I take this medication.”

 

 

  1. The nurse is collecting data on a 7-year-old child who is suspected of having episodes of absence seizures. Which of the following questions to the mother will assist in providing information that will identify the symptoms associated with these types of seizures?
1. “Does twitching occur in the face and neck?”
2. “Does the muscle twitching occur on one side of the body?”
3. “Does the muscle twitching occur on both sides of the body?”
4. “Does the child have a blank expression during these episodes?”

 

 

  1. The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing were present?
1. Rigid extension and tremors of all extremities
2. Flaccid paralysis of all extremities
3. Flexion of the upper extremities and extension of the lower extremities
4. Abnormal extension of the upper and lower extremities with some internal rotation

 

 

  1. The nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which of the following positions on return from the operating room?
1. Supine
2. Side-lying
3. High-Fowler’s and on the left side
4. Trendelenburg’s and on the right side

 

 

  1. The nurse provides discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which of the following statements, if made by the mother, indicates a need for further education?
1. “My child should not swim in deep water.”
2. “I need to prevent my child from blowing the nose.”
3. “My child can swim in the lake as long as the water is not deep.”
4. “My child can take a shower or bath as long as I place Vaseline on cotton balls or earplugs in the ears.”

 

 

  1. The pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which of the following items would the nurse offer to the child?
1. Cola with ice
2. A glass of milk
3. Cool cherry-flavored drink
4. Green gelatin

 

  1. The nurse is providing home care instructions to a mother of a 9-year-old child diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. The nurse would instruct the mother that the child:
1. Can return to school immediately
2. Cannot return to school until seen by the physician in 1 week
3. Should be kept at home until the antibiotic eye drops have been administered for 1 week
4. Should be kept at home until the antibiotic eye drops have been administered for 24 hours

 

 

  1. The nurse is providing instructions to a mother of a child with strabismus of the right eye. The physician has prescribed “patching” for the child, and the parent is instructed in the procedure. Which of the following, if stated by the parent, indicates an understanding of the procedure?
1. “I will place the patch on the left eye.”
2. “I will place the patch on both eyes.”
3. “I will place the patch on the right eye.”
4. “I will alternate the patch from the right to left eye daily.”

 

 

  1. The nurse is reviewing the physician’s prescriptions on a child following a tonsillectomy. Which of the following physician prescriptions would the nurse question?
1. Suction the child if coughing.
2. Discharge to home when alert and tolerating fluids.
3. Provide clear cool liquids to the child when awake.
4. Instruct the parent to avoid giving the child milk or milk products.

 

 

  1. The nurse is caring for a 2-year-old child with an ear infection who requires the administration of antibiotic ear drops. The nurse observes the mother administering the ear drops to the child. Which of the following observations, if made by the nurse, indicates that the mother is performing the procedure correctly?
1. The mother pulls the earlobe down and back.
2. The mother must wear gloves when administering the medication.
3. The mother pulls the earlobe up and back to administer the drops.
4. The mother holds the child in a sitting position when administering the ear drops.

 

 

  1. The ambulatory care nurse makes a follow-up telephone call to the mother of a child who underwent a myringotomy with insertion of tympanostomy tubes on the previous day. The mother of the child tells the nurse that the child is complaining of discomfort. The nurse would instruct the mother to:
1. Call the physician immediately.
2. Give the child acetaminophen (Tylenol) for the discomfort.
3. Give the child children’s aspirin, and call the physician if it does not help.
4. Call the local pharmacist regarding a stronger over-the-counter analgesic.

 

 

  1. The nurse is assisting in providing an educational session to new mothers regarding the methods that will decrease the risk of recurrent otitis media in infants. Which of the following statements, if made by a mother in the group, indicates a need for further instruction?
1. “I need to feed the infant in an upright position.”
2. “I should not provide the infant with a bottle during naptime.”
3. “Bottle-feeding should be discontinued as soon as possible.”
4. “I need to discontinue breast-feeding as soon as possible.”

 

 

  1. A nursing student is preparing a clinical conference. The topic of the discussion is caring for the child with cystic fibrosis (CF). Which of the following comments by the student would indicate that the student needs further review of information about cystic fibrosis?
1. It is transmitted as an autosomal recessive trait.
2. It is a disease that causes mucus that is formed to be abnormally thick.
3. It is a disease that causes dilation of the passageways of many organs.
4. It is a chronic multisystem disorder affecting the exocrine glands.

 

 

  1. The nurse reviews the health record of a 2-year-old child and notes that the physician has documented that the results of a Mantoux test have indicated an area of induration measuring 5 mm. The nurse would interpret these results as:
1. Positive
2. Negative
3. Inconclusive
4. Definitive, requiring a repeat test

 

 

  1. The nurse has provided instructions to the mother of a child with cystic fibrosis (CF) about appropriate dietary measures. Which of the following statements, if made by the mother, indicates an understanding of the diet that should be provided to the child?
1. “The diet needs to be low in fat.”
2. “The diet needs to be low in protein.”
3. “The diet needs to be high in calories.”
4. “The diet needs to be low in calories.”

 

 

  1. The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant:
1. In a supine, side-lying position
2. Prone, with the head of the bed elevated 15 degrees
3. With the head at a 60-degree angle with the neck slightly flexed
4. With the head and chest at a 30-degree angle, with the neck slightly extended

 

 

 

  1. The nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which of the following statements, if made by the mother, indicates a need for further instruction?
1. “I will take the child out into the cool, humid night air.”
2. “I should place a steam vaporizer in the child’s room.”
3. “I need to place a cool mist humidifier in the child’s room.”
4. “I can bring the child into a closed bathroom and have the child inhale steam from running water.”

 

 

  1. The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:
1. Extreme fatigue
2. The presence of pain
3. An airway obstruction
4. The presence of dehydration

 

 

 

  1. The nurse is preparing for administering ribavirin (Virazole) to a child with respiratory syncytial virus (RSV). Which of the following supplies will the nurse obtain for the administration of this medication?
1. An intravenous (IV) pole
2. A pair of goggles
3. A protective isolation gown
4. An intramuscular (IM) syringe

 

 

 

  1. A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome (SIDS). The student plans to write on a handout that it is best to place an infant in which of the following positions for sleep?
1. On the back or prone
2. On the back or supine
3. On the stomach or prone
4. On the stomach or supine

 

 

  1. A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L. The nurse interprets that this finding is indicative of:
1. A negative test
2. A positive test
3. An unrelated finding
4. Suggestive of CF and requires a repeat test

 

MSC:   Integrated Process: Nursing Process—Assessment

 

  1. The nursing student is caring for an infant with a respiratory infection and is monitoring for signs of dehydration. The nursing instructor asks the student to identify the most reliable method of determining fluid loss. The instructor determines that the student understands this method when the student states that the plan is to:
1. Monitor output.
2. Monitor body weight.
3. Assess the mucous membranes.
4. Obtain a temperature every 2 hours.

 

 

  1. The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse includes to monitor the child for signs of:
1. Bleeding
2. Failure to thrive
3. Congestive heart failure (CHF)
4. Decreased tolerance to stimulation

 

 

 

  1. The nurse is reviewing the physician’s prescriptions for a child with rheumatic fever (RF) who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which of the following nursing actions is most appropriate?
1. Administer the aspirin if the child’s temperature is elevated.
2. Administer the aspirin if the child experiences any joint pain.
3. Consult with the physician to verify the prescription.
4. Administer acetaminophen (Tylenol) instead of the aspirin for temperature elevation.

 

 

 

  1. The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The initial nursing action is to:
1. Call a code.
2. Place the infant in a prone position.
3. Place the infant in a knee-chest position.
4. Contact the respiratory therapy department.

 

 

  1. The nurse is caring for an infant with congenital heart disease. Which of the following signs, if noted in the infant, would alert the nurse to the early development of congestive heart failure (CHF)?
1. Pallor
2. Strong sucking reflex
3. Diaphoresis during feeding
4. Slow and shallow breathing

 

  1. The nurse reviews the physician’s prescriptions for a child with a streptococcal infection. The physician prescribes an antistreptolysin O titer. Based on this prescription, which of the following would the nurse suspect in the child?
1. Rheumatic fever (RF)
2. Aortic valve disease (AVD)
3. Pulmonic valve disease (PVD)
4. Congestive heart failure (CHF)

 

nt

 

  1. The nurse is caring for a child with congestive heart failure (CHF). The nurse provides instructions to the mother regarding the procedure for administration of the prescribed digoxin (Lanoxin). Which of the following statements, if made by the mother, indicates a need for further education?
1. “I can mix the medication with food.”
2. “If more than one dose is missed, I need to call the physician.”
3. “I need to take the child’s pulse before administering the medication.”
4. “If the child vomits after being given the medication, I should not repeat the dose.”

 

 

  1. The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child’s record, the nurse would expect to note documentation of which of the following most common assessment findings?
1. Cyanosis
2. Severe bradycardia
3. Asymptomatic findings
4. Higher than normal body weight

 

 

  1. The nurse is collecting data on a child with a diagnosis of rheumatic fever (RF). Which of the following questions would the nurse initially ask the mother of the child?
1. “Has the child been vomiting?”
2. “Has the child had any diarrhea?”
3. “Does the child complain of chest pain?”
4. “Has the child complained of a sore throat within the past few months?”

 

 

  1. The nurse is reviewing the health record of an infant with a diagnosis of congenital heart disease. The nurse notes documentation in the record that the infant has clubbing of the fingers. The nurse understands that this finding is caused by:
1. Chronic fatigue
2. Poor oxygenation
3. Poor sucking ability
4. Consistent sucking on the fingers

 

 

  1. The nurse is admitting a child who arrived from the emergency department after treatment for acetaminophen (Tylenol) overdose. The nurse reviews the child’s record and expects to note that the child received which of the following for the acetaminophen overdose?
1. Epoetin alfa (Epogen)
2. Protamine sulfate
3. Acetylcysteine (Mucomyst)
4. Ethylenediaminetetraacetic acid (EDTA)

 

 

  1. The nurse is monitoring a child who is receiving EDTA with BAL (British anti-Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which of the following laboratory test results?
1. Cholesterol level
2. Blood urea nitrogen (BUN) level
3. Complete blood cell (CBC) count
4. Hemoglobin and hematocrit (H&H) levels

 

 

  1. The mother of a child with an umbilical hernia calls the clinic and reports to the nurse that the child has been vomiting and is complaining of pain in the abdominal area. The nurse would most appropriately instruct the mother to:
1. Contact the physician.
2. Keep the child on clear liquids.
3. Apply an ice pack to the abdomen.
4. Administer acetaminophen (Tylenol) suppositories to the child.

 

 

  1. The nurse is reviewing the physician’s documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the physician has documented the presence of:
1. Scleral jaundice
2. Projectile vomiting
3. Currant jelly–type stools
4. Pale-colored and hard stools

 

 

  1. The nurse is preparing to care for a newborn infant following creation of a colostomy for the treatment of imperforate anus. In the immediate postoperative period, the nurse plans to inspect the stoma, knowing that it is expected to be:
1. Bleeding
2. Gray in color
3. Dark blue in color
4. Red and edematous

 

 

  1. The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung’s disease. Which of the following questions to the mother will most specifically elicit information regarding this disorder?
1. “Does your infant have diarrhea?”
2. “Is your infant constantly vomiting?”
3. “Does your infant constantly spit up feedings?”
4. “Does your infant have foul-smelling, ribbon-like stools?”

 

 

  1. The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table, with the knees pulled up toward the chest. The nurse assists the physician with further assessment of the progression of the child’s pain, knowing that the physician will palpate the abdomen:
1. Midway between the liver and the gallbladder
2. Midway between the left iliac crest and the umbilicus
3. Midway between the left inguinal area and the acetabulum
4. Midway between the right anterior superior iliac crest and the umbilicus

 

 

  1. The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the instructions when the mother states to include which of the following in the child’s diet?
1. Corn
2. Wheat cereal
3. Rye crackers
4. Oatmeal biscuits

 

 

  1. The nurse is developing a plan of care for an infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse suggests to document in the plan of care to position the child:
1. In an infant seat placed in the crib
2. Prone with the head of the bed elevated
3. Supine with the head at a 90-degree angle
4. Supine with the head of the bed at a 30-degree angle

 

 

  1. The nurse is assigned to care for an infant following a cleft lip repair. The nurse is asked to observe the parent in the procedure for cleaning the lip repair site. The nurse determines that the parent is performing the procedure correctly if the parent uses which of the following solutions to clean the site?
1. Ice water
2. Sterile water
3. Half-strength alcohol
4. Full strength hydrogen peroxide

 

 

  1. The nurse is preparing a plan of care for an infant who will be returning from the recovery room following the surgical repair of a cleft lip located on the right side of the lip. On return from the recovery room, the nurse plans to position the infant:
1. Prone and flat
2. Supine and flat
3. On the left side
4. On the right side

 

MSC:   Integrated Process: Nursing Process—Planning

 

  1. The nursing student is asked to administer a tepid bath to a child with a fever. The student avoids which of the following when performing this procedure?
1. Applies alcohol-soaked cloths over the child’s body
2. Uses a water toy to distract the child during the bath
3. Places lightweight pajamas on the child after the bath
4. Squeezes water over the child’s body, using the washcloth

 

 

  1. A nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The nurse monitors the child closely and notifies the physician if which of the following is noted?
1. Weight increase of 0.5 kg
2. Temperature of 100.8º F rectally
3. Blood pressure (BP) unchanged from baseline
4. A decrease in urine output to 0.5 mL/kg/hr

 

 

  1. A female adolescent with type 1 diabetes mellitus has been chosen for her school’s cheerleading squad. She visits the school nurse to obtain information regarding adjustments needed in her treatment plan for diabetes. The school nurse instructs the student to:
1. Eat half the amount of food normally eaten.
2. Take two times the amount of prescribed insulin on practice and game days.
3. Take the prescribed insulin 1 hour prior to practice or game time rather than in the morning.
4. Eat six graham crackers or drink a cup of orange juice prior to practice or game time.

 

 

  1. The nurse has been caring for an adolescent newly diagnosed with type 1 diabetes mellitus. The nurse provides instructions to the adolescent regarding the administration of insulin. The nurse tells the adolescent to:
1. Use only the stomach and thighs for injections.
2. Rotate each insulin injection site on a daily basis.
3. Use the same site for injections for 1 month before rotating to another site.
4. Use one major site for the morning injection and another site for the evening injection for 2 to 3 weeks before changing major sites.

 

 

  1. The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and would expect to note which of the following?
1. A normal T4 level
2. An elevated T4 level
3. An elevated thyroid-stimulating hormone (TSH) level
4. A decreased TSH level

 

TOP:    Content Area: Child Health

MSC:   Integrated Process: Nursing Process—Assessment

 

  1. A nursing student is caring for a hospitalized child who has hypotonic dehydration. The nursing instructor asks the student to describe this type of dehydration. The instructor determines that the nursing student understands the physiology associated with this type of dehydration if the student states which of the following?
1. “It causes the serum sodium level to rise above 150 mEq/L.”
2. “It occurs when the loss of electrolytes is greater than the loss of water.”
3. “It occurs when the loss of water is greater than the loss of electrolytes.”
4. “It occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body.”

 

 

  1. The nurse is caring for an infant with gastroenteritis who is being treated for dehydration. The nurse reviews the health record and notes that the physician has documented that the infant is mildly dehydrated. Which of the following assessment findings would the nurse find in a child with mild dehydration?
1. Anuria
2. Pale skin color
3. Sunken fontanels
4. Dry mucous membranes

 

 

  1. The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. The nurse determines that the parents have a proper understanding of preventing and managing hypoglycemia if the parents state that they will:
1. Administer glucagon immediately if shakiness is felt.
2. Give the child 8 oz of diet cola at the first sign of weakness.
3. Report to the emergency department if the blood glucose level is 65 mg/dL.
4. Carry a glucose source when leaving home in case a hypoglycemic reaction occurs.

 

 

  1. The nurse provides instructions to the parent of a newborn to bring the infant to the well-baby clinic for a phenylketonuria (PKU) rescreening blood test. The parent brings the infant to the clinic, and the blood test is drawn. The results of the test indicate a serum phenylalanine level of 1.0 mg/dL. The nurse interprets these results as:
1. Positive
2. Negative
3. Inconclusive
4. Requiring rescreening at age 6 weeks

 

 

  1. The nurse is reviewing the physician’s prescriptions for a child hospitalized with nephrotic syndrome. Which of the following dietary prescriptions would the nurse expect to be prescribed for the child?
1. A low-fat diet
2. A full liquid diet
3. A high-protein, high-salt diet
4. A normal protein, mild sodium diet

 

 

  1. A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. The student collects the specimen by:
1. Attaching a urinary collection device to the infant’s perineum for collection
2. Catheterizing the infant using the smallest available Foley catheter
3. Obtaining the specimen from the diaper by squeezing the diaper after the infant voids
4. Noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids

 

 

  1. The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which of the following questions to the mother would elicit data associated with the cause of this disease?
1. “Has your child had any diarrhea?”
2. “Have you noticed any rashes on your child?”
3. “Did your child recently complain of a sore throat?”
4. “Did your child sustain any injuries to the kidney area?”

 

 

  1. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse would expect to note which of the following findings documented in the child’s record?
1. Polyuria
2. Weight gain
3. Hypotension
4. Grossly bloody urine

 

 

 

  1. The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which of the following is a priority in the plan of care?
1. Wound care
2. Pain control measures
3. Measurement of intake
4. Cold and heat applications

 

 

  1. A nursing student is assigned to care for a child following surgery to correct cryptorchidism. The nursing instructor reviews the plan of care developed by the student and determines that the student is adequately prepared to care for the child if the student identifies which priority in the plan of care following this type of surgery?
1. Prevent tension on the suture.
2. Force oral fluids, and monitor I&O.
3. Monitor urine for glucose and acetone.
4. Encourage coughing and deep breathing every hour.

 

 

  1. A nurse is developing a plan of care for a 4-year-old child scheduled for a renal biopsy. Based on the developmental level of the child the nurse considers which of the following?
1. Masturbation is common in this age group.
2. Body image may be a concern for the child.
3. Fears of mutilation may be present in the child.
4. The urination pattern will cause embarrassment for the child.

 

 

  1. The mother of a newborn male infant with hypospadias asks the nurse why circumcision cannot be performed. The most appropriate response by the nurse is which of the following?
1. “Circumcision will cause an infection.”
2. “Circumcision is not performed in a newborn.”
3. “Circumcision will cause difficulty with urination.”
4. “Circumcision has been delayed to save tissue for surgical repair.”

 

 

 

  1. The nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by:
1. Covering the bladder with a sterile gauze dressing
2. Covering the bladder with a dry sterile dressing
3. Applying sterile water soaks to the bladder mucosa
4. Covering the bladder with a sterile, nonadhering dressing

 

 

  1. The nurse is developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. The nurse determines that which of the following is a priority for the child?
1. Promoting bed rest
2. Restricting oral fluids
3. Encouraging visits from friends
4. Allowing the child to play with the other children in the playroom

 

  1. The nurse is collecting data on a child brought to the health care clinic by the mother with a one-week-old cat scratch. While assessing the scratch the nurse notes redness, heat, swelling, and red streaking surrounding the area. The child states that the scratch hurts. Cellulitis is diagnosed. When providing home care instructions, which of the following statements made by the mother indicates a need for further education?
1. “The child should rest in bed.”
2. “I should apply cool, moist soaks every 4 hours.”
3. “I should take the child’s temperature and watch for a fever.”
4. “The affected extremity should be elevated and immobilized.”

 

 

  1. The nurse is providing instructions to the mother of a child with herpetic gingivostomatitis. Which of the following responses, if stated by the mother after teaching, would indicate that further instruction is required?
1. “I will offer my child soft, bland foods.”
2. “I will encourage my child to drink fluids.”
3. “I will give my child frozen ice pops to assist with fluid intake.”
4. “I will not give my child anything to eat for 2 days to allow the lesions to heal and crust over.”

 

  1. The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation?
1. Heart rate
2. Lung sounds
3. Level of consciousness
4. Amount of edema at the site of the burn injury

 

 

  1. A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which of the following will be prescribed initially?
1. Insertion of a Foley catheter
2. Insertion of a nasogastric tube
3. Administration of an anesthetic agent for sedation
4. Application of an antimicrobial agent to the burns

 

 

  1. The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin 1% (Nix) has been prescribed. Which of the following statements, if made by the mother regarding the use of the medication, indicates a need for further education?
1. “I need to purchase the medication from the pharmacy.”
2. “After rinsing out the medication, I need to avoid washing my child’s hair for 24 hours.”
3. “I need to shampoo my child’s hair, apply the medication, and leave it on for 10 minutes and then rinse it out.”
4. “I need to shampoo my child’s hair, apply the medication, and leave the medication on for 24 hours.”

 

 

  1. The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which of the following assessment findings would the nurse expect to note documented in the infant’s record regarding this condition?
1. Full range of motion in the affected hip
2. An apparent short femur on the unaffected side
3. Asymmetrical adduction of the affected hip when placed supine, with the knees and hips flexed
4. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

 

 

  1. The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip (DDH). The child will be placed in the Pavlik harness. Which of the following statements by the family would indicate that they understand the care of their child while placed in the Pavlik harness?
1. “I know that the harness must be worn continuously.”
2. “I will bring my child back to the orthopedic office in a month so the straps can be checked.”
3. “I realize that I will also need to put two diapers on my child so that the harness does not get soiled.”
4. “I will watch for any redness or skin irritation where the straps are applied and call the doctor if there is any irritation.”

 

 

 

  1. The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which of the following nursing actions would be most appropriate?
1. Report the findings to the physician.
2. Document the findings, and reassess the situation in 4 hours.
3. Encourage the child to keep the arm elevated for the next 24 hours.
4. Tell the child that this is normal and will disappear when the cast is dry.

 

 

  1. An adolescent is seen in the emergency department following an athletic injury. It is suspected that the child has sprained an ankle. X-rays have been obtained, and a fracture has been ruled out. The nurse is providing instructions to the adolescent regarding home care for treatment of the sprain. Which of the following instructions would the nurse provide to the adolescent?
1. Elevate the extremity, and maintain strict bed rest for a period of 7 days.
2. Immobilize the extremity, and maintain the extremity in a dependent position.
3. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice.
4. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.

 

 

 

  1. The nurse is reinforcing instructions to the mother of a child who has a plaster cast applied to the left arm. Which of the following statements, if made by the mother, indicates a need for further education?
1. “I should use a heat lamp to help the cast dry.”
2. “I should cover the cast with plastic when the child bathes or showers.”
3. “I should call the physician if the cast feels warm or hot or has an unusual smell or odor.”
4. “I should keep small toys and sharp objects away from the cast and be sure that my child does not put anything inside the cast.”

 

 

 

  1. The nurse is assisting a physician during the examination of an infant with developmental hip dysplasia. The physician performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which of the following is noted?
1. A shrill cry from the infant
2. Asymmetry of the affected hip
3. Reduced range of motion in the affected hip
4. A palpable click during abduction of the affected hip

 

 

  1. The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which of the following statements, if made by one of the parents, indicates an understanding of the use of the harness?
1. “I can remove the harness to bathe my infant.”
2. “I need to remove the harness to feed my infant.”
3. “I need to remove the harness to change the diaper.”
4. “My infant needs to remain in the harness at all times.”

 

 

  1. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which of the following statements, if made by one of the parents, indicates a need for further instructions?
1. “I cannot place powder under the brace.”
2. “I need to place a soft shirt on my child under the brace.”
3. “I need to encourage my child to perform prescribed exercises.”
4. “I need to be sure to apply lotion on the skin under the brace.”

 

 

  1. The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by assessing for a(n):
1. Lack of appetite
2. Elevated temperature
3. Decrease in the urinary output
4. Increase in the blood pressure

 

  1. The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which of the following findings would the nurse expect to note in this child?
1. Bradycardia
2. Tachycardia
3. Hyperactivity
4. A reddened appearance to the cheeks of the face

 

 

  1. Oral iron is prescribed for a child with iron deficiency anemia. The nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron:
1. Between meals
2. Just before a meal
3. Just after the meal
4. With a fruit low in vitamin C

 

 

 

  1. The nurse provides instructions to the mother of a child with sickle cell disease. Which of the following statements, if made by the mother, indicates a need for further education?
1. “I need to be sure that my child has adequate rest periods.”
2. “I need to take my child’s temperature and watch for a fever.”
3. “I need to encourage my child to drink large amounts of fluids.”
4. “I need to make sure that my child spends some time in the sun to help prevent a sickle cell crisis.”

 

  1. The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 cells/mm3 and the platelet count is 150,000 cells/mm3. Which of the following nursing interventions will the nurse incorporate into the plan of care?
1. Avoid unnecessary injections.
2. Maintain strict neutropenic precautions.
3. Encourage quiet play activities.
4. Encourage the child to use a soft toothbrush.

 

 

  1. The nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which of the following statements, if made by the student, indicates a need for further research?
1. Males inherit hemophilia from their fathers.
2. Hemophilia A results from deficiency of factor VIII.
3. Females inherit the carrier status from their fathers.
4. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome.

 

 

  1. The nurse is providing instructions to the mother of a 3-year-old child with hemophilia regarding care of the child. Which of the following statements, if made by the mother, indicates a need for further education?
1. “I need to cancel all the dental appointments that I made for my child.”
2. “If my child gets a cut, I should hold pressure on it until the bleeding stops.”
3. “I should check the house and remove any household items that can easily fall over.”
4. “I should move furniture with sharp corners out of the way and pad the corners of the furniture.”

 

 

  1. A child is brought to the emergency department after falling from a high swing and landing on the back. The nurse notes that the client also has hemophilia. Because of the client’s history and the nature of the injury, the nurse should first collect data about:
1. Blood in the urine
2. Oxygen saturation
3. Presence of headache
4. Presence of slurred speech

 

 

  1. The nurse is asked to prepare for the hospital admission of a child with sickle cell disease (SCD) who is being admitted for the treatment of vaso-occlusive pain crisis. The nurse prepares for the admission, anticipating that which of the following will be prescribed for the child?
1. NPO status
2. Intravenous (IV) fluids
3. Meperidine (Demerol) for pain
4. Intubation for the administration of oxygen

 

 

 

  1. A nursing student is assigned to care for a child with sickle cell disease (SCD). The nursing instructor asks the student to describe the causative factors related to this disease. Which of the following statements, if made by the student, indicates a need for further research?
1. SCD is an autosomal recessive disease.
2. If each parent carries the trait, the children will inherit the trait.
3. Children with the HbS (sickle cell hemoglobin) trait are not symptomatic.
4. If one parent has the HbS trait and the other parent is normal, there is a 50% chance that each offspring will inherit the trait.

 

 

  1. The nurse is caring for a child with hemophilia and is reviewing the results that were sent from the laboratory. The nurse would expect to note which of the following results in this child?
1. Shortened prothrombin time (PT)
2. Prolonged prothrombin time (PT)
3. Shortened partial thromboplastin time (PTT)
4. Prolonged partial thromboplastin time (PTT)

 

 

 

  1. A child is seen in the health care clinic for complaints of fever. On data collection, the nurse notes that the child is pale, is tachycardic, and has petechiae. Aplastic anemia is suspected. Which of the following diagnostic tests will confirm the diagnosis of aplastic anemia?
1. Platelet count
2. Granulocyte count
3. Red blood cell count
4. Bone marrow biopsy

 

 

  1. The nurse is collecting data on a 9-year-old child suspected of having a brain tumor. Which of the following questions would the nurse ask to elicit data related to the classic symptoms of a brain tumor?
1. “Do you have trouble seeing?”
2. “Do you feel tired all the time?”
3. “Do you have headaches late in the day?”
4. “Do you feel sick to your stomach, and do you throw up in the morning?”

 

 

  1. The nurse has reviewed the physician’s prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse most appropriately prepares to:
1. Collect a 24-hour urine sample.
2. Perform a neurological assessment.
3. Assist with a bone marrow aspiration.
4. Send the child to the radiology department for a chest x-ray.

 

 

  1. The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms tumor. The nurse is developing a plan of care for the child and suggests including which of the following in the plan of care?
1. Monitor the temperature for hypothermia.
2. Monitor the blood pressure for hypotension.
3. Inspect the urine for the presence of hematuria at each voiding.
4. Palpate the abdomen for an increase in the size of the tumor every 8 hours.

 

 

  1. The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than _____ cells/mm3.
1. 80,000
2. 100,000
3. 120,000
4. 150,000

 

 

  1. The nurse is providing home care instructions to the mother of a child receiving radiation therapy. Which of the following statements, if made by the mother, indicates a need for further education?
1. “I should dress my child in loose clothing.”
2. “My child may need more rest periods because the radiation will cause fatigue.”
3. “I won’t need to limit the amount of sun that my child gets.”
4. “I need to try to provide food and fluids to prevent dehydration.”

 

 

  1. The nurse is reviewing the record of a 10-year-old child suspected of having Hodgkin’s disease. The nurse anticipates noting which of the following characteristic manifestations documented in the assessment notes?
1. Fever
2. Malaise
3. Painful lymph nodes in the supraclavicular area
4. Painless and movable lymph nodes in the cervical area

 

 

 

  1. The nurse is reviewing the laboratory and diagnostic test results of a child scheduled to be seen in the clinic. The nurse notes that the physician documented that diagnostic studies revealed the presence of Reed-Sternberg cells. The nurse prepares to assist the physician to discuss which of the following with the parents of the child?
1. Treatment options for leukemia
2. Treatment options for neuroblastoma
3. Treatment options for Hodgkin’s disease
4. Treatment options for infectious mononucleosis

 

 

 

  1. The nurse is monitoring for bleeding in a child following surgery for removal of a brain tumor. The nurse checks the head dressing and notes the presence of dried blood on the back of the dressing. The child is alert and oriented, and the vital signs and neurological signs are stable. Which of the following nursing actions would be most appropriate initially?
1. Change the dressing.
2. Document the findings.
3. Recheck the dressing in 1 hour.
4. Check the operative record to determine whether a drain is in place.

 

 

  1. A child is scheduled for allogeneic bone marrow transplantation (BMT). The parent of the child asks the nurse about the procedure. The nurse tells the parent that this type of transplantation involves:
1. Aspiration of bone marrow from the child
2. Obtaining bone marrow from the child’s twin
3. Obtaining bovine (cow) bone marrow and administering it to the child
4. Obtaining bone marrow from a donor who matches the child’s tissue type

 

 

  1. The student nurse is presenting a clinical conference, and the topic of discussion is human immunodeficiency virus (HIV) in children. The student is focusing the discussion on the methods of transmission of the virus. Which of the following would be included in the discussion?
1. HIV cannot be spread by hugging, holding, or touching other people.
2. HIV can be transmitted from open wounds but only if there is skin-to-skin contact.
3. HIV is only able to be transmitted from an infected mother to her baby through breast milk.
4. HIV infection cannot be transmitted by unprotected sexual intercourse if the female uses an intrauterine device as birth control.

 

 

  1. The nurse is reviewing the laboratory results of studies on a 4-month-old infant and notes that the human immunodeficiency virus (HIV) antibody test is positive. The nurse determines that this test result indicates which of the following?
1. The infant has HIV.
2. The infant is infected with the HIV virus.
3. The mother is infected with the HIV virus.
4. This is a significant result, indicating a repeat test in 1 month.

 

 

 

  1. The nurse is caring for a child with acquired immunodeficiency syndrome (AIDS) and notes the presence of mouth sores. The nurse provides instructions to the mother regarding maintaining adequate nutritional intake in the child. Which of the following statements, if made by the mother, indicates a need for further education?
1. “I should weigh my child each morning.”
2. “It is best to store the food at room temperature.”
3. “Salty foods are important to maintain an appropriate sodium level in the child.”
4. “Milk, juice, or water should really be offered after a meal rather than before a meal.”

 

 

 

  1. The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which of the following will be a component of the instructions that the nurse provides to the mother?
1. Immunizations will not be given to the child with HIV infection.
2. The child and the siblings will need to receive inactivated polio vaccine.
3. The immunization schedule needs to be altered because of the HIV infection.
4. Immunizations will be given to the child with HIV infection but will not be initiated until the child is 3 years old.

 

 

  1. A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The nurse has explained to the mother the purpose of the blood test. Which of the following comments by the mother would indicate that further explanation is required for the mother to understand the purpose of the blood test?
1. “The CD4+ count is used to determine the child’s immune status.”
2. “The CD4+ count identifies the specific diagnosis of HIV infection.”
3. “The CD4+ count is used to identify the risk for disease progression.”
4. “The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age.”

 

 

  1. The nurse is providing instructions to the mother of a child who has been exposed to human immunodeficiency virus (HIV) infection. The nurse instructs the mother to notify the physician if which of the following symptoms occurs in the child?
1. Hyperactivity
2. Lethargy or fatigue
3. Irritability and fussiness
4. Coughing or chest congestion

 

 

  1. A 3-year-old child with human immunodeficiency virus (HIV) infection is being discharged from the hospital. The nurse is providing instructions to the mother regarding home care and infection control measures. Which of the following statements, if made by the mother, indicates a need for further education?
1. “I should discard any unused food immediately.”
2. “If the nipple becomes soft and sticky, I will discard the nipple.”
3. “I need to wash all vegetables carefully before preparing them.”
4. “I should wash the eating utensils, baby bottle, and dishes in the dishwasher.”

 

 

  1. The nurse is providing instructions to the mother of a child with human immunodeficiency virus (HIV) infection regarding immunizations. Which of the following statements, if made by the mother, indicates an understanding of the immunization schedule?
1. “The hepatitis B vaccine is not to be given to my child.”
2. “My child will receive all the vaccines like any other child.”
3. “Family members in the household need to receive the influenza vaccine.”
4. “Blood tests need to be evaluated before any immunizations are given to my child.”

 

 

  1. A child was seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus) vaccine. One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which of the following instructions would the nurse provide to the mother?
1. Call the physician.
2. Apply warm compresses on the site.
3. Return to the health care clinic immediately.
4. Apply cold compresses for 24 hours following the injection.

 

 

 

  1. The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Prior to administering the vaccine, which of the following questions would the nurse ask the mother of the child?
1. “Has the child had any sore throats?”
2. “Has the child been eating properly?”
3. “Is the child allergic to any antibiotics?”
4. “Has the child been exposed to any infections?”

 

 

  1. A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother as to how to obtain a cellophane tape rectal specimen. Which of the following statements, if made by the mother, indicates an understanding of the correct procedure to obtain the specimen?
1. “I need to collect the specimen after I give my child a bath.”
2. “I need to collect the first bowel movement of the day and place it in a sealed container.”
3. “I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination.”
4. “I need to place a piece of transparent cellophane tape lightly over the anal area after my child has a bowel movement and bring it to the clinic for examination.”

 

 

 

  1. An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. Laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse informs the mother of the test results and provides instruction regarding care of the adolescent. Which of the following statements, if made by the mother, indicates an understanding of care measures?
1. “I need to keep my child on bed rest for 3 weeks.”
2. “I will call the physician if my child is still feeling tired in 1 week.”
3. “I need to isolate my child so that the respiratory infection is not spread to others.”
4. “I need to call the physician if my child complains of abdominal pain or left shoulder pain.”

 

 

 

  1. The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which of the following supplies would the nurse bring to the child’s room to prevent transmission of the virus?
1. Mask and gloves
2. Gown and gloves
3. Goggles and gloves
4. Gown, gloves, and goggles

 

 

  1. The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding the prevention of the transmission of the infection to siblings and other household members. Which of the following instructions does the nurse provide?
1. Isolate the child from others because the virus is transmitted by breathing and coughing.
2. Wash sheets and towels used by the child separately in bleach to prevent spread of the infection to others.
3. Avoid allowing the children to share drinking glasses or eating utensils, because the disease is transmitted through saliva.
4. Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection through urine and feces.

 

 

  1. A child hospitalized with pertussis is in the convalescent stage, and the nurse is preparing the child for discharge. The nurse has provided instructions to the parents for home care of the child. Which of the following statements, if made by a parent, indicates a need for further education?
1. “It is important that my child drinks plenty of fluids.”
2. “We need to try to maintain a quiet environment to prevent episodes of coughing spells.”
3. “We need to teach the other members of the family how to use good hand washing techniques to prevent the spread of infection.”
4. “I need to make sure that the child is isolated from the other children for at least 2 weeks to prevent the spread of the virus to them.”

 

 

  1. A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home. She asks the nurse if the child is infectious to the other children. The most appropriate response by the nurse is:
1. “The infectious period occurs after the lesions begin.”
2. “The infectious period begins when the lesions begin to crust.”
3. “The infectious period is not known, and it is possible that the children may develop the chickenpox.”
4. “The infectious period begins 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and crusting of the lesions.”

 

 

 

  1. A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which of the following statements if made by the mother indicates a need for further education?
1. “Quiet activities are allowed.”
2. “The child should play inside for now.”
3. “Visitors are not allowed for at least 1 month.”
4. “The regular schedule regarding naps should be resumed.”

 

 

MULTIPLE RESPONSE

 

  1. Cerebral palsy (CP) is a term applied to a disorder that impairs movement and posture. The effects on perception, language, and intellect are determined by the type that is diagnosed. What are the potential warning signs of CP? Select all that apply.
1. The infant’s arms or legs are stiff or rigid.
2. By 8 months of age, the infant can sit without support.
3. A high risk factor for CP is very low birth weight.
4. The child has strong head control but a limp body posture.
5. If the infant is able to crawl, only one side is used to propel himself or herself.
6. The infant has feeding difficulties, such as poor sucking and swallowing.

 

 

  1. A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. Diagnostic x-rays of the child reveal that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse provides instructions to the mother regarding cast care at home. Which teaching points would the nurse provide the mother? Select all that apply.
1. The cast should be dry in about 6 hours.
2. The cast is water-resistant, so the child is able to take a bath or a shower.
3. The cast will mold to the body part.
4. The cast needs to be kept dry, because when wet it will begin to disintegrate.
5. Keep the cast elevated for the first day on pillows.
6. Make sure that the child can frequently wiggle the fingers.

 

 

  1. The clinic nurse is assessing a child suspected of having juvenile rheumatoid arthritis (JRA). Which of the following assessment items would the nurse expect to find in a child who has been diagnosed with JRA? Select all that apply.
1. Hematuria
2. Morning stiffness
3. Painful, stiff, and swollen joints
4. Limited range of motion of the joints
5. Stiffness that develops later in the day
6. History of late afternoon temperature, with temperature spiking up to 105° F

 

 

 

  1. Which of the following interventions are appropriate for a child placed in protective isolation for neutropenia? Select all that apply.
1. Placing the child on a low-bacteria diet
2. Changing dressings using sterile technique
3. Peeling fruits and vegetables before allowing the child to eat them
4. Allowing fresh-cut flowers in the room as long as they are kept in a vase with water
5. Allowing individuals who are ill to visit as long as they wear a mask

 

 

 

COMPLETION

 

  1. Augmentin 500 mg orally every 6 hours is prescribed for a child with an upper respiratory infection. The medication is supplied as 200 mg/5 mL. How many milliliters will be administered in each dose? (Enter the answer in the space provided.)

Answer: __________ mL

 

 

 

SHORT ANSWER

 

  1. A mother brings her child to the emergency department. Based on the child’s sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottis is suspected. In anticipation of the physician’s prescriptions, number the following actions in the appropriate order for delivering nursing interventions for this child. (Number 1 is the first action, and number 6 is the last action.)

1      Prepare for assisted ventilation and have necessary equipment available.

2      Obtain a pulse oximetry reading.

3      Obtain an axillary temperature.

4      Assess breath sounds by auscultation.

5      Obtain weight for correct antibiotic dose infusion.

6      Ask the mother about the precipitating events related to the child’s condition.

 

 

 

 

Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition

 

Fundamentals and Issues of Nursing

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse has a prescription to give ear drops to a 2-year-old child. The nurse positions the child’s ear properly by pulling the pinna of the ear:
1. Upward and outward
2. Downward and outward
3. Downward and backward
4. Upward and backward

 

 

 

  1. A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. When the client expresses concern about his or her ability to perform this procedure at home, the nurse would best respond with which of the following?
1. “Tell me more about your concerns about going home.”
2. “Do you want to stay in the hospital a few more days?”
3. “Maybe a friend will do the feeding for you.”
4. “Have you discussed your feelings with your family and doctor?”

 

  1. The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should do which of the following when caring for this client to maintain client safety?
1. Keep the client in a supine position.
2. Change the NG tube with every other feeding.
3. Check for tube placement and residual amount at least every 4 hours.
4. Increase the rate of the feeding if the infusion falls behind schedule.

 

 

 

  1. The client with pancreatitis is being weaned from parenteral nutrition (PN). The client asks the nurse why the PN cannot just be stopped. The nurse includes in a response to the client that which of the following complications could occur with sudden termination of PN formula?
1. Dehydration
2. Hypokalemia
3. Hypernatremia
4. Rebound hypoglycemia

 

  1. The nurse hears in intershift report that a client receiving parenteral nutrition (PN) at 100 mL/hr has bilateral crackles and 1+ pedal edema. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lb in 2 days. Which of the following nursing actions should the nurse take first?
1. Encourage the client to cough and deep-breathe.
2. Compare the intake and output records of the last 2 days.
3. Slow the PN infusion rate to 50 mL/hr per infusion pump.
4. Administer the prescribed daily diuretic, and check the client in 2 hours.

 

 

  1. The nurse is caring for a client receiving parenteral nutrition (PN) via a central line. The nurse should monitor which of the following to detect the development of the most common complication of PN?
1. Temperature
2. Daily weight
3. Intake and output (I&O)
4. Serum blood urea nitrogen (BUN) level

 

 

  1. The nurse is providing care to a client with continuous tube feedings through a nasogastric (NG) tube. The nurse should avoid doing which of the following, which is not part of the standard care for a client receiving enteral nutrition?
1. Check the residual every 4 hours.
2. Check for placement every 4 hours.
3. Hang a new feeding bag every 72 hours.
4. Check for placement prior to administering medications through the tube.

 

 

 

  1. The nurse is monitoring the nutritional status of the client receiving enteral nutrition. The nurse monitors which of the following to determine the effectiveness of the tube feedings for this client?
1. Daily weight
2. Calorie count
3. Serum protein level
4. Daily intake and output

 

 

  1. A client is scheduled for insertion of a peripherally inserted central catheter (PICC) and the nurse explains the advantages of this catheter. The nurse determines that the client needs additional information about the catheter if the client makes which statement?
1. “It is reasonable in cost.”
2. “There is less pain and discomfort than other types of catheters.”
3. “This type of catheter is very reliable.”
4. “It is specifically designed for short-term use.”

 

 

  1. A nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse interprets that which of the following complications has been experienced by the client?
1. Phlebitis
2. Infection
3. Infiltration
4. Thrombosis

 

 

  1. The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which of the following frequencies?
1. Every hour
2. Every 2 hours
3. Every 3 hours
4. Every 4 hours

 

 

  1. The client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first?
1. Shut off the infusion.
2. Sit the client up in bed.
3. Remove the angiocatheter and IV.
4. Place the client in Trendelenburg’s position.

 

  1. The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced:
1. Phlebitis of the vein
2. Infiltration of the IV line
3. Hypersensitivity to the IV solution
4. Allergic reaction to the IV catheter material

 

 

  1. The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which of the following supplies from the unit supply area for use in applying pressure to the site after removing the IV catheter?
1. Band-Aid
2. Alcohol swab
3. Betadine swab
4. Sterile 2  2 gauze

 

 

  1. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?
1. Change the IV tubing.
2. Attach a new needleless device.
3. Wipe the tubing port with Betadine.
4. Scrub the needleless device with an alcohol swab.

 

 

  1. The nurse is collecting data from an African-American client scheduled for surgery. Which of the following questions would be of least priority for the nurse to ask on initial assessment?
1. “Do you ever experience chest pain?”
2. “Do you have any difficulty breathing?”
3. “Do you have a close family relationship?”
4. “Do you frequently have episodes of headache?”

 

  1. The nurse is providing discharge instructions to an Asian-American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which of the following nursing actions is most appropriate?
1. Continue with the instructions verifying client understanding.
2. Walk around to the client so that you continuously face the client.
3. Identify the importance of the instructions for the maintenance of health care.
4. Give the client a dietary booklet, and return later to continue with the instructions.

 

 

  1. The nurse is planning to instruct the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware that this ethnic group:
1. Primarily eats raw fish
2. Enjoys eating red meat
3. Views food as a primary form of socialization
4. Eats bland food and food that lacks color, flavor, and texture

 

 

  1. The nurse is preparing to assist a Jewish-American client with eating lunch. A kosher meal is delivered to the client. Which of the following nursing actions is most appropriate in assisting the client with the meal?
1. Unwrap the eating utensils for the client.
2. Replace the plastic utensils with metal eating utensils.
3. Carefully place the food from the paper plates to glass plates.
4. Ask the client to unwrap the eating utensils, and allow the client to prepare the meal for eating.

 

 

  1. The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. When meeting the client, the nurse should plan to do which of the following?
1. Avoid touching the client.
2. Greet the client with a handshake.
3. Smile and use humor throughout the entire admission process.
4. Avoid any affirmative nods during the conversations with the client.

 

 

  1. The nurse is assisting in developing a postoperative plan of care for a 40-year-old male Filipino-American client scheduled for an appendectomy. The nurse includes which of the following in the plan of care?
1. Offer pain medication on a regular basis as prescribed.
2. Offer pain medication when nonverbal signs of discomfort are identified.
3. Inform the client that he will need to ask for pain medication when needed.
4. Allow the client to maintain control and request pain medication on his own.

 

 

  1. The nurse is planning the menu for a Chinese-American client with the hospital dietitian. On collaboration with the dietitian, the meal plan is designed to include which of the following foods generally included in the diet of this cultural group?
1. Milk
2. Vegetables
3. Rice pudding
4. Fruit and yogurt

 

 

  1. The nurse is preparing to assist in examining a Hispanic-American child who was brought to the clinic by the mother. During assessment of the child, the nurse would avoid which of the following?
1. Admiring the child
2. Taking the child’s temperature
3. Obtaining an interpreter if necessary
4. Asking the mother questions about the child

 

 

  1. The nurse plans to do dietary teaching with an African-American client. The nurse understands that foods preferred by individuals of this culture are which of the following?
1. Rice
2. Fruits
3. Red meat
4. Fried foods

 

  1. The registered nurse (RN) gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The RN notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the:
1. Error will result in suspension.
2. Incident will be reported to the board of nursing.
3. Incident will be documented in the personnel file.
4. Incident report is a method of promoting quality care and risk management.

 

 

  1. The registered nurse (RN) has been caring for a terminally ill client. The RN has developed a close relationship with the family of the client. Which of the following nursing interventions will the RN avoid in dealing with the family during this difficult time?
1. Making decisions for the family
2. Encouraging family discussion of feelings
3. Accepting the family’s expressions of anger
4. Facilitating the use of spiritual practices identified by the family

 

 

 

  1. A registered nurse (RN) who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The most appropriate initial action by the RN is which of the following?
1. Call security.
2. Call the police.
3. Call the nursing supervisor.
4. Lock the co-worker in the medication room until help is obtained.

 

 

  1. A hospitalized client tells the registered nurse (RN) that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the RN for assistance in obtaining a witness to the will. The most appropriate response to the client is which of the following?
1. “I will sign as a witness to your signature.”
2. “You will need to find a witness on your own.”
3. “Whoever is available at the time will sign as a witness for you.”
4. “I will call the nursing supervisor to seek assistance regarding your request.”

 

 

  1. The nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the physician has prescribed a medication dose that is twice the amount that the client has reported taking prior to admission. The most appropriate nursing action is to:
1. Contact the physician directly.
2. Administer the medication as prescribed.
3. Question the client regarding the accuracy of the reported dosage.
4. Ask the physician about the prescription the next time the physician makes rounds.

 

  1. The registered nurse (RN) is caring for a client with severe cardiac disease. While caring for the client, the client states, “If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me.” The most appropriate nursing action is to:
1. Tell the client that the family must agree with the request.
2. Plan a client conference with the nursing staff to share the client’s request.
3. Tell the client that it is necessary to notify the physician of the client’s request.
4. Tell the client that this procedure cannot legally be refused by a client if the physician believes that it is necessary to save the client’s life.

 

 

  1. The registered nurse (RN) has made an error in documenting an assessment finding on a client in the client’s record and obtains the record to correct the error. The RN corrects the error by:
1. Documenting a late entry into the client’s record
2. Trying to erase the error to make space for writing in the correct data
3. Using white correction fluid to delete the error and writing in the correct data
4. Drawing one line through the error, initialing and dating the line, and then providing the correct information

 

 

 

  1. The registered nurse (RN) hears a client calling out for help. The RN hurries down the hallway to the client’s room and finds the client lying on the floor. The RN performs a thorough assessment and assists the client back to bed. The physician is notified of the incident, and the nurse completes an incident report. Which of the following would the RN document on the incident report?
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get out of bed.

 

 

  1. An adult client is brought to the emergency department by emergency medical services after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which of the following is the best initial action?
1. Obtain a court order for the surgical procedure.
2. Transport the victim to the operating room for surgery.
3. Call the police to identify the client and locate the family.
4. Ask the emergency medical services team to sign the informed consent.

 

 

  1. A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the physician that the client had terminal cancer. The emergency department physician examines the client and asks the registered nurse (RN) to contact the medical examiner regarding an autopsy. The family of the client tells the RN that they do not want an autopsy performed. Which of the following responses to the family is most appropriate?
1. “An autopsy is mandatory for any client who is DOA.”
2. “The decision is made by the medical examiner.”
3. “I will contact the medical examiner regarding your request.”
4. “It is required by federal law. Why don’t we talk about it, and why don’t you tell me how you feel?”

 

 

  1. The nurse is caring for a client whose physician prescribes airborne precautions. The nurse notes that the client is scheduled for magnetic resonance imaging (MRI). Which of the following nursing actions is most appropriate in preparing the client for the test?
1. Place the client in gown, gloves, and mask.
2. Request that the MRI technicians wear masks.
3. Delay the test until airborne precautions are discontinued.
4. Place a surgical mask on the client for transport and for contact with other individuals.

 

  1. The nurse employed in the ambulatory care department hears a client in the waiting room call out, “Help, fire!” The nurse rushes to the waiting room and finds the wastebasket on fire. Which action should the nurse take first?
1. Confine the fire.
2. Extinguish the fire.
3. Activate the fire alarm.
4. Remove the clients from the waiting room.

 

 

  1. The physician writes a prescription to apply a heating pad to a client’s back. The nurse implements the prescription and avoids which of the following?
1. Setting the heating pad on a low setting
2. Placing the heating pad under the client
3. Assessing the heating pad periodically for proper electrical function
4. Assessing the skin integrity frequently for signs of burns

 

  1. The nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to:
1. Place the ice pack directly on the eye.
2. Avoid the use of commercially prepared ice bags.
3. Keep the ice pack on the eye continuously for 24 hours.
4. Wrap a plastic bag filled with ice with a pillowcase, and place it on the eye.

 

 

  1. A filled blood specimen tube was dropped and broken in the client’s room. Which of the following actions by the nursing assistant is incorrect?
1. Uses tongs to collect any broken glass
2. Wears gloves for the cleaning procedure
3. Blots up the spill with a face cloth or cloth towel
4. Disinfects the area of the blood spill with a dilute bleach solution

 

 

  1. The nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning to care for the client, which of the following actions is the priority? The nurse:
1. Speaks slowly to the client
2. Moves slowly when approaching the client
3. Bargains with the client to prevent the violent episodes
4. Projects an attitude of calmness when caring for the client

 

 

  1. A community health nurse is providing an educational session on childhood poisoning at a local school. The topic of the discussion is preventive measures to avoid accidental poisoning. The nurse includes instructions that if an accidental poisoning occurs to immediately:
1. Call an ambulance.
2. Call the poison control center.
3. Induce vomiting.
4. Bring the child to the emergency department.

 

 

  1. A nurse is conducting a basic life support (BLS) recertification class and is discussing automated external defibrillation (AED) when a member of the class asks the nurse to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The nurse correctly responds with:
1. Bilaterally, under the right-sided and left-sided clavicles
2. Parallel, between the umbilicus and the left-sided nipple
3. Centered on the upper and lower halves of the sternum
4. Under the right-sided clavicle and to the left of the nipple in the midaxillary line

 

 

 

  1. The nurse is initiating one-rescuer cardiopulmonary resuscitation (CPR) on an adult client. After ventilating the client, the nurse places the hands in which of the following positions to begin chest compressions?
1. On the lower half of the sternum
2. On the lower third of the sternum
3. On the upper third of the sternum
4. On the upper half of the sternum

 

 

  1. A nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. The nurse then opens the victim’s airway by using the:
1. Head tilt–chin lift
2. Head tilt–jaw thrust
3. Jaw thrust maneuver
4. Chin lift position

 

 

 

  1. The nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which of the following landmarks to do the abdominal thrust maneuver?
1. The umbilicus and the groin
2. The lower abdomen and chest
3. The umbilicus and xiphoid process
4. The groin and the xiphoid process

 

 

 

  1. The nurse employed in the pediatric unit working on the 11 PM to 7 AM shift finds an infant unresponsive and without respirations or a pulse. After opening the airway and initiating ventilation, the nurse delivers chest compressions at a minimum rate of:
1. 140 times/min
2. 100 times/min
3. 80 times/min
4. 60 times/min

 

 

  1. A nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the most appropriate pulse point to use when determining pulselessness on an infant. The nurse undergoing recertification replies that the correct pulse point is:
1. Radial
2. Carotid
3. Brachial
4. Popliteal

 

 

  1. An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which of the following actions next?
1. Performs cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating
2. Administers rescue breathing during the defibrillation
3. Charges the machine and immediately pushes the discharge buttons on the console
4. Orders personnel away from the client, charges the machine, and depresses the discharge buttons

 

 

 

  1. The client has been defibrillated unsuccessfully three times using an automatic external defibrillator (AED). The nurse determines that which of the following actions should be taken next?
1. Defibrillate one more time, and then terminate the resuscitation effort.
2. Perform cardiopulmonary resuscitation (CPR) for 5 minutes, and then defibrillate three more times.
3. Administer sodium bicarbonate intravenously, and resume defibrillation attempts.
4. Perform cardiopulmonary resuscitation (CPR) for 1 minute, assess, and then defibrillate up to three more times.

 

 

 

  1. The nurse has completed four cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the nurse should:
1. Stop CPR.
2. Continue CPR.
3. Prepare for defibrillation.
4. Prepare for the administration of bicarbonate.

 

 

 

  1. The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of lay persons. Which of the following behaviors by one of the participants would indicate the need for further review?
1. Letting the fingers rest on the chest
2. Keeping the shoulders directly over the hands
3. Straightening the arms and locking the elbows
4. Placing the heel of the hand over the lower half of the sternum

 

 

  1. The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse takes which priority action?
1. Obtains a court order for the surgery
2. Sends the client to surgery without the consent form being signed
3. Has the hospital chaplain sign the informed consent immediately
4. Obtains a telephone consent from the family member witnessed by two persons

 

 

 

  1. The preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following statements by the nurse is most likely to stimulate further discussion between the client and the nurse?
1. “If it’s any help, everyone is nervous before surgery.”
2. “I will be happy to explain the entire surgical procedure to you.”
3. “Can you share with me what you’ve been told about your surgery?”
4. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can anticipate.”

 

 

  1. The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions first?
1. Ensure that the client has voided.
2. Administer all the daily medications.
3. Practice postoperative breathing exercises.
4. Verify that the client has not eaten for the last 24 hours.

 

 

  1. The nurse is assigned to assist in caring for a client who recently returned from the operating room (OR). On data collection, the nurse notes that the client’s vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which of the following actions should the nurse plan to take first?
1. Shake the client gently to arouse.
2. Call the surgeon immediately.
3. Cover the client with a warm blanket.
4. Recheck the vital signs in 15 minutes.

 

 

 

  1. The nurse has just reassessed the condition of the postoperative client who was admitted 1 hour ago to the surgical unit. The nurse monitors which of the following parameters during the next hour most carefully?
1. Urinary output of 20 mL/hr
2. Temperature of 37.6° C (99.6° F)
3. Blood pressure of 116/78 mm Hg
4. Serous drainage on the surgical dressing

 

 

  1. The client is admitted to the surgical unit postoperatively with a wound drain (Jackson-Pratt) in place. Which of the following correctly describes the primary purpose of a Jackson-Pratt?
1. It decreases the risk of infection.
2. It decreases the risk of evisceration and dehiscence.
3. It provides an accurate measurement of wound drainage.
4. It assists in the evacuation of fluid and blood from the surgical wound.

 

 

  1. When performing a surgical dressing change of a client’s abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The priority nursing action at this time is to:
1. Apply a povidone-iodine (Betadine)–soaked sterile dressing.
2. Leave the incision exposed to the air to dry the area.
3. Apply a sterile dressing soaked with normal saline.
4. Irrigate the wound, and apply a dry sterile dressing.

 

 

  1. The nurse is reviewing the physician’s prescription sheet for the preoperative client, which states that the client must be NPO after midnight. The nurse should clarify which of the following medications should be given to the client and not withheld?
1. Ferrous sulfate
2. Atenolol (Tenormin)
3. Cyclobenzaprine (Flexeril)
4. Conjugated estrogen (Premarin)

 

 

  1. The client who underwent preadmission testing prior to a surgical procedure had serum laboratory studies drawn, including complete blood count, electrolytes, coagulation studies, and creatinine. Which of the following laboratory results should be reported to the surgeon immediately?
1. Platelet count, 210,000/mm3
2. Serum sodium (Na) level, 141 mEq/L
3. Hemoglobin (Hgb) level, 8.9 g/dL
4. Serum creatinine level, 0.8 mg/dL

 

 

  1. The client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. The nurse should position the client:
1. In a semi-Fowler’s position
2. With the head of the bed elevated 45 degrees
3. With the head of the bed elevated no more than 15 degrees
4. With the foot of the bed elevated as much as tolerated by the client

 

 

  1. The nurse is assisting the physician with a bedside liver biopsy. When the procedure is complete, the nurse assists the client into which of the following positions?
1. Left side-lying, with the right-sided arm elevated above the head
2. Right side-lying, with the left-sided arm elevated above the head
3. Left side-lying, with a small pillow or towel under the puncture site
4. Right side-lying, with a small pillow or towel under the puncture site

 

 

  1. The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse assists the client into which of the following positions?
1. Left-sided lateral Sims position
2. Right-sided lateral Sims position
3. Left side-lying, with the head of the bed elevated 45 degrees
4. Right side-lying, with the head of the bed elevated 45 degrees

 

 

 

  1. The client with right-sided pleural effusion by chest x-ray is being prepared for a thoracentesis. The nurse assists the client to which of the following positions for the procedure?
1. Sims position, with the head of the bed flat
2. Left side-lying position, with the head of the bed elevated 45 degrees
3. Prone, with the head turned to the side supported by a pillow
4. Right side-lying position, with the head of the bed elevated 45 degrees

 

 

  1. The client is about to undergo a lumbar puncture (LP). The nurse tells the client that which of the following positions will be used during the procedure?
1. Side-lying position, with a pillow under the hip
2. Prone, with a pillow under the abdomen
3. Prone, in a slight Trendelenburg’s position
4. Side-lying position, with legs pulled up and head bent down onto chest

 

 

 

  1. The client has had surgery to repair a fractured left-sided hip. The nurse will use which of the following important items when repositioning the client from side to side in bed?
1. Bed pillow
2. Abductor splint
3. Adductor splint
4. Overhead trapeze

 

 

 

  1. The nurse has admitted a client to the clinical nursing unit following right-sided mastectomy. The nurse plans to place the right-sided arm in which of the following positions?
1. Level with the right-sided atrium
2. Elevated above shoulder level
3. Elevated on one or two pillows
4. Dependent to the right-sided atrium

 

 

  1. The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. The nurse notes the urine beginning to flow and next:
1. Immediately inflates the balloon
2. Inserts the catheter 2.5 to 5 cm farther, then inflates the balloon
3. Inserts the catheter until resistance is met, then inflates the balloon
4. Withdraws the catheter approximately 1 inch, then inflates the balloon

 

  1. The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse takes which immediate action?
1. Has the client hold a breath
2. Places the client in a prone position
3. Immerses the end of the tube in sterile saline
4. Places a sterile dressing over the end of the chest tube

 

 

 

  1. The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client’s closed-chest drainage system. The nurse determines that which of the following is occurring?
1. The pneumothorax is resolving.
2. The drainage chamber is full.
3. The suction to the system is shut off.
4. There is an air leak somewhere in the system.

 

 

  1. A nurse is inserting a nasogastric (NG) tube for an adult client. During the procedure, the client begins to cough and have difficulty breathing. The priority action at this time is which of the following?
1. Quickly insert the NG tube.
2. Remove the tube, and notify the physician.
3. Remove the tube, and reinsert when the client fully recovers.
4. Pull back on the tube, and wait until the client is breathing easily.

 

 

  1. The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which of the following is a priority nursing action?
1. Assess tube placement.
2. Administer the antacid by gravity flow.
3. Aspirate to determine residual volume.
4. Follow medication administration with 30 mL of sterile saline.

 

 

 

  1. Treatment for a client with bleeding esophageal varices has been unsuccessful and the physician decides to insert a Sengstaken-Blakemore tube. The nurse brings which of the following items to the bedside so that it is available at all times?
1. An obturator
2. A Kelly clamp
3. An irrigation set
4. A pair of scissors

 

 

  1. The male client complains of pain as the nurse is inflating the balloon following insertion of a Foley catheter. The nurse takes which of the following actions immediately?
1. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
2. Remove the catheter, and reinsert a new one that is one size smaller.
3. Finish inflating the balloon; the discomfort is normal and temporary.
4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

 

  1. The unit manager is reviewing documentation describing a client’s progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control for the prior 48 hours. The manager’s first activity after making the observation of deviation from the path is to contact the client’s:
1. Family to determine what is wrong
2. Assigned nurse to increase client care interventions
3. Physician to determine measures to discharge the client
4. Case manager to determine whether the predicted variance has been negotiated with the health insurer

 

 

 

  1. The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. The nurse managers anticipate that the channel of communication and authority will be characterized by an organizational chart that is:
1. Flat
2. Vertical
3. Circular
4. Horizontal

 

 

 

  1. Which client would the emergency department triage nurse classify as emergent?
1. A client with a displaced fracture
2. A client with a temperature of 101° F
3. A client with a simple laceration and soft tissue injury
4. A client with crushing substernal pain who is short of breath

 

  1. The graduate nurse is interviewed by the manager of a unit that has three vacancies and is told that the manager’s leadership style is one of letting the staff nurses make the decisions about the unit’s operations. When the interviewee meets with the day nursing staff, the graduate nurse hears examples of unit issues indicating that the manager’s approach is laissez-faire. Which of the following questions should the graduate nurse ask to confirm her suspicions?
1. “Does the manager facilitate decision making by the group?”
2. “Does the manager maintain control and make all decisions?”
3. “Does the manager assume a passive, nondirective approach?”
4. “Does the manager change style according to the needs of the group?”

 

 

 

  1. The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which of the following statements, if made by the nurse manager, would reflect the manager’s use of legitimate power?
1. “The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors.”
2. “If you don’t follow the new policy and procedure, I’ll have no choice but to give you a notice about poor performance—which could lead to termination of your employment.”
3. “Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization’s effort to continue to improve quality care.”
4. “You’re just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way.”

 

 

  1. For which of the following client situations would a consultation with a rapid response team (RRT) be most appropriate?
1. 45-year-old, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4° F, heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg
2. 72-year-old, 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion), temperature 97.8° F, heart rate 92 beats/min, respirations 28 breaths/min, blood pressure 136/86 mm Hg, anxious about going home
3. 56-year-old, fourth hospital day after coronary artery bypass procedure, sore chest, pain with walking, temperature 97° F, heart rate 84 beats/min, respirations 22 breaths/min, blood pressure 122/78 mm Hg, bored with hospitalization
4. 86-year-old, 48 hours after operative repair of fractured hip (nail inserted), alert, oriented, using patient-controlled analgesia (PCA) pump, temperature 96.8° F, heart rate 60 beats/min, respirations 16 breaths/min, blood pressure 120/82 mm Hg, talking with daughter

 

 

 

  1. The nurse assigned to four clients reviews client data at the beginning of the shift. Which information is assessed as the highest priority?
1. Hemoglobin, 12.2 g/dL
2. Potassium level, 3.6 mEq/L
3. Pulse oximetry reading, 89%
4. Urine output, 240 mL/8 hr

 

 

MULTIPLE RESPONSE

 

  1. The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client? Select all that apply.
1. Sit leaning forward.
2. Inhale deeply and quickly.
3. Sit upright or lean slightly back.
4. Hold the mouthpiece tightly with the teeth.
5. Keep a tight seal between the lips and the mouthpiece.
6. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

 

 

  1. From the following list of nursing activities, select those that the registered nurse (RN) can delegate to the licensed practical nurse or licensed vocational nurse (LPN/LVN). Select all that apply.
1. Assessment
2. Urinary catheterization
3. Endotracheal suctioning
4. Intravenous push medication administration
5. Intramuscular medication administration
6. Subcutaneous medication administration

 

 

  1. Of the following list of responsibilities for disaster preparedness in the United States, identify those that are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA). Select all that apply.
1. Provide monetary relief.
2. Provide crisis counseling.
3. Identify and train personnel.
4. Deploy National Guard troops.
5. Handle inquiries from families.
6. Issue presidential declarations.

 

 

  1. The community health nurse is preparing to teach “personal and family preparedness for disasters” to a group of parents of school-age children. From the following list of items to be kept ready, identify the appropriate items that should be identified by the nurse. Select all that apply.
1. Flashlight
2. Supply of batteries
3. Battery-operated radio
4. Extra pair of eyeglasses
5. Three-week supply of nonperishable food
6. Three-week supply of water (1 gallon per person per day)

 

 

  1. The nurse is providing instructions to the client being discharged to home with a peripherally inserted central catheter (PICC). The nurse provides which instructions to the client? Select all that apply.
1. Wear a Medic-Alert tag or bracelet.
2. Report redness or swelling at the catheter insertion site.
3. Have a repair kit available in the home for use if needed.
4. Keep activity level to a minimum while this catheter is in place.
5. Cover the PICC dressing with plastic when in the shower or bath.

 

 

COMPLETION

 

  1. The physician prescribes 1000 mL of 0.9% normal saline (NS) to run over 8 hours. The drop factor is 10 drops/1 mL. The nurse adjusts the flow rate to run at how many drops per minute? (Round off your answer to the nearest whole number and enter the answer in the space provided.)

Answer: __________ drops per minute

 

 

  1. The physician prescribes meperidine hydrochloride (Demerol), 40 mg stat, for a postoperative client in pain. The medication label states meperidine hydrochloride (Demerol), 50 mg/mL. How many milliliters will the nurse prepare to administer to the client? (Enter the answer in the space provided.)

Answer: __________ mL

 

 

  1. The physician prescribes atenolol (Tenormin), 0.05 g orally daily. The label on the medication bottle states atenolol (Tenormin), 25-mg tablets. How many tablets will the nurse administer to the client? (Enter the answer in the space provided.)

Answer: __________ tablet(s)

 

 

 

  1. The physician’s prescription reads potassium chloride (KCl) 30 mEq to be added to 1000 mL normal saline and to be administered over a 10-hour period. The label on the medication bottle reads 4 mEq (KCl)/mL. The nurse prepares how many milliliters of potassium chloride (KCl) to administer the correct dose of medication? (Enter the answer in the space provided.)

Answer: __________ mL

 

 

 

  1. Ampicillin sodium, 250 mg in 50 mL of normal saline, is being administered over a period of 30 minutes. The drop factor is 10 drops/mL. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many drops per minute? (Enter the answer in the space provided.)

Answer: __________ drops per minute

 

 

  1. The physician prescribes 1000 mL of normal saline to be infused over a period of 10 hours. The drop factor is 15 drops/mL. The nurse adjusts the flow rate at how many drops per minute? (Enter the answer in the space provided.)

Answer: ___________ drops per minute

 

 

  1. The client is to receive 1000 mL of D5W at 100 mL/hr. The drop factor is 10 drops/mL. The nurse adjusts the flow rate to deliver how many drops per minute? (Enter the answer in the space provided.)

Answer: __________ drops per minute

 

 

  1. The physician prescribes an intramuscular (IM) dose of 250,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin) 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? (Enter the answer in the space provided.)

Answer: __________ mL

 

 

  1. The physician prescribes 500 mL of 0.9% normal saline to run over 6 hours. The drop factor is 10 drops/1 mL. The nurse adjusts the flow rate to run at how many drops per minute? (Enter the answer in the space provided.)

Answer: __________ drops per minute

 

 

 

  1. The physician’s prescription reads cyanocobalamin (vitamin B12), 150 mcg by the intramuscular route. The medication label reads cyanocobalamin (vitamin B12), 100 mcg/mL. The nurse prepares to administer how many mL to the client? (Enter the answer in the space provided.)

Answer: __________ mL

 

  1. The physician prescribes a bolus of 500 mL of 0.9% normal saline to run over 4 hours. The drop factor is 10 drops/1 mL. The nurse plans to adjust the flow rate at how many drops per minute? (Enter the answer in the space provided.)

Answer: __________ drops per minute

 

 

 

Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition

 

Maternity

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, “How does the milk get secreted from the breast?” The best response by the nurse should be:
1. “Testosterone stimulates the secretion of milk, which is called lactogenesis.”
2. “Oxytocin stimulates the secretion of milk, which is called lactogenesis.”
3. “Prolactin stimulates the secretion of milk, which is called lactogenesis.”
4. “Progesterone stimulates the secretion of milk, which is called lactogenesis.”

 

 

  1. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement, if made by the client, indicates a need for further education?
1. “I need to stay on the diabetic diet.”
2. “I will perform glucose monitoring at home.”
3. “I need to avoid exercise because of the negative effects on insulin production.”
4. “I need to be aware of any infections and report signs of infection immediately to my health care provider.”

 

 

  1. A client has been seen in the clinic and has been diagnosed with endometriosis. The client asks the nurse to describe this condition. The best response by the nurse should be:
1. “It causes the cessation of menstruation.”
2. “It is also known as primary dysmenorrhea.”
3. “It is pain that occurs during ovulation.”
4. “It is the presence of tissue outside the uterus that resembles the endometrium.”

 

 

  1. A client calls the physician’s office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which of the following in the urine?
1. Estrogen
2. Progesterone
3. Human chorionic gonadotropin (hCG)
4. Follicle-stimulating hormone (FSH)

 

  1. The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?
1. It maintains the uterine lining for implantation.
2. It stimulates metabolism of glucose and converts the glucose to fat.
3. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.
4. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

 

 

  1. A client is seen in the health care clinic with a diagnosis of mild anemia. The anemia is believed to be a result of her menstrual period. The client asks the nurse how much blood is lost during a menstrual period. The nurse bases the response on which of the following amounts of blood lost during this time?
1. 40 mL
2. 60 mL
3. 80 mL
4. 100 mL

 

 

 

  1. The rubella vaccine has been prescribed for a new mother. Which of the following statements should the postpartum nurse make when providing information about the vaccine to the client?
1. “You will need a second vaccination at your 6-week postpartum visit.”
2. “You should avoid sexual intercourse for 2 weeks after the administration of the vaccine.”
3. “You should not become pregnant for 1 to 3 months after the administration of the vaccine.”
4. “You should avoid heat and extreme temperature changes for a week after the administration of the vaccine.”

 

 

  1. The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds to the client by telling her that the gender of the fetus can be determined by weeks:
1. 6 to 8
2. 8 to 10
3. 13 to 16
4. 20 to 22

 

 

  1. The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was and the client reports February 9, 2012. Using Nägele’s rule, the nurse determines that the estimated date of confinement (delivery) is:
1. October 16, 2012
2. November 16, 2012
3. October 7, 2012
4. November 7, 2012

 

 

  1. A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which of the following is the appropriate nursing action?
1. Instruct the client to avoid walking.
2. Assess for signs of venous thrombosis.
3. Tell the client that this is normal during pregnancy.
4. Instruct the client to elevate her legs consistently throughout the day.

 

 

  1. A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/min. Which of the following nursing actions is appropriate?
1. Document the findings.
2. Notify the physician.
3. Inform the client that everything is normal and fine.
4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.

 

 

  1. The nurse is caring for a pregnant client who has herpes genitalis. The nurse provides instructions to the client about treatment modalities that may be necessary for treatment of this condition. Which of the following statements, if made by the client, indicates an understanding of these treatment measures?
1. “I do not need to abstain from sexual intercourse.”
2. “I need to use vaginal creams after I douche every day.”
3. “I need to douche and perform a sitz bath three times a day.”
4. “It may be necessary to have a cesarean section for delivery.”

 

 

 

  1. A pregnant client tests positive for the hepatitis B virus (HBV). The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which of the following responses by the nurse is most appropriate?
1. “Breast-feeding is allowed after the baby has been vaccinated with immune globulin.”
2. “Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby.”
3. “You will not be able to breast-feed the baby until 6 months after delivery.”
4. “Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery.”

 

 

  1. The nurse is collecting data from a client who is at 32 weeks’ gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?
1. 22 cm
2. 28 cm
3. 32 cm
4. 40 cm

 

 

  1. A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate?
1. Contact the physician.
2. Instruct the client to maintain bed rest for the remainder of the pregnancy.
3. Instruct the client that these are common and may occur throughout the pregnancy.
4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

 

 

 

  1. The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The physician has documented the presence of Goodell’s sign. The nurse determines that this sign is indicative of:
1. A softening of the cervix
2. The presence of fetal movement
3. The presence of human chorionic gonadotropin (hCG) in the urine
4. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus

 

 

  1. The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term?
1. “It is the thinning of the lower uterine segment.”
2. “It is the fetal movement that is felt by the mother.”
3. “It is irregular painless contractions that occur throughout pregnancy.”
4. “It is the soft blowing sound that can be heard when the uterus is auscultated.”

 

 

 

  1. A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the client that fetal movements will be noted between _____ weeks’ gestation.
1. 6 and 8
2. 8 and 10
3. 12 and 14
4. 16 and 20

 

 

  1. A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which of the following would the nurse anticipate to be prescribed for this client?
1. Immunization with rubella
2. Retesting rubella titer during pregnancy
3. Counseling the mother regarding therapeutic abortion
4. Antibiotics, to be taken throughout the pregnancy

 

 

  1. The nursing instructor is reviewing a plan of care formulated by a nursing student who is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of the Kegel exercises. Which of the following responses, made by the student, indicates an understanding of the purpose of these types of exercises?
1. “The exercises will help reduce backaches.”
2. “The exercises will help prevent ankle edema.”
3. “The exercises will help prevent urinary tract infections.”
4. “The exercises will help strengthen the pelvic floor in preparation for delivery.”

 

 

  1. The nurse in a health care clinic is instructing a client how to perform kick counts. Which of the following statements, if made by the client, indicates a need for further education?
1. “I should lie on my back to perform the procedure.”
2. “I will use a clock or a timer and record the number of movements or kicks.”
3. “I should count the fetal movements for 30 to 60 minutes three times a day.”
4. “I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks.”

 

 

  1. A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following information will the nurse provide to the client?
1. “The fetus is challenged by uterine contractions to obtain the necessary information.”
2. “The test is an invasive procedure and requires that you sign an informed consent.”
3. “The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed.”
4. “An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly.”

 

 

 

  1. A client in the second trimester of pregnancy is seen in the health care clinic. The client tells the nurse that she is a hostess at a local restaurant and is on her feet most of the day. She states that she has frequent low back pains and ankle edema by the end of the day. The nurse provides instructions to the woman about measures to relieve the discomfort. Which of the following statements, made by the client, indicates an understanding of how to relieve these discomforts?
1. “When I get home I should lie on my left side, with my feet in a dorsiflexed position.”
2. “I should soak in a tub bath of hot water when I get home and then perform pelvic tilt exercises.”
3. “When I get home I should lie on my right side, with my feet elevated on a pillow, and put a heating pad on my back.”
4. “When I get home I should lie on the floor, with my legs elevated onto a couch, and turn my hips and knees at right angles.”

 

 

  1. A pregnant client calls the nurse at the physician’s office and reports that she has noticed a thin, colorless, vaginal drainage. Which of the following information would be most appropriate for the nurse to provide to the client?
1. Come to the clinic immediately.
2. Report to the emergency department at the maternity center immediately.
3. The vaginal discharge may be bothersome but is a normal occurrence.
4. Use tampons if the discharge is bothersome but be sure to change the tampons every 2 hours.

 

 

 

  1. The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the physician has documented the test results as reactive. The nurse interprets that this result indicates:
1. Normal findings
2. Abnormal findings
3. The need for further evaluation
4. That the findings on the monitor were difficult to interpret

 

 

  1. The pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. The nurse would tell the client to _____ the knee when the cramps occur.
1. Dorsiflex the foot while extending
2. Dorsiflex the foot while flexing
3. Plantar flex the foot while flexing
4. Plantar flex the foot while extending

 

 

 

  1. The nurse is providing instructions about treatment for hemorrhoids to the client who is in the second trimester of pregnancy. Which of the following statements, if made by the client, indicates a need for further instruction?
1. “I should perform Kegel exercises as you have instructed.”
2. “Cool sitz baths will help in relieving the discomfort.”
3. “I should apply heat packs to the hemorrhoids to help them shrink.”
4. “I can apply ice packs to the hemorrhoids to assist in relieving discomfort.”

 

 

  1. The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse would instruct the client to supplement the dietary source of calcium by eating which of the following foods?
1. Dried fruits
2. Creamed spinach
3. Hard cheese
4. Fresh squeezed orange juice

 

 

  1. The nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. The nurse would encourage the client to increase intake of which of the following foods that are highest in folic acid?
1. Cheese
2. Chicken
3. Rice
4. Green leafy vegetables

 

 

  1. The pregnant client asks the nurse about the type of exercises that are allowable during her pregnancy. The nurse would instruct the client that the safest exercise to engage in is which of the following?
1. Swimming
2. Water skiing
3. Aerobic exercising
4. Downhill skiing

 

  1. A pregnant client reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following assessment, tuberculosis is suspected. A sputum culture is obtained, and Mycobacterium tuberculosis is identified in the sputum. The nurse provides instructions to the client regarding therapeutic management of tuberculosis. Which of the following instructions does the nurse provide to the client?
1. The need for therapeutic abortion is required.
2. Medication will not be started until after delivery of the fetus.
3. Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.
4. The newborn must receive medication therapy immediately following birth.

 

 

  1. The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which of the following statements, if made by the client, indicates a need for further education?
1. “It is best that I rest on my left side to promote blood return to the heart.”
2. “I need to avoid excessive weight gain to prevent increased demands on my heart.”
3. “I need to try to avoid stressful situations because stress increases the workload on the heart.”
4. “During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection.”

 

 

  1. A nurse is collecting data on a pregnant client in the first trimester of pregnancy whose medical record indicates the presence of iron deficiency anemia. The nurse would monitor the client to detect which of the following signs indicating that this problem has not yet resolved?
1. Increased vaginal secretions
2. Pink mucous membranes
3. Complaints of increased frequency of voiding
4. Complaints of daily headaches and fatigue

 

 

  1. A nurse has just received the intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which of the following clients is most at risk for developing postdelivery endometritis?
1. A primigravida with a normal spontaneous vaginal delivery
2. A gravida II who delivered vaginally following an 18-hour labor
3. A client experiencing an elective cesarean delivery at 38 weeks’ gestation
4. An adolescent experiencing an emergency cesarean delivery for fetal distress

 

 

  1. A nurse is conducting a routine screening to detect a client’s risk for toxoplasmosis parasite infection during pregnancy. The nurse would ask the client about which of the following items to determine this risk?
1. Number of sexual partners during pregnancy
2. Presence in the home of cats who use a kitty litter box for elimination
3. Exposure to children with rashes or gastrointestinal symptoms
4. History of high fevers or unusual rashes during the first 6 weeks of pregnancy

 

 

  1. The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which of the following is the priority nursing action?
1. Monitoring daily weight
2. Assessing for edema
3. Monitoring the temperature
4. Monitoring the apical pulse

 

 

  1. The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which of the following data, if noted on the client’s record, would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?
1. The client’s previous deliveries were by cesarean section.
2. The client’s last baby weighed 10 lb at birth.
3. The client has a family history of type 1 diabetes.
4. The client is 5 feet, 3 inches tall and weighs 165 lb.

 

 

  1. The nurse is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require:
1. Increased insulin
2. Decreased insulin
3. Increased caloric intake
4. Decreased caloric intake

 

  1. The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which of the following?
1. Milk
2. Tea
3. Coffee
4. Orange juice

 

 

  1. The nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following is documented in the client’s record?
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is completely dilated.
4. The client begins to expel clear vaginal fluid.

 

 

 

  1. The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which most appropriate nursing actions?
1. Placing the mother in a supine position
2. Administering oxygen via face mask
3. Increasing the rate of the intravenous (IV) oxytocin infusion
4. Documenting the findings and continuing to monitor the fetal patterns

 

  1. The nurse is assisting the nurse midwife in preparing to perform Leopold’s maneuver on a pregnant client. The nurse instructs the client about the procedure and then:
1. Asks the client to urinate
2. Asks the client to drink 8 oz of water
3. Locates the fetal heart tones with a fetoscope
4. Warms the sonogram gel before placing it on the client’s abdomen

 

  1. A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which of the following findings indicates that the rate of the infusion needs to be decreased?
1. Increased urinary output
2. A fetal heart rate of 180 beats/min
3. Three contractions occurring in a 10-minute period
4. Adequate resting tone of the uterus palpated between contractions

 

 

  1. The nurse is monitoring a client in labor whose membranes ruptured spontaneously. The initial nursing action is to:
1. Take the client’s blood pressure.
2. Provide peripads to the client.
3. Determine the fetal heart rate.
4. Note the amount, color, and odor of the amniotic fluid.

 

  1. The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:
1. Hematoma
2. Placenta previa
3. Uterine atony
4. Placental separation

 

 

  1. The nurse is preparing to care for a client in labor. The physician has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which of the following is implemented prior to the beginning of the infusion?
1. Placing the client on complete bed rest
2. Continuous electronic fetal monitoring
3. An IV infusion of antibiotics
4. Placing a code cart at the client’s bedside

 

 

 

  1. The nurse provides a list of discharge instructions to the client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further instructions?
1. Begin abdominal exercises immediately.
2. Notify the physician if I develop a fever.
3. Lift nothing heavier than the newborn for at least 2 weeks.
4. Turn on my side and push up with my arms to get out of bed.

 

 

  1. The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse assesses that the amniotic fluid is normal if it has which of the following characteristics?
1. Clear and dark amber color
2. Light green color with no odor
3. Thick white color with no odor
4. Straw-colored, with flecks of vernix

 

MSC:   Integrated Process: Nursing Process—Assessment

 

  1. The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which of the following nursing interventions as the highest priority?
1. Monitoring fetal status
2. Providing comfort measures
3. Changing the client’s position frequently
4. Keeping the significant other informed of the progress of the labor

 

 

  1. The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following findings would alert the nurse to a compromise?
1. Maternal fatigue
2. Coordinated uterine contractions
3. The passage of meconium
4. Progressive changes in the cervix

 

 

 

  1. The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:
1. Provide pain relief measures.
2. Promote ambulation every 30 minutes.
3. Prepare the client for an amniotomy.
4. Monitor the oxytocin (Pitocin) infusion closely.

 

  1. The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?
1. Place the client in Trendelenburg’s position.
2. Gently push the cord into the vagina.
3. Find the closest telephone, and page the physician stat.
4. Call the delivery room to notify the staff that the client will be transported immediately.

 

 

  1. The nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?
1. Hemorrhage
2. Infection
3. Chronic hypertension
4. Disseminated intravascular coagulation

 

 

  1. The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action would be which of the following?
1. Turn the client on her back, and administer oxygen by nasal cannula at 2 to 4 L/min.
2. Turn the client on her side, and administer oxygen by face mask at 8 to 10 L/min.
3. Turn the client on her back, and administer oxygen by face mask at 8 to 10 L/min.
4. Turn the client on her side, and administer oxygen by nasal cannula at 2 to 4 L/min.

 

 

 

  1. An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. The nurse would prepare the client for:
1. Delivery of the fetus
2. Strict monitoring of intake and output
3. Complete bed rest for the remainder of the pregnancy
4. The need for weekly monitoring of coagulation studies until the time of delivery

 

 

  1. The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?
1. Hypotonic
2. Precipitate
3. Hypertonic
4. Preterm labor

 

  1. The nurse has collected the following data on a client in labor: the fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, the nurse should take which most appropriate action?
1. Prepare for imminent delivery.
2. Continue to monitor the client.
3. Report the findings to the obstetrician.
4. Report the FHR to the anesthesiologist on call.

 

 

  1. A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client states that her “water broke” before coming to the hospital. The most appropriate nursing action would be to:
1. Sit the client in a high Fowler’s position.
2. Call the pharmacy for a tocolytic medication.
3. Get intravenous (IV) therapy equipment and solution from the storage area.
4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

 

 

 

  1. The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the following?
1. Ask the client to turn on her side.
2. Ask the client to urinate and empty her bladder.
3. Ask the client to lie flat on her back, with her knees and legs flat and straight.
4. Massage the fundus gently prior to determining the level of the fundus.

 

 

  1. The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the client’s vital signs every:
1. Hour for the first 2 hours and then every 4 hours
2. 15 minutes during the first hour and then every 30 minutes for the next

2 hours

3. 30 minutes during the first hour and then every hour for the next 2 hours
4. 5 minutes for the first 30 minutes and then every hour for the next 4 hours

 

 

  1. The nurse is providing nutritional counseling to a new client who is breast-feeding her newborn. The nurse instructs the client that her calorie needs need to increase by approximately how many calories a day?
1. 100
2. 300
3. 500
4. 1000

 

 

  1. The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable:
1. When ambulating
2. During breast-feeding
3. While taking sitz baths
4. When the client arrives home and activities are increased

 

 

 

  1. The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin’s phases of regeneration. The student is asked about client behaviors that are most likely to occur during this phase. Which of the following responses, made by the student, indicates an understanding of this phase?
1. “The client would be independent.”
2. “The client initiates activities on her own.”
3. “The client participates in mothering tasks.”
4. “The client is self-focused and talks to others about labor.”

 

 

  1. The nurse is assisting a new client with learning how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client’s first child. Which of the following nursing interventions will least likely assist in promoting mother-infant interaction and bonding?
1. Accepting the client’s feelings
2. Acknowledging the client’s apprehension
3. Leaving the infant with the client so that she will be required to provide the care
4. Assisting the client with giving the baths to allow her to become more at ease

 

 

  1. The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse will plan to instruct the client to:
1. Apply a heating pad to breasts for comfort.
2. Wear a breast shield to correct nipple inversion.
3. Wear a supportive brassiere continuously for 72 hours.
4. Use the manual breast pump provided to express milk.

 

 

  1. The postpartum client who had a vaginal delivery of a healthy newborn has a prescription for a sitz bath. The nurse who is assisting the client tells the client that the sitz bath will:
1. Numb the tissue.
2. Stimulate a bowel movement.
3. Reduce the edema and swelling.
4. Promote healing and provide comfort.

 

  1. The nurse is monitoring a new client in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss?
1. A temperature of 100.4º F
2. An increased pulse rate of 88 to 102 beats/min
3. A blood pressure change from 130/88 to 124/80 mm Hg
4. An increase in the respiratory rate from 18 to 22 breaths/min

 

 

  1. The nurse is providing instructions to the client who has been diagnosed with mastitis. Which of the following statements, if made by the client, indicates a need for further education?
1. “I need to wear a supportive bra to relieve the discomfort.”
2. “I need to stop breast-feeding until this condition resolves.”
3. “I can use analgesics to assist in alleviating some of the discomfort.”
4. “I need to take antibiotics, and I should begin to feel better in 24 to 48 hours.”

 

 

  1. The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which of the following clients would be least likely at risk for the development of thrombophlebitis in the postpartum period?
1. A 35-year-old client who reports that she smokes
2. A 26-year-old client with a family history of thrombophlebitis
3. A 37-year-old client in her fourth pregnancy who is overweight
4. A 22-year-old client in her first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

 

 

  1. The nurse is monitoring the client for signs of postpartum depression. Which of the following, if noted in the client, would indicate the need for further assessment related to this form of depression?
1. The client demonstrates an interest in the surroundings.
2. The client is caring for the infant in a loving manner.
3. The client constantly complains of tiredness and fatigue.
4. The client looks forward to visits from the father of the newborn.

 

 

  1. The nurse caring for a client with a diagnosis of subinvolution understands that which of the following is a primary cause of this diagnosis?
1. Afterpains
2. Retained placental fragments from delivery
3. Increased progesterone levels
4. Increased estrogen levels

 

 

  1. The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse plans to take which action first?
1. Massage the uterus until firm.
2. Take the client’s blood pressure.
3. Ask the client about the presence of pain.
4. Recheck the amount of drainage on the peripad.

 

 

  1. When participating in the planning of care of a postpartum client who plans to breast-feed her infant, the nurse realizes the importance of including which of the following in the teaching plan to prevent the development of mastitis?
1. Offer only one breast at each feeding.
2. Massage distended areas as the infant nurses.
3. Cleanse nipples with a mild antibacterial soap before and after infant feedings.
4. Express and discard milk from the affected breast at the first signs of mastitis.

 

 

  1. The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and notes that the heart rate is normal if which of the following is noted?
1. A heart rate of 100 beats/min
2. A heart rate of 140 beats/min
3. A heart rate of 180 beats/min
4. A heart rate of 190 beats/min

 

 

  1. The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and determines that the respiratory rate is normal if which of the following is noted?
1. A respiratory rate of 20 breaths/min
2. A respiratory rate of 40 breaths/min
3. A respiratory rate of 70 breaths/min
4. A respiratory rate of 80 breaths/min

 

 

 

  1. The nurse is performing an assessment on a neonate. The nurse is preparing to measure the head circumference of the neonate. The nurse would:
1. Wrap the paper tape around the newborn’s head, and measure just above the eyebrows.
2. Place the paper tape under the newborn’s head, wrap around the occiput, and measure just above the eyes.
3. Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn’s mouth.
4. Place the paper tape under the newborn’s head at the base of the skull, and wrap around to the front, just above the eyes.

 

 

  1. The nurse is checking the reflexes of a neonate. In eliciting the Moro reflex, the nurse would do which of the following?
1. Stimulate the perioral cavity with a finger.
2. Clap hands, or slap the mattress.
3. Stimulate the ball of the infant’s foot with firm pressure.
4. Stimulate the pads of the infant’s hands with firm pressure.

 

 

  1. The nurse is planning to administer an injection of vitamin K to a newborn. In preparing to administer the injection, the nurse would select which of the following injection sites?
1. The gluteal muscle
2. The lower aspect of the rectus femoris muscle
3. The medial aspect of the upper third of the vastus lateralis muscle
4. The lateral aspect of the middle third of the vastus lateralis muscle

 

 

  1. The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, is gasping, and has a heart rate below 100 beats/min. The nurse understands that the number of ventilations per minute that will be delivered to this neonate is _____ breaths/min.
1. 20 to 40
2. 40 to 60
3. 70 to 80
4. 80 to 100

 

 

  1. The nurse is performing an initial assessment on a newborn. On assessment of the newborn’s head, the nurse notes that the ears are low-set. Which of the following nursing actions would be most appropriate initially?
1. Notify the physician.
2. Document the findings.
3. Arrange for hearing testing.
4. Cover the ears with gauze pads.

 

  1. The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which of the following observations, if made by the nurse, indicates that the client is performing the procedure correctly?
1. The client cleans the newborn’s ears and then moves to the eyes and the face.
2. The client begins to wash the newborn by starting with the eyes and face.
3. The client washes the arms, chest, and back, followed by the neck, arms, and face.
4. The client washes the entire newborn’s body and then washes the eyes, face, and scalp.

 

 

  1. The nurse is providing instructions to the client regarding cord care. Which of the following statements, if made by the client, indicates a need for further education?
1. “Alcohol may be used if prescribed to clean the cord.”
2. “The cord will fall off in 1 to 2 weeks.”
3. “I should clean the cord two or three times a day.”
4. “I need to fold the diaper above the cord to prevent infection.”

 

 

  1. The nurse is providing instructions to the client of a breast-fed newborn who has hyperbilirubinemia. Which of the following instructions does the nurse provide to the client?
1. Increase the frequency of the breast-feeding.
2. Stop the breast-feedings, and switch to bottle-feeding permanently.
3. Provide bottled water feedings between the breast-feeding sessions.
4. Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently.

 

 

  1. The nurse is monitoring a newborn that was born to a client who abuses alcohol. Which of the following findings would the nurse expect to note when assessing this newborn?
1. Lethargy
2. Irritability
3. Higher than normal birth weight
4. A greater than normal appetite when feeding

 

 

 

  1. The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which of the following findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome?
1. Hypotension and bradycardia
2. Tachypnea and retractions
3. Acrocyanosis and grunting
4. The presence of a barrel chest, with acrocyanosis

 

 

 

  1. The nurse is checking a newborn’s 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. What is the newborn’s 1-minute Apgar score?
1. 7
2. 9
3. 8
4. 10

 

 

 

  1. The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which of the following misunderstandings on the part of the client about nutrition during pregnancy?
1. Iron supplements should be taken throughout pregnancy.
2. Pregnancy greatly increases the risk of malnourishment for the mother.
3. Calcium intake should be increased for the duration of the pregnancy.
4. The maternal diet significantly influences fetal growth and development.

 

 

MULTIPLE RESPONSE

 

  1. A vaginal examination of a client in labor would specifically determine which of the following? Select all that apply.
1. Effacement
2. Dilation
3. Station
4. Bloody show
5. Contraction effort

 

 

 

  1. Which of the following are modes of heat loss in the newborn? Select all that apply.
1. Convection
2. Radiation
3. Conduction
4. Urination
5. Evaporation

 

 

  1. The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following findings are associated with abruptio placentae? Select all that apply.
1. Acute abdominal pain
2. A hard, “board-like” abdomen
3. Painless, bright red vaginal bleeding
4. Increased uterine resting tone on fetal monitoring
5. Uterine tenderness

 

 

  1. The nurse provides which instructions to the client following delivery regarding care of the episiotomy site to prevent infection? Select all that apply.
1. Change the perineum pads three times a day.
2. Take a warm sitz baths three times a day.
3. Wipe the perineum from front to back after voiding and defecation.
4. Use warm water to rinse the perineum after elimination.
5. Report a foul-smelling discharge.

 

 

  1. The nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. The nurse provides which instructions to the client regarding relief of the engorgement? Select all that apply.
1. Feed the infant at least every 2 hours for 15 to 20 minutes on each side.
2. Avoid breast-feeding during the time of breast engorgement.
3. Apply moist heat to both breasts for about 20 minutes before a feeding.
4. Massage the breasts gently during a feeding, from the outer areas to the nipples.
5. Wear a supportive bra between feedings.

 

 

  1. On the second postpartum day, a client complains of burning, urgency, and frequency of urination. A urinalysis is obtained, and the results indicate the presence of a urinary tract infection. The nurse instructs the client regarding which measures to take for the prevention and treatment of the infection? Select all that apply.
1. Urinate frequently throughout the day.
2. Fluid intake should be increased to at least 3000 mL/day.
3. Prescribed medication must be taken until it is completed.
4. Foods and fluids that will increase urine alkalinity should be consumed.
5. Wipe the perineal area from front to back after urinating.

 

 

 

 

Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition

 

Mental Health

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, “I wish you would just be my friend.” The appropriate response by the nurse is:
1. “I am your friend.”
2. “Our relationship is a therapeutic and helping one.”
3. “I can’t be your friend. I’m the nurse, and you’re the client.”
4. “You have plenty of friends. You don’t need me to be your friend, too.”

 

 

  1. The nurse is developing a care plan that will include goals that will help the client achieve an optimal level of functioning and appropriate resource utilization. When the nurse enters the client’s room, the client asks the nurse, “Could you ask the physician to let me have a pass for the weekend?” The nursing response that assists the client in achieving these goals is:
1. “When your doctor comes in, I will ask for a pass for the weekend.”
2. “When the physician arrives on the unit, I will let him or her know that you have a question.”
3. “I will call the doctor and find out if you can have a pass so that you can make your arrangements.”
4. “You can’t have a pass for the weekend. You are not ready, and I’m sure that your doctor will say no.”

 

 

  1. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which of the following subjects?
1. Facilitating behavioral change
2. Promoting self-esteem in the client
3. Establishing the parameters of the relationship
4. Promoting problem solving skills in the client

 

  1. The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status, which indicates that:
1. The admission was mandated by court order.
2. The admission was made without the client’s consent.
3. The client has the right to demand and obtain release from the hospital.
4. The client was committed by a group of designated mental health professionals.

 

 

  1. The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, “I haven’t had an appetite at all for the last few weeks.” Which of the following responses by the nurse would be best?
1. “The last few weeks?”
2. “You haven’t had an appetite at all?”
3. “When the medication begins to work, you will begin to feel better.”
4. “Think about everything that you have been through. It will take time for your appetite to improve.”

 

 

  1. A nurse in the emergency department is preparing to care for a female client who has just been sexually assaulted. Which of the following client behaviors would demonstrate denial?
1. The client is calm and quiet.
2. The client is blaming her sister for the incident.
3. The client is justifying unacceptable self-behaviors.
4. The client is verbalizing generalizations about the incident.

 

 

  1. The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses’ station, becomes very loud and offensive, and demands to be seen by the physician immediately. The appropriate nursing intervention is which of the following?
1. Inform the client that the behavior is unacceptable.
2. Tell the client to wait in his or her room until report is over.
3. Offer to assist the client to an examination room until the physician is notified.
4. Tell the client that the physician will be called as soon as report is completed.

 

 

  1. The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes that include the belief that the food is being poisoned. The nurse develops strategies that will encourage the client to discuss feelings and plans to:
1. Use open-ended questions and silence.
2. Focus on the components of adequate nutrition.
3. Focus on the fact that the client’s beliefs are untrue.
4. Instruct the client about the need for adequate nutrition.

 

  1. The mental health nurse has been meeting with a client on a weekly basis and, over the past several weeks, the client has been consistently 15 minutes late. Which of the following nursing actions is appropriate regarding the client’s lateness for the scheduled meetings?
1. Ignore the behavior.
2. Tell the client that the meetings will be terminated.
3. Ask the client if something is going on that the client may have difficulty handling.
4. Because the client is consistently late, begin to arrive 15 minutes later than the scheduled time also.

 

 

  1. A mental health nurse who has been meeting with a client with a diagnosis of post-traumatic stress disorder is in the termination phase of the nurse-client relationship. The nurse notes that the client has been quiet and withdrawn and interprets the client’s behavior as:
1. An indication of the need for antidepressants
2. An inability of the client to terminate from the nurse
3. A normal behavior that can occur during termination
4. An indication of the need for additional therapy sessions

 

 

  1. The nurse is preparing for the arrival of a new client at a drug abusers’ residential treatment center and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is:
1. Milieu therapy
2. Aversion conditioning
3. Systematic desensitization
4. Cognitive-behavioral therapy

 

  1. A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and instructs the client that:
1. The client will talk to himself or herself to control actions more effectively.
2. The client will take medication daily to control the condition.
3. The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.
4. The client will meet with others with the same problem in a support group that focuses on the client’s phobia.

 

 

 

  1. The nurse is conducting a group therapy session when a female client, who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. The appropriate nursing action is which of the following?
1. Tell the client that it is not safe to leave.
2. Encourage the client to stay, and ask the client what she is feeling.
3. Tell the client that if she leaves she cannot return to this therapy group.
4. Lock the door so that the client cannot leave at this potentially vulnerable time.

 

 

  1. The nurse is helping to conduct a group therapy session. During the session, a male client threatens to act out physically and states that he will punch another member of the group. Which of the following is the appropriate initial nursing action?
1. Tell the client that he must leave immediately.
2. Call security to come to the session immediately.
3. Tell the client that he can talk about his anger but cannot act on it in during the group session.
4. Tell the client that if he hits another client, he will be restrained and placed in seclusion.

 

 

 

  1. The nurse is preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which of the following would be appropriate for the nurse to include in the plan of care?
1. Avoid providing rewards to the client.
2. Promote complete independence in the client.
3. Reward the client when a desired behavior is performed.
4. Provide consistent negative reinforcement to promote appropriate behaviors.

 

 

  1. A nursing student is conducting a clinical conference and is describing the characteristics associated with milieu therapy. Which of the following statements, if made by the student, indicates an understanding of the focus of this form of therapy?
1. “Milieu therapy provides a cognitive approach to changing behavior.”
2. “A living, learning, or working environment is the focus of milieu therapy.”
3. “Milieu therapy provides a behavior modification approach type of therapy.”
4. “A behavioral approach to changing behavior is the focus of milieu therapy.”

 

 

  1. A nurse working in an urgent care center is interviewing a woman with vague somatic complaints. When the nurse is alone with the client, however, the client states that she was raped a few weeks ago but still feels “as if it just happened to me.” The nurse should make which therapeutic response to the client?
1. “It is very, very hard to get over these types of feelings after being raped.”
2. “What do you think you should do to reduce the likelihood that you will be raped again?”
3. “Tell me more about what happened, and what causes you to feel like the rape just

occurred.”

4. “It’s hard, but try to keep a sense of perspective. After all, it’s been a while since the rape occurred.”

 

 

  1. The nurse is developing a plan of care for a client admitted to the psychiatric unit at high risk for suicide. The focus of the plan is to promote a safe and therapeutic environment. Which of the following interventions would the nurse include in the plan of care?
1. Place the client in a private room.
2. Establish a therapeutic relationship.
3. Assign a leadership task to the client.
4. Maintain a distance of 10 inches at all times.

 

  1. A client admitted to the mental health unit with depression states to the nurse, “My life has been such a failure; nothing I do turns out right.” Which of the following responses by the nurse would be therapeutic?
1. “You are certainly entitled to your own opinion.”
2. “I know just how you feel. I have those days myself once in a while.”
3. “I disagree with you; we all have some value and accomplishments in life.”
4. “You seem very discouraged. Can you think of anything recently that went as you planned?”

 

  1. A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?
1. Grandiose delusions of being a czar of Russia
2. Constant physical activity and poor oral intake
3. Constant, incessant talking, with sexual innuendoes
4. Outlandish behaviors and wearing odd and eccentric clothing

 

 

 

  1. A nurse is working with a client who is delusional. The client says to the nurse, “The leaders of a religious cult are being sent to assassinate me.” Which of the following is the best response by the nurse?
1. “I don’t believe that what you are telling me is true.”
2. “There are no religious cults in this area that are going to kill you.”
3. “What makes you think that cult members are being sent to hurt you?”
4. “I don’t know about a religious cult. Are you afraid that people are trying to hurt you?”

 

 

 

  1. A woman is seen in the emergency department in a severe state of anxiety following assault and battery. The nurse places highest priority on taking which of the following nursing actions at this time?
1. Remaining with the client
2. Encouraging the client to talk about her feelings
3. Teaching the client deep-breathing techniques
4. Putting the client in a quiet room, away from other clients

 

 

  1. An older female client with delirium becomes agitated and confused at night. The nurse’s most important strategy for this is to do which of the following?
1. Turn off the television and radio, and use a nightlight.
2. Keep soft lighting and the television on during the night.
3. Change the client’s room to one nearer the nurses’ station.
4. Play soft instrumental music all night, and do not turn down the lights.

 

 

 

  1. A mental health nurse is assigned to care for a client with a diagnosis of undifferentiated schizophrenia. The nurse uses which of the following approaches when planning care for this client?
1. Allow the client to set the goals for the plan of care.
2. Let the client act out initially, and use the quiet room and restraints as needed.
3. Provide assistance with grooming and nutrition until the client’s thinking has cleared.
4. Repeatedly point out inconsistencies in the client’s communication during initial treatment.

 

 

 

  1. The nurse is talking with a male client who is actively hallucinating. The client is fearful that the voices he hears will direct him to kill himself or will hurt him directly. Which of the following nursing statements would be therapeutic at this time?
1. “I can hear the voices too, but they are telling you to go to bed now.”
2. “I know whose voices you are hearing and told them not to hurt you.”
3. “I know you believe they are going to cause you harm, but it’s not true.”
4. “I don’t hear them, but it must be frightening to hear voices that others can’t hear.”

 

 

  1. The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority?
1. Ineffective coping
2. Chronic low self-esteem
3. Risk for self-mutilation
4. Social isolation

 

  1. A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client’s daughter is hypervigilant and anxious. The daughter says to the nurse, “My mother’s brain will be shocked with electricity. How can the doctor even think about doing this to her?” Which of the following responses by the nurse would be therapeutic?
1. “I think you need to speak directly to the psychiatrist.”
2. “Maybe you’ll feel better if you see the ECT room and speak to the staff.”
3. “Your mother has decided to have this treatment. You should support her.”
4. “It sounds as though you are very concerned about the procedure. Let’s discuss the procedure.”

 

 

 

  1. The nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that the priority of care at this time is which of the following?
1. Providing safety for the client and other clients on the unit
2. Offering the client a less stimulated area in which to calm down and gain control
3. Assisting in caring for the client in a controlled environment, such as a quiet room
4. Providing the other clients on the unit with a sense of comfort and safety by isolating the client

 

  1. A female client diagnosed with catatonic stupor is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?
1. Ask direct questions to encourage talking.
2. Leave the client alone but check on her every 30 minutes.
3. Sit beside the client in silence, with occasional open-ended questions.
4. Take the client into the dayroom with other clients for added supervision.

 

 

 

  1. A client who has sustained severe injuries in a motorcycle accident was diagnosed with intensive care unit (ICU) psychosis. The nurse would be most likely to conclude that the client’s status is improving if the client:
1. Increases the number of hours slept at one time and is increasingly alert
2. Appears to be delirious but has stopped trying to pull out the nasogastric tube
3. Tells his wife, “I feel better, but the doctors want to give me a lethal injection.”
4. Keeps his eyes fixed on the nurses while they are working in the room but has stable vital signs

 

 

  1. A nurse caring for a client recently admitted to the hospital for anorexia nervosa enters the client’s room and finds her in the middle of performing rapid exercises. Which action would be the priority?
1. Interrupt the client, and offer to take her for a walk.
2. Allow the client to complete her exercise program.
3. Ignore the behavior, and return when the client is finished.
4. Tell the client that she is not allowed to exercise rigorously.

 

  1. The postsurgical client with a history of heavy alcohol intake is at risk for delirium tremens (DTs), which would be manifested by:
1. Hypotension, ataxia, muscular rigidity, and tactile hallucinations
2. Coarse hand tremor, agitation, hallucinations, and hypotension
3. Hypotension, stupor, agitation, headache, and auditory hallucinations
4. Fever, hypertension, changes in level of consciousness, and hallucinations

 

 

  1. A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client’s spouse states, “I don’t know why I don’t get out of this rotten situation.” Which of the following would be the therapeutic response by the nurse?
1. “This is not a good time to make that decision.”
2. “What would your spouse think about your decision?”
3. “What aspects of this situation are the most difficult for you?”
4. “You seem to have a good grip on this situation. You probably should get out.”

 

  1. The nurse monitors this client with a history of opioid abuse for which of the following signs and symptoms associated with opioid withdrawal?
1. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor
2. Increased appetite, irritability, anxiety, restlessness, anxiety, and altered concentration
3. Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), hypertension, agitation, and paranoia
4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis

 

 

  1. The nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse suspects that the client has suddenly discontinued taking which of the following prescribed medications?
1. Sertraline (Zoloft)
2. Diazepam (Valium)
3. Haloperidol (Haldol)
4. Fluoxetine (Prozac)

 

 

 

  1. A nurse is admitting a client who is in a state of starvation because of anorexia nervosa. Which of the following roommate choices would indicate a lack of understanding by the nurse regarding the admitting client’s health needs?
1. A client with pneumonia
2. A client who had back surgery
3. A client with a fractured pelvis
4. A client who has had a myocardial infarction

 

 

  1. A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I don’t want help. I have other things to attend to that are more important.” The nurse attempts to discuss the client’s concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which of the following actions at this time?
1. Call the nursing supervisor.
2. Restrain the client, and call the physician.
3. Call security to block the exits to the nursing unit.
4. Tell the client that readmission is not possible after leaving against medical advice (AMA).

 

 

  1. The nurse will monitor the client with a history of heroin addiction for which of the following signs of heroin withdrawal?
1. Constipation, insomnia, and hallucinations
2. Staggering gait, slurred speech, and violent outbursts
3. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis
4. Decreased heart rate and blood pressure and dry nose, mouth, and skin

 

 

  1. The nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if the client:
1. Exhibits impulsive behavior
2. Exhibits disorganized behavior
3. Has a history of suicide attempts
4. Has an immediate plan for a suicide attempt

 

 

  1. A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which of the following comments by the nurse would be therapeutic at this time?
1. “What is causing you to become agitated?”
2. “Why are you intent on upsetting the other clients?”
3. “Please stop so I don’t have to put you in seclusion.”
4. “You are going to be restrained if you do not change your behavior.”

 

 

  1. A nurse is having a conversation with a depressed client on an inpatient psychiatric unit. The client says to the nurse, “Things would be so much better for everyone if I just weren’t around.” Which of the following responses by the nurse would be appropriate at this time?
1. “You sound very unhappy. Are you thinking of harming yourself?”
2. “Those feelings will go away when your medication really takes effect.”
3. “Have you talked to anyone specifically about what is bothering you?”
4. “I know what you mean; everyone gets that way when they are depressed.”
  1. The nurse interprets that which of the following comments by the client whose husband uses violence against her is consistent with the presence of low self-esteem commonly found with battered wife syndrome?
1. “I’m lucky to be married to a man who really loves me the way that he does.”
2. “I told him that this is his last chance; if it happens again, I’m leaving for good.”
3. “I stay because there’s enough in it for me; I don’t have to work full time this way.”
4. “Things would be fine at home if I just could do better. He has a lot of pressures on him at work.”

 

  1. The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, “There’s no one left to care about me. Everyone that I have loved is now gone.” The nurse would make which response to the client?
1. “That doesn’t sound like the real you talking!”
2. “I’m sure you have someone if you think hard enough.”
3. “It sounds as though you are feeling all alone right now.”
4. “I don’t believe that, and I really don’t think you do either.”

 

  1. A client has been admitted to the inpatient psychiatric unit because the client has displayed violent behavior and is at risk for potentially harming others. Which of the following should the nurse avoid doing when caring for this client?
1. Admitting the client to a room near the nurses’ station
2. Facing the client while speaking and providing nursing care
3. Arranging for a security officer to be available in the general area
4. Closing the door to the client’s room when giving care to the client

 

MSC:   Integrated Process: Nursing Process—Implementation

 

  1. A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which of the following is the priority nursing action at this time?
1. Stay with the client at all times.
2. Request that a friend of the client remain with the client at all times.
3. Have the client put on a hospital gown, and remove the client’s clothing from the room.
4. Suggest placing the client in a seclusion room where all potentially dangerous articles have been removed.

 

  1. The client admitted to the mental health unit with major depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today, the client appears in the dayroom dressed and well-groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client’s behavior?
1. Continue to monitor the client’s behavior from a distance.
2. Document that the client is adapting to the unit and is feeling safe.
3. Notify the staff of these observations at the team meeting, which will begin in 3 hours.
4. Speak to the client personally about the nurse’s observations, and ask if the client is thinking about suicide.

 

 

  1. The nurse is preparing a client for discharge who was hospitalized following a suicide attempt. The nurse evaluates that the client could benefit from further development of coping strategies if the client was overheard making which of the following statements prior to discharge?
1. “I know now that I can’t be all things to all people all the time.”
2. “It is important for me to take my medications just as prescribed.”
3. “It’s been good to learn better ways to deal with the stresses in my life.”
4. “I know that I won’t become depressed again after the treatment I received here.”

 

 

  1. A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. The immediate nursing action is which of the following?
1. Take the client’s vital signs.
2. Call the mental health crisis team and notify them that a client who attempted suicide is being admitted to the hospital.
3. Perform a focused assessment, paying particular attention to the client’s neurological status.
4. Assess the client’s respiratory status and for the presence of neck injuries.

 

MULTIPLE RESPONSE

 

  1. An acutely depressed client is receiving cognitive-behavioral therapy. The nurse is developing a plan of care for the client and includes interventions that focus on this type of therapy. Which of the following interventions would the nurse include? Select all that apply.
1. Assisting the client to identify and test negative cognition
2. Assisting the client to develop alternative thinking patterns
3. Assisting the client to participate in the treatment process
4. Assisting the client to rehearse new cognitive and behavioral responses
5. Assisting the client with the administration of antidepressant medications
6. Assisting the client’s family to participate in group therapy on a regular basis

 

 

  1. The nurse caring for the hospitalized client diagnosed with bulimia nervosa would closely monitor which of the following? Select all that apply.
1. Exercise patterns
2. Intake and output
3. Electrolyte levels
4. Pupillary response
5. Deep tendon reflexes
6. Elimination patterns

 

 

 

Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition

 

Nursing Sciences

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The client with diabetes mellitus has a blood glucose level on admission of 596 mg/dL. The nurse anticipates that this client would be experiencing which of the following types of acid-base imbalance?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

 

 

 

  1. The nurse is admitting a client with a diagnosis of Guillain-Barré syndrome to the hospital. The nurse knows that if the disease is severe enough, the client will be at risk for which of the following acid-base imbalances?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

 

 

 

  1. A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse would monitor this client for signs of which of the following electrolyte disorders that could accompany the acid-base imbalance?
1. Hypokalemia
2. Hypercalcemia
3. Hypochloremia
4. Hypernatremia

 

 

  1. The client with a chronic airflow limitation (CAL) is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client’s respiratory status would avoid doing which of the following?
1. Keeping the head of the bed elevated
2. Monitoring the flow rate of supplemental oxygen
3. Assisting the client to turn, cough, and breathe deeply
4. Encouraging the client to breathe slowly and shallowly

 

 

  1. An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse would do which of the following to help the client experiencing this acid-base disorder?
1. Put the client in a supine position.
2. Provide emotional support and reassurance.
3. Withhold all sedative or antianxiety medications.
4. Tell the client to breathe very deeply but more slowly.

 

 

  1. A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse would plan to most carefully note the results of which of the following electrolytes, which could dramatically decline with effective treatment of the acidosis?
1. Sodium
2. Potassium
3. Magnesium
4. Phosphorus

 

 

  1. The nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client’s safety, knowing the risks of this imbalance, by carefully implementing which of the following prescribed precautions?
1. Contact isolation
2. Seizure precautions
3. Bleeding precautions
4. Neutropenic precautions

 

 

  1. The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse expects to note which of the following findings associated with an anticipated acid-base disturbance?
1. Disorientation and dyspnea
2. Drowsiness, headache, and tachypnea
3. Tachypnea, dizziness, and paresthesias
4. Decreased respiratory rate and depth, cardiac irregularities

 

 

  1. A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse should monitor this client, expecting to note which of the following signs and symptoms?
1. Disorientation and dyspnea
2. Decreased respiratory rate and depth
3. Drowsiness, headache, and tachypnea
4. Tachypnea, dizziness, and paresthesias

 

 

 

  1. The nurse enters a client’s room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is dyspneic and has a bounding pulse. The nurse listens to the client’s lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which of the following complications of blood transfusion therapy?
1. Bacteremia
2. Fluid overload
3. Hypervolemic shock
4. Allergic transfusion reaction

 

 

  1. A unit of packed red blood cells (PRBCs) was just received from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which of the following features?
1. An air vent
2. An in-line filter
3. A microdrip chamber
4. Tinted tubing to protect the blood from light

 

  1. The nurse overhears the physician stating that the client who is in hypovolemic shock requires plasma expansion. The nurse anticipates that the physician will write a prescription to transfuse which of the following blood products to this client?
1. Albumin
2. Platelets
3. Cryoprecipitate
4. Packed red blood cells

 

 

  1. The nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which of the following clients has the least risk for developing third-spacing of fluid?
1. Client with a major burn
2. Client with an ischemic stroke
3. Client with Laënnec’s cirrhosis
4. Client with chronic renal failure

 

 

  1. The nurse is caring for a group of clients on the clinical nursing unit. Which of the following clients should the nurse plan to monitor for signs of fluid volume deficit?
1. Client with an ileostomy
2. Client in acute renal failure
3. Client in congestive heart failure
4. Client with controlled hypertension

 

 

  1. The nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse should monitor the client for hypokalemia as a side effect of therapy if the client has been receiving which of the following medications?
1. Spironolactone (Aldactone)
2. Bumetanide (Bumex)
3. Triamterene (Dyrenium)
4. Amiloride HCl (Midamor)

 

 

  1. The nurse is providing dietary teaching to a client receiving a potassium-sparing diuretic about foods that are low in potassium. The nurse should include which of the following on a list of foods that have low potassium content?
1. Apple
2. Carrots
3. Spinach
4. Avocado

 

 

  1. The nurse is obtaining the intershift report for a group of assigned clients. Which of the following assigned clients should the nurse monitor closely for signs of hyperkalemia?
1. A client with ulcerative colitis
2. A client with Cushing’s syndrome
3. A client admitted 6 hours ago with a 40% burn injury
4. A client who has a history of long-term laxative abuse

 

 

  1. The nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. The nurse plans to irrigate the NGT with which of the following solutions to maintain homeostasis?
1. Tap water
2. Sterile water
3. 0.9% sodium chloride
4. 0.45% sodium chloride

 

 

  1. The nurse is caring for a client with Paget’s disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse checks to see that which of the following medications is available in the stock medication supply for possible use to reverse this elevation?
1. Vitamin D
2. Calcium chloride
3. Calcium gluconate
4. Calcitonin

 

 

  1. The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse determines that the client’s status is returning to normal if he no longer exhibits which of the following?
1. Tetany
2. Tremors
3. Areflexia
4. Muscular excitability

 

 

  1. The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who has undergone lumbar puncture. Evaluation of the results by the nurse leads to the determination that which of the following CSF findings is abnormal?
1. Red blood cells, 0
2. Glucose, 52 mg/dL
3. Protein, 100 mg/dL
4. White blood cells, 3 cells/mm3

 

 

 

  1. The client with a history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client’s blood level of the medication is within the therapeutic range if the value reported is which of the following?
1. 6 mcg/mL
2. 15 mcg/mL
3. 28 mcg/mL
4. 35 mcg/mL

 

 

  1. The client with chronic obstructive pulmonary disease (COPD) has had a sample for a serum theophylline level drawn as part of routine follow-up care. Which of the following results would lead the nurse to conclude that the client has most likely been compliant with medication therapy?
1. 3 mcg/mL
2. 7 mcg/mL
3. 14 mcg/mL
4. 24 mcg/mL

 

 

  1. A long-term care nurse about to give a daily dose of digoxin (Lanoxin) is told that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which of the following actions first?
1. Administer the daily dose of the medication.
2. Report the finding to the health care provider.
3. Record the normal value on the intershift report sheet.
4. Gather data from the client related to signs of toxicity.

 

 

 

  1. The client is receiving oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse anticipates carrying out a prescription to do which of the following?
1. Hold the next dose of warfarin.
2. Increase the next dose of warfarin.
3. Administer the next dose of warfarin.
4. Stop the warfarin, and administer heparin.

 

 

  1. The adult client has had serum electrolyte levels drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which of the following results?
1. Sodium level, 142 mEq/L
2. Chloride level, 103 mEq/L
3. Potassium level, 5.4 mEq/L
4. Bicarbonate level, 24 mEq/L

 

 

  1. The client with heart disease is scheduled to receive a daily morning dose of furosemide (Lasix). The nurse would report which of the following serum potassium levels to the health care provider before administering the daily dose?
1. 5.1 mEq/L
2. 4.2 mEq/L
3. 3.8 mEq/L
4. 3.0 mEq/L

 

 

 

  1. The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that the presence of which of the following could cause a false-negative result?
1. Iodine
2. Colchicine
3. Ascorbic acid
4. Acetylsalicylic acid

 

 

  1. The nurse receives a telephone laboratory report indicating that a diabetic client has a glycosylated hemoglobin A1c level of 7.6%. The nurse plans to provide diabetic teaching in which of the following priority areas?
1. Avoidance of infection
2. Rotation of insulin injection sites
3. Measures to prevent hyperglycemia
4. Avoidance of hypoglycemic episodes

 

 

MULTIPLE RESPONSE

 

  1. The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client that it is most important to immediately report which of the following symptoms of a transfusion reaction, if they occur? Select all that apply.
1. Chills
2. Sleepiness
3. Fatigue
4. Chest pain
5. Low back pain
6. Difficulty breathing

 

 

  1. The nurse is monitoring the client for hypocalcemia. Which of the following are indicative of this imbalance? Select all that apply.
1. Muscle cramps
2. Tingling sensations
3. Hyperactive reflexes
4. Severe muscle weakness
5. Irritability
6. Memory impairment

 

 

 

 

Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition

 

Pharmacology

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a client in labor. The nurse reviews the physician’s prescriptions and notes that the client has a prescription for butorphanol tartrate (Stadol). The nurse understands that this medication is prescribed for:
1. Pain relief
2. Increasing uterine contractions
3. Decreasing uterine contractions
4. Promoting fetal lung maturity

 

 

  1. The postpartum nurse is caring for a client with an epidural catheter in place for opioid analgesic administration following cesarean birth. If the client develops respiratory depression and requires naloxone (Narcan) as an antidote, the client may complain of which of the following?
1. Increase in her pain level
2. Decrease in her pain level
3. Increase in the amount of itching from the opioid used in the epidural
4. Decrease in the amount of itching from the opioid used in the epidural

 

 

  1. A client experiencing preterm labor at the twenty-ninth week of gestation has been admitted to the hospital. The client has a prescription to receive betamethasone (Celestone). The nurse understands that the medication will do which of the following?
1. Prevent spontaneous delivery.
2. Stop the uterine contractions.
3. Promote maturation of the fetal lungs.
4. Accelerate the growth rate of the fetus.

 

 

  1. A client with preeclampsia is receiving magnesium sulfate. The nurse assesses the client closely for which sign of magnesium toxicity?
1. Proteinuria
2. Hyperactive deep tendon reflexes
3. Respiratory rate of 10 breaths/min
4. Serum magnesium level of 5 mEq/L

 

 

  1. A pregnant client who has human immunodeficiency virus (HIV) infection is being seen in the antenatal clinic. The nurse recalls that zidovudine (AZT) therapy will be initiated when the fetus has reached how many weeks of gestation?
1. 4
2. 14
3. 24
4. 34

 

 

  1. The nurse has a routine prescription to instill erythromycin ointment (Ilotycin) into the eyes of a newborn. The nurse plans to explain to the parents that the purpose of the medication is to:
1. Help the newborn to see more clearly.
2. Guard against infection acquired during intrauterine life.
3. Ensure the sterility of the conjunctiva in the newborn.
4. Protect the newborn from contracting an eye infection during birth.

 

  1. The nurse has a routine prescription to administer an injection of phytonadione (vitamin K) to the newborn. Before giving the medication, the nurse explains to the client that this medication will:
1. Prevent clotting abnormalities in the newborn.
2. Stimulate the liver to produce vitamin K.
3. Prevent vitamin deficiency of fat-soluble vitamins.
4. Supplement the infant, because breast milk and formula are low in vitamin K.

 

 

  1. The client who has developed atrial fibrillation is not responding to medication therapy and has been placed on warfarin (Coumadin). The nurse is doing discharge dietary teaching with the client. The nurse would tell the client to avoid which of the following foods while taking this medication?
1. Cherries
2. Potatoes
3. Broccoli
4. Spaghetti

 

 

  1. A client in preterm labor is being started on intravenous magnesium sulfate to stop the contractions. The nurse checks the medication to ensure that which medication is available as an antidote if needed?
1. Magnesium oxide
2. Vitamin K
3. Aluminum hydroxide
4. Calcium gluconate

 

 

 

  1. The nurse had just given an intramuscular dose of methylergonovine (Methergine) to a client following delivery of an infant. The nurse determines that this medication had the intended effect after evaluating for which of the following findings?
1. Decreased pulse rate
2. Increased urine output
3. Improved uterine tone
4. Increased blood pressure

 

 

  1. The nurse is told that the result of a serum carbamazepine (Tegretol) level for a child who is receiving the medication for the control of seizures is 10 mcg/mL. Based on this laboratory result, the nurse anticipates that the physician will prescribe:
1. Discontinuation of the medication
2. A decrease of the dosage of the medication
3. An increase of the dosage of the medication
4. Continuation of the presently prescribed dosage

 

 

  1. The nurse is providing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which of the following statements, if made by the mother, indicates an understanding of the use of this medication?
1. “I shouldn’t rub the medication into the skin.”
2. “The medication is applied everywhere except the face.”
3. “I need to wash the sites gently before I apply the medication.”
4. “I need to apply the medication generously and allow it to absorb.”

 

 

  1. The nurse working in the ambulatory care center is providing medication instructions about methylphenidate (Ritalin) to the mother of a child with attention-deficit/hyperactivity disorder (ADHD). The nurse recommends that the mother give the medication to the child:
1. At bedtime
2. With the evening meal
3. Just before the noontime meal
4. In the morning, 2 hours before breakfast

 

 

  1. A child has been prescribed to take tetracycline hydrochloride. The nurse providing medication information to the mother would plan to emphasize which of the following most important instructions about giving this medication to the child?
1. Give the medication with milk.
2. Give the medication with ice cream.
3. Mix the medication in a Styrofoam cup.
4. Use a straw when giving the medication.

 

 

  1. The nurse is providing instructions to the parent of a child with iron deficiency anemia about the administration of a liquid oral iron supplement. Which of the following statements, if made by the parent, indicates an understanding of the administration of this medication?
1. “I should give the iron with food.”
2. “I can mix the iron with cereal to give it.”
3. “I should add the iron to the formula in the baby’s bottle.”
4. “I should use a medicine dropper and place the iron near the back of the throat.”

 

 

  1. The client with psoriasis is being treated with calcipotriene (Dovonex) cream. Administration of high doses of this medication can cause which side effect?
1. Alopecia
2. Hyperkalemia
3. Hypercalcemia
4. Thinning of the skin

 

 

  1. Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which of the following should the nurse include in the instructions?
1. Apply twice a day, and leave it open to the air.
2. Apply once a day, and leave it open to the air.
3. Apply twice a day, and cover it with a sterile dressing.
4. Apply once a day, and cover it with a sterile dressing.

 

  1. A nurse is caring for a female client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium (Solaraze). The nurse teaches the client that this medication is from which class of medications?
1. Anti-infectives
2. Vitamin A lotions
3. Coal tar preparations
4. Nonsteroidal anti-inflammatory drugs (NSAIDs)

 

TOP:    Content Area: Pharmacology

MSC:   Integrated Process: Teaching and Learning

 

  1. The client with muscle aches and a diagnosis of rheumatism has been given a prescription for capsaicin topical cream. The nurse evaluates that the client understands the use of the medication if the client states that:
1. The medication will act as a local analgesic.
2. The medication acts by decreasing muscle spasms.
3. The medication will cause redness, flaking, and the skin to peel.
4. A heating pad should be put on the area after applying the medication.

 

 

  1. The client with a burn injury is applying mafenide (Sulfamylon) to the wound. The client calls the physician’s office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse instructs the client to:
1. Discontinue the medication.
2. Apply a thinner film than prescribed to the burn site.
3. Continue with the treatment, as this is expected.
4. Come to the office to see the physician immediately.

 

 

  1. The client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite (Dakin solution) to be used in the care of the wound. The nurse would do which of the following while using this solution?
1. Rinse off immediately following irrigation.
2. Pour onto sterile sponges, and pack in wound.
3. Let the solution run freely over normal skin tissue.
4. Use each bottle of solution for 2 weeks before replacing.

 

  1. An adolescent client with severe cystic acne has been prescribed isotretinoin (Accutane). Which statement by the client would suggest the need for further teaching?
1. “I will return to the clinic for blood tests.”
2. “If my lips begin to burn, it is probably because of the medication.”
3. “My eyes may become dry and burn as a result of the medication.”
4. “I need to take my vitamin A supplement so that the treatment will work.”

 

 

  1. An ambulatory care client with allergic dermatitis has been given a prescription for a tube of diphenhydramine (Benadryl) 1% to use as a topical agent. The nurse determines that the medication was effective if which of the following was assessed?
1. Nighttime sedation
2. Decrease in urticaria
3. Absence of ecchymoses
4. Healing of burned tissue

 

  1. The client with cancer has received a course of chemotherapy and received fluorouracil (Adrucil). The nurse should plan to tell the client to report which of the following immediately?
1. Alopecia
2. Headache
3. Stomatitis and diarrhea
4. Changes in color vision

 

  1. The nurse reviewing a medical record notes that high concentrations of methotrexate followed by leucovorin (citrovorum factor, folic acid) are being given to the client with cancer. The nurse correctly interprets that the reason for therapy with leucovorin is to:
1. Preserve normal cells.
2. Promote protein synthesis.
3. Promote medication excretion.
4. Hasten the effect of the methotrexate.

 

  1. The nurse understands that an indication for the use of asparaginase (Elspar) is:
1. Lung cancer
2. Breast cancer
3. Metastatic prostate cancer
4. Acute lymphocytic leukemia

 

 

  1. The nurse is caring for a client on the oncology unit who has developed stomatitis during chemotherapy. The nurse would plan which of the following measures to treat this complication?
1. Rinse the mouth with diluted baking soda or saline.
2. Use lemon and glycerin swabs liberally on painful oral lesions.
3. Place the client on NPO status for 12 hours, then resume liquids.
4. Brush the teeth and use nonwaxed dental floss at least twice a day.

 

 

  1. The client who has been diagnosed with cancer is to receive chemotherapy with both cisplatin (Platinol-AQ) and vincristine (Oncovin). The client asks the nurse why both medications must be given together. The nurse’s response is based on the understanding that the purpose of using both medications is to:
1. Prevent the destruction of normal cells.
2. Increase the destruction of tumor cells.
3. Decrease the risk of the alopecia and stomatitis.
4. Increase the likelihood of erythrocyte and leukocyte recovery.

 

  1. The nurse tells the client with leukemia who is receiving chemotherapy that allopurinol (Zyloprim) has been added to the medication list. When the client asks the purpose of the new medication, the nurse responds that the allopurinol is intended to prevent:
1. Nausea
2. Diarrhea
3. Muscle spasms
4. Hyperuricemia

 

 

  1. The client with breast cancer has been given a prescription for cyclophosphamide (Cytoxan). The nurse determines that the client understands the proper use of the medication if the client states that he or she will:
1. Increase dietary intake of potassium.
2. Take the medication with large meals.
3. Decrease dietary intake of magnesium.
4. Increase fluid intake to 2 to 3 L/day.

 

 

  1. The nurse should be prepared to institute bleeding precautions in the client receiving antineoplastic medication if which of the following results were reported from the lab?
1. Clotting time, 12 seconds
2. Ammonia level, 28 mcg/dL
3. Platelet count, 50,000 cells/mm3
4. White blood cell count (WBC), 4500/mm3

 

 

  1. The client with cancer is about to be started on mitomycin (Mutamycin). The nurse should suggest contacting the physician after noting that the client is also taking which of the following medications?
1. Furosemide (Lasix)
2. Ondansetron (Zofran)
3. Warfarin (Coumadin)
4. Allopurinol (Zyloprim)

 

 

  1. A client with diabetes mellitus taking daily NPH insulin has been started on therapy with dexamethasone (Decadron). The nurse anticipates that which of the following adjustments in medication dosage will be made?
1. Decreased NPH insulin
2. Increased NPH insulin
3. Lower dose of dexamethasone (Decadron) than usual
4. Higher dose of dexamethasone (Decadron) than usual

 

 

  1. The nurse monitors the blood glucose level of the client who received NPH insulin at 7 AM with an understanding that the client may experience a hypoglycemic reaction between:
1. 9 to 11 AM
2. 1 to 7 PM
3. 7 to 11 PM
4. Midnight to 6 AM

 

 

  1. The nurse evaluates that the family of a client newly diagnosed with diabetes mellitus correctly understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat:
1. Diabetic ketoacidosis
2. Hypoglycemia from insulin overdose
3. Hyperglycemia from insufficient insulin
4. Hyperglycemia occurring on “sick days”

 

 

  1. The nurse is teaching a client with hyperthyroidism regarding the prescribed medication propylthiouracil (PTU). The nurse determines that teaching has been successful if the client states that he will report which of the following symptoms to the physician?
1. Fever
2. Nervousness
3. Tiredness
4. Fatigue

 

 

 

  1. The nurse teaches the client with hypocalcemia to take calcium carbonate (Os-Cal) at which time?
1. With breakfast
2. At lunch time
3. Just before a meal
4. One hour after a meal

 

 

  1. The nurse teaches the client being discharged to home with a prescription for a daily dose of prednisone to take the medication:
1. In the early morning
2. In the middle of the day
3. An hour before bedtime
4. Anytime of the day

 

 

  1. The nurse monitors the client taking octreotide acetate (Sandostatin) for acromegaly for which most frequent side effect of this medication?
1. Diarrhea
2. Dyspnea
3. Constipation
4. Bradycardia

 

 

 

  1. A client with a history of coronary artery disease has developed diabetes insipidus as a result of cranial surgery. The client’s medication therapy will include vasopressin (Pitressin). The nurse monitors this client most carefully for which of the following sign/ symptom that indicates an adverse effect of this medication?
1. Depression
2. Chest pain
3. Nagging cough
4. Joint stiffness

 

MSC:   Integrated Process: Nursing Process—Assessment

 

  1. The client has a prescription for sucralfate (Carafate) four times daily. The nurse writes in the medication record to administer the medication at which of the following times?
1. With meals and at bedtime
2. Every 6 hours around the clock
3. One hour after meals and at bedtime
4. One hour before meals and at bedtime

 

 

  1. The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) has begun taking misoprostol (Cytotec). Evaluation of the effectiveness of the misoprostol in preventing a side effect of chronic NSAID use is determined by the nurse if the client reports which of the following?
1. “I have fewer muscle aches.”
2. “My joint mobility has improved.”
3. “I no longer have pain above my stomach.”
4. “I am no longer experiencing constipation.”

 

 

  1. The client in the preoperative holding area has been given a dose of scopolamine. The nurse assesses the client for which of the following side effects of the medication?
1. Dry mouth
2. Diaphoresis
3. Excessive urination
4. Pupillary constriction

 

 

  1. The client with gastroesophageal reflux disease (GERD) has a new prescription for pantoprazole (Protonix). Which of the following instructions should the nurse plan to provide to the client?
1. Chew the pill thoroughly.
2. Swallow the tablet whole.
3. Crush the pill if it is difficult to swallow.
4. Headache is expected to occur.

 

 

  1. The client is experiencing diarrhea. The nurse reviews the client’s PRN medication prescription sheet and plans to administer which of the following medications for this problem?
1. Sennosides (Senokot)
2. Bisacodyl (Dulcolax Bowel Prep Kit)
3. Psyllium (Metamucil)
4. Loperamide (Imodium)

 

 

  1. The client with recurrent constipation has been prescribed psyllium (Metamucil). Teaching provided by the nurse should include which of the following instructions?
1. Mix the psyllium powder with any cold beverage.
2. Mix the psyllium powder with 4 oz of a hot beverage.
3. Mix the psyllium powder with gelatin, applesauce, or pudding.
4. Mix the psyllium powder with 8 oz of water or juice followed by drinking an additional 8 oz of liquid.

 

 

  1. The nurse is reading the medication list for a postoperative client and notes that a PRN prescription for ondansetron (Zofran) was administered. Evaluation of the effectiveness of the medication is determined by the nurse if the client makes which of the following statements?
1. “My headache is gone.”
2. “The dizziness has stopped.”
3. “I no longer feel nauseous.”
4. “The pain at my incision has decreased.”

 

 

 

  1. An older client has been receiving cimetidine (Tagamet). The nurse should report to the physician that the client is experiencing a side effect of the medication if which of the following is noted during the assessment?
1. Tremors
2. Stiff joints
3. Confusion
4. Constipation

 

  1. The nurse monitors the client receiving the first dose of albuterol (Proventil HFA) for which of the following side effects of this medication?
1. Drowsiness
2. Tachycardia
3. Hyperglycemia
4. Hyperkalemia

 

 

  1. The client has a prescription to receive pirbuterol (Maxair) two puffs and beclomethasone two puffs by metered-dose inhaler. The nurse plans to give these medications most effectively by:
1. Administering the beclomethasone before the pirbuterol
2. Administering the pirbuterol before the beclomethasone
3. Alternating a single puff of each hourly, beginning with the beclomethasone
4. Alternating a single puff of each hourly, beginning with the pirbuterol

 

 

  1. The client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone (Azmacort) by inhalation. The nurse plans to monitor the client for which of the following signs and symptoms during the change?
1. Chills, fever, generalized rash
2. Vomiting and diarrhea, increased thirst
3. Blurred vision, headache, and insomnia
4. Anorexia, nausea, weakness, and fatigue

 

 

 

  1. The client taking theophylline has a serum theophylline level of 15 mcg/mL. The nurse interprets that this result is _____ the therapeutic range.
1. Below
2. Near the top of
3. In excess of
4. In the middle of

 

 

  1. The client is taking cetirizine (Zyrtec). The nurse teaches the client to expect which of the following side effects of this medication?
1. Diarrhea
2. Excitability
3. Drowsiness
4. Excess salivation

 

 

  1. The client is scheduled to receive acetylcysteine (Mucomyst) 20% solution diluted in 0.9% normal saline by nebulizer. Which of the following outcomes would the nurse expect to see as a result of the administration of this medication?
1. Bronchodilation
2. Decreased coughing
3. Absence of wheezing
4. Thinning of respiratory secretions

 

 

  1. The physician prescribes cromolyn (Intal) for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will:
1. Suppress an allergic response.
2. Promote bronchodilation.
3. Decrease the risk of infection.
4. Eliminate the need for a rescue inhaler.

 

  1. The nurse teaching the client about the effects of diphenhydramine (Benadryl), an ingredient in the cough suppressant prescribed for the client, should plan to tell the client to do which of the following while taking this medication?
1. Take it on an empty stomach.
2. Avoid activities requiring mental alertness.
3. Use alcohol for additional effect in reducing cough.
4. Avoid chewing sugarless gum or using oral rinses mouth.

 

 

  1. The physician has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse teaches the client to monitor for:
1. Constipation
2. Painful coughing
3. Difficulty swallowing
4. Increased urination

 

 

  1. A client with heart disease is taking digoxin (Lanoxin) and complains of having no appetite, diarrhea, and blurry vision. The nurse notes that the client’s serum potassium (K) level is 3.0 ng/mL. Based on analysis of the data, what might the nurse anticipate assessing when reviewing the digoxin level results?
1. Digoxin level lower than 0.5 ng/mL
2. Digoxin level higher than 2 ng/mL
3. Digoxin level of 1.8 ng/mL
4. Digoxin level of 0 ng/mL because of diarrhea

 

 

 

  1. The nurse is providing medication information to a client who is beginning medication therapy with enalapril (Vasotec). The nurse reminds the client that which of the following is an anticipated, although unpleasant, side effect of this medication?
1. Rapid pulse
2. Persistent dry cough
3. Increased blood pressure
4. Metallic taste in the mouth

 

 

  1. A client has recently begun medication therapy with propranolol (Inderal). The long-term care nurse should plan to notify the physician if which of the following assessment findings is noted?
1. Complaints of insomnia
2. Audible expiratory wheezes
3. Decrease in heart rate from 86 to 78 beats/min
4. Decrease in blood pressure from 162/90 to 136/84 mm Hg

 

 

  1. A client having a myocardial infarction is receiving alteplase (Activase) therapy. Which of the following actions should be carried out by the nurse to monitor for the most frequent adverse effect?
1. Monitor for bleeding.
2. Assess for allergic reaction.
3. Evaluate the client for muscle weakness.
4. Monitor for signs and symptoms of infection.

 

  1. A client is receiving scheduled doses of lovastatin (Mevacor). The nurse evaluates that the medication is having the intended effect if the nurse notes which of the following client data?
1. Weight loss
2. Increased pulse rate
3. Lowered blood pressure
4. Decreased cholesterol level

 

 

  1. A client taking verapamil (Calan) has been given information about side effects of this medication. The nurse determines that the client understands the information shared if the client states that he or she will watch for which of the following most common side effects of this medication?
1. Weight loss
2. Constipation
3. Nasal stuffiness
4. Abdominal cramping

 

 

 

  1. The nurse has a prescription to give a first dose of hydrochlorothiazide (HydroDIURIL) to an assigned client. The nurse would question the prescription if the client has a history of allergy to which of the following?
1. Iodine
2. Shellfish
3. Penicillin
4. Sulfa drugs

 

 

  1. The nurse has a prescription to give a client a scheduled dose of digoxin (Lanoxin). Prior to administering the medication, the nurse assesses for which of the following manifestations that could indicate digoxin toxicity?
1. Dyspnea, edema, and palpitations
2. Chest pain, hypotension, and paresthesias
3. Constipation, dry mouth, and sleep disorder
4. Double vision, loss of appetite, and nausea

 

 

  1. A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client’s blood pressure and administers nitroglycerin, gr 1/4 sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which of the following actions next?
1. Administer another nitroglycerin tablet.
2. Administer 10 L of oxygen via nasal cannula.
3. Call for a 12-lead electrocardiogram (ECG) to be performed.
4. Wait an additional 5 minutes, then give a second nitroglycerin tablet.

 

 

 

  1. The long-term care client with a history of heart failure has developed paroxysmal nocturnal dyspnea (PND). The nurse reviews the client’s medication record and determines that which of the following medications has been prescribed to treat the PND?
1. Bumetanide (Bumex)
2. Propranolol (Inderal)
3. Warfarin (Coumadin)
4. Acetylsalicylic acid (aspirin)

 

 

 

  1. The nurse is working with a client receiving an intravenous heparin sodium drip. The nurse should review which of the following laboratory studies to determine the therapeutic effect of heparin for the client?
1. Bleeding time
2. Thrombin time
3. Prothrombin time (PT)
4. Partial thromboplastin time (PTT)

 

 

  1. The ambulatory care nurse is providing instructions to a client with a urinary tract infection (UTI) being started on medication therapy with nitrofurantoin (Macrodantin), a urinary antiseptic agent. The nurse tells the client that:
1. It can cause urinary retention.
2. It will cause the urine to become clear.
3. If taken with meals, it will help decrease the risk for gastrointestinal (GI) upset.
4. The sun should be avoided because it is a sulfa-based medication.

 

  1. A client is beginning to take trimethoprim-sulfamethoxazole (Bactrim) for a recurrent urinary tract infection (UTI). The nurse would give the client which of the following instructions regarding this medication?
1. Discontinue medication when symptoms subside.
2. Expect rashes or skin changes as a result of therapy.
3. Take most doses early in the day when fluid intake is greatest.
4. Take each dose with 8 oz of water, and drink extra water each day.

 

  1. A client with a urinary tract infection (UTI) has been prescribed to take ciprofloxacin (Cipro). The nurse notes that the client also has a prescription for theophylline written by a pulmonologist. The nurse should do which of the following?
1. Clarify the medication prescriptions.
2. Encourage intake of antacids.
3. Schedule the doses to be given together.
4. Schedule the doses to be given at the same time.

 

 

  1. The client with a urinary tract infection (UTI) has dysuria and is given a prescription for phenazopyridine (Pyridium) for symptom relief. The nurse provides medication teaching with this client and tells the client to:
1. Take the medication at bedtime.
2. Take the medication before meals.
3. Notify the physician if headache occurs.
4. Expect the urine to become reddish-orange.

 

 

  1. The nurse is preparing a subcutaneous dose of bethanechol (Urecholine) prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which of the following medications is available on the emergency cart for use if needed?
1. Vitamin K
2. Mucomyst
3. Atropine sulfate
4. Protamine sulfate

 

 

  1. A client who has undergone renal transplant is receiving ongoing therapy with cyclosporine (Sandimmune). The nurse would be sure to immediately report the results of periodic laboratory results that indicate which of the following?
1. Decreased creatinine level
2. Decreased hemoglobin level
3. Elevated blood urea nitrogen (BUN) level
4. Decreased white blood cell (WBC) count

 

 

 

  1. A client is receiving tacrolimus (Prograf) to prevent organ rejection. Which of the following is a nursing considerations associated with this medication?
1. Give with cyclosporine (Sandimmune).
2. Assess for hypoglycemia.
3. Give with grapefruit juice.
4. Assess platelet count for thrombocytopenia.

 

  1. A client must begin medication therapy with mycophenolate mofetil (CellCept) to prevent organ rejection following renal transplantation. The nurse plans to provide which of the following teaching points to the client?
1. Take the dose following meals.
2. Notify the physician if a fever develops.
3. Open the capsule and mix with food before use.
4. Take the medication with an aluminum-based antacid.

 

 

  1. The client in renal failure is receiving epoetin alfa (Epogen). The nurse would monitor this client for which adverse effect of this medication?
1. Depression
2. Bradycardia
3. Fever
4. Hypertension

 

 

 

  1. The preoperative medication sheet identifies that cyclopentolate (Cyclogyl) is prescribed for a client prior to cataract surgery. The nurse understands that the action of the medication is to:
1. Lubricate the affected eye.
2. Dilate the pupil of the affected eye.
3. Promote miosis of the affected eye.
4. Constrict the pupil of the affected eye.

 

  1. The client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client:
1. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid
2. Lies supine, pulls down on the lower lid, and puts the drop in the lower lid
3. Tilts the head back, pulls down on the lower lid, and puts the drop in the lower lid
4. Lies with head to the right, puts the drop in the inner canthus, and slowly turns to the left while blinking

 

 

  1. The nurse teaching a mother how to administer ear drops to an infant tells the mother to pull the child’s ear:
1. Up and back and direct the solution onto the eardrum
2. Down and back and direct the solution onto the eardrum
3. Up and back and direct the solution toward the wall of the canal
4. Down and back and direct the solution toward the wall of the canal

 

 

  1. The nurse is describing medication side effects to a client who is taking a benzodiazepine. The nurse tells the client to take the medication only as prescribed because of the most serious risk of:
1. Headache
2. Skin rashes
3. Dependence
4. Gastrointestinal side effects

 

 

  1. The nurse would question the physician if which of the following medications was prescribed for a client with glaucoma?
1. Pilocarpine HCl (Pilocar)
2. Pilocarpine nitrate
3. Atropine sulfate (Isopto Atropine)
4. Carteolol hydrochloride (Ocupress)

MSC:   Integrated Process: Nursing Process—Implementation

 

  1. When teaching the client about the effects of a miotic medication, the nurse plans to tell the client that the medication will:
1. Reshape the lens to eliminate blurred vision.
2. Interrupt the drainage of aqueous humor from the eye.
3. Dilate the pupil to reduce intraocular pressure.
4. Lower intraocular pressure and improve blood flow to the retina.

 

 

 

  1. Betaxolol (Betoptic) eye drops have been prescribed for the client with glaucoma. The nurse monitoring this client for side effects of the medication would place highest priority on which of the following?
1. Pulse rate
2. Blood glucose
3. Respiratory rate
4. Oxygen saturation

 

 

  1. The client who has sustained an eye injury has been prescribed prednisolone (Inflamase). The nurse would most carefully monitor for side effects of this medication if the client has which of the following health problems listed on the medical record?
1. Cirrhosis
2. Hypertension
3. Diabetes mellitus
4. Chronic constipation

 

  1. The client with chronic glaucoma is being started on medication therapy with acetazolamide (Diamox). The nurse teaches the client that which of the following symptoms can occur early in the use of this medication?
1. Diuresis
2. Fatigue
3. Headache
4. Loss of libido

 

 

  1. The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen (Tylenol) overdose. Which of the following medications should the nurse plan to have readily available if the suspected diagnosis is confirmed?
1. Auranofin (Ridaura)
2. Pentostatin (Nipent)
3. Fludarabine (Fludara)
4. Acetylcysteine (Mucomyst)

 

 

  1. The client reports frequent use of acetaminophen (Tylenol) for relief of frequent headaches and other discomforts. The nurse should evaluate which of the diagnostic data to determine if the client is at risk for toxicity?
1. The chest x-ray
2. The upper gastrointestinal x-ray results
3. The electrocardiogram
4. The liver function studies

 

 

  1. The client with a history of spinal cord injury is beginning medication therapy with baclofen (Lioresal). The nurse determines that the client understands the side effects of the medication if the client states which of the following?
1. “The medication may make me drowsy.”
2. “The medication can cause high blood pressure.”
3. “The medication may increase my sensitivity to bright light.”
4. “The medication may cause me to have some muscle pain.”

 

 

  1. The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Tensilon). Evaluation of the results indicates that the test is positive. Which of the following would be the expected response noted by the nurse?
1. Joint pain for the next 15 minutes
2. A decrease in muscle strength within 1 to 3 minutes
3. An increase in muscle strength within 1 to 3 minutes
4. Feelings of faintness or dizziness for 5 to 10 minutes

 

 

  1. The nurse is assisting in the care of a client with myasthenia gravis who is receiving pyridostigmine (Mestinon). Which of the following medications should the nurse plan to have readily available should the client develop cholinergic crisis because of excessive medication dosage?
1. Vitamin K
2. Atropine sulfate
3. Protamine sulfate
4. Acetylcysteine (Mucomyst)

 

MSC:   Integrated Process: Nursing Process—Planning

 

  1. The client with myasthenia gravis becomes increasingly weaker. The physician injects a dose of edrophonium (Tensilon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which of the following reactions if the client is in cholinergic crisis?
1. No change in the condition
2. Complaints of muscle spasms
3. An improvement of the weakness
4. A temporary worsening of the condition

 

  1. The nurse is providing instructions to a client beginning medication therapy with divalproex sodium (Depakote) for treatment of absence seizures. The nurse instructs the client that which of the following represents the most frequent side effect of this medication?
1. Tinnitus
2. Irritability
3. Blue vision
4. Nausea and vomiting

 

 

  1. The nurse is speaking with a female client taking phenytoin (Dilantin) for seizure control. The client states that she has started using birth control pills to prevent pregnancy. Which of the following would be an important point for the nurse to stress to the client?
1. Oral contraceptives decrease the effectiveness of phenytoin.
2. Severe gastrointestinal side effects can occur when phenytoin and oral contraceptives are taken together.
3. There is an increased risk of thrombophlebitis when phenytoin and oral contraceptives are taken at the same time.
4. Phenytoin may decrease effectiveness of birth control pills, and additional measures should be taken to avoid pregnancy.

 

 

  1. The nurse is reading the laboratory results for a client being treated with carbamazepine (Tegretol) for prophylaxis of complex partial seizures. When evaluating the client’s laboratory data, the nurse determines that which of the following values is consistent with an adverse effect of this medication?
1. Blood urea nitrogen (BUN), 19 mg/dL
2. Sodium level, 136 mEq/L
3. Platelet count, 350,000/mm3
4. White blood cell count, 3200/mm3

 

  1. The nurse is caring for a client receiving codeine sulfate for pain. The nurse determines that the client is experiencing a side effect of the medication based on which of the following findings?
1. Distended jugular veins
2. Bounding peripheral pulses
3. No bowel movement in 3 days
4. Change in blood pressure from 120/60 to 140/80 mm Hg

 

 

  1. The nurse is administering a prescribed dose of dexamethasone (Decadron) to a client following cranial surgery. Which of the following interventions would the nurse perform to assess for a common side effect of this medication?
1. Monitor for hair loss.
2. Monitor laboratory test results for hyperkalemia.
3. Assess for decreased skin turgor.
4. Obtain a prescription for blood glucose monitoring.

 

  1. The client with a new medication prescription for allopurinol (Zyloprim) asks the nurse, “I know this is for gout, but how does it work?” In formulating a response, the nurse understands that allopurinol:
1. Decreases uric acid production
2. Reduces the production of fibrinogen
3. Lowers the risk of sulfa crystal formation in the urine
4. Prevents influx of calcium ions during cell depolarization

 

 

 

  1. The client newly diagnosed with gout has been prescribed allopurinol (Zyloprim). The nurse would be concerned if the client was also currently taking:
1. Digoxin (Lanoxin)
2. Adenosine (Adenocard)
3. Warfarin (Coumadin)
4. Ergonovine maleate (Ergotrate)

 

 

 

  1. The client tentatively diagnosed with gout has received a prescription for colchicine. The nurse understands that colchicine is a(n):
1. Anti-inflammatory agent specific for gout
2. Nonsteroidal anti-inflammatory drug (NSAID)
3. Analgesic that relieves pain
4. Osmotic diuretic that facilitates the removal of uric acid

 

  1. The client with osteoarthritis is receiving diclofenac sodium (Voltaren). The nurse would be concerned about the administration of this medication if the client’s history and physical included a diagnosis of:
1. Graves’ disease
2. Peptic ulcer disease
3. Coronary artery disease
4. Benign prostatic hypertrophy

 

 

  1. Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse determines that the medication is having the intended effect if which of the following is noted in the client?
1. Increased muscle tone
2. Increased range of motion
3. Decreased muscle spasms
4. Decreased local pain and tenderness

 

  1. Dantrolene sodium (Dantrium) is prescribed for the client experiencing flexor spasms. The client asks the nurse how the medication is going to help. The nurse replies that this medication acts:
1. To depress the spinal reflexes causing the spasms
2. On the central nervous system (CNS) to suppress spasms
3. Directly on the skeletal muscle to relieve the spasms
4. Within the spinal cord to suppress excess reflex activity

 

  1. The nurse is reviewing laboratory results for a client taking dantrolene sodium (Dantrium). The nurse should notify the physician if which of the following is noted on the laboratory report sheet?
1. Creatinine level, 0.6 mg/dL
2. Platelet count, 290,000/mm3
3. Blood urea nitrogen (BUN) level, 9 mg/dL
4. Lactic dehydrogenase (LDH) level, 600 units/L

 

 

  1. The nurse is reviewing the medical record of a newly assigned client and notes that the client is receiving cyclobenzaprine hydrochloride (Flexeril) for the treatment of muscle spasms. The nurse questions the prescription if which of the following disorders is noted in the admission history?
1. Hypothyroidism
2. Chronic bronchitis
3. Recurrent pneumonia
4. Angle-closure glaucoma

 

 

 

  1. The nurse is assigned to care for a client with multiple sclerosis who is receiving an intravenous (IV) dose of methocarbamol (Robaxin). The nurse monitors the client knowing that which of the following is an expected side effect?
1. Dark green colored urine
2. Excitability
3. Insomnia
4. Hypertension

 

  1. The nurse is collecting data from a client with a history of renal transplantation. The nurse understands that the medication of choice for preventing organ rejection is:
1. Probenecid
2. Indomethacin (Indocin)
3. Prednisone
4. Cyclosporine (Sandimmune)

 

  1. Cyclosporine (Sandimmune) is prescribed for the client following allogenic kidney transplantation. The nurse provides instructions to the client regarding the medication and tells the client that:
1. There are no known adverse effects of the medication.
2. The medication will need to be taken for a period of 6 months.
3. Blood levels of the medication will need to be measured periodically.
4. The medication is administered by the intravenous (IV) route on a monthly basis.

 

 

  1. Blood work has been drawn on a client who has been taking cyclosporine (Sandimmune) following allogenic liver transplantation. The nurse checks the results of which of the following tests to determine the presence of an adverse effect related to this medication?
1. Hematocrit level
2. Hemoglobin level
3. Cholesterol level
4. Blood urea nitrogen (BUN) level

 

 

  1. Dapsone (DDS) is prescribed for a client with acquired immunodeficiency syndrome (AIDS) for the treatment of toxoplasmosis. The nurse provides medication instructions and determines that the client understands the instructions if the client states that he or she will:
1. Report a sore throat to the physician.
2. Discontinue the medication if nausea develops.
3. Plan to take the medication every 4 hours around the clock.
4. Expect that abdominal pain and jaundice will occur as normal side effects.

 

 

  1. The client who is seropositive for human immunodeficiency virus (HIV) has been taking ritonavir (Norvir). The nurse tells the client that which follow-up laboratory study will be necessary while taking this medication?
1. Platelet count
2. Triglyceride level
3. Prothrombin time (PT)
4. International normalized ratio (INR)

 

 

  1. The client who is seropositive for human immunodeficiency virus (HIV) has been taking stavudine (d4T, Zerit XR). The nurse assesses which of the following most closely while the client is taking this medication?
1. Appetite
2. Gastrointestinal function
3. Presence of paresthesia
4. Level of consciousness (LOC)

 

  1. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet (Foscavir). The nurse reviews the physician’s prescriptions, expecting to note a prescription for which of the following laboratory tests while this client is taking the medication?
1. CD4+ cell count
2. Serum albumin level
3. Serum creatinine level
4. Lymphocyte count

 

  1. The client with acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The nurse caring for the client monitors the client most closely for signs of:
1. Nausea
2. Fatigue
3. Infection
4. CD4+ cell count

 

 

  1. The client with human immunodeficiency virus (HIV) infection has been started on therapy with zidovudine (AZT, Retrovir). The nurse reviews the physician’s prescriptions, expecting to note that which of the following laboratory tests have been prescribed?
1. Blood culture
2. Blood glucose level
3. Blood urea nitrogen level (BUN)
4. Complete blood cell count (CBC)

 

 

  1. The nurse is preparing to administer pentamidine isethionate (Pentam 300) to an assigned client by the intravenous route. The nurse plans to monitor which of the following most closely after administering this medication?
1. Capillary refill
2. Peripheral pulses
3. Blood pressure (BP)
4. Level of consciousness

 

 

  1. Ketoconazole (Nizoral) is prescribed for an assigned client. The nurse prepares to administer the medication:
1. With food
2. With an antacid
3. With 8 oz of water
4. On an empty stomach

 

  1. A client receiving long-term therapy with lithium carbonate (Lithobid) exhibits muscle tremors, confusion, vomiting, and diarrhea. The nurse anticipates that the results of the latest test of the serum lithium level will be between:
1. 0 and 0.5 mEq/L
2. 0.6 and 1.0 mEq/L
3. 1.0 and 1.3 mEq/L
4. 1.5 and 2.0 mEq/L

 

 

  1. The nurse is administering thioridazine hydrochloride (Mellaril). The nurse will monitor the client carefully for which of the following?
1. Weight gain
2. Photosensitivity
3. Cardiac dysrhythmias
4. Extrapyramidal movements

 

  1. A client has been started on therapy with lithium carbonate (Lithobid). The nurse instructs the client to do which of the following?
1. Limit salt intake.
2. Limit food intake.
3. Maintain a fluid intake of 2 to 3 L/day.
4. Stop the medication if gastrointestinal (GI) disturbances occur.

 

 

  1. The nurse is discussing the past week’s activities with a client receiving amitriptyline hydrochloride. The nurse determines that the medication is most effective for this client if the client reports which of the following?
1. A decrease in appetite
2. Sleeping 14 to 16 hours each day
3. Ability to get to work on time each day
4. Having difficulty concentrating on an activity

 

 

 

  1. The client taking buspirone hydrochloride (BuSpar) for 1 month is scheduled for a follow-up appointment. The nurse gathers data from the client and interprets that the medication is effective if the client reports an absence of:
1. Delusions
2. Paranoid thoughts
3. Palpitations and anxiety
4. Alcohol withdrawal symptoms

 

  1. The nurse employed in the mental health clinic is interviewing a female client who has had clomipramine hydrochloride (Anafranil) prescribed. The nurse interprets that the client is noncompliant with taking the medication as prescribed if the client exhibits which of the following behaviors?
1. Tired, fatigued appearance
2. Complaints of hunger and fatigue
3. Slight dizziness when standing up quickly
4. Frequently checking her purse for her keys

 

 

  1. The client has been started on medication therapy with alprazolam (Xanax). When the nurse teaches the client that the medication should not be discontinued abruptly, the client asks why. The nurse should incorporate which of the following when formulating a reply?
1. The client is likely to suffer irreversible kidney damage.
2. The client is likely to become resistant to medication effects.
3. It will make the medication much less effective if it must be restarted.
4. Rebound central nervous system (CNS) excitation could occur, including seizure activity.

 

 

 

  1. The client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse reviews the results of laboratory studies for this client to detect which of the following adverse effects of this medication?
1. Platelet count
2. Blood glucose level
3. Liver function
4. White blood cell (WBC) count

 

 

 

COMPLETION

 

  1. The nurse is preparing to administer a 50-mcg dose of medication to a client. The medication is available in 100 mcg/5 mL. How many mL should the nurse administer?

Answer: __________ mL

 

 

  1. A client is prescribed to receive metoclopramide (Reglan) 5 mg IV. How many milliliters should the nurse administer if the available concentration is 10 mg/2 mL?

Answer: __________ mL

 

 

 

MULTIPLE RESPONSE

 

  1. The nurse is assigned to care for a client with metastatic breast cancer who is taking tamoxifen citrate (Soltamox). The nurse plans to monitor for which of the following changes in laboratory values for this client? Select all that apply.
1. Increased lipase level
2. Increased serum potassium level
3. Increasing blood glucose level
4. Increase in serum calcium level
5. Decreased low-density lipoprotein levels

 

 

 

  1. When teaching the client with adrenal insufficiency about cortisone (Cortone), the nurse should include which of the following? Select all that apply.
1. Increase intake of sodium.
2. Take the medication with food.
3. Increase intake of potassium-rich foods.
4. Stay away from people with active infections.
5. Discontinue the medication when symptoms subside.
6. Notify the physician if illness occurs or surgery is anticipated.

 

  1. The client has begun therapy with oxtriphylline. The nurse determines that the client understands dietary alterations if the client states to limit which of the following while taking this medication? Select all that apply.
1. Milk
2. Coffee
3. Oysters
4. Oranges
5. Pineapple
6. Chocolate

 

 

  1. The nurse has provided discharge instructions to a client being placed on long-term anticoagulant therapy with warfarin (Coumadin). Adequate learning would be evident if the client makes which of the following statements? Select all that apply.
1. “I will inform my dentist that I am taking Coumadin.”
2. “I may take over-the-counter medications as needed.”
3. “I should alternate the timing of my daily dose of Coumadin.”
4. “I will have my blood levels checked as prescribed by my physician.”
5. “I will report any signs of blood in my urine or stool to my physician.”
6. “I should use a firm-bristled toothbrush to prevent the side effects of Coumadin.”

 

  1. The nurse is assisting in the care of a client being discharged on phenytoin (Dilantin), 100 mg 3 times daily, for seizure control. When providing client teaching about this medication, the nurse should be sure to include which of the following points? Select all that apply.
1. Break the capsules so they are easier to swallow.
2. Use a soft toothbrush while taking this medication.
3. If a dose is missed, just wait until the next one is due.
4. Alcohol should be avoided while taking this medication.
5. The medication may turn the client’s urine pink, red, or brown.
6. Sore throat is a common side effect of the medication and is nothing to worry about.

 

 

  1. The client with schizophrenia has been started on medication therapy with clozapine (Clozaril). Which of the following are side effects of this medication? Select all that apply.
1. Diarrhea
2. Sedation
3. Dry mouth
4. Weight loss
5. Orthostatic hypotension
6. Presence of a fixed stare

 

 

 

  1. The client has begun taking phenelzine (Nardil). At the initiation of therapy, which of the following items does the nurse teach the client to allow in the diet? Select all that apply.
1. Avocados
2. Figs and raisins
3. Bologna or salami
4. Carrots or radishes
5. Sweet potatoes and squash
6. Red wine, such as Chianti or sherry

 

 

  1. The nurse has a prescription to administer a dose of iron by a parenteral route to an assigned client. Which of the following would the nurse implement to administer this medication correctly via the intramuscular route? Select all that apply.
1. Use a Z-track method.
2. Administer the medication only in the deltoid.
3. Aspirate for blood after the needle is inserted.
4. Use an air lock when drawing up the medication.
5. Change the needle after drawing up the dose and before injection.
6. Massage the injection site well after injection to hasten absorption.