RegisteredNurseTech

Makulot Gameplan

noreply@blogger.com (RegisteredNurseTech) — Sun, 06 Sep 2009 11:23:00 +0000

BACKGROUND

Mt. Maculot is one of the most popular daytrip destinations. It is so popular that on weekends and summer months, there is a sari-sari store at the campsite. This mountain, at the heart of Batangas, is known as a landmark for locals and travellers alike; it is easily identifiable because of its abruptly terminating east side - forming a cliff that is challenging for rock climbers and breathtaking to everybody else. Others describe the shape of the mountain as 'igloo-like'.

At 830 MASL, the mountain has three destinations: the grotto, the peak and the rockies (685 MASL). These can all be covered by a traverse dayhike. Most climbers head to the Rockies. This rocky formation stands beside Taal Lake, creating a scenic view, encompassing the whole of Taal Lake including the world-famous Taal volcano; as well the plains of Batangas. From a distance looms, on opposite sides, Mt. Makiling and the Tagaytay Highlands. If you follow Batangas Bay to the South you can see Maricaban Island, and beyond that, Mindoro's Mt. Halcon. The climbing time is variable; experienced climbers can reach the Rockies in a matter of two hours. From the Rockies, one can continue to the peak (830 MASL) or the Grotto on the other side of the mountain. You can also do the traverse vice-versa, starting off at the Grotto and ending at the Rockies. The Grotto area is grassy, but it then the trail becomes forested until it reaches the summit - and down. Either way, the trails are steep but Maculot is one mountain where you can stay the visual rewards are really worth the effort.

SPECIAL CONCERNS
There are no permits required in Maculot and it is generally safe, even for beginners. During April weekends, however, there may be too many climbers. The Rockies is quite small and can only accommodate 30 is sufficient for hiking trips.

Although taking less than 10 minute, the trail from the campsite to the Rockies is very steep. Beginners must be assisted during this leg of the trip.

There are two registration sites: the "tindahan" and the brgy. outpost near the mountaineers' store. You only need to register in either one of them. At times, the registration process is not enforced.

Background and Special concern -got from pinoymountaineer.com

Itineraries:

Itinerary for Mt. Maculot climb courtesy of kirishi thru pinoymountaineers site:
(Modified IT for 2 days:)
TRAVERSE- FIRST DAY:
1300 Northern group will meet at JAC Liner-near Buendia (Gil Puyat LRT Station) then lunch at nearby fastfood or foodstore.
1400 Board Lemery-bound bus[LIPA BUS STOP] from Buendia (P124) via JAC Liner
1700 ETA Cuenca Municipal Hall. Either walk or take trike to jump-off
1800 ETA jump-off point, start traverse.
1915 ETA Grotto, pitch tents
1930 cook dinner
2000 dinner
2030 socialan-activities/games/etc
2300 lights out

SECOND DAY:
0700 wake up call
0745 breakfast
0800 take pictures at Grotto
0830 set out for the peak via forested trail
1100 ETA summit...lunch.
1230 start descent to shoulder campsite and rockies
1430 ETA rockies; take pictures
1500 ETA start descent to mountaineer's store
1620 ETA mountaineer's store...tidy up then head back to the highway for Manila-bound bus

ROCKIES- FIRST DAY:
1300 Northern group will meet at JAC Liner-near Buendia (Gil Puyat LRT Station) then lunch at nearby fastfood or foodstore.
1400 Board Lemery-bound bus[LIPA BUS STOP] from Buendia (P124) via JAC Liner
1700 ETA Cuenca Muncipal Hall. Walk or take trike to jump-off. Pay P10 registration fee.
1730 start trek
1915 arrive at campsite, pitch tents
1930 cook dinner
2000 dinner
2030 socialan-activities/games/etc
2300 lights out
SECOND DAY:
0700 wake up call
0745 breakfast
0830 head for Rockies
0845 at Rockies...pictorials
0930 return to campsite
1000 socialan-pahinga...more pictorials
1100 early lunch
1130 start descent
1300 back at jump-off...tidy up then head back to the highway from Manila-bound bus.

Where: Mt Makulot, Cuenca Batangas
When: ?
Who:
NORTHERN GROUP:
1. computerhazard888 - Valenzuela/ 0917-8715623
2. hellokitty888(Cecille)[tentative] - Valenzuela/ 0917-8841770
3. kirishi - Manila/ 0920-8422614 / 4175118
4. goodguy23 - Taguig/ 0915-8783764
5. johnbrew - Manila/ 0923-8891708
6. polarbear -QC/ 0915-6409067
7. sandugo - Pasig City/0929-3003961
8. destined child - Marikina/ 0922-3449624
9. eingheL24(Angela){tentative pa raw] - Marikina
10. yobs -QC/ 0915-1140512(tentative)
11. kuneknek - QC/ 0927-4973204(tentative)
12. GTraveler - Marikina/ 0910-4296305
13. limmax - Manila/Kalookan/ 0922 889-1672 (tentative)
14. vincecarter - Manila/ 0905-2648578
15. yandiler007 - Makati/ 0922-8713493

SOUTHERN GROUP:
1. skateboxx - Batangas /0927-5094528
2. murex- Binan/ 0918-6615168 (tentative)
3. qtnice - 0908-4590260
4. lups - Cavite/ 0908-7650008
5. simplylheng - 0908-1416196
6. edibokyo - Batangas /0916-8802059
7. jeepneyko - San Pedro, Laguna/ 0927-263-3198 (Globe)/ 0923-886-9149 (SUN)

Do's and Don'ts:
• Observe cleanliness
• No military uniform and paraphernalia, or those resembling such items
• Wear pants and long sleeve (leg and arm warmer)
• Waterproof things
• Be polite and courteous to people we meet on the trail
• Bring sufficient cold weather clothing

What to bring:
Individual . . .

- Flashlight
- Head lamp
- Extra Batteries
- Rain Gear (Rain Coat )
- Trail water
- Trail food (energy bar, candies, life saver, banana chips for potassium source)
- Hiking Gear
- Jacket
- Gloves (hand protection)
- Toiletries
- Cup, spoon and fork
- 3-4 L of water
- Weather proof Tent (look for your partner)
- Sleeping bag, fleece blanket
- Earth Pad
- Zip-lock plastic
-personal medication

Others: - Plastic bags and plates
- Knife – 3
- Iwatani 4-5
- Lamps
- Kovea Stove
- Cooking ware – 3 (pan, rice pot, pot (kaldero))-----> biggie size

Etc etc. – radio, camera

Assignments-

Sponsors (Tents):
1. computerhazard888 = 6-8 pax + 4-5pax
2. greenbaythera = 4-5 pax
3. yobs = 4-5 pax (magpapahiram sya if di makakarating)
Sponsors (Foods, etc):

Stoves + butane:
1. kirishi
2. computerhazard888
3. johnbrew

Cooking ware-pan, rice pot, pot----->biggie size?
Lamp-johnbrew, computerhazzard, ?

Meal-
Lunch1- rice, beef tapa,chicken adobo (cooked)
Dinner1-rice, ensaladang talong and bagoong, chicken tinola
Socials- chips, liquor, hotdog
Breakfast- rice, noodles, corned beef, bread, itlog na pula

To buy-?
Rice
Chicken adobo-chicken 1 kg, onion, pepper,soy sauce
eggplant
bagoong
tomato
chicken tinola ingresients
noodles-6 pcs
corned beef- 3 cans
bread- 4 loaves
itlog na pula- 6 pcs

NCLEX practice #1

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 10:07:00 +0000

1. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?

A) Heart rate

B) Muscle tone

C) Cry

D) Color

The correct answer is D: Color

Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

2. A mother telephones the clinic and says “I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.” The nurse's best response would be which of these?

A) "This type of stool is normal for breast fed infants. Keep doing as you have."

B) "The stool should have turned to light brown by now. We need to test the stool."

C) "Formula supplements might need to be added to increase the bulk of the stools."

D) "Water should be offered several times each day in addition to the breast feeding."

The correct answer is A: "This type of stool is normal for breast fed infants. Keep doing as you have."

In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency. No change in feedings is indicated.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

3. A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?

A) Suggest isometric exercises

B) Maintain the client on bed rest

C) Ambulate for several minutes

D) Apply ice to the extremity

The correct answer is B: Maintain the client on bed rest

The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

4. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?

A) Separation anxiety

B) Fear of pain

C) Loss of control

D) Bodily injury

The correct answer is A: Separation anxiety

While a toddler will experience all of the stresses, separation from parents is the major stressor.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

5. The nurse is speaking to a group of parents and elementary school teachers about care for children with rheumatic fever. It is a priority to emphasize that

A) home schooling is preferred to classroom instruction

B) children may remain strep carriers for years

C) most play activities will be restricted indefinitely

D) clumsiness and behavior changes should be reported

The correct answer is D: clumsiness and behavior changes should be reported

A major manifestation of rheumatic fever that reflects central nervous system involvement is chorea. Early symptoms of chorea include behavior changes and clumsiness. Chorea is characterized by sudden, aimless, irregular movements of the extremities, involuntary facial grimaces, speech disturbances, emotional lability, and muscle weakness. Chorea is transitory and all manifestations eventually disappear.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

6. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?

A) Cardizem SR tablet (diltiazem)

B) Lanoxin liquid

C) Os-cal tablet (calcium carbonate)

D) Tylenol liquid (acetaminophen)

The correct answer is A: Cardizem SR tablet (diltiazem)

Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The provider must substitute another medication.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

7. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is

A) avoiding alcohol use during this time

B) observing the client for hypotension

C) abrupt discontinuation of the drug

D) assessing for mild physical symptoms

The correct answer is A: avoiding alcohol use during this time

Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

8. A client with considerable pain asks, “What is your opinion regarding acupuncture as a drug-free method for alleviating pain?” The nurse responds, "I'd forget about it as those weird non-Western treatments can be scary." The nurse's response is an example of

A) prejudice

B) discrimination

C) ethnocentrism

D) cultural insensitivity

The correct answer is C: ethnocentrism

Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one''s own are strange, bizarre, or unenlightened, and therefore wrong. Ethnocentrism refers to the unconscious tendency to look at others through the lens of one''s own cultural norms and customs and to take for granted that one''s own values are the only objective reality. At a more complex level, the ethnocentrist regards others as inferior or immoral and believes his or her own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of his or her own value judgments.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

9. To obtain data for the nursing assessment, the nurse should:

A) observe carefully the client’s nonverbal behaviors

B) adhere to pre-planned interview goals and structure

C) allow clients to talk about whatever they want

D) elicit clients' description of their experiences, thoughts and behaviors

The correct answer is D: elicit clients'' description of their experiences, thoughts and behaviors

The nurse’s understanding of the client rests on the comprehensiveness of assessment data obtained by listening to the client’s self revelation.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

10. During the two-month well-baby visit, the mother complains that formula seems to stick to her baby's mouth and tongue. Which of the following would provide the most valuable data for nursing assessment?

A) Inspect the baby's mouth and throat

B) Obtain cultures of the mucous membranes

C) Flush both sides of the mouth with normal saline

D) Use a soft cloth to attempt to remove the patches

The correct answer is D: Use a soft cloth to attempt to remove the patches

Candidiasis can be distinguished from coagulated milk when attempts to remove the patches with a soft cloth are unsuccessful.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

11. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to

A) promote verbal and nonverbal communication with both the client and the interpreter

B) speak only a few sentences at a time and then pause for a few moments

C) plan that the encounter will take more time than if the client spoke English

D) ask the client to speak slowly and to look at the person spoken to

The correct answer is A: promote verbal and nonverbal communication with both the client and the interpreter

The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

12. A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first

A) support the planning committee and post the new schedule

B) explore how the planning committee evaluated barriers to the plan

C) design a different approach to deliver care with fewer staff

D) retain the previous staffing pattern for another 6 months

The correct answer is B: explore how the planning committee evaluated barriers to the plan

The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated. The manager wants to build the staff''s skills at implementing change. Helping the committee evaluate its decision-making is a useful step before rejecting or implementing the change. When possible all affected by the change should be involved in the planning. The question is whether staff input has been thoroughly taken into consideration.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

13. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?

A) Skin irritation

B) Drug tolerance

C) Severe headaches

D) Postural hypotension

The correct answer is B: Drug tolerance

Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

14. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?

A) Allow the infant to drink the liquid from a medicine cup

B) Administer the medication with a syringe next to the tongue

C) Mix the medication with the infant's formula in the bottle

D) Hold the child upright and administer the medicine by spoon

The correct answer is B: Administer the medication with a syringe next to the tongue

Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

15. A mother calls the clinic, concerned that her 5 week-old infant is "sleeping more than her brother did." What is the best initial response?

A) "Do you remember his sleep patterns?"

B) "How old is your other child?"

C) "Why do you think this a concern?"

D) "Does the baby sleep after feeding?"

The correct answer is C: "Why do you think this a concern?"

Open ended questions encourage further discussion and conversation, thereby eliciting further information.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

16. Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?

A) Ninety-ninety

B) Buck's

C) Bryant

D) Russell

The correct answer is A: Ninety-ninety

Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is surgically placed through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction ropes and pulleys are applied.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

17. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?

A) Acceptance of the pregnancy

B) Acceptance of the termination of the pregnancy

C) Acceptance of the fetus as a separate and unique being

D) Satisfactory resolution of fears related to giving birth

The correct answer is A: Acceptance of the pregnancy

During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

18. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?

A) Temperature of 102 degrees Fahrenheit

B) Pulse rate of 98 beats per minute

C) Respiratory rate of 32

D) Blood pressure of 90/50

The correct answer is C: Respiratory rate of 32

Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

19. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should

A) instruct the client to breathe into a paper bag

B) place the client in a high Fowler's position

C) assist the client with pursed lip breathing

D) administer oxygen at 6L/minute via nasal cannula

The correct answer is C: assist the client with pursed lip breathing

Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

20. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

A) Pack the nose and ears with sterile gauze

B) Apply pressure to the injury site

C) Apply bulky, loose dressing to nose and ears

D) Apply an ice pack to the back of the neck

The correct answer is C: Apply bulky, loose dressing to nose and ears

Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. (2004). Current medical Diagnosis and Treatment. (43rd edition). USA:McGraw-Hill.

21. A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention should be included in the plan of care to reduce leg pain?

A) elevate the legs above the heart

B) increase ingestion of caffeine products

C) apply cold compresses

D) lower the legs to a dependent position

The correct answer is D: lower the legs to a dependent position

Ischemic pain is relieved by placing feet in a dependent position. This position improves peripheral perfusion.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

22. A diabetic client asks the nurse why the provider ordered a glycosylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:

A) Provides a more precise blood glucose value than self-monitoring

B) Is performed to detect complications of diabetes

C) Measures circulating levels of insulin

D) Reflects an average blood sugar for several months

The correct answer is D: Reflects an average blood sugar for several months

Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 2-3 months and can be used to monitor client adherence to the therapeutic regimen.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

23. Which statement describes factors that help build personal power in an organization?

A) Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with success

B) Goals are met with the use of networking, mentoring, and coalition building

C) High visibility and formal power are maintained with a confrontational style

D) Credibility to one's position is enhanced when professional dress and demeanor are employed

The correct answer is B: Goals are met with the use of networking, mentoring, and coalition building

Networking, mentoring, and coalition building are positive uses of personal power to meet goals.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

24. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have

A) scrotal discoloration

B) sustained painful erection

C) inability to achieve erection

D) heaviness in the affected testicle

The correct answer is D: heaviness in the affected testicle

The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

25. Which statement describes the advantage of using a decision grid for decision making?

A) It is both a visual and a quantitative method of decision making

B) It is the fastest way for group decision making

C) It allows the data to be graphed for easy interpretation

D) It is the only truly objective way to make a decision in a group

The correct answer is A: It is both a visual and a quantitative method of decision making

A decision grid allows the group to visually examine alternatives and evaluate them quantitatively with weighting.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

26. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating

A) "I will increase sodium and fluids and restrict potassium."

B) "I will increase potassium and sodium and restrict fluids."

C) "I will increase sodium, potassium and fluids."

D) "I will increase fluids and restrict sodium and potassium."

The correct answer is A: "I will increase sodium and fluids and restrict potassium."

The manifestations of Addison''s disease due to mineralocorticoid deficiency, resulting from renal sodium wasting and potassium retention, include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company

27. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

A) Report the behavior to the charge nurse

B) Talk with the client to find out about the preferred herbal preparation

C) Contact the client's primary care provider

D) Explain the importance of the medication to the client

The correct answer is B: Talk with the client to find out about the preferred herbal preparation

Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death."

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

28. During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to

A) Ask the client for more information about the nature of the bruises

B) Ask the client and then the family about the findings

C) Report the bruising to social services to follow-up

D) Document the findings on the admission sheet

The correct answer is A: Ask the client for more information about the nature of the bruises

"Cupping" is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness of the illness. There is typically no need to ask an adult’s family members.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

29. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?

A) Massage legs frequently

B) Frequent turning

C) Moisten skin with lotions

D) Apply moist heat to reddened areas

The correct answer is B: Frequent turning

Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

30. Dual diagnosis indicates that there is a substance abuse problem as well as a

A) cross addiction

B) mental disorder

C) disorder of any type

D) medical problem

The correct answer is B: mental disorder

Dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

31. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t. I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily

A) psychological

B) physical

C) biological

D) social-cultural

The correct answer is A: psychological

With psychological dependence, it is the client’s thoughts and attitude toward alcohol that produce craving and compulsive use.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

32. A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?

A) Report this immediately to the nurse manager

B) Confront the nurse about the suspected drug use

C) Sign the narcotic sheet and document the event in an incident report

D) Counsel the colleague about the risky behaviors

The correct answer is A: Report this immediately to the nurse manager

The incident must be reported to the appropriate supervisor, for both ethical and legal reasons. This is not an incident that a co-worker can resolve without referral to a manager.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing. Upper Saddle River, N.J.: Pearson Prentice Hall.

33. A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse's best response to this request?

A) "That's a good choice, and I know it is your favorite. You can have it today."

B) "I'm sorry, that is not a good choice, but you could have pasta."

C) "I know that is your favorite, but let me help you pick another lunch."

D) "You cannot have the peanut butter until you are feeling better."

The correct answer is C: "I know that is your favorite, but let me help you pick another lunch."

Children with AGN who have edema, hypertension oliguria and azotemia may have dietary restrictions limiting sodium, fluids, protein and potassium. Giving the child a short explanation and offering to talk about an alternative is appropriate for this age.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

34. The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?

A) History of obesity

B) Prescribed use of a monoamine oxidase (MAO) inhibitor

C) Diagnosis of vascular disease

D) Takes antacids frequently

The correct answer is B: Prescribed use of a monoamine oxidase (MAO) inhibitor

SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

35. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

A) "Touching the abdomen could cause cancer cells to spread."

B) "Examining the area would cause difficulty to the child."

C) "Pushing on the stomach might lead to the spread of infection."

D) "Placing any pressure on the abdomen may cause an abnormal experience."

The correct answer is A: "Touching the abdomen could cause cancer cells to spread."

Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

36. The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?

A) Severe diarrhea for 24 hours

B) Nausea with anorexia

C) Alternating constipation and diarrhea

D) Vomiting for over 48 hours

The correct answer is A: Severe diarrhea for 24 hours

Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

37. Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)?

A) Permission to videotape

B) Salivary pH

C) Mini-mental status exam

D) Pre-anesthesia work-up

The correct answer is D: Pre-anesthesia work-up

ECT is delivered under general anesthesia and the client should be prepared as for any procedure involving anesthesia.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

38. A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?

A) Serum potassium

B) Protein intake

C) Lactose tolerance

D) Serum albumin

The correct answer is D: Serum albumin

When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

NCLEX practice #2

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 10:03:00 +0000

1. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?

A) Teach the parents how to perform cardiopulmonary resuscitation

B) Recommend that the parents give in when he holds his breath to prevent anoxia

C) Advise the parents to ignore breath holding because breathing will begin as a reflex

D) Instruct the parents on how to reason with the child about possible harmful effects

The correct answer is C: Advise the parents to ignore breath holding because breathing will begin as a reflex

If temper tantrums are accompanied by breath holding, the parents need to know that this behavior will not result in harm to the child. Ignoring the breath holding is the best response to this benign behavior.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

2. Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?

A) "I know there is a problem since my baby is always constipated."

B) "My child doesn't like many fruits and vegetables, but she really loves her milk."

C) "I can't understand why my child is not eating as much as she did 4 months ago."

D) "My child doesn't drink a whole glass of juice or water at 1 time."

The correct answer is B: "My child doesn''t like many fruits and vegetables, but she really loves her milk."

About 2 to 3 cups of milk a day are sufficient for the young child''s needs. Sometimes excess milk intake, a habit carried over from infancy, may exclude many solid foods from the diet. As a result, the child may lack iron and develop a so-called milk anemia. Although the majority of infants with iron deficiency are underweight, many are overweight because of excessive milk ingestion.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

3. Delirium tremens could best be described as

A) disorganized thinking, feelings of terror and non-purposeful behavior

B) a generalized shaking of the body accompanied by repetitive thoughts

C) an excited state accompanied by disorientation, hallucination and tachycardia

D) single or multiple jerks caused by rapid contracting muscles

The correct answer is C: an excited state accompanied by disorientation, hallucination and tachycardia

During delirium tremens syndrome (DTS), the client experiences confusion, disorientation, hallucinations, tachycardia, hypertension, extreme tremors, agitation, diaphoresis, and fever.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

4. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing?

A) Fear

B) Helplessness

C) Self-blame

D) Rejection

The correct answer is C: Self-blame

Domestic violence victims may be immobilized by a variety of affective responses, one being self-blame. The victim believes that a change in their behavior will cause the abuser to become nonviolent, and may even have been told this by their abuser. This is an untrue but not uncommon myth.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?

A) Fluid restriction 1000cc per day

B) Ambulate in hallway 4 times a day

C) Administer analgesic therapy as ordered

D) Encourage increased caloric intake

The correct answer is C: Administer analgesic therapy as ordered

The main general interventions in the treatment of a sickle cell crisis are bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement, and antibiotics to treat any existing infection.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescence is most often associated with what other finding?

A) Sexual promiscuity

B) Poor body image

C) Dropping out of school

D) Drug experimentation

The correct answer is B: Poor body image

As the adolescent gains weight, there is a lessening sense of self esteem and poor body image.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

7. When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?

A) It has no clear etiology

B) Enuresis may be associated with sleep phobia

C) It has a definite genetic link

D) Enuresis is a sign of willful misbehavior

The correct answer is A: It has no clear etiology

Although predictive factors associated with enuresis have been identified, no clear etiology has been determined.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

8. The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?

A) Chest pain

B) Peripheral edema

C) Nail clubbing

D) Lethargy

The correct answer is B: Peripheral edema

When crackles are heard bibasilarly, congestive heart failure is suspected. This is often accompanied by peripheral edema secondary to fluid overload caused by ineffective cardiac pumping.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

9. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?

A) Food

B) Warmth

C) Security

D) Comfort

The correct answer is C: Security

While the infant has many physical needs, it must be touched, loved, and stimulated to develop security and trust.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

10. A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is

A) "You need to take your medicine, this is how you get well."

B) "If you refuse your medicine, we’ll just have to give you a shot."

C) "What is it about the medicine that you don’t like?"

D) "I can see that you are uncomfortable right now, I’ll wait until tomorrow."

The correct answer is C: "What is it about the medicine that you don’t like?"

Nursing interventions for clients with psychotic disorders are aimed at establishing a trusting relationship, establishing clear communications, presenting reality and reinforcing appropriate behavior.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

11. A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?

A) Information is clarified as needed

B) A teacher-coach role is taken by the mentor

C) The mentee accepts feedback objectively

D) The mentor is randomly assigned by administration

The correct answer is B: A teacher-coach role is taken by the mentor

Both the mentor and mentee, the nurse manager, initially need to be open to a positive learning experience. The teacher-coach is the priority for the outcome of an ideal relationship.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

12. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?

A) "Take at least 2 weeks off from work."

B) "You will need another chest x-ray in 6 weeks."

C) "Take your temperature every day."

D) "Complete all of the antibiotic even if your findings decrease."

The correct answer is D: "Complete all of the antibiotic even if your findings decrease."

To avoid a recurrence of the pneumonia the client must complete all of the prescribed medication at the prescribed dosing intervals.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

13. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider?

A) Height and weight percentiles vary widely

B) Growth pattern appears to have slowed

C) Recumbent and standing height are different

D) Short term weight changes are uneven

The correct answer is A: Height and weight percentiles vary widely

On the growth curve, height and weight should be close in percentiles at this age. A wide difference may indicate a problem.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

14. The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

A) "Do not worry. Epilepsy can be treated with medications."

B) "The seizure may or may not mean your child has epilepsy."

C) "Since this was the first convulsion, it may not happen again."

D) "Long term treatment will prevent future seizures."

The correct answer is B: "The seizure may or may not mean your child has epilepsy."

There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown) etiologies.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

15. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?

A) Gestational age assessment suggested growth retardation

B) Meconium was cleared from the airway at delivery

C) Phototherapy was used to treat Rh incompatibility

D) The infant received mechanical ventilation for 2 weeks

The correct answer is D: The infant received mechanical ventilation for 2 weeks

Bronchopulmonary dysplasia is an iatrogenic disease caused by therapies such as use of positive-pressure ventilation used to treat lung disease.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

16. The nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?

A) Reprimand the child and give a 15 minute "time out"

B) Maintain a permissive attitude for this behavior

C) Use patience and a sense of humor to deal with this behavior

D) Assert authority over the child through limit setting

The correct answer is C: Use patience and a sense of humor to deal with this behavior

The nurse should help the parents see that negativity as a normal part of growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

17. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to

A) begin mouth to mouth resuscitation

B) give the child water to help in swallowing

C) perform 5 abdominal thrusts

D) call for the emergency response team

The correct answer is C: perform 5 abdominal thrusts

At this age, the most effective way to clear the airway of food is to perform abdominal thrusts.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

18. An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

A) "Have you had a recent heart attack?"

B) "Do you become short of breath during your normal daily activities?"

C) "How many pillows do you use at night to sleep comfortably?"

D) "Do you smoke?"

The correct answer is B: "Do you become short of breath during your normal daily activities?"

These are the findings of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

19. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?

A) Pre-interaction

B) Orientation

C) Working

D) Termination

The correct answer is C: Working

During the working phase alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

20, A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being "too sick to return to work." The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior

A) is controlled by their subconscious mind

B) is manipulative to avoid work responsibilities

C) would respond to psychoeducational strategies

D) could be modified through reality therapy

The correct answer is A: is controlled by their subconscious mind

Persons with somatoform disorder do not intend to feign illness; their complaints are not under their conscious control. Showing intention to use feigned physical complaints to accomplish some goal is called "malingering" or a factitious disorder.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

21. The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?

A) Protection for the granulation tissue

B) Heal infection

C) Debride eschar

D) Keep the tissue intact

The correct answer is D: Keep the tissue intact

If the black tissue, (eschar) is dry and intact no treatment is necessary. If the area changes (cellulitis, pain) this is a sign of infection, requiring debridement.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

22. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should

A) administer a placebo

B) encourage increased fluid intake

C) administer the prescribed analgesia

D) recommend relaxation exercises for pain control

The correct answer is C: administer the prescribed analgesia

Relief of pain is the expected outcome for treatment of sickle cell crisis. Pain, especially chronic pain, may be present even without overt signs.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

23. Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to

A) pass the catheter into the abdominal cavity

B) place the tubing into the urinary bladder

C) visualize abdominal organs for catheter placement

D) insert the catheter into the stomach

The correct answer is A: pass the catheter into the abdominal cavity

The preferred procedure in the surgical treatment of hydrocephalus is placement of a ventriculoperitoneal shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, usually the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt can be guided into the peritoneal cavity.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

24. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?

A) "My pain is deep in my chest behind my breast bone."

B) "When I sit up the pain gets worse."

C) "As I take a deep breath the pain gets worse."

D) "The pain is right here in my stomach area."

The correct answer is A: "My pain is deep in my chest behind my breast bone."

The pain of angina is usually localized chest pain.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

25. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child?

A) Make certain the child is maintained in correct body alignment.

B) Be sure the traction weights touch the end of the bed.

C) Adjust the head and foot of the bed for the child's comfort

D) Release the traction for 15-20 minutes every 6 hours PRN.

The correct answer is A: Make certain the child is maintained in correct body alignment.

Observe for correct body positioning with emphasis on alignment of shoulders, hips, and legs.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

26. A child is sent to the school nurse by a teacher who has a written note that fifth disease is suspected. Which characteristic would the nurse expect to find?

A) Macule that rapidly progresses to papule and then vesicles

B) Erythema on the face, primarily on cheeks giving a "slapped face" appearance

C) Discrete rose pink macules will appear first on the trunk and fade when pressure is applied

D) Koplik spots appear first followed by a rash that appears first on the face and spreads downward

The correct answer is B: Erythema on the face, primarily on cheeks giving a "slapped face" appearance

Fifth disease is also referred to it as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. It is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases that all have similar rashes. The other 4 diseases are measles, rubella, scarlet fever, and Dukes'' disease. People will not know that a child has parvovirus infection until the rash appears, and by that time the child is no longer contagious.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

27. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?

A) Cereal

B) Eggs

C) Meat

D) Juice

The correct answer is A: Cereal

The guidelines of the American Academy of Pediatrics recommend that one new food be introduced at a time, beginning with strained cereal.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

28. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse?

A) Chewable aspirin is the preferred analgesic

B) Topical cortisone ointment relieves itching

C) Papules, vesicles, and crusts will be present at one time

D) The illness is only contagious prior to lesion eruption

The correct answer is C: Papules, vesicles, and crusts will be present at one time

All 3 stages of the chicken pox lesions will be present on the child''s body at the same time.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

29. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?

A) Risk for injury

B) Risk for knowledge deficit

C) Altered thought process

D) Disturbance in self-esteem

The correct answer is A: Risk for injury

Accidents increase as a result of intoxication. Studies indicate alcohol is a factor in 50% of motor vehicle fatalities, 53% of all deaths from accidental falls, 64% of fatal fires, and 80% of suicides.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

30. Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about

A) mental development delays

B) evil eye or envy of others

C) fright from spiritual beings

D) balance in body systems

The correct answer is B: evil eye or envy of others

Matiasma, "Bad eye" or "evil eye, " results from the envy or admiration of others. The belief is that the eye is able to harm a wide variety of things, including inanimate objects, but children are particularly susceptible to attack. Persons of Greek heritage employ a variety of preventive mechanisms to thwart the effects of envy, including protective charms in the form of amulets consisting of blessed wood or incense.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

31. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?

A) "I cannot give this medication as it is written. I have no idea of what you mean."

B) "Would you please clarify what you have written so I am sure I am reading it correctly?"

C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."

D) "Please print in the future so I do not have to spend extra time attempting to read your writing."

The correct answer is B: "Would you please clarify what you have written so I am sure I am reading it correctly?"

Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

32. The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is

A) recurring crises

B) continuing drug use

C) rationalizing comments

D) missing appointments

The correct answer is B: continuing drug use

Continuing to use the drug demonstrates lack of commitment to the treatment program. This fact must be understood by the nurse as part of the disease of addiction.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

33. The nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?

A) Chronic vessel plaque formation

B) Pulmonary embolism

C) Occlusions at the vessel bifurcations

D) Coronary artery aneurysms

The correct answer is D: Coronary artery aneurysms

Kawasaki disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

34. The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize

A) the need for at least 5 servings of dairy products daily

B) restriction of fluid intake to less than 1 liter per day

C) the importance of walking as much as possible

D) early recognition of findings associated with tetany

The correct answer is C: the importance of walking as much as possible

Mobility must be emphasized to prevent demineralization and breakdown of bones.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

35. A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse would anticipate which of the following findings?

A) Lethargy

B) Heat intolerance

C) Diarrhea

D) Skin eruptions

The correct answer is A: Lethargy

In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen consumption, decreasing oxidation of nutrients for energy, and producing less body heat. Therefore, the nurse can expect the client to complain of constipation, lethargy and an inability to get warm.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

36. When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention?

A) Use medications to lower the temperature set point

B) Apply extra layers of clothing to prevent shivering

C) Immerse the child in a tub containing cool water

D) Give a tepid sponge bath prior to giving an antipyretic

The correct answer is A: Use medications to lower the temperature set point

Conditions such as infection, malignancy, allergy, central nervous system lesion and radiation cause the temperature set-point to be raised. Because the temperature set point is normal in hyperthermia and elevated in fever, different measures must be taken in order to be effective. The most effective intervention in the management of fever is the administration of antipyretics which lower the set point. Too rapid cooling of a febrile child can lead to seizure activity.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

37. The nurse should initiate discharge planning for a client

A) when the client or family demonstrate readiness to learn self care modalities

B) when informed that a date for discharge has been determined

C) upon admission to a hospital unit or the emergency room

D) when the client's condition is stabilized on the assigned unit

The correct answer is C: upon admission to a hospital unit or the emergency room

With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to an emergency room or hospital unit.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

38. What is the most important consideration when teaching parents how to reduce risks in the home?

A) Age and knowledge level of the parents

B) Proximity to emergency services

C) Number of children in the home

D) Age of children in the home

The correct answer is D: Age of children in the home

Age and developmental level of the child are most important considerations in providing a framework for anticipatory guidance.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

39. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the functioning of the client's recent memory?

A) "Name the year." "What season is this?" (pause for answer after each question)

B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number."

C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."

D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."

Recent memory is the ability to recall events in the immediate past and up to 2 weeks previously.

Estes, M.E.Z. (2002). Health Assessment and Physical Examination, (2nd Ed). Albany, NY: Delmar.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

40. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?

A) Respiratory rate of 42

B) Lethargy for the past hour

C) Apical pulse of 54

D) Coughing up copious secretions

The correct answer is A: Respiratory rate of 42

Signs of impending airway obstruction include increased respiratory rate and pulse; substernal, suprasternal and intercostal retractions; flaring nares; and increased restlessness or agitation.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

NCLEX practice #3

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:59:00 +0000

1. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should

A) eat foods high in sodium to increase sputum liquefaction

B) use oxygen during meals to improve gas exchange

C) perform exercise after respiratory therapy to enhance appetite

D) cleanse the mouth of dried secretions to reduce risk of infection

The correct answer is B: use oxygen during meals to improve gas exchange

Clients with emphysema breathe easier when using oxygen while eating.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

2. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and

A) increased retention of albumin in the vascular system

B) decreased colloidal osmotic pressure in the capillaries

C) fluid shift from interstitial spaces into the vascular space

D) reduced tubular reabsorption of sodium and water

The correct answer is B: decreased colloidal osmotic pressure in the capillaries

The increased glomerular permeability to protein causes a decrease in serum albumin, which results in decreased colloidal osmotic pressure.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

3. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would best prepare the child?

A) Introduce the child to all staff the day before surgery

B) Explain the surgery 1 week prior to the procedure

C) Arrange a tour of the operating and recovery rooms

D) Encourage the child to bring a favorite toy to the hospital

The correct answer is B: Explain the surgery 1 week prior to the procedure

A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

4. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?

A) All lesions crusted

B) Elevated temperature

C) Rhinorrhea and coryza

D) Presence of vesicles

The correct answer is A: All lesions crusted

The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

5. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?

A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble

B) With fear of rejection causing increased rage toward the victim

C) With a new commitment to seek counseling to assist with their marital problems

D) With relief, and welcomes the separation as a means to have some personal time

The correct answer is B: With fear of rejection causing increased rage toward the victim

The fear of rejection, abandonment, and loss only serve to increase the batterer’s rage at the partner.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

6. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with

A) recreational and social needs

B) feelings of anger

C) life’s stressors

D) issues of guilt and disappointment

The correct answer is C: life’s stressors

Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings, but substance abuse itself eventually increases negative feelings.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

7. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?

A) Leave the room and return five minutes later and give the medicine

B) Explain to the child that the medicine must be taken now

C) Give the medication to the father and ask him to give it

D) Mix the medication with ice cream or applesauce

The correct answer is A: Leave the room and return five minutes later and give the medicine

Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

8. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?

A) Decreased cardiac output

B) Tissue hypoxia

C) Cerebral edema

D) Reduced oxygen saturation

The correct answer is B: Tissue hypoxia

When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, resulting from a decrease in the oxygen carrying capacity of the blood.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

9. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?

A) Discuss with the mother sharing parenting responsibilities

B) Set time aside to get the mother to express her feelings and concerns

C) Arrange for the parents to attend infant care classes

D) Talk with the father and help him accept the wife's decision

The correct answer is B: Set time aside to get the mother to express her feelings and concerns

Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be clarified.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

10. Which of these parents’ comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?

A) "I noticed a little lump a little above the belly button."

B) "The baby seems hungry all the time."

C) "Mild vomiting turned into vomiting that shot across the room."

D) "We notice irritation and spitting up immediately after feedings."

The correct answer is C: "Mild vomiting turned into vomiting that shot across the room."

Mild regurgitation or emesis that progresses to projectile vomiting is a pattern associated with pyloric stenosis as an initial finding. The other findings are present, though not immediately.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

11. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?

A) "I should position my baby completely facing me with my baby's mouth in front of my nipple."

B) "The baby should latch onto the nipple and areola areas."

C) "There may be times that I will need to manually express milk."

D) " I can switch to a bottle if I need to take a break from breast feeding."

The correct answer is D: " I can switch to a bottle if I need to take a break from breast feeding."

Babies adapt more quickly to the breast when they are not confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

12. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?

A) Blood urea nitrogen

B) Acid phosphatase

C) Bilirubin

D) Sedimentation rate

The correct answer is C: Bilirubin

In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver function tests will confirm the diagnosis.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

13. The nurse, assisting in applying a cast to a client with a broken arm, knows that the

A) cast material should be dipped several times into the warm water

B) cast should be covered until it dries

C) wet cast should be handled with the palms of hands

D) casted extremity should be placed on a cloth-covered surface

The correct answer is C: wet cast should be handled with the palms of hands

Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

14. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?

A) Increased 10% in height

B) 2 deciduous teeth

C) Tripled the birth weight

D) Head > chest circumference

The correct answer is C: Tripled the birth weight

The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

15. A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

A) "I understand that a glass of wine with dinner is healthy."

B) "Beer is not really hard alcohol, so I guess I can drink some."

C) "If I drink, my baby may be harmed before I know I am pregnant."

D) "Drinking with meals reduces the effects of alcohol."

The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."

Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

16. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?

A) Retractions in the intercostal tissues of the thorax

B) Chest pain aggravated by respiratory movement

C) Cyanosis and mottling of the skin

D) Rapid, shallow respirations

The correct answer is A: Retractions in the intercostal tissues of the thorax

Slight intercostal retractions are normal, however in disease states, especially in severe airway obstruction, retractions become extreme.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

17. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?

A) "Do you want to take this pretty red medicine?"

B) "You will feel better if you take your medicine."

C) "This is your medicine, and you must take it all right now."

D) "Would you like to take your medicine from a spoon or a cup?"

The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"

At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

18. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?

A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking only to family gatherings."

B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor."

C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"

D) "A recovering person cannot return to drinking without starting the addiction process over."

The correct answer is D: "A recovering person cannot return to drinking without starting the addiction process over."

Recovery requires total abstinence from all drugs.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

19. The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?

A) "It measures a child’s intelligence."

B) "It assesses a child's development."

C) "It evaluates psychological responses."

D) " It helps to determine problems."

The correct answer is B: "It assesses a child''s development."

The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

20. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?

A) May drink as much milk as desired

B) Can have milk mixed with other foods

C) Will benefit from fat-free cow's milk

D) Should be limited to 3-4 cups of milk daily

The correct answer is D: Should be limited to 3-4 cups of milk daily

More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

21.A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history offered by the family members would be recognized by the nurse as associated with the diagnosis, and communicated to the provider?

A) "My partner's breathing rate is usually below 12."

B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."

C) "It seems our sex life is nonexistent over the past 6 months."

D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print."

The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."

The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. (2004). Current medical Diagnosis and Treatment. (43rd edition). USA:McGraw-Hill.

22. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should

A) review the medications the client is receiving

B) increase the formula infusion rate

C) increase the amount of water used to flush the tube

D) attach a rectal bag to protect the skin

The correct answer is A: review the medications the client is receiving

Antibiotics and medications containing sorbitol may induce diarrhea.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

23. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

A) Jumping rope

B) Tying shoelaces

C) Riding a tricycle

D) Playing hopscotch

The correct answer is C: Riding a tricycle

Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

24. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?

A) 14 minutes

B) 10 minutes

C) 15 minutes

D) Nine minutes

The correct answer is C: 15 minutes

Frequency is the time from the beginning of one contraction to the beginning of the next contraction.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

25. The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?

A) Cooing

B) Imitation of sounds

C) Throaty sounds

D) Laughter

The correct answer is B: Imitation of sounds

Imitation of sounds such as "da-da" is expected at this time.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

26. The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should

A) observe the child's behavior on at least 2 occasions

B) consult with the teacher about how to control impulsivity

C) compile a history of behavior patterns and developmental accomplishments

D) compare the child's behavior with classic signs and symptoms

The correct answer is C: compile a history of behavior patterns and developmental accomplishments

A complete behavioral, and developmental history plays an important role in determining the diagnosis.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

27. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?

A) Touring the coronary intensive unit

B) Mailing a video tape to the home

C) Assessing the client's learning style

D) Administering a written pre-test

The correct answer is C: Assessing the client''s learning style

As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

28. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?

A) Seizures

B) Withdrawal

C) Craving

D) Marked tolerance

The correct answer is B: Withdrawal

The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol intake. Seizure activity is one withdrawal symptom but there are many others, like nausea and tremor.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

29. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

A) transparent film dressing

B) wet dressing with debridement granules

C) wet to dry with hydrogen peroxide

D) moist saline dressing

The correct answer is D: moist saline dressing

This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

White, L., and Duncan, G,. (2002). Medical-Surgical Nursing An Integrated Approach (2nd ed.). Australia: Delmar.

30, An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of

A) septicemia

B) dehydration

C) hypokalemia

D) hypercalcemia

The correct answer is B: dehydration

Clinical findings of dehydration include lethargy, irritability, dry skin, and increased pulse.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

31 The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s remarks most likely indicate

A) neologisms

B) flight of ideas

C) loose associations

D) word salad

The correct answer is C: loose associations

Though the client’s statements are not typical of logical communication, remarks 2 and 3 contain elements of the preceding sentence (moon, walk). Option A refers to making up words that have personal meaning to the client, and option B – flight of ideas defines nearly continuous flow of speech, jumping from one unconnected topic to another. Option D – word salad refers to stringing together real words into nonsense “sentences” that have no meaning for the listener.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

32 The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?

A) Take the client's vital signs

B) Place the client in a sitting position with legs dangling

C) Contact the health care provider

D) Administer the PRN antianxiety agent

The correct answer is B: Place the client in a sitting position with legs dangling

Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Saxton, D. & Nugent, P. (2002). Mosby''s Comprehensive Review of Nursing for NCLEX-RN. St. Louis, Missouri: Mosby

33.The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

A) high in carbohydrates and proteins

B) low in carbohydrates and proteins

C) high in carbohydrates, low in proteins

D) low in carbohydrates, high in proteins

The correct answer is A: high in carbohydrates and proteins

Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

34. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to

A) Dress the child warmly to avoid chilling

B) Keep the child away from other children for the duration of the rash

C) Clean the affected areas with tepid water and detergent

D) Wrap the child's hand in mittens or socks to prevent scratching

The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching

A toddler with atopic dermatitis needs to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possibly a secondary infection.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

35. Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?

A) measure head circumference

B) place in airborne isolation

C) provide passive range of motion

D) provide an over-the-crib protective top

The correct answer is A: measure head circumference

In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to the bed on admission to the unit.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

36. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?

A) Age 40 years

B) Lactose intolerance

C) Family history of breast cancer

D) Use of cocaine on weekends

The correct answer is D: Use of cocaine on weekends

Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

37.A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication?

A) Potassium level

B) Arterial blood gasses

C) Blood urea nitrogen

D) Thiocyanate

The correct answer is D: Thiocyanate

Thiocyanate levels rise with the metabolism if nitroprusside is taken, and this can cause cyanide toxicity. Thiocyanate should not be over 1 millimole/liter.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

38. During the evaluation phase for a client, the nurse should focus on

A) All finding of physical and psychosocial stressors of the client and in the family

B) The client's status, progress toward goal achievement, and ongoing re-evaluation

C) Setting short and long-term goals to insure continuity of care from hospital to home

D) Select interventions that are measurable and achievable within selected timeframes

The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-evaluation

The evaluation step of the nursing process focuses on the client''s status, progress toward goal achievement and ongoing re-evaluation of the plan of care. The other possible answers focus on other steps of the nursing process.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.'

39. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to

A) have the unlicensed assistive personnel (UAP) reheat the food if the client wishes

B) ask the client what foods are acceptable or are unacceptable

C) encourage her to eat for healing and strength

D) schedule the dietitian to meet with the client as soon as possible

The correct answer is B: ask the client what foods are acceptable or are unacceptable

Many Hispanic women subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the client or family.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

40. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by

A) seeking medical help for the victim's injuries

B) minimizing the episode and underestimating the victim’s injuries

C) contacting a close friend and asking for help

D) being very remorseful and assisting the victim with medical care

The correct answer is B: minimizing the episode and underestimating the victim’s injuries

Many batterers lack an understanding of the effects of their behavior on the victim and use excessive minimization and denial.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

NCLEX practice #4

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:54:00 +0000

1. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?

A) "There is a probability of life-long complications."

B) "Cystic fibrosis results in nutritional concerns that can be dealt with."

C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."

D) "You will work with a team of experts and also have access to a support group that the family can attend."

The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."

All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern. Other information of interest is that cystic fibrosis is an autosomal recessive disease. For these parents there is a 25% chance that each pregnancy will result in a child with cystic fibrosis.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

2. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to

A) ask the client about the refusal of certain pain medications

B) talk with the client's family about the situation

C) report the situation to the primary care provider

D) document the situation in the notes

The correct answer is A: ask the client about the refusal of certain pain medications

Beliefs regarding pain are one of the oldest culturally-related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

3. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?

A) "My child has lost 3 pounds in the last month."

B) "Urinary output seemed to be less over the past 2 days."

C) "All the pants have become tight around the waist."

D) "The child prefers some salty foods more than others."

The correct answer is C: "All the pants have become tight around the waist."

Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

4. Post-procedure nursing interventions for electroconvulsive therapy include

A) applying hard restraints if seizure occurs

B) permitting client to sleep for 4 to 6 hours

C) remaining with client until oriented

D) expecting long-term memory loss

The correct answer is C: remaining with client until oriented

The client awakens post-procedure 20-30 minutes after treatment and appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self care. The time frame will vary, but it will not take several hours.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

5.A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

A) transparent dressing

B) dry sterile dressing with antibiotic ointment

C) wet to dry dressing

D) occlusive moist dressing

The correct answer is D: occlusive moist dressing

This wound has granulation tissue present and must be protected. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

6. First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?

A) The pediatrician must examine the baby

B) Emergency equipment should be available

C) This breathing pattern is normal

D) A future referral may be indicated

The correct answer is C: This breathing pattern is normal

Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

7. Which of the following nursing assessments for an infant is most valuable in identifying serious visual defects?

A) Red reflex test

B) Visual acuity

C) Pupil response to light

D) Cover test

The correct answer is A: Red reflex test

A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

8. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?

A) When a family member offers information about their loved one

B) When the client threatens self-harm and harm to others

C) When the provider decides the family has a right to know the client's diagnosis

D) When a visitor insists that the visitor has been given permission by the client

The correct answer is B: When the client threatens self-harm and harm to others

Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the public. (Tarasoff decision,1974)

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Townsend, M. (2003). Psychiatric Mental Health Nursing. Philadelphia: Saunders.

9. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?

A) Schedule the therapy thirty minutes after meals

B) Teach the child not to cough during the treatment

C) Confine the percussion to the rib cage area

D) Place the child in a prone position for the therapy

The correct answer is C: Confine the percussion to the rib cage area

Percussion (clapping) should be only done in the area of the rib cage.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

10. The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is

A) "Although the results are here, your doctor will explain them later."

B) "Your child has fewer red blood cells that carry oxygen."

C) "The blood cells that carry nutrients to the cells are too large."

D) "There are not enough blood cells in your child's circulation."

The correct answer is B: "Your child has fewer red blood cells that carry oxygen."

The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

11. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?

A) Gonorrhea

B) Chlamydia

C) Herpes

D) HIV

The correct answer is B: Chlamydia

Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

12. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly “bothers” other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?

A) Reading

B) Checkers

C) Cards

D) Ping-pong

The correct answer is D: Ping-pong

This provides an outlet for physical energy and requires limited attention. The other options would over-tax the client’s level of self-control.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

13. The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?

A) Stressors in the home

B) Medication compliance

C) Exposure to hot temperatures

D) Alcohol use

The correct answer is B: Medication compliance

Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of schizophrenia. Compliance with daily doses is a critical assessment finding.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

14. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?

A) "The violence is temporarily caused by unusual circumstances, don’t stop hoping for a change."

B) "Perhaps, if you understood the need to abuse, you could stop the violence."

C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?"

D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."

The correct answer is D: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."

Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

15. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?

A) Increase fluid intake to prevent dehydration

B) Place client on a pressure reducing support surface

C) Use skin care products designed for use with incontinence

D) Increase caloric intake to aid healing

The correct answer is B: Place client on a pressure reducing support surface

This client is at greatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relieve pressure, shear and friction forces.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

16. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the

A) Yang, the positive force that represents light, warmth, and fullness

B) Yin, the negative force that represents darkness, cold, and emptiness

C) use of improper hot foods, herbs and plants

D) a failure to keep life in balance with nature and others

The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness

Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

17. A mother asks the nurse if she should be concerned about her child’s tendency to stutter. What assessment data will be most useful in counseling the parent?

A) Age of the child

B) Sibling position in family

C) Stressful family events

D) Parental discipline strategies

The correct answer is A: Age of the child

During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most important in determining if any true dysfunction might be occurring.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

18. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?

A) Monitor for hyperkalemia

B) Place in protective isolation

C) Precautions with position changes

D) Administer diuretics as ordered

The correct answer is C: Precautions with position changes

Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, clients are at high risk for pathological fractures.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

19. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?

A) Assess for generalized edema

B) Monitor for increased urinary output

C) Encourage rest during hyperactive periods

D) Note patterns of increased blood pressure

The correct answer is D: Note patterns of increased blood pressure

Evaluation for hypertension is a key assessment in the course of the disease.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

20. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?

A) Maintaining and preserving function

B) Anticipating side effects of therapy

C) Supporting coping with limitations

D) Ensuring compliance with medications

The correct answer is A: Maintaining and preserving function

To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture, and active and passive range of motion exercises are important interventions for maintaining function of affected joints.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

21.In a child with suspected coarctation of the aorta, the nurse would expect to find

A) strong pedal pulses

B) diminishing carotid pulses

C) normal femoral pulses

D) bounding pulses in the arms

The correct answer is D: bounding pulses in the arms

Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased blood flow to the upper extremities resulting in increased pressure and pulses.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

22. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?

A) Hyperextension of the neck with passive shoulder flexion

B) Flexion of the hip and knees with passive flexion of the neck

C) Flexion of the legs with rebound tenderness

D) Hyperflexion of the neck with rebound flexion of the legs

The correct answer is B: Flexion of the hip and knees with passive flexion of the neck

This is known as a positive Brudzinski’s sign (flexion of hip and knees with passive flexion of the neck). A positive Kernig’s sign, the inability to extend the knee to more than 135 degrees without pain behind the knee while the hip is flexed, usually establishes the diagnosis of meningitis.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

23. At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates

A) Feelings of increasing anxiety related to paranoia

B) Social isolation related to altered thought processes

C) Sensory perceptual alteration related to withdrawal from environment

D) Impaired verbal communication related to impaired judgment

The correct answer is B: Social isolation related to altered thought processes

Hostile alertness and absence of involvement with people are findings supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication suggest altered thinking processes.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

24. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?

A) Bulimia

B) Anorexia

C) Obesity

D) Malnutrition

The correct answer is C: Obesity

Many factors contribute to the high rate of obesity in school aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

25. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?

A) Widening pulse pressure

B) Pleural friction rub

C) Distended neck veins

D) Bradycardia

The correct answer is C: Distended neck veins

In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

26. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?

A) Stand on 1 foot

B) Catch a ball

C) Skip on alternate feet

D) Ride a bicycle

The correct answer is A: Stand on 1 foot

At this age, gross motor development allows a child to balance on 1 foot.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

27. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?

A) Change the baby to whole milk

B) Add chocolate syrup to the bottle

C) Continue with the present formula

D) Offer fruit juice frequently

The correct answer is C: Continue with the present formula

The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

28. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?

A) Say 2 words

B) Pull up to stand

C) Sit without support

D) Drink from a cup

The correct answer is C: Sit without support

The age at which the normal child develops the ability to sit steadily without support is 8 months.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

29. A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for premature infants because it

A) contains less lactose

B) is higher in calories/ounce

C) provides antibodies

D) has less fatty acid

The correct answer is C: provides antibodies

Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

30. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client?

A) "No, it would be best if you brought the client some reading material that she could read at night."

B) "No, your presence may cause the client to become more anxious."

C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."

D) "Yes, would you like to spend the night when the client’s behavior indicates that she is frightened?"

The correct answer is C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."

Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

31. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?

A) 9 month-old who stays with a sitter 5 days a week

B) 20 month-old who has just learned to climb stairs

C) 10 year-old who occasionally stays at home unattended

D) 15 year-old who likes to repair bicycles

The correct answer is B: 20 month-old who has just learned to climb stairs

Toddlers are at most risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

32. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?

A) Cartoon stickers

B) Large wooden puzzle

C) Blunt scissors and paper

D) Beach ball

The correct answer is B: Large wooden puzzle

Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

33. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for

A) Anxiety, unconscious anger, and hostility

B) Guilt, indecisiveness, poor self-concept

C) Psychomotor retardation or agitation

D) Meticulous attention to grooming and hygiene

The correct answer is C: Psychomotor retardation or agitation

Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

34. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?

A) Aerobic exercise classes

B) Transportation for shopping trips

C) Reminiscence groups

D) Regularly scheduled social activities

The correct answer is C: Reminiscence groups

According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of elders as ego integrity vs despair.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

35. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behaviors are warning signs to indicate that the client may be

A) headed for relapse

B) feeling hopeless

C) approaching recovery

D) in need of increased socialization

The correct answer is A: headed for relapse

It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

36. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?

A) Standing and sitting

B) In both arms

C) After exercising

D) Supine position

The correct answer is B: In both arms

Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, causing a false high in that arm.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

37. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should

A) Inform the client that she must wait until the program ends at 5:00 pm to leave

B) Give the client simple information about what she will be doing

C) Tell the client you will call someone to come for her and suggest joining the exercise group while she waits

D) Firmly direct the client to her assigned group activity

The correct answer is C: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits

Comforting and distraction, key approaches in validation therapy are the kindest and most effective for clients who have advancing dementia. The distressed, disoriented client should be gently oriented to reduce fear and increase the sense of safety and security, but reorientation often is ineffective when the client has moderate dementia and/or is upset. Environmental changes provoke stress and fear, especially in clients suffering from Alzheimer’s disease.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

38. Which type of accidental poisoning would the nurse expect to occur in children under age 6?

A) Oral ingestion

B) Topical contact

C) Inhalation

D) Eye splashes

The correct answer is A: Oral ingestion

The greatest risk for young children is from oral ingestion. While children under age 6 may come in contact with other poisons or inhale toxic fumes, these are not common.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

39. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?

A) Activity intolerance caused by fatigue related to chronic tissue hypoxia

B) Impaired mobility related to chronic obstructive pulmonary disease

C) Self care deficit caused by fatigue related to dyspnea

D) Ineffective airway clearance related to increased bronchial secretions

The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia

Activity intolerance describes a condition in which the client''s physiological capacity for activities is compromised.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

40. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?

A) The alveoli will degenerate

B) Chronic bronchoconstriction of the large airways will occur

C) Lung remodeling and permanent changes in lung function will result

D) The client will experience frequent bouts of pneumonia

The correct answer is C: Lung remodeling and permanent changes in lung function will result

While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help reinforce the need for daily management of the disease whether or not the client "feels better."

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

NCLEX practice #5

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:49:00 +0000

1. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to

A) dehydration

B) diminished blood volume

C) decreased cardiac output

D) renal failure

The correct answer is C: decreased cardiac output

Cardiac output and urinary output are directly correlated. The nurse should suspect a drop in cardiac output if the urinary output drops.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

2. When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?

A) Try to vigorously stimulate normal breathing

B) Ask the RN to assess the vital signs

C) Measure the pulse oximetry

D) Continue to monitor respirations

The correct answer is D: Continue to monitor respirations

12 respirations per minute is tolerated post-operatively. A range from 8 to 10 gives cause for concern. At that point pulse oximetry is taken to determine whether that rate is providing sufficient oxygenation. Vigorous stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask the registered nurse (RN) to check the findings.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

3. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?

A) Tell the parents to bring the child to the clinic for further evaluation

B) Refer the school officials to printed materials about this viral illness

C) Inform the teacher that the child is receiving antibiotics for the rash

D) Explain that this rash is not contagious and does not require isolation

The correct answer is D: Explain that this rash is not contagious and does not require isolation

Fifth Disease is a viral illness with an uncertain period of communicability (perhaps 1 week prior to and 1 week after onset). Isolation of the child with Fifth Disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the provider.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

4. The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the provider?

A) Lifts head from the prone position

B) Rolls from abdomen to back

C) Responds to parents' voices

D) Falls forward when sitting

The correct answer is D: Falls forward when sitting

Sitting without support is expected at this age.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

5. When a client is having a general tonic clonic seizure, the nurse should

A) hold the client's arms at their side

B) place the client on their side

C) insert a padded tongue blade in client's mouth

D) elevate the head of the bed

The correct answer is B: place the client on their side

This position keeps the airway patent and prevents aspiration.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

6. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

A) S3 heart sound

B) Thready pulse

C) Flattened neck veins

D) Hypoventilation

The correct answer is A: S3 heart sound

Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF) because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

7. When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?

A) follow-up on lab values before the visit

B) observe client findings for the effectiveness of antibiotics

C) ask for a log of urinary output

D) ask for the log of the oral intake

The correct answer is C: ask for a log of urinary output

The nurse must monitor the urine output as a priority because it is the best indictor of renal function. The other options would be appropriate after an evaluation of the urine output.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

8. The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be

A) "Do you want to discuss this with your pastor?"

B) "We will help you deal with those thoughts."

C) "Is your life so terrible that you want to end it?"

D) "Have you thought about how you would do it?"

The correct answer is D: "Have you thought about how you would do it?"

This response provides an opening to discuss intent and means of committing suicide. It helps in assessing the severity of the risk, since clients who have formulated a suicide plan are closer to suicidal behavior than those who have had vague, non-specific thoughts.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

9. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?

A) Low tar cigarettes are less harmful during pregnancy

B) There is a relationship between smoking and low birth weight

C) The placenta serves as a barrier to nicotine

D) Moderate smoking is effective in weight control

The correct answer is B: There is a relationship between smoking and low birth weight

Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or placenta previa, decreasing the growth potential of the fetus.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

10. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?

A) Hold the infant at frequent intervals.

B) Assess for neonatal withdrawal syndrome

C) Offer fluids to prevent dehydration

D) Administer paregoric to stop diarrhea

The correct answer is B: Assess for neonatal withdrawal syndrome

Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial signs are central nervous system hyper irritability and gastro-intestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during the period of withdrawal.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

11. Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?

A) Direct confrontation

B) Reality orientation

C) Projective identification

D) Active listening

The correct answer is D: Active listening

Use of therapeutic communication skills such as silence and active listening encourages verbalization of feelings.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

12. Clients with mitral stenosis would likely manifest findings associated with congestion in the

A) pulmonary circulation

B) descending aorta

C) superior vena cava

D) bundle of His

The correct answer is A: pulmonary circulation

Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left ventricle and the lack of a competent valve to prevent back-flow into the pulmonary vein.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

13. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, the nurse should understand that adolescents with hemophilia _______.

A) must have structured activities

B) often take part in active sports

C) explain limitations to peer groups

D) avoid risks after bleeding episodes

The correct answer is B: often take part in active sports

An age-appropriate treatment goal is to establish an age-appropriate safe environment. Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental characteristics of this age group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

14. When an autistic client begins to eat with her hands, the nurse can best handle the problem by

A) placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."

B) commenting, "I believe you know better than to eat with your hand."

C) jokingly stating, "Well I guess fingers sometimes work better than spoons."

D) removing the food and stating, "You can’t have anymore food until you use the spoon."

The correct answer is A: placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."

This response identifies instruction and verbal expectation with adaptive behavior.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

15. What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?

A) The disease will incubate longer and progress more slowly in this infant

B) The infant is very susceptible to infections

C) Growth and development patterns will proceed at a normal rate

D) Careful monitoring of renal function is indicated

The correct answer is B: The infant is very susceptible to infections

HIV infected children are susceptible to opportunistic infections due to a compromised immune system.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

16. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?

A) Arterial septal defect

B) Patent ductus arteriosus

C) Aortic stenosis

D) Ventricular septal defect

The correct answer is D: Ventricular septal defect

While assessments for conduction disturbance should be included following repair of any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His), is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

17. The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when

A) an individual displays restlessness

B) there are obvious signs of depression

C) conducting any health assessment

D) the resident reports memory lapses

The correct answer is C: conducting any health assessment

A mental status assessment is a critical part of baseline information, and should be a part of every examination.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

18. While teaching a client about their medications, the client asks how long it will take before the therapeutic effects of lithium occur. What is the best response of the nurse?

A) Immediately

B) Several days

C) 2 weeks

D) 1 month

The correct answer is C: 2 weeks

Lithium is started immediately to treat bipolar disorder because it is quite effective in controlling mania. Lithium takes approximately 2 weeks to effect change in a client’s symptoms.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

19. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize

A) learning relaxation techniques

B) limiting alcohol use

C) eating smaller meals

D) avoiding passive smoke

The correct answer is A: learning relaxation techniques

The only factor that can enhance the client''s response to pain medication for angina is reducing anxiety through relaxation methods. Anxiety can be great enough to make the pain medication totally ineffective.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

20. The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?

A) Younger siblings adapt very well

B) Visitation is helpful for both

C) The siblings may enjoy privacy

D) Those cared for at home cope better

The correct answer is B: Visitation is helpful for both

Contact with the ill child helps siblings understand the reasons for hospitalization and maintains their relationships.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

21. The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism?

A) Denial

B) Projection

C) Intellectualization

D) Rationalization

The correct answer is D: Rationalization

Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations for unacceptable actions. Both the teller and the listener find the rationalizations more satisfactory than the reality.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

22. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?

A) Maintain a low sodium diet

B) Take a diuretic with lithium and avoid excessive fluids

C) Don't be overly concerned if feelings of depression occur

D) Come in for evaluation of serum lithium levels regularly

The correct answer is D: Come in for evaluation of serum lithium levels regularly

This is especially important during hot weather, which may cause excessive perspiration, a loss of sodium and consequently an increase in serum lithium concentration. Diuretics should be avoided, as they could result in an increased serum lithium level. Excessive thirst is a common early finding that subsides over time but may recur. Initiation of treatment for elevated mood at times results in onset of a depressive episode that can be accompanied by risk for self-harm. Clients should be cautioned to report any symptoms of mood instability.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

23. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called

A) craving

B) crashing

C) outward bound

D) nodding out

The correct answer is B: crashing

Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling referred to as crashing.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

24. Clients taking which of the following drugs are at risk for depression?

A) Steroids

B) Diuretics

C) Folic acid

D) Aspirin

The correct answer is A: Steroids

Adverse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. Examples of drugs that can lead to ongoing side effects include: phenothiazines, corticosteroids, and reserpine.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

25. The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these describes the normal pathway?

A) AV node, SA node, Bundle of His, Purkinje fibers

B) Purkinje fibers, SA node, AV node, Bundle of His

C) Bundle of His, Purkinje fibers, SA node , AV node

D) SA node, AV node, Bundle of His, Purkinje fibers

The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers

This is the pathway of a normal electrical impulse through the heart.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

26. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to

A) check for subcutaneous emphysema in the upper torso

B) reposition the client to improve the level of comfort

C) call the provider as soon as possible

D) check for any increase in the amount of thoracic drainage

The correct answer is A: check for subcutaneous emphysema in the upper torso

Continuous bubbling in the water seal chamber is an abnormal finding 2 hours after a lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an air leak in the system. Thus the conclusion is that the problem is one of an air leak in the lung. This client may need to be returned to surgery to deal with the sustained air leak. Action by the provider is required to prevent further complications.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

27. In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?

A) White patches

B) Green drainage

C) Reddened tissue

D) Eschar development

The correct answer is C: Reddened tissue

As the wound granulates, redness indicates healing.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

28. The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is

A) pain

B) impaired gas exchange

C) cardiac output altered: decreased

D) fluid volume excess

The correct answer is C: cardiac output altered: decreased

All nursing interventions should be focused on improving cardiac output. Increasing cardiac output is the primary goal of therapy. Comfort will improve as the client improves and the respiratory status will improve as cardiac output increases.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

29. The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with the parents, the nurse should communicate that

A) circumcision can be performed at any time

B) initial repair is delayed until 6-8 years of age

C) post-operative appearance will be normal

D) surgery will be performed in stages

The correct answer is D: surgery will be performed in stages

Hypospadias, a condition in which the urethral opening is located on the ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

30. While planning care for a preschool aged child, the nurse takes developmental needs into consideration. Which of the following would be of the most concern to the nurse?

A) Playing imaginatively

B) Expressing shame

C) Identifying with family

D) Exploring the playroom

The correct answer is B: Expressing shame

Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt in the toddler stage.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

31. The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

A) assess the client's airway

B) call for help

C) establish that the client is unresponsive

D) see if anyone saw the client fall

The correct answer is C: establish that the client is unresponsive

The first step in CPR is to establish responsiveness. The second is to call for help, and the third is to ensure an open airway.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

32. After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment, but I don’t want my husband to leave me." Which response by the nurse would assist the client?

A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can’t get well."

B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had been pressured to come."

C) "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to seek treatment on an outpatient basis."

D) "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you."

The correct answer is D: "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you."

This response gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. Dependency issues are significant for the client, fostering ambivalence.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

33. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response?

A) "You’ve made some decisions."

B) "Are you thinking about killing yourself?"

C) "I’m so glad to hear that you’ve made some decisions."

D) "You need to discuss your decisions with your therapist."

The correct answer is B: "Are you thinking about killing yourself?"

Sudden mood elevation and energy may signal increased risk of suicide. The nurse must validate suicidal ideation as a beginning step in evaluating seriousness of risk.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

34. What is the best way for the nurse to obtain the health history of a 14 year-old client?

A) Have the mother present to verify information

B) Allow an opportunity for the teen to express feelings

C) Use the same type of language as the adolescent

D) Focus the discussion of risk factors in the peer group

The correct answer is B: Allow an opportunity for the teen to express feelings

Adolescents need to express their feelings. Generally, they talk freely when given an opportunity and some privacy to do so.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

35. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include

A) pointing out inconsistencies in speech patterns to correct thought disorders

B) accepting client and the client's behavior unconditionally

C) encouraging dependency in order to develop ego controls

D) consistent limit-setting enforced 24 hours per day

The correct answer is D: consistent limit-setting enforced 24 hours per day

Treatment approaches that include restructuring the personality, assisting the person with advancing developmental level and setting limits for maladaptive behavior such as acting out.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

36. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next?

A) Give the medication as ordered

B) Call the provider to clarify the dose

C) Recognize that antibiotics are over-prescribed

D) Hold the medication as the dosage is too low

The correct answer is A: Give the medication as ordered

Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

37. A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management style is

A) Participative or democratic

B) Ultraliberal or communicative

C) Autocratic or authoritarian

D) Laissez faire or permissive

The correct answer is C: Autocratic or authoritarian

Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience who need strong direction, while a participative or democratic style is usually more successful on nursing units

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

38. The nurse understands that one reason domestic violence remains extensively undetected is

A) few battered victims seek medical care

B) there is typically a series of minor, vague complaints

C) expenses due to police and court costs are prohibitive

D) very little knowledge is currently known about batterers and battering relationships

The correct answer is B: there is typically a series of minor, vague complaints

Signs of abuse may not be clearly manifested and include a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness. These may be covert indications of abuse that go undetected. Victim complaints may be vague reflecting their ambivalence about disclosing the abuse.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

39. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?

A) Have respiratory support equipment available

B) Immediately place her in the seclusion room

C) Assess the client for anxiety and agitation

D) Administer prn dose of IM antipsychotic medication

The correct answer is A: Have respiratory support equipment available

Persons receiving neuroleptic medication experiencing torticollis and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

40. The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?

A) observe for edema proximal to the site

B) irrigate with 5 ml of 0.9% Normal Saline

C) palpate for a thrill over the fistula

D) check color and warmth in the extremity

The correct answer is C: palpate for a thrill over the fistula

To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. The other options are not related to evaluation of patency.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

NCLEX practice #6

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:45:00 +0000

1. A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?

A) Allow the child to continue normal activities

B) Schedule frequent rest periods

C) Limit exposure to other children

D) Restrict activities to inside the house

The correct answer is A: Allow the child to continue normal activities

Physical activity is important in a two year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucus secretion and helps develop normal breathing patterns.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

2. The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown

A) Ileostomy

B) Transverse colostomy

C) Ileal conduit

D) Sigmoid colostomy

The correct answer is A: Ileostomy

Ileostomy output contains gastric and enzymatic agents that when present on skin can denuded skin in several hours. Because of the caustic nature of this stoma output adequate peristomal skin protection must be delivered to prevent skin breakdown.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

3. During seizure activity which observation is the priority to enhance further direction of treatment?

A) Observe the sequence or types of movement

B) Note the time from beginning to end

C) Identify the pattern of breathing

D) Determine if loss of bowel or bladder control occurs

The correct answer is A: Observe the sequence or types of movement

It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rests solely on the seizure description.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

4. A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?

A) 50% increase in birth weight

B) Head circumference greater than chest

C) Crying when the parents leave

D) Able to stand up briefly in play pen

The correct answer is A: 50% increase in birth weight

Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18 months.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

5. The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?

A) bronchial breath sounds in outer lung fields

B) decreased tactile fremitus

C) hacking, nonproductive cough

D) hyper-resonance of areas of consolidation

The correct answer is A: bronchial breath sounds in outer lung fields

Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

6. The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?

A) Vegetables

B) Cereal

C) Fruit

D) Meats

The correct answer is B: Cereal

Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

7. The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?

A) Large volume of urinary output with each voiding

B) Involuntary voiding with coughing and sneezing

C) Frequent urination

D) Urine is dark and concentrated

The correct answer is C: Frequent urination

Clients with BPH have overflow incontinence with frequent urination in small amounts day and night.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

8. When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to

A) avoid smoking near the client

B) turn off oxygen during meals

C) adjust the liter flow to 10 as needed

D) remind the client to keep mouth closed

The correct answer is A: avoid smoking near the client

Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

9. The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?

A) 1in 4 chance for each child to carry that trait

B) 1in 4 risk for each child to have the disease

C) 1in 2 chance of avoiding the trait and disease

D) 1in 2 chance that each child will have the disease

The correct answer is B: 1in 4 risk for each child to have the disease

Cystic fibrosis has an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Billings, D.M. (2001). Review for the NCLEX-RN. New York: Lippincott Williams & Wilkins.

10. In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to

A) avoid overheating during physical activities

B) maintain normal activity with some restrictions

C) be cautious of others with viruses or temperatures

D) maintain routine immunizations

The correct answer is A: avoid overheating during physical activities

Fluid loss caused by overheating and dehydration can trigger a crisis.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

11. The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents?

A) The ethical sense and feelings of justice are developing

B) Attempts to control the family use new coping styles

C) Insecurity and attention getting are common motives

D) Complex thought processes help to resolve conflicts

The correct answer is A: The ethical sense and feelings of justice are developing

The child is developing a sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

12. The nurse has been assigned to four clients in the emergency room, each experiencing one of these conditions. Which client condition would the nurse check first?

A) Viral pneumonia with atelectasis

B) Spontaneous pneumothorax with a respiratory rate of 38

C) Tension pneumothorax with slight tracheal deviation to the right

D) Acute asthma with episodes of bronchospasm

The correct answer is C: Tension pneumothorax with slight tracheal deviation to the right

Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

13. The nurse understands that during the "tension building" phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of

A) anger

B) helplessness

C) calm

D) explosiveness

The correct answer is B: helplessness

Battered individuals internalize appropriate anger of the batterer’s unfairness. They feel depressed, with a sense of helplessness when their partner explodes, in spite of their best efforts to please the batterer.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

14. An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, "Where do babies come from?" What is the nurse's best response to the parent?

A) "When a child asks a question, give a simple answer."

B) "Children ask many questions, but are not looking for answers."

C) "This question indicates interest in sex beyond this age."

D) "Full and detailed answers should be given to all questions."

The correct answer is A: "When a child asks a question, give a simple answer."

During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask 1 question, they are looking for 1 answer. When they are ready, they will ask for more detailed information.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

15. In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?

A) Compliance with treatment regimens

B) Looking different from their peers

C) Lacking independence in activities

D) Reliance on family for their social support

The correct answer is B: Looking different from their peers

Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

16. The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?

A) Glucose level of 120

B) History of myocardial infarction

C) Long term steroid usage

D) Diet high in carbohydrates

The correct answer is C: Long term steroid usage

Steroid dependency tends to delay wound healing. If the client also smokes, the risk is increased.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

17. The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect?

A) Pelvic tip downward

B) Right leg lengthening

C) Ortolani sign

D) Characteristic limp

The correct answer is D: Characteristic limp

Developmental dysplasia produces a characteristic limp in children who are walking.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

18. The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take?

A) Notify the provider

B) Palpate the anterior fontanel

C) Feel the posterior fontanel

D) Record these normal findings

The correct answer is D: Record these normal findings

The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

19. The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?

A) Report a persistent cough to the health care provider

B) The child can return to school in 4 days

C) Administer chewable aspirin for pain

D) The child may gargle with saline as necessary for discomfort

The correct answer is A: Report a persistent cough to the health care provider

Persistent coughing should be reported to the health care provider as this may indicate bleeding.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

20. The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?

A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus

B) Opening the bottom of the pouch, allowing the flatus to be expelled

C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape

D) Assisting the client to ambulate to reduce the flatus in the pouch

The correct answer is B: Opening the bottom of the pouch, allowing the flatus to be expelled

The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and close the bottom of the pouch.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

21. A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource?

A) The state nurse practice act in which the assignment is made

B) With a nurse colleague who has worked in that state 2 years ago

C) The policies and procedures of the assigned agency in that state

D) The Nursing Social Policy Statement within the United States

The correct answer is A: The state nurse practice act in which the assignment is made

The state nurse practice act is the governing document of the scope of practice in the given state.

Haynes, L., Boese, T., and Butcher, H. (2004). Nursing in contemporary Society. Upper Saddle River, N.J.: Pearson Prentice Hall.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

22. A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling to herself and speaking to the radio. A desirable outcome for this client’s care will be

A) expresses feelings appropriately through verbal interactions

B) accurately interprets events and behaviors of others

C) demonstrates improved social relationships

D) engages in meaningful and understandable verbal communication

The correct answer is D: engages in meaningful and understandable verbal communication

The outcome must be related to the diagnosis and supporting data. Data support impaired verbal communication deficit as a nursing diagnosis. No direct data are presented related to feelings or to thinking processes, though disorganized verbalizations are typically taken to indicate disorganized thinking.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

23. The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?

A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue

B) To cover the bony prominence and areas where there is skin breakdown

C) The client knows what type of clothing to wear when weighed

D) To reduce the tendency of the client to hide objects under his or her clothing

The correct answer is D: To reduce the tendency of the client to hide objects under his or her clothing

The client may conceal weights on their body to create the illusion of increased weight gain.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

24 A client continually repeats phrases that others have just said. The nurse recognizes this behavior as

A) autistic

B) echopraxis

C) echolalic

D) catatonic

The correct answer is C: echolalic

Echolalia is repeating words or phrases heard before.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

25. The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?

A) Elicit reflexes

B) Measure height and weight

C) Auscultate heart and lungs

D) Examine the ears

The correct answer is C: Auscultate heart and lungs

The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

26. At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response?

A) "This is normal at this time of day."

B) "How long has this been occurring?"

C) "Do you offer fluids at night?"

D) "Have you tried waking her to urinate?"

The correct answer is B: "How long has this been occurring?"

Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

27. A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?

A) Call the health care provider

B) Check vital signs

C) Position in high Fowler's

D) Administer oxygen

The correct answer is D: Administer oxygen

When dealing with a medical emergency, the rule is airway first, then breathing, and then circulation. Starting oxygen is the priority.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

28. The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?

A) Avoid climbing stairs for 3 months

B) Ambulate using crutches only

C) Sleep only on your back

D) Do not cross your legs

The correct answer is D: Do not cross your legs

When the client is immediately post-op, hip flexion should not exceed 60 degrees, and after discharge it should not exceed 90 degrees.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

29. A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to

A) Promote healing and strengthen the immune system

B) Provide a well balanced nutritional intake

C) Stimulate increased peristalsis absorption

D) Spare protein catabolism to meet metabolic needs

The correct answer is D: Spare protein catabolism to meet metabolic needs

Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

30. A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?

A) Low hemoglobin

B) Hypernatremia

C) High serum creatinine

D) Hyperkalemia

The correct answer is A: Low hemoglobin

Although hemodialysis improves or corrects electrolyte imbalances it has no effect on improving anemia.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

31. Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?

A) The child learns voluntary sphincter control through repetition

B) Myelination of the spinal cord is completed by this age

C) Neuronal impulses are interrupted at the base of the ganglia

D) The toddler can understand cause and effect

The correct answer is B: Myelination of the spinal cord is completed by this age

Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, sometime between the ages of 18 to 24 months of age.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

32. A client is unconscious following a tonic-clonic seizure. What should the nurse do first?

A) check the pulse

B) administer Valium

C) place the client in a side-lying position

D) place a tongue blade in the mouth

The correct answer is C: place the client in a side-lying position

Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

33. A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by

A) requiring the client to mop the floor

B) restricting the client’s fluids throughout the day

C) withholding privileges each time the voiding occurs

D) toileting the client more frequently with supervision

The correct answer is D: toileting the client more frequently with supervision

With a client suffering from altered thought processes, the most appropriate nursing approach to change this behavior is by taking an active role in attending to the physical need.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

34. When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother?

A) It is likely that all sons are affected

B) There is a 50% probability that sons will have the disease

C) Every daughter is likely to be a carrier

D) There is a 25% chance a daughter will be a carrier

The correct answer is D: There is a 25% chance a daughter will be a carrier

Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

35. A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?

A) Maintain good nutrition

B) Stay in school

C) Keep in contact with the child's father

D) Get adequate sleep

The correct answer is A: Maintain good nutrition

Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

36. A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?

A) Provide the ordered humidified oxygen via mask

B) Suction the mouth and the nose

C) Check the mouth and radial pulse

D) Start the ordered intravenous fluids

The correct answer is C: Check the mouth and radial pulse

The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation, then stabilize the client. The other nursing actions would follow.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

37. The nurse is caring for a post-op colostomy client. The client begins to cry, saying "I'll never be attractive again with this ugly red thing." What should be the first action taken by the nurse?

A) Arrange a consultation with a sex therapist experienced in working with colostomy clients

B) Suggest sexual positions that hide the colostomy

C) Invite the partner to participate in colostomy care after viewing an instructional video

D) Encourage the client to discuss her feelings about the colostomy

The correct answer is D: Encourage the client to discuss her feelings about the colostomy

One of the greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible. However, the client’s personal feelings about the stoma and colostomy care, as well as the client''s specific concerns, need to be assessed to accurately identify the problem(s) to be solved. An assessment should occur before specific suggestions for dealing with the sexual concerns are given.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

38. Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?

A) Involuntary rhythmic stereotypic movements and tongue protrusion

B) Cheek puffing, involuntary movements of extremities and trunk

C) Agitation, constant state of motion

D) Hyperpyrexia, severe muscle rigidity, malignant hypertension

The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant hypertension

Hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs indicative of NMS (neuroleptic malignant syndrome).

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

39. Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client?

A) An accurate measurement of intake is not reliable

B) The food pyramid is not used in this age group

C) A serving size at this age is about 2 tablespoons

D) Total intake varies greatly each day

The correct answer is C: A serving size at this age is about 2 tablespoons

In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

40. A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The nurse knows that the most likely reason for the HSV-1 infection in this client is

A) immunosuppression

B) emotional stress

C) unprotected sexual activities

D) contact with saliva

The correct answer is A: immunosuppression

The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1 is an opportunistic infection. The other options may result in HSV-1. However, they are not the most likely causes in clients with HIV.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

NCLEX practice #7

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:41:00 +0000

1. When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?

A) Speak directly to the interpreter while presenting information and use pauses for questions

B) Talk to the interpreter in advance and leave the client and interpreter alone

C) Include a family member and direct communications to that person

D) Face the client while presenting the information as the interpreter talks in the native language

The correct answer is D: Face the client while presenting the information as the interpreter talks in the native language

Communication is the cornerstone of an effective teaching plan, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, face the client and present the information to the client, allow the interpreter to translate the content. Facing the client allows non-verbal communication to take place between the client and nurse.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

2. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?

A) Sports and games with rules

B) Finger paints and water play

C) "Dress-up" clothes and props

D) Chess and television programs

The correct answer is A: Sports and games with rules

The purpose of play for the 7 year-old is developing cooperation. Rules are very important. Logical reasoning and social skills are developed through play.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

3. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?

A) Compulsive behavior

B) Sense of impending doom

C) Fear of flying

D) Predictable episodes

The correct answer is B: Sense of impending doom

The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

4. A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?

A) Teaching the child self care skills

B) Preparing for independent toileting

C) Promoting the child's optimal development

D) Helping the family decide on long term care

The correct answer is C: Promoting the child''s optimal development

The primary goal of nursing care for a developmentally challenged child is to promote the child''s optimum development.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

5. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?

A) Neuro malignant syndrome

B) Acute extrapyramidal syndrome

C) Glaucoma, prostatic hypertrophy

D) Parkinson's disease, atypical tremors

The correct answer is C: Glaucoma, prostatic hypertrophy

Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine (Cogentin) because the drug is an anticholinergic agent. Cogentin is used to treat the side effects of antipsychotic medications.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

6. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?

A) They are able to make simple association of ideas

B) They are able to think logically in organizing facts

C) Interpretation of events originate from their own perspective

D) Conclusions are based on previous experiences

The correct answer is B: They are able to think logically in organizing facts

The child in the concrete operations stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

7. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

A) Strange bed and surroundings

B) Separation from parents

C) Presence of other toddlers

D) Unfamiliar toys and games

The correct answer is B: Separation from parents

Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

8. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

A) High Fowler's

B) Supine

C) Left lateral

D) Low Fowler's

The correct answer is A: High Fowler''s

Sitting in a chair or resting in a bed in high Fowler''s position decreases the cardiac workload and facilitates breathing.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

9. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?

A) Administration of cough suppressants

B) Increasing oral fluid intake to 3000 cc per day

C) Maintaining bed rest with bathroom privileges

D) Performing chest physiotherapy twice a day

The correct answer is B: Increasing oral fluid intake to 3000 cc per day

Secretion removal is enhanced with adequate hydration which thins and liquefies secretions.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

10. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to

A) reports of difficulty falling and staying asleep

B) expression of persistent suicidal thoughts

C) lack of enjoyment in usual pleasures

D) reduced senses of taste and smell

The correct answer is C: lack of enjoyment in usual pleasures

Lack of enjoyment in usual pleasures is the definition of “anhedonia,” which is a common finding in depression.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

11. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

A) A 13 month-old unable to walk

B) A 20 month-old only using 2 and 3 word sentences

C) A 24 month-old who cries during examination

D) A 30 month-old only drinking from a sippy cup

The correct answer is D: A 30 month-old only drinking from a sippy cup

A 30 month-old should be able to drink from a cup without a cover.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

12. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

A) Elevate the leg on 2 pillows

B) Apply support stockings

C) Apply warm compresses

D) Maintain complete bed rest

The correct answer is A: Elevate the leg on 2 pillows

The first goal of nonpharmacologic interventions is to minimize edema of the affected extremity by leg elevation.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

13. A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?

A) elbow

B) mummy

C) jacket

D) clove hitch

The correct answer is A: elbow

The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

14. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?

A) Give written pre and post tests

B) Ask questions during practice

C) Allow another diabetic to assist

D) Observe a return demonstration

The correct answer is D: Observe a return demonstration

Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

15. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?

A) congenital cardiac defects

B) an acute febrile illness

C) prolonged hypoxemia

D) severe multiple trauma

The correct answer is C: prolonged hypoxemia

Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia. Children usually have both cardiac and respiratory arrest.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

16. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that the client

A) should remain on bed rest in a semi-Fowler's position

B) should alternate ambulation with bed rest with legs elevated

C) may ambulate and sit in chair as tolerated

D) may ambulate as tolerated and remain in semi-Fowlers position in bed

The correct answer is B: should alternate ambulation with bed rest with legs elevated

Encourage alternating periods ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client with gradually increasing periods of ambulation.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

17. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?

A) perform defibrillation

B) administer epinephrine as ordered

C) assess for presence of pulse

D) institute CPR

The correct answer is C: assess for presence of pulse

Artifact (interference) can mimic ventricular fibrillation on a cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client’s pulse.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

18. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is

A) "Eat a balanced diet for your age."

B) "Increase your intake of protein and Vitamin A."

C) "Decrease fatty foods from your diet."

D) "Do not use caffeine in any form, including chocolate."

The correct answer is A: "Eat a balanced diet for your age."

A diet for a teenager with acne should be a well balanced diet for their age. There are no recommended additions and subtractions from the diet.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

19. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to

A) administer pain medication

B) suction excessive tracheobronchial secretions

C) assist client to turn, deep breathe and cough

D) monitor oxygen saturation

The correct answer is B: suction excessive tracheobronchial secretions

Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway which is always the priority nursing intervention.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

20. The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?

A) They occur about 2 years earlier than for males.

B) They begin about the same time for males.

C) They begin just prior to the onset of puberty.

D) They are characterized by an increase in height of 4 inches each year.

The correct answer is A: They occur about 2 years earlier than for males.

Normally, females in their teenage years experience a growth spurt about 2 years earlier than their male peers.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

21. A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to

A) Notify the primary care provider immediately

B) Suggest in-patient psychiatric care

C) Respect the client's confidential disclosure

D) Phone the family to warn them of the risk

The correct answer is A: Notify the primary care provider immediately

Not only does the client report suicidal intent, he had formulated a plan and taken steps to implement it. The primary care provider and the rest of the health care team will arrange for treatment given the client’s serious risk for self-destructive behavior. Hospitalization and most probably work with the family are indicated. The nurse should never agree to help a client “keep secrets” from the health care team.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

22. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds:

A) "The complaints of at least 3 common findings."

B) "The absence of any opportunistic infection."

C) "CD4 lymphocyte count is less than 200."

D) "Developmental delays in children."

The correct answer is C: "CD4 lymphocyte count is less than 200."

CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for Disease Control defined AIDS as having a positive HIV plus one of these – the presence of an opportunistic infection or a CD4 lymphocyte count of less than 200.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

23. A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?

A) Altered nutrition: less than body requirements

B) Potential complication hemorrhage

C) Ineffective individual coping

D) Fluid volume excess

The correct answer is B: Potential complication hemorrhage

Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

24. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?

A) Offer ice cream every 2 hours

B) Place the child in a supine position

C) Allow the child to drink through a straw

D) Observe swallowing patterns

The correct answer is D: Observe swallowing patterns

The nurse should observe for increased swallowing frequency, which would signal hemorrhage.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

25. The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should

A) Offer small meals of high calorie soft food

B) Assist the client to sit in a chair for meals

C) Provide additional servings of fruits and raw vegetables

D) Encourage the client to eat fish, liver and chicken

The correct answer is A: Offer small meals of high calorie soft food

If the client is losing weight because of poor appetite due to the pain, assist in selecting foods that are high in calories and nutrients, to provide more nourishment with less chewing. Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw movements when eating, suggest that foods be pureed.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

26. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings?

A) Ingestion of tetracycline

B) Excessive fluoride intake

C) Oral iron therapy

D) Poor dental hygiene

The correct answer is B: Excessive fluoride intake

The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel''s porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

27. The nursing care plan for a client with decreased adrenal function should include

A) encouraging activity

B) placing client in reverse isolation

C) limiting visitors

D) measures to prevent constipation

The correct answer is C: limiting visitors

Any exertion, either physical or emotional, places additional stress on the adrenal glands which could precipitate an Addisonian crisis. The plan of care should protect this client from the physical and emotional exertion of visitors.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

28. Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?

A) Direct sunlight

B) Foods containing tyramine

C) Foods fermented with yeast

D) Canned citrus fruit drinks

The correct answer is A: Direct sunlight

Phenothiazine increases sensitivity to the sun, making clients especially susceptible to sunburn. The nurse should recommend that clients treated with phenothiazines use sunblock consistently.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

29. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?

A) Several otitis media episodes in the last year

B) Weight and height in the 10th percentile since birth

C) Takes frequent rest periods while playing

D) Changing food preferences and dislikes

The correct answer is C: Takes frequent rest periods while playing

Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

30. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?

A) Arrange to change client care assignments

B) Explain that this behavior is expected

C) Discuss the appropriate use of "time-out"

D) Explain that the child needs extra attention

The correct answer is B: Explain that this behavior is expected

During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

31. The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is

A) "You think that someone wants to poison you?"

B) "Why do you think the food is poisoned?"

C) "These feelings are a symptom of your illness."

D) "You’re safe here. I won’t let anyone poison you."

The correct answer is A: "You think that someone wants to poison you?"

This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

32. A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?

A) Counsel the woman to consent to HIV screening

B) Perform tests for sexually transmitted diseases

C) Discuss her high risk for cervical cancer

D) Refer the client to a family planning clinic

The correct answer is A: Counsel the woman to consent to HIV screening

The client''s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

33. A 15 year-old client with a lengthy confining illness is most at risk for altered psycho-emotional growth and development due to

A) loss of control

B) insecurity

C) dependence

D) lack of trust

The correct answer is C: dependence

The client role fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

34. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

A) urinary output of 30 ml per hour

B) no complaints of thirst

C) increased hematocrit

D) good skin turgor around burn

The correct answer is A: urinary output of 30 ml per hour

For a child of this age, this is adequate output, yet does not suggest overload.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

35. Which of these variations in the newborn results from the presence of maternal hormones?

A) Engorgement of the breasts

B) Mongolian spots

C) Edema of the scrotum

D) Lanugo

The correct answer is A: Engorgement of the breasts

Breast engorgement occurs in both sexes as a result of the withdrawal of maternal hormones after birth.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

36. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first?

A) Clear the area of any hazards

B) Place the child on its side

C) Restrain the child

D) Give the prescribed anticonvulsant

The correct answer is B: Place the child on its side

Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a patent airway and oxygenation must be assured.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

37. A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?

A) An 18 month-old who ate an undetermined amount of crystal drain cleaner

B) A 14 month-old who chewed 2 leaves of a philodendron plant

C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)

D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid

The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner

Drain cleaner is very alkaline. Orange juice is acidic and will help to neutralize this substance.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

38. The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?

A) Encourage the client to cough and deep breathe every 2 hours

B) Place the client in contact isolation

C) Provide a diet high in protein

D) Institute seizure precautions

The correct answer is A: Encourage the client to cough and deep breathe every 2 hours

Respiratory infections are common because of fluid in the retro-peritoneum pushing up against the diaphragm, causing shallow respirations. Coughing and deep breathing every 2 hours will diminish the occurrence of this complication.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

39. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?

A) Acceptance of the pregnancy

B) Focus on fetal development

C) Anticipation of the birth

D) Ambivalence about pregnancy

The correct answer is C: Anticipation of the birth

Directing activities toward preparation for the newborn''s needs and personal adjustment are indicators of appropriate emotional response in the third trimester.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

40. The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?

A) Nutrition

B) Elimination

C) Activity

D) Safety

The correct answer is D: Safety

Safety is a care priority for all inpatients, and a depressed client is at acute risk for self-destructive behavior. Precautions to prevent suicide must be a part of the nursing care plan.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

NCLEX practice #8

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:37:00 +0000

1. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time?

A) Altered tissue perfusion

B) Risk for fluid volume deficit

C) High risk for hemorrhage

D) Risk for infection

The correct answer is D: Risk for infection

Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

2. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to

A) convince the client that the hospital staff is trying to help

B) help the client to enter into group recreational activities

C) provide interactions to help the client learn to trust staff

D) arrange the environment to limit the client’s contact with other clients

The correct answer is C: provide interactions to help the client learn to trust staff

Establishing trust helps clients feel safer, and facilitates a therapeutic alliance between staff and client.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

3. A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should

A) Expose the cast to air and turn the child frequently

B) Use a heat lamp to reduce the drying time

C) Handle the cast with the abductor bar

D) Turn the child as little as possible

The correct answer is A: Expose the cast to air and turn the child frequently

The child should be turned every two hours, with the cast''s surface exposed to the air.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

4. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend _________ exercises

A) isometric

B) range of motion

C) aerobic

D) isotonic

The correct answer is A: isometric

The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

5. A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?

A) Use only cloth diapers that are rinsed in bleach

B) Do not use occlusive ointments on the rash

C) Use commercial baby wipes with each diaper change

D) Discontinue a new food that was added to the infant's diet just prior to the rash

The correct answer is D: Discontinue a new food that was added to the infant''s diet just prior to the rash

The addition of new foods to the infant''s diet can be a cause of diaper dermatitis.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

6. The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect?

A) confusion

B) loss of half of visual field

C) shallow respirations

D) tonic-clonic seizures

The correct answer is C: shallow respirations

ALS is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

7. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?

A) Institute seizure precautions

B) Weigh the child twice per shift

C) Encourage the child to eat protein-rich foods

D) Relieve boredom through physical activity

The correct answer is A: Institute seizure precautions

The severity of the acute phase of AGN is variable and unpredictable; therefore a child with edema, hypertension, and gross hematuria may be subject to complications. Anticipatory preparation such as seizure precautions are needed.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

8. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

A) "Focus on your sons' needs during the first days at home."

B) "Tell each child what he can do to help with the baby."

C) "Suggest that your husband spend more time with the boys."

D) "Ask the children what they would like to do for the newborn."

The correct answer is A: "Focus on your sons'' needs during the first days at home."

In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

9. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mg/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mg of Lidocaine/minute?

A) 60 microdrops/minute

B) 20 microdrops/minute

C) 30 microdrops/minute

D) 40 microdrops/minute

The correct answer is A: 60 microdrops/minute

2 gm=2000 mg

2000 mgm/500 cc = 4 mg/x cc

2000x = 2000

x= 2000/2000 = 1 cc of IV solution/minute

CC x 60 microdrops = 60 microdrops/minute

Olsen, J.L., Giangrasso, A.P., and Shrimpton, D. (2004). Medical Dosage Calculations. (8th Edition). Upper Saddle River, New Jersey: Pearson Prentice Hall.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

10. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

A) Raise the head of the bed at least 30 degrees

B) Encourage ambulation within 24 hours

C) Maintain in a flat position, logrolling as needed

D) Encourage leg contraction and relaxation after 48 hours

The correct answer is C: Maintain in a flat position, logrolling as needed

The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn the client who is on bed rest.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

11. Which behavioral characteristic describes the domestic abuser?

A) Alcoholic

B) Over confident

C) High tolerance for frustrations

D) Low self-esteem

The correct answer is D: Low self-esteem

Batterers were usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, and have a great need to exercise control or power over their partners.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

12. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

A) unequal leg length

B) limited adduction

C) diminished femoral pulses

D) symmetrical gluteal folds

The correct answer is A: unequal leg length

Shortening of the affected leg is a sign of developmental dysplasia of the hip.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

13. A client with schizophrenia is receiving haloperidol (Haldol) 5 mg T.I.D. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect?

A) Oculogyric crisis

B) Tardive dyskinesia

C) Nystagmus

D) Dysphagia

The correct answer is A: Oculogyric crisis

This refers to involuntary muscles spasm of the eye. There are medications to treat these side effects, for example Artane.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

14. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to

A) Give the client orientation materials and review the unit rules and regulations

B) Introduce him/herself and accompany the client to the client’s room

C) Take the client to the day room and introduce her to the other clients

D) Ask the nursing assistant to get the client’s vital signs and complete the admission search

The correct answer is B: Introduce him/herself and accompany the client to the client’s room

Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

15. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would

A) assist the client to use the bedside commode

B) administer stool softeners every day as ordered

C) administer antidysrhythmics prn as ordered

D) maintain the client on strict bed rest

The correct answer is B: administer stool softeners every day as ordered

Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation (the Valsalva maneuver) produced rhythm disturbances, then antidysrhythmics would be appropriate.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

16. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?

A) "Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior."

B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"

C) "Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs."

D) "You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done."

The correct answer is B: "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"

This response encourages the client to get in touch with their feelings and utilize problem solving steps to reduce guilt feelings.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

17. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?

A) Ask the client if he has noticed any bleeding or dark stools

B) Tell the client to call 911 and go to the emergency department immediately

C) Schedule a repeat Hemoglobin and Hematocrit in 1 month

D) Tell the client to schedule an appointment with a hematologist

The correct answer is A: Ask the client if he has noticed any bleeding or dark stools

Normal hemoglobin for males is 13.0 - 18 g/100 ml. Normal hematocrit for males is 42 - 52%. These values are below normal and indicate mild anemia. The first thing the nurse should do is ask the client if he''s noticed any bleeding or change in stools that could indicate bleeding from the GI tract.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

18. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

A) has increased airway obstruction

B) has improved airway obstruction

C) needs to be suctioned

D) exhibits hyperventilation

The correct answer is A: has increased airway obstruction

The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, no data supports the need for suctioning.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

19. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

A) Check vital signs

B) Massage the fundus

C) Offer a bedpan

D) Check for perineal lacerations

The correct answer is B: Massage the fundus

The nurse’s first action should be to massage the fundus until it is firm, as uterine atony is the primary cause of bleeding in the first hour after delivery.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

20. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?

A) Norplant is safe and may be removed easily

B) Oral contraceptives should not be used by smokers

C) Depo-Provera is convenient with few side effects

D) The IUD gives protection from pregnancy and infection

The correct answer is B: Oral contraceptives should not be used by smokers

The use of oral contraceptives in a woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

21. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report

A) loss of consciousness

B) feeding problems

C) poor weight gain

D) fatigue with crying

The correct answer is A: loss of consciousness

While parents should report any of these findings, they need to call the provider immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

22. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to

A) A social worker from the local hospital

B) A physical therapist to improve fine motor coordination

C) An activity therapist from the community center

D) Another client with diabetes mellitus and takes insulin

The correct answer is B: A physical therapist to improve fine motor coordination

A physical therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing. Upper Saddle River, N.J.: Pearson Prentice Hall.

23. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the

A) surgical repair of a diseased coronary artery

B) placement of an automatic internal cardiac defibrillator

C) procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

D) non-invasive radiographic examination of the heart

The correct answer is C: procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass (CABG) is the surgical procedure to repair a diseased coronary artery.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

24. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: “We just don’t know how he caught the disease!” The nurse's response is based on an understanding that

A) AGN is a streptococcal infection that involves the kidney tubules

B) the disease is easily transmissible in schools and camps

C) the illness is usually associated with chronic respiratory infections

D) it is not "caught" but is a response to a previous B-hemolytic strep infection

The correct answer is D: it is not "caught" but is a response to a previous B-hemolytic strep infection

AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior, and is considered as a noninfectious renal disease.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

25. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?

A) Trust

B) Initiative

C) Independence

D) Self-esteem

The correct answer is C: Independence

In Erikson’s theory of development, toddlers struggle to assert independence. They often use the word “no” even when they mean yes. This stage is called autonomy versus shame and doubt

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

26. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?

A) "I have constant blurred vision."

B) "I can't see on my left side."

C) "I have to turn my head to see my room."

D) "I have specks floating in my eyes."

The correct answer is C: "I have to turn my head to see my room."

Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

27. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight change at 6 months of age?

A) Double the birth weight

B) Triple the birth weight

C) Gain 6 ounces each week

D) Add 2 pounds each month

The correct answer is A: Double the birth weight

Although growth rates vary, infants normally double their birth weight by 6 months.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

28. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?

A) These side effects are common and should subside in a few days

B) The client is probably having an allergic reaction and should discontinue the drug

C) Taking the lithium on an empty stomach should decrease these symptoms

D) Decreasing dietary intake of sodium and fluids should minimize the side effects

The correct answer is A: These side effects are common and should subside in a few days

Nausea, metallic taste and fine hand tremors are common side effects that usually subside quickly. Informing clients of these possible reactions can help them tolerate these initial difficulties and continue taking the drug, obtaining therapeutic effects.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

29. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?

A) "Nursing will help contract the uterus and reduce your risk of bleeding."

B) "Breastfeeding twins will take too much energy after the hemorrhage."

C) "The blood transfusion may increase the risks to you and the babies."

D) "Lactation should be delayed until the "real milk" is secreted."

The correct answer is A: "Nursing will help contract the uterus and reduce your risk of bleeding."

Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

30. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing

A) "This position of my lips helps to keep my airway open."

B) "I can expel more when I pucker up my lips to breathe out."

C) "My mouth doesn't get as dry when I breathe with pursed lips."

D) "With prolonging breathing out with pursed lips the little areas in my lungs don't collapse."

The correct answer is D: "With prolonging breathing out with pursed lips the little areas in my lungs don''t collapse."

Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of the weak alveolar walls from the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing. This is the major reason to use it. The other options are secondary beneficial effects of pursed-lip breathing.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

31. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

A) Review the client's weight pattern over the year

B) Ask the mother to record her diet for the last 24 hours

C) Encourage her to talk about her view of herself

D) Give her several pamphlets on postpartum nutrition

The correct answer is C: Encourage her to talk about her view of herself

To an adolescent, body image is very important. The nurse must acknowledge this before assessment and teaching.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

32. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of "suppression"?

A) "I don't remember anything about what happened to me."

B) "I'd rather not talk about it right now."

C) "It's all the other guy's fault! He was going too fast."

D) "My mother is heartbroken about this."

The correct answer is A: "I don''t remember anything about what happened to me."

Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion, "voluntary forgetting," is generally used to protect one’s own self esteem.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

33. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

A) Place pillows under the knees

B) Use elastic stockings continuously

C) Encourage range of motion and ambulation

D) Massage the legs twice daily

The correct answer is C: Encourage range of motion and ambulation

Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

34. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse would be to inform them that

A) circumcision is delayed so the foreskin can be used for the surgical repair

B) this procedure is contraindicated because of the permanent defect

C) there is no medical indication for performing a circumcision on any child

D) the procedure should be performed as soon as the infant is stable

The correct answer is A: circumcision is delayed so the foreskin can be used for the surgical repair

Even if only mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair if needed.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

35. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is

A) Progressive failure to adapt

B) Feelings of anger or hostility

C) Reunion wish or fantasy

D) Feelings of alienation or isolation

The correct answer is D: Feelings of alienation or isolation

The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self imposed or can occur as a result of the inability to express feelings. At this stage of development it is important to achieve a sense of identity and peer acceptance.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

36. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would

A) instruct the client to maintain a regular diet the day prior to the examination

B) restrict the client's fluid intake 4 hours prior to the examination

C) administer a laxative to the client the evening before the examination

D) inform the client that only 1 x-ray of his abdomen is necessary

The correct answer is C: administer a laxative to the client the evening before the examination

Bowel prep is important because it will allow greater visualization of the bladder and ureters.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

37. The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is

A) re-orientation to reality

B) elimination of symptoms

C) protection from harm to self or others

D) return to independent functioning

The correct answer is C: protection from harm to self or others

Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

38. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?

A) 3 episodes of vomiting in 1 hour

B) Periodic crying and irritability

C) Vigorous sucking on a pacifier

D) No measurable voiding in 4 hours

The correct answer is D: No measurable voiding in 4 hours

The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

39. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

A) a cerebral vascular accident

B) postoperative meningitis

C) medication reaction

D) metabolic alkalosis

The correct answer is A: a cerebral vascular accident

Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

40. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize

A) they can expect the child will be mentally retarded

B) administration of thyroid hormone will prevent problems

C) this rare problem is always hereditary

D) physical growth/development will be delayed

The correct answer is B: administration of thyroid hormone will prevent problems

Early identification and continued treatment with hormone replacement corrects this condition.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

NCLEX practice #9

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:32:00 +0000

1. A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to

A) insufficient oxygenation of the cardiac muscle

B) potential circulatory overload

C) left ventricular overload

D) electrolyte imbalance

The correct answer is A: insufficient oxygenation of the cardiac muscle

Due to ischemia of the heart muscle, the client experiences pain. This happens because an MI can block or interfere with the normal cardiac circulation.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

2. The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?

A) Change the pillow covers every month

B) Wash bed linens in warm water with a cold rinse

C) Wash and rinse the bed linens in hot water

D) Use air filters in the furnace system

The correct answer is C: Wash and rinse the bed linens in hot water

For asthma clients who are sensitive to house dust-mites it is essential the mattresses and pillows are encased in allergen-impermeable covers. All bed linens such as pillow cases, sheets and blankets should be washed and rinsed weekly in hot water at temperatures above 130 degrees Fahrenheit, the temperature necessary to kill the dust-mites.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

3. The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?

A) "What is your reason for wanting such a plan?"

B) "Have you talked with your provider about this?"

C) "Let us discuss your rights as a couple"

D) "Write your ideal plan for the next class"

The correct answer is C: "Let us discuss your rights as a couple"

Discussion of the provider''s role and the couple''s rights and limitations in selecting birth options must precede development of a plan.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

4. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be

A) Reduce fear and protect self-esteem

B) Minimize anxiety and delay apprehension

C) Avoid conflict and leave unpleasant situations

D) Increase independence and communicate more often

The correct answer is A: Reduce fear and protect self-esteem

Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which the client admits that they are feeling various emotions.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

5. A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority?

A) Remove protective arm devices one at a time for short periods with supervision

B) Initiate by mouth feedings when alert, with the return of the gag reflex

C) Introduce to the parents how to cleanse the suture line with the prescribed protocol

D) Position the infant on the back after feedings throughout the day

The correct answer is A: Remove protective arm devices one at a time for short periods with supervision

The major efforts in the postoperative period are directed toward protecting the operative site. Elbow restraints should be used and only 1 arm released at a time with close supervision by the nurse and/or parents.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

6. When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?

A) risk for injury: hemorrhage

B) risk for injury related to peripheral neuropathy

C) altered nutrition: less than body requirements

D) fluid volume excess: ascites

The correct answer is A: risk for injury: hemorrhage

Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. Hemorrhage, especially from esophageal varices can be life threatening. This takes priority over the other nursing diagnosis.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

7. A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?

A) Determine that adequate mist is supplied

B) Inspect the nares and ears for skin breakdown

C) Lubricate the tips of the cannula before insertion

D) Maintain sterile technique when handling cannula

The correct answer is B: Inspect the nares and ears for skin breakdown

Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation. Nasal cannula administering oxygen should not be lubricated with petroleum jelly.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

8. A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?

A) Increase bladder tone by delaying voiding

B) When laundering clothing, rinse several times

C) Use plain water for the bath, shampooing hair last

D) Have the child use antibacterial soaps while bathing

The correct answer is C: Use plain water for the bath, shampooing hair last

Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTI''s in young girls.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

9. While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?

A) Flexion of lower extremities

B) Negative Ortolani response

C) Lengthened leg of affected side

D) Irregular hip symmetry

The correct answer is D: Irregular hip symmetry

Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

10. A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis

A) Low serum albumin

B) High serum cholesterol

C) Abnormally low white blood cell count

D) Elevated creatine phosphokinase (CPK)

The correct answer is D: Elevated creatine phosphokinase (CPK)

An elevated CPK is a common finding in the client with an MI. CPK levels begin to rise approximately 3 to 12 hours after an acute MI, peak in 24 hours, and return to normal within 2 to 3 days. Troponin levels rise as well.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

11. A child with tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to

A) assessment of oxygenation

B) observation for developmental delays

C) prevention of infection

D) maintenance of adequate nutrition

The correct answer is A: assessment of oxygenation

All of the above would be important in a child diagnosed with tetralogy of Fallot. However, persistent hypoxemia causes acidosis which further decreases pulmonary blood flow. Additionally, low oxygenation leads to development of polycythemia and resultant neurologic complications.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

12. On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?

A) Periorbital edema, absent light reflex and translucent tympanic membrane

B) Irritability, rhinorrhea, and bulging tympanic membrane

C) Diarrhea, retracted tympanic membrane and enlarged parotid gland

D) Vomiting, pulling at ears and pearly white tympanic membrane

The correct answer is B: Irritability, rhinorrhea, and bulging tympanic membrane

Clinical manifestations of otitis media include irritability, rhinorrhea, bulging tympanic membrane, and pulling at ears.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

13. Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess

A) right ventricular pressure

B) left ventricular end-diastolic pressure

C) acid-base balance

D) coronary artery stability

The correct answer is B: left ventricular end-diastolic pressure

The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure. Pulmonary artery pressures are an assessment tool used to determine the ability of the heart to receive and pump blood effectively.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

14. The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?

A) Diaphoresis and shakiness

B) Reduced lower leg sensation

C) Intense thirst and hunger

D) Painful hematoma on thigh

The correct answer is A: Diaphoresis and shakiness

Diaphoresis is a sign of hypoglycemia which warrants immediate attention.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

15. When teaching new parents prevention of sudden infant death syndrome (SIDS) what is the most important practice the nurse should instruct them to do?

A) Place the infant in a supine or side lying position for sleep

B) Do not allow anyone to smoke in the home

C) Follow recommended immunization schedule

D) Be sure to check infant every one hour

The correct answer is A: Place the infant in a supine or side lying position for sleep

Current thinking is that infants become hypoxic when they sleep because of positional narrowing of the airway and respiratory inflammation. The most compelling data comes from studies that link sleep habits with an increased risk of SIDS. Sleeping in the prone position may cause oropharyngeal obstruction or affect the thermal balance or arousal state. Sleep apnea is not the cause of SIDS. Because of research findings and the "Back to Sleep" campaign, the incidence of sleep apnea and the number of SIDS deaths have dropped dramatically.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

16. In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?

A) Increased edema and weight gain

B) Unchanged urine specific gravity

C) Rapid protein excretion

D) Decreased blood potassium

The correct answer is B: Unchanged urine specific gravity

When fluids are restricted, the client continues to excrete large amounts of dilute urine. This finding supports the diagnosis. Normally, urine is more concentrated with reduced fluid intake.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

17. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What other finding would the nurse expect?

A) Flushed skin

B) Bradycardia

C) Mental confusion

D) Hypotension

The correct answer is C: Mental confusion

Crackles suggest pneumonia, which is likely to be accompanied by mental confusion related to hypoxia.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

18. A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse?

A) Para 2, Gravida 1

B) Nulligravida 2, Para 1

C) Primigravida 1, Para 1

D) Gravida 2, Para 1

The correct answer is D: Gravida 2, Para 1

Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability. Therefore a woman pregnant with her second child would be described as Gravida 2, Para 1. Primipara refers to a woman who has completed one pregnancy to the period of viability. Multipara refers to a woman who has completed 2 or more pregnancies to the stage of viability.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

19. You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?

A) "I will be receiving continuous doses of medication."

B) "I should call the nurse before I take additional doses."

C) "I will call for assistance if my pain is not relieved."

D) "The machine will prevent an overdose."

The correct answer is B: "I should call the nurse before I take additional doses."

Patient controlled analgesia offers the client more control. The client should be instructed to initiate additional doses as needed without asking for assistance unless there is insufficient control of the pain.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

20. The nurse is planning care for a client with increased intracranial pressure. The best position for this client is

A) Trendelenburg

B) Prone

C) Semi-Fowlers

D) Side-lying with head flat

The correct answer is C: Semi-Fowlers

Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

21. A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?

A) Holistic healing

B) Spiritual advising

C) Herbal preparations

D) Witchcraft potions

The correct answer is A: Holistic healing

This traditional folk practitioner uses holistic methods for illnesses not related to witchcraft. Many times, the curandero works with traditional health care providers to restore health.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

22. The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about

A) alcohol use during pregnancy

B) usual nutritional intake

C) family genetic disorders

D) maternal and paternal ages

The correct answer is A: alcohol use during pregnancy

This cluster of facial characteristics is often linked to fetal alcohol syndrome (FAS). Lifelong developmental delays of varying severity can result.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

23. A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client, and is aware that gradual emptying is preferred over complete emptying because it reduces the

A) potential for renal collapse

B) potential for shock

C) intensity of bladder spasms

D) chance of bladder atrophy

The correct answer is B: potential for shock

Complete, rapid emptying can cause shock and hypotension due to sudden changes in the abdominal cavity.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

24. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in

A) Hearing, speech, and sight

B) Endurance, strength, and mobility

C) Learning, creativity, and judgment

D) Balance, flexibility, and coordination

The correct answer is C: Learning, creativity, and judgment

Cognitive impairments are due to physiological processes that affect memory and other higher-level cognitive processes.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

25. The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model?

A) An appointed board oversees any administrative decisions

B) Nursing departments share responsibility for client outcomes

C) Staff groups are appointed to discuss nursing practice and client education issues

D) Non-nurse managers supervise nursing staff in groups of units

The correct answer is B: Nursing departments share responsibility for client outcomes

Shared governance or self-governance is a method of organizational design that promotes empowerment of nurses to give them responsibility for client care issues.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

26. A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?

A) Hot dog, carrot sticks, gelatin, milk

B) Soup, blenderized soft foods, ice cream, milk

C) Peanut butter and jelly sandwich, chips, pudding, milk

D) Baked chicken, applesauce, cookie, milk

The correct answer is B: Soup, blenderized soft foods, ice cream, milk

In a child with cleft palate repair, parents should prepare soft foods and avoid those foods with particles that might traumatize the surgical site.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

27. The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?

A) crackles in the lungs

B) confusion and restlessness

C) distended neck veins

D) use of accessory muscles

The correct answer is B: confusion and restlessness

Neurological changes, including impaired mental status, are early signs of inadequate oxygenation.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

28. The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?

A) An excess of red blood cells

B) An excess of white blood cells

C) A deficiency of clotting factor VIII

D) A deficiency of clotting factors VIII and IX

The correct answer is C: A deficiency of clotting factor VIII

Hemophilia A is characterized by an absence or deficiency of Factor VIII.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

29. The nurse would expect which eating disorder to cause the greatest fluctuations in potassium?

A) binge eating disorder

B) anorexia nervosa

C) bulimia

D) purge syndrome

The correct answer is C: bulimia

With bulimia the purging process tends to make the body dehydrated and to lower the level of potassium in the blood. Low potassium levels can cause weakness, abdominal cramping and irregular heart rhythms.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

30. The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?

A) Ask family members to dress the client

B) Encourage the client to dress more quickly

C) Allow the client the time needed to dress

D) Demonstrate methods on how to dress more quickly

The correct answer is C: Allow the client the time needed to dress

Clients with Parkinson''s disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all. Any form of hurrying the client will result in a very upset and immobilized client.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

31. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has

A) achieved developmental milestones at an erratic rate

B) delay in musculoskeletal development

C) displayed difficulty with speech development

D) delay in achievement of most developmental milestones

The correct answer is D: delay in achievement of most developmental milestones

The majority of children with AIDS have neurological involvement. There is decreased brain growth as evidenced by microcephaly and abnormal neurologic findings. Developmental delays are common, and after achieving normal development, there may be loss of milestones. The other options are accurate but are too limited to be the best response.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

32. A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is

A) central nervous system damage

B) moderate anemia

C) renal tubule damage

D) growth impairment

The correct answer is A: central nervous system damage

The most serious consequences of chronic lead poisoning occur in the central nervous system. Neural cells are destroyed by the toxic effects of the lead, resulting in many problems with the intellect ranging from mild deficits to mental retardation and even death.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

33. A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?

A) Call a chaplain

B) Deny the feelings

C) Cite recovery statistics

D) Listen to the client

The correct answer is D: Listen to the client

Therapeutic communications are based on attentive listening to expressed feelings. If the nurse is not familiar with the cultural beliefs of a client, acceptance of feelings is followed by questions about the beliefs.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

34. The registered nurse (RN) is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these outcomes suggested by the practical nurse (PN) should be considered the priority nursing goal following cast application?

A) The infant will experience minimal pain

B) Muscle spasms will be relieved

C) Mobility will be managed as tolerated

D) Tissue perfusion will be maintained

The correct answer is D: Tissue perfusion will be maintained

Immediately following cast application, the chief goal is to maintain circulation and tissue perfusion around the cast. Permanent tissue damage can occur within a few hours if perfusion is not maintained.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

35. The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding?

A) Rapid respirations

B) Diaphoresis

C) Swelling of lower extremity

D) Positive Babinski's sign

The correct answer is C: Swelling of lower extremity

The most common signs of deep vein thrombosis are pain in the region of the thrombus and unilateral swelling distal to the site.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

36. The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?

A) Impaired gas exchange related to acute infection and sputum production

B) Ineffective airway clearance related to sputum production and ineffective cough

C) Ineffective breathing pattern related to acute infection

D) Anxiety related to hospitalization and role conflict

The correct answer is B: Ineffective airway clearance related to sputum production and ineffective cough

Ineffective airway clearance is defined as the inability to cough effectively. While the other diagnoses may be appropriate for this client, this is the only one supported directly by the assessment data given.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

37. A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?

A) Lethargy

B) Agitation

C) Ataxia

D) Hearing loss

The correct answer is A: Lethargy

The level of consciousness or responsiveness is the most important measure of the client''s rising intracranial pressure. Look for lethargy, delay in response to verbal suggestions and slowing of speech. Assess for rising blood pressure or widening pulse pressure and for respiratory irregularities. There may be vomiting, usually projectile, without the presence of nausea.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

38. In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?

A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses

B) Place the client into the bed and administer the ordered PRN analgesic

C) Check the client for bladder distention and the client's urinary catheter for kinks

D) Turn the television off and then assist client to use relaxation techniques

The correct answer is C: Check the client for bladder distention and the client''s urinary catheter for kinks

These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter, and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

39. At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially

A) Allow the staff to change assignments

B) Clarify reasons for current assignments

C) Help staff see the complexity of issues

D) Facilitate creative thinking on staffing

The correct answer is D: Facilitate creative thinking on staffing

The "moving phase" of change involves viewing the problem from a new perspective, and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate staff''s solving the problem.

Sullivan, E. and Decker, P. (2001). Effective Leadership and Management in Nursing. Upper Saddle River, N.J.: Prentice Hall.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

40. When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?

A) digestive problems

B) amenorrhea

C) Electrolyte imbalance

D) blood disorders

The correct answer is B: amenorrhea

Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

NCLEX practice #10

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:27:00 +0000

1. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is

A) high risk for infection related to vomiting

B) altered family processes related to chronic illness

C) fluid volume deficit related to vomiting

D) risk for aspiration related to loss of consciousness

The correct answer is D: risk for aspiration related to loss of consciousness

The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for the child is from airway blockage, as might follow aspiration.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

2. A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The nurse should communicate to other personnel that the appropriate approach is to

A) touch the baby after looking at him

B) talk very slowly while speaking to him

C) avoid touching the child

D) look only at the parents

The correct answer is A: touch the baby after looking at him

In many cultures, an "evil eye" is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

3. The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to

A) avoid caffeine

B) keep feet dry

C) reduce stress

D) wear gloves

The correct answer is A: avoid caffeine

The most important teaching for this client is avoid caffeine after stopping smoking. The question is asking what is the most important teaching. The other approaches tend to be needed less frequently and so are less of a priority.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

4. A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?

A) Prone

B) Dorsal recumbent

C) Semi-Fowler

D) Supine

The correct answer is C: Semi-Fowler

The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

5. A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify his understanding?

A) "This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed."

B) "I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy."

C) "If I have cancer at stage 3 it means I have less involvement of the cancer."

D) "After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle."

The correct answer is C: "If I have cancer at stage 3 it means I have less involvement of the cancer."

Stage 3 is the most extensive involvement of cancer with any type.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

6. The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by

A) inserting a fenestrated catheter with a whistle tip without suction

B) completing suction pass in 30 seconds with pressure of 150 mm Hg

C) hyperoxygenation with 100% O2 for 1 to 2 minutes before and after each suction pass

D) minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter

The correct answer is C: hyperoxygenation with 100% O2 for 1 to 2 minutes before and after each suction pass

Administer supplemental 100% oxygen through the mechanical ventilator or manual resuscitation bag for 1 to 2 minutes before, after and between suctioning passes to prevent hypoxemia.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

7. The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?

A) "The infant will get the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours at birth at separate injection sites."

B) "The second dose can be given at 1 to 2 months of age."

C) "The third dose should be given at least 16 weeks from the second dose."

D) "The last dose in the series is not to be given before age 24 weeks."

The correct answer is C: "The third dose should be given at least 16 weeks from the second dose."

The third dose is to be given 16 weeks from the first dose and 8 weeks from the second dose. All of the other options are correct information. These infants will also need to have the blood tested for hepatitis titers and antibodies between 9 and 15 months.

http://www.cdc.gov/nip January-June 2004 (2004). http://www.cdc.gov/nip January-June 2004 http://www.cdc.gov/nip January-June 2004

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

8. At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about pre-conception diet changes. Which of the statements made by the nurse is best?

A) "Include fibers in your daily diet."

B) "Increase green leafy vegetable intake."

C) "Drink a glass of milk with each meal."

D) "Eat at least 1 serving of fish weekly."

The correct answer is B: "Increase green leafy vegetable intake."

Folic acid sources should be included in the diet and are critical in the pre-conceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

9. During the beginning shift assessment of a client with asthma who is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?

A) Pulse oximetry reading of 89%

B) Crackles at the base of the lungs on auscultation

C) Rapid shallow respirations with intermittent wheezes

D) Excessive thirst with a dry cracked tongue

The correct answer is C: Rapid shallow respirations with intermittent wheezes

Of the given findings this has the greatest risk for potential complications. Shallow and rapid respirations may indicate that the client is losing muscle strength required to breath. The intermittent wheezes could be an indication of an increase in narrowed small airways and a worsening condition.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

10. The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach the nurse manager should:

A) discuss with the staff how to deal with any defensive behavior

B) explain to the unit staff why change is necessary

C) assist the staff during the acceptance of the new changes

D) clarify what the changes mean to the community and hospital

The correct answer is B: explain to the unit staff why change is necessary

The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it. The phase is completed when staff comprehend the need for change.

Marriner-Tomey, A. (2000). Guide to Nursing Management and Leadership. . St. Louis: Mosby.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

11. With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?

A) An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago

B) An adolescent admitted the prior night with Tylenol intoxication

C) A middle-aged client with an internal automatic defibrillator and complaints of “passing out at unknown times” admitted yesterday

D) A school-aged child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts

The correct answer is A: An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago

This client is the most stable and has a chronic condition. Tylenol intoxication requires at least 3 to 4 days of intensive observation for the risk of hepatic failure. The other clients would be considered unstable.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

12. On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, “I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night.” Which nursing diagnoses would be most important for this client?

A) Anxiety related to hospitalization

B) Ineffective airway clearance related to potential thick secretions

C) Altered health maintenance related to preventative behaviors associated with asthma

D) Impaired gas exchange related to bronchoconstriction and mucosal edema

The correct answer is D: Impaired gas exchange related to bronchoconstriction and mucosal edema

Pulse oximetry reflects oxygenation of arterial blood. While the other diagnoses may be appropriate for this client, they are not the most appropriate priority at the time of admission.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

13. The nurse uses the DRG (Diagnosis Related Group) manual to

A) classify nursing diagnoses from the client's health history

B) identify findings related to a medical diagnosis

C) determine reimbursement for a medical diagnosis

D) implement nursing care based on case management protocol

The correct answer is C: determine reimbursement for a medical diagnosis

DRG''s are the basis of prospective payment plans for reimbursement for Medicare clients.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

14. The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

A) Reduce the environmental stimuli

B) Offer formula every 2 hours

C) Talk to the newborn while feeding

D) Rock the baby frequently

The correct answer is A: Reduce the environmental stimuli

This newborn appears to be withdrawing from substances taken by the mother before its birth. Reducing noise and light will reduce the central nervous system responses to stimuli.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

15. A client comes into the community health center upset and crying stating “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: "Pheochromocytoma." Which response should the nurse state initially?

A) "Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid)"

B) This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline

C) "Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor"

D) "You probably have had episodes of sweating, heart pounding and headaches"

The correct answer is A: "Pheochromocytomas usually aren''t cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid)"

All of the options are correct information. The best response of the nurse is to address the issue presented by the client “fear of cancer.” Pheochromocytomas may release large amounts of adrenaline into the bloodstream after an injury or during surgery. For this reason, they can be life-threatening if unrecognized or untreated.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

16. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

A) Pleuritic pain on inspiration

B) Dry mucus membranes in the mouth

C) A decrease in respiratory rate from 34 to 24

D) Decrease in chest wall expansion

The correct answer is D: Decrease in chest wall expansion

The respiratory status of a client with this acute bacterial pneumonia known as Legionnaires'' disease is critical. Note that all of these findings would be of concern -- the task is to select the priority. Chest wall expansion reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness may indicate hypoxemia. If these occurred the client may then need mechanical ventilation. Option A is expected with such infections of the lung. Option B indicates dehydration which may result in

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

17. A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a

A) chest x-ray

B) blood culture

C) sputum culture

D) PPD intradermal test

The correct answer is D: PPD intradermal test

The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

18. Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers to a group of young adults?

A) "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods."

B) "Prostate cancer is the most common cancer in American men with results to threaten sexuality and life."

C) "Colorectal cancer is the second-leading cause of cancer-related deaths in the United States."

D) "Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all cancers."

The correct answer is A: "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods."

It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements offer correct information.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

19. While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

A) Jaundice evident at 26 hours

B) Hematocrit of 55%

C) Serum bilirubin of 12mg

D) Positive Coombs' test

The correct answer is C: Serum bilirubin of 12mg

The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg., the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

20. The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best statement by the nurse should be that,

A) "A child's bone is more flexible and can be bent 45 degrees before breaking."

B) "Bones of children are more porous than adults’ and often have incomplete breaks."

C) "Compression of porous bones produces a buckle or torus type break."

D) "Bone fragments often remain attached by a periosteal hinge."

The correct answer is B: "Bones of children are more porous than adults’ and often have incomplete breaks."

This allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side fails, causing an incomplete fracture.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

21. A 67 year-old client is admitted with substernal chest pain with that radiates to the jaw. The admitting diagnosis is acute myocardial infraction (MI). The priority nursing diagnosis for this client during the first 24 hours is

A) constipation related to immobility

B) high risk for infection

C) impaired gas exchange

D) fluid volume deficit

The correct answer is C: impaired gas exchange

In the immediate post MI period, impaired gas exchange related to oxygen supply and demand is a major problem.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

22. A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for

A) rebound tenderness

B) left lower quadrant dullness

C) rounded swelling above the pubis

D) urinary discharge

The correct answer is C: rounded swelling above the pubis

Swelling above the pubis is representative of a distended bladder in the male client.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

23. The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?

A) Confront the nurse about the suspicions in a private meeting

B) Schedule a staff conference, without the nurse present, to collect information

C) Consult the human resources department about the issue and needed actions

D) Counsel the employee to resign to avoid investigation

The correct answer is C: Consult the human resources department about the issue and needed actions

To avoid legal repercussions, the nurse needs to consult with the human resources department for proper procedure for documentation, counseling and available resources. The employee may be protected under the Americans with Disabilities Act.

Haynes, L., Boese, T., and Butcher, H. (2004). Nursing in contemporary Society. Upper Saddle River, N.J.: Pearson Prentice Hall.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

24. The nurse is caring for a client with status epilepticus. The most important nursing assessment(s) of this client is/are

A) intravenous drip rate

B) level of consciousness

C) pulse and respiration

D) injuries to the extremities

The correct answer is B: level of consciousness

Cerebral blood flow undergoes a 250% increase during seizure activity depleting oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client’s level of consciousness continuously. Even when seizures are controlled, the client may be unconscious for a while.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

25. A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to

A) gently rub the skin with a cotton swab to relieve itching

B) place the favorite books and push-pull toys in the crib

C) check every few hours for the next day or 2 for swelling in the baby's feet

D) turn the baby with the abduction stabilizer bar every 2 hours

The correct answer is C: check every few hours for the next day or 2 for swelling in the baby''s feet

A child in a hip spica cast must be checked for circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation. For children beyond the neonatal period, traction and/or surgery followed by hip spica casting are usually needed.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

26. An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication?

A) Determine third party payment plan for this treatment

B) The client’s manual dexterity

C) Proximity to health care services

D) Ability to use visual assistive devices

The correct answer is B: The client’s manual dexterity

Inability to self administer eye drops is a common problem among the elderly due to decreased finger dexterity.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

27. While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?

A) Positive Homan's sign

B) Fever and chills

C) Dyspnea and cough

D) Sensory impairment

The correct answer is C: Dyspnea and cough

Vegetation from the infected heart valves often leads to pulmonary embolism in the client with infective endocarditis. Cough, pleuritic chest pain and dyspnea are early symptoms.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

28. A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?

A) Bradycardia

B) Lethargy

C) Irritability

D) Vomiting

The correct answer is A: Bradycardia

The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

29. A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager implement initially?

A) Set daily goals and establish priorities for each hour and each day.

B) Ask for additional assistance when you feel overwhelmed.

C) Keep a time log of your day in hourly blocks for at least 1 week.

D) Complete each task before beginning another activity in selected instances.

The correct answer is C: Keep a time log of your day in hourly blocks for at least 1 week.

Apply the nursing process to time management, so the assessment of the current activities is the initial step. A baseline is established for activities and time use so that needed changes can be pinpointed.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

30. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to

A) suggest 3 to 4 warm sitz baths per day

B) cleanse the genitalia twice a day with soap and water

C) spray warm water over genitalia after urination

D) apply heat or cold to lesions as desired

The correct answer is A: suggest 3 to 4 warm sitz baths per day

Frequent sitz baths may sooth the area and reduce inflammation. The other actions are correct actions however, they would not address the entire group of findings.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

31. The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to

A) rinse the tooth in water before placing it in the socket

B) place the tooth in a clean plastic bag for transport to the dentist

C) hold the tooth by the roots until reaching the emergency room

D) ask the child to replace the tooth even if the bleeding continues

The correct answer is A: rinse the tooth in water before placing it in the socket

Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth in its socket within 30 minutes, avoiding contact with the root. The child should be taken to the dentist as soon as possible.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

32. A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?

A) Weight gain of 2 pounds or more in a 48 hour period

B) Urinating 4 to 5 times each day

C) A significant decrease in appetite

D) Appearance of non-pitting ankle edema

The correct answer is A: Weight gain of 2 pounds or more in a 48 hour period

It is critical for clients to report and be treated for rapid weight gain, decreased urinary output, worsening nocturnal orthopnea, pitting ankle edema, and other findings of chronic heart failure. Hospitalization may be avoided with early intervention.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

33. Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager?

A) To help an elderly client to the bathroom

B) To empty a Foley catheter bag

C) To bathe a woman with internal radon seeds

D) To feed a 2 year-old with a broken arm

The correct answer is C: To bathe a woman with internal radon seeds

A client with internal radiation is complex care and not suitable to be assigned to a UAP. Additionally, the client would not receive a complete bath because of the radiation risks.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

34. A client is admitted for COPD. Which findings would require the nurse's immediate attention?

A) Nausea and vomiting

B) Restlessness and confusion

C) Low-grade fever and cough

D) Irritating cough and liquefied sputum

The correct answer is B: Restlessness and confusion

Respiratory failure may be signaled by excessive somnolence, restless, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

35. The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?

A) Non-intention tremors and urgency with voiding

B) Echolalia and a shuffling gait

C) Muscle spasm and a bent over posture

D) Intention tremor and jerky movement of the elbows

The correct answer is B: Echolalia and a shuffling gait

Clients with Parkinson''s disease have a very distinctive gait with quick short steps (shuffling) which may increase in speed so that they are unable to stop. They also have echolalia which means the repeating of phrases or words that are directed to them during conversation. In the other options, only one of the findings is associated with Parkinson’s disease: non-intention tremors, bent over posture, and the cogwheel or jerky movement of the elbows.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

36. Which finding would be the most characteristic of an acute episode of reactive airway disease?

A) auditory gurgling

B) inspiratory laryngeal stridor

C) auditory expiratory wheezing

D) frequent dry coughing

The correct answer is C: auditory expiratory wheezing

In an acute episode of reactive airway disease, breathing is likely to be characterized by wheezing on expiration. This sound is made as air is forced through the narrowed passages and often can be heard by the naked ear without a stethoscope.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

37. Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?

A) "I may experience seizures if I stop the medication abruptly."

B) "I may experience an increase in my heart rate for a few weeks."

C) ”I can expect to feel nervousness the first few weeks."

D) “I can have a heart attack if I stop this medication suddenly."

The correct answer is D: “I can have a heart attack if I stop this medication suddenly."

Discontinuing beta blockers suddenly can cause angina, hypertension, dysrhythmias, or an MI.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

38. Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?

A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals

B) A glycosylated hemoglobin is to be obtained at least twice a year

C) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment

D) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment

The correct answer is A: A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals

The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals. The goals for persons with diabetes define the target A1c level as less than or equal to 6.5% or less than 7.0%. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends that a glycosylated hemoglobin be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. Most would agree, however, that an A1c level greater than 9.0% is poor control for all patient types.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

39. A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note

A) high protein

B) clear color

C) elevated sed rate

D) increased glucose

The correct answer is A: high protein

A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

40. The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?

A) Right ventricle, left ventricle, right atrium, left atrium

B) Left ventricle, right ventricle, left atrium, right atrium

C) Right atrium, right ventricle, left atrium, left ventricle

D) Right atrium, left atrium, right ventricle, left ventricle

The correct answer is C: Right atrium, right ventricle, left atrium, left ventricle

This is the pathway of blood flow through the heart.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

NCLEX practice #11

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:21:00 +0000

1. The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. The need to avoid which of these should be emphasized to the client?

A) Large indoor gatherings

B) Exposure to sunlight

C) Active physical exercise

D) Foods rich in vitamin K

The correct answer is D: Foods rich in vitamin K

Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy, decreasing Coumadin''s effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

2. An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks: ”When can the tube can be used for feeding?” The nurse's best response would be which of these comments?

A) "Feedings can begin in 5 to 7 days."

B) "The feeding tube can be used immediately."

C) "The stomach contents and air must be drained first."

D) "Healing of the incision must be complete before feeding."

The correct answer is C: "The stomach contents and air must be drained first."

After surgery for gastrostomy tube placement, the catheter is left open and attached to gravity drainage for 24 hours or more.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

3. To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the

A) finger and toenail quicks

B) eyes

C) perianal area

D) external ear canals

The correct answer is B: eyes

Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.

Estes, M.E.Z. (2002). Health Assessment and Physical Examination, (2nd Ed). Albany, NY: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

4. A woman who delivered 5 days ago and had been diagnosed with pregnancy induced hypertension (PIH) calls the hospital triage nurse hotline to ask for advice. She states, “I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next?

A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her provider within the next day.

B) Advise the client to have someone bring her to the emergency room as soon as possible.

C) Ask the client to stay on the line, get the address and send an ambulance to the home.

D) Ask what the client has taken? How often? Ask about other specific complaints.

The correct answer is C: Ask the client to stay on the line, get the address and send an ambulance to the home.

The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital. For at risk clients, PIH (preeclampsia and eclampsia) may occur prior to, during or after delivery. After delivery, the window of time can be up to ten days.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

5. The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is

A) "Drink 3000 to 4000 cc of fluid each day for one month."

B) "Limit fluid intake to 1000 cc each day for one month."

C) "Increase intake of citrus fruits to three servings per day."

D) "Restrict milk and dairy products for one month."

The correct answer is A: "Drink 3000 to 4000 cc of fluid each day for one month."

Drinking three to four quarts (3000 to 4000 cc) of fluid each day will aid passage of fragments and help prevent formation of new calculi.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

6. The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as

A) Laissez-faire

B) Autocratic

C) Participative

D) Group

The correct answer is C: Participative

A participative style of management involves staff in decision-making processes. Staff/manager interactions are open and trusting. Most work efforts are joint endeavors.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

7. The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?

A) Weight reduction

B) Stress management

C) Physical exercise

D) Smoking cessation

The correct answer is D: Smoking cessation

Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of reducing oxygenation and constricting blood vessels.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

8. The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is

A) advising client to restrict sodium intake

B) taking the blood pressure in the left arm

C) elevating her left arm above heart level

D) compressing the drainage device

The correct answer is B: taking the blood pressure in the left arm

Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

9. The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated

A) "I can only wear cotton socks."

B) "I cannot go barefoot around my house."

C) "I will trim corns and calluses regularly."

D) "I should ask a family member to inspect my feet daily."

The correct answer is C: "I will trim corns and calluses regularly."

Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

10. A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?

A) Intraventricular hemorrhage

B) Retinopathy of prematurity

C) Bronchial pulmonary dysplasia

D) Necrotizing enterocolitis

The correct answer is B: Retinopathy of prematurity

While there are other causes for retinal damage in the premature infant, maintaining the oxygen concentration below 40% reduces this important risk factor.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

11. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager's best response is:

A) "Let’s move on to a new action that deals with the problem."

B) "I think you need to reserve judgment until after all suggestions are offered."

C) "Very well thought out. Your analytic skills and interest are incredible."

D) "Let’s move to the ‘what if…’ as related to these objections and explore spin off ideas."

The correct answer is D: "Let’s move to the ‘what if…’ as related to these objections and explore spin off ideas."

The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Exploration of the nurses objections would encourage the generation of new ideas.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

12. A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug?

A) Tranquilization, numbing of emotions

B) Sedation, analgesia

C) Relief of insomnia and phobias

D) Diminished tachycardia and tremors associated with anxiety

The correct answer is A: Tranquilization, numbing of emotions

The anti-anxiety drugs produce tranquilizing effects and may numb the emotions.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

13.A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?

A) Cardiopulmonary resuscitation

B) Insertion of a chest tube

C) Oxygen therapy

D) Assisted ventilation

The correct answer is B: Insertion of a chest tube

Because a portion of the lung has collapsed, a chest tube will be inserted to restore negative pressure in the chest cavity.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

14. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present

A) Temperature of 99.5 degrees Fahrenheit with painful urination

B) An open, reddened wound on the heel

C) Insomnia and daytime fatigue

D) Nausea with 2 episodes of vomiting

The correct answer is B: An open, reddened wound on the heel

When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

15. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

A) Expiratory wheezes

B) Blurred vision

C) Ascites

D) Dilated pupils

The correct answer is C: Ascites

Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

16. A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:

A) Impaired gas exchange

B) Metabolic acidosis

C) Renal insufficiency

D) Fluid volume deficit

The correct answer is D: Fluid volume deficit

In fluid volume deficit, serum BUN, Na+ and hematocrit may be elevated secondary to hemoconcentration.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

17. The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?

A) Anticoagulant

B) Liquid antacid

C) Antihistamine

D) Cardiac glycoside

The correct answer is C: Antihistamine

Elderly people are susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the elderly, especially at high doses.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

18. A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?

A) Avoid Alka-Seltzer because it contains aspirin

B) Take Alka-Seltzer at a different time of day than the warfarin

C) Select another antacid that does not inactivate warfarin

D) Use on-half the recommended dose of Alka-Seltzer

The correct answer is A: Avoid Alka-Seltzer because it contains aspirin

Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

19. The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to

A) begin cardiopulmonary resuscitation

B) prepare for immediate defibrillation

C) notify the "Code" team and provider

D) assess airway breathing and circulation

The correct answer is D: assess airway breathing and circulation

The nurse must first assess the client to determine the appropriate next step. In this case the first step the nurse must take is to evaluate the A, B, C''s.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

20. The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?

A) Risk for injury

B) Self care deficit

C) Alteration in comfort

D) Alteration in mobility

The correct answer is C: Alteration in comfort

Relieving pain is the number one objective of this client''s plan of care.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

21. While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?

A) monitor intake and output

B) provide good skin care

C) assess level of consciousness

D) assist with range of motion

The correct answer is C: assess level of consciousness

An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

22. The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?

A) Rapid bounding pulse

B) Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)

C) Profuse diaphoresis

D) Slow, irregular respirations

The correct answer is D: Slow, irregular respirations

A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

23. The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

A) Extreme fatigue

B) Increased appetite

C) Intense itching

D) Constipation

The correct answer is A: Extreme fatigue

Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

24. A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?

A) Decrease the analgesic dosage by half

B) Discontinue the analgesic

C) Continue the same analgesic dosage

D) Prescribe a less potent drug

The correct answer is C: Continue the same analgesic dosage

Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

25. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client

A) "Be sure and eat a fat-free diet until the test."

B) "Do not eat or drink anything but water for 12 hours before the blood test."

C) "Have the blood drawn within 2 hours of eating breakfast."

D) "Stay at the laboratory so 2 blood samples can be drawn an hour apart."

The correct answer is B: "Do not eat or drink anything but water for 12 hours before the blood test."

Blood lipid levels should be measured on a fasting sample.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

26. In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?

A) Uterine atony

B) Genital lacerations

C) Retained placenta

D) Clotting disorder

The correct answer is B: Genital lacerations

Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

27. The community health nurse has been caring for an adolescent with a history of morbid obesity, asthma, and hypertension, and is 22 weeks pregnant. Which of these lab reports need to be called to the teen’s provider within the next hour?

A) hemoglobin 11 g/L and calcium 6 mg/dl

B) magnesium 0.8 mEq/L and creatinine 3 mg/dl

C) blood urea nitrogen 28 and glucose 225 mg/dl

D) hematocrit 33% and platelets 200,000

The correct answer is B: magnesium 0.8 mEq/L and creatinine 3 mg/dl

The magnesium is low and the creatinine is high which indicates renal failure. With the history of hypertension, the findings exhibit the risk of preeclampsia. The client’s lab values are all abnormal except for the platelets. The client needs to be referred for immediate follow up with a provider.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

28. A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include

A) The escalation of fees with a decreased reimbursement percentage

B) High costs of diagnostic and end-of-life treatment procedures

C) Increased numbers of elderly and of the chronically ill of all ages

D) A steep rise in provider fees and in insurance premiums

The correct answer is A: The escalation of fees with a decreased reimbursement percentage

The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee for service. Reimbursement for Medicare and Medicaid recipients based on fee for service also escalates health care costs.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

29. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this client’s plan of care within the initial 24 hours?

A) Wear masks with shields if there is potential for fluid splash

B) Use disposable utensils and plates for meals

C) Wear gown and gloves during client contact

D) Provide soft easily digested food with frequent snacks

The correct answer is C: Wear gown and gloves during client contact

HAV is usually transmitted via the fecal-oral route, i.e., someone with the virus handles food without washing his or her hands after using the bathroom. The virus can also be contracted by drinking contaminated water, eating raw shellfish from water polluted with sewage or by being in close contact with a person who''s infected — even if that person has no signs and symptoms. In fact, the disease is most contagious before signs and symptoms ever appear. The nurse should recognize the importance of isolation precautions from the initial contact with the client on admission until the noncontagious convalescence period.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

30. The nurse is teaching a 27 year-old client with asthma about their therapeutic regime. Which statement would indicate the need for additional instruction?

A) "I should monitor my peak flow every day."

B) "I should contact the clinic if I am using my medication more often."

C) "I need to limit my exercise, especially activities such as walking and running."

D) "I should learn stress reduction and relaxation techniques."

The correct answer is C: "I need to limit my exercise, especially activities such as walking and running."

Limiting physical activity in an otherwise healthy, young client should not be necessary. If exercise intolerance exists, the asthma management plan should include specific medications to treat the problem such as using an inhaled beta-agonist 5 minutes before exercise. The goal is always to return to a normal lifestyle.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

31. The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?

A) Instruct the client to wear a high efficiency particulate air mask in public places.

B) Ask a family member to supervise daily compliance

C) Schedule weekly clinic visits for the client

D) Ask the health care provider to change the regimen to fewer medications

The correct answer is B: Ask a family member to supervise daily compliance

Direct-observed therapy (DOT) is a recognized method for ensuring client compliance to the drug regimen. A program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

32. Which of these clients would the triage nurse request the provider examine immediately?

A) A 5 month-old infant who has audible wheezing and grunting

B) An adolescent who has soot over the face and shirt

C) A middle-aged man with second degree burns over the right hand

D) A toddler with singed ends of long hair that extends to the waist

The correct answer is A: A 5 month-old infant who has audible wheezing and grunting

The age and the findings suggest this client is at immediate risk for respiratory complications.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

33. The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to

A) encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class

B) assist the parents to plan quiet play activities at home

C) stress to the parents that they will need relief care givers

D) instruct the parents to avoid contact with persons with infection

The correct answer is A: encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class

While all suggestions are appropriate, the education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency care of their child.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

34. The nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which of the following activities would be an appropriate diversional activity?

A) Kicking balloons with right leg

B) Playing "Simon Says"

C) Playing hand held games

D) Throw bean bags

The correct answer is C: Playing hand held games

Immobilization with traction must be maintained until bone ends are in satisfactory alignment. Activities that increase mobility interfere with the goals of treatment.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

35. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?

A) Death is personified as the bogeyman or devil

B) Death is perceived as being irreversible

C) The child feels guilty for the grandmother's death

D) The child is worried that he, too, might die

The correct answer is A: Death is personified as the bogeyman or devil

Personification of death is typical of this developmental level.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

36. A confused client has been placed in physical restraints by order of the provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?

A) Assist the client with activities of daily living

B) Monitor the clients physical safety

C) Evaluate for basic comfort needs

D) Document mental status and muscle strength

The correct answer is A: Assist the client with activities of daily living

The person to whom the activity is delegated must be capable of performing it . The UAP is capable of assisting clients with basic needs.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

37. A nurse who is a native English speaker admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially

A) Request a Spanish interpreter

B) Speak through the family or co-workers

C) Use pictures, letter boards, or monitoring

D) Assess the client's ability to speak English

The correct answer is D: Assess the client''s ability to speak English

Despite the cultural heritage, the nurse cannot make assumptions. Stereotyping is to be avoided. The nurse should assess the client''s comfort and ability in speaking English.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

38. A newborn presents with a pronounced cephalhematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

A) Pain related to periosteal injury

B) Impaired mobility related to bleeding

C) Parental anxiety related to knowledge deficit

D) Injury related to intracranial hemorrhage

The correct answer is C: Parental anxiety related to knowledge deficit

This hematoma is related to pressure at the time of labor and birth. The condition resolves within a few days. Parental anxiety must be addressed by listening to their fears and explaining the nature of this common alteration.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

39. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?

A) Playing with toys in a back yard flower garden

B) Eating small amounts of grass while playing "farm"

C) Playing with cars on the pavement near burning leaves

D) Throwing a ball to a neighborhood child who has poison ivy

The correct answer is C: Playing with cars on the pavement near burning leaves

Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

40. The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?

A) B, D, and K

B) A, D, and K

C) A, C, and D

D) A, B, and C

The correct answer is B: A, D, and K

The uptake of fat soluble vitamins is decreased in children with Cystic Fibrosis. Vitamins A, D, and K are fat soluble and are likely to be deficient in clients with Cystic Fibrosis.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

NCLEX practice #12

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 09:16:00 +0000

1. The nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's syndrome?

A) rubeola

B) meningitis

C) varicella

D) hepatitis

The correct answer is C: varicella

Varicella (chicken pox) and influenza are viral illnesses that have been identified as increasing the risk for Reye''s syndrome. Use of aspirin is contraindicated for children with these infections.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

2. The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?

A) Hypertonic neuro reflex

B) Immediate CNS depression

C) Lethargy and sleepiness

D) Jitteriness at 24-48 hours

The correct answer is D: Jitteriness at 24-48 hours

Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

3. After the shift report in a labor and delivery unit which of these clients would the nurse check first?

A) A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94

B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated

C) A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced

D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum

The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum

This client has an actual complication. The others present with findings of potential complications.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

4. In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must

A) assess the brachial pulses

B) breathe once every 5 compressions

C) use both hands to apply chest pressure

D) compress 80-90 times per minute

The correct answer is B: breathe once every 5 compressions

For a 5 year-old, the nurse should give 1 breath for every 5 compressions.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

5. A client arrived in the USA from a developing country 1 week ago. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS. There is a history of these findings: unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of

A) Acute tuberculosis with a productive cough of discolored sputum for over three months

B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen

C) Pseudomembranous colitis and C. difficile

D) Exacerbation of polyarthritis with severe pain

The correct answer is A: Acute tuberculosis with a productive cough of discolored sputum for over three months

The client being admitted has the classic findings of pulmonary tuberculosis. Of the available choices, the client in option A would be the most appropriate roommate. It is acceptable to put clients with similar diagnoses in the same room when no other alternative exists. Clients are considered contagious until the cough is eliminated with medications, which initially is a combination of 4 simultaneous drugs.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

6. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be high

A) calorie, low fat, low sodium

B) protein, low fat, low carbohydrate

C) protein, high calorie, unrestricted fat

D) carbohydrate, low protein, moderate fat

The correct answer is C: protein, high calorie, unrestricted fat

The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

7. The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should

A) irrigate it as ordered with distilled water

B) irrigate it as ordered with normal saline

C) place the end of the tube in water to see if the water bubbles

D) withdraw the tube several inches and reposition it

The correct answer is B: irrigate it as ordered with normal saline

Nasogastric tubes are only irrigated with normal saline to maintain patency.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

8. The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in

A) calcium

B) fiber

C) sodium

D) carbohydrate

The correct answer is C: sodium

The client with Meniere''s disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

9. For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rho (D) immune globulin within 72 hours of birth?

A) Rh negative mother with Rh positive baby

B) Rh negative mother with Rh negative baby

C) Rh positive mother with Rh positive baby

D) Rh positive mother with Rh negative baby

The correct answer is A: Rh negative mother with Rh positive baby

An Rh- mother who delivers an Rh+ baby may develop antibodies to the fetal red cells to which she may be exposed during pregnancy or at placental separation. If the Coombs test is negative, no sensitization has occurred. TheFor which of the following mother-baby pairs should the nurse review the Coomb''s'' test in preparation for administering Rho(D) immune globulin is given to block antibody formation in the mother.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

10. What is the major purpose of community health research?

A) Describe the health conditions of populations

B) Evaluate illness in the community

C) Explain the health conditions of families

D) Identify the health conditions of the environment

The correct answer is A: Describe the health conditions of populations

Community health focuses upon aggregate population care.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

11. The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?

A) Sexually transmitted infection

B) Exposure to teratogens

C) Maternal hypertension

D) Chromosomal abnormalities

The correct answer is C: Maternal hypertension

Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

12. A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?

A) MMR

B) Hib

C) IPV

D) DtaP

The correct answer is A: MMR

Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body''s ability to form antibodies.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

13. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by

A) Reduced oxygen capacity of cells due to lack of iron

B) An imbalance between red cell destruction and production

C) Depression of red and white cells and platelets

D) Inability of sickle shaped cells to regenerate

The correct answer is B: An imbalance between red cell destruction and production

Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

14. Which action is most likely to ensure the safety of the nurse while making a home visit?

A) Observe no evidence of weapons in the home during the visit

B) Prior to the visit, review the client's record for any previous entries about violence

C) Remain alert at all times and leave if cues suggest the home is not safe

D) Carry a cell phone, pager and/or hand held alarm for emergencies

The correct answer is C: Remain alert at all times and leave if cues suggest the home is not safe

No person or equipment can guarantee nurses'' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards and sources of assistance. Become acquainted with neighbors. Be alert and confident while parking the car, walking to the client''s door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

15. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?

A) Moist mucous membranes

B) Urinary frequency

C) Poor skin turgor

D) Increased blood pressure

The correct answer is C: Poor skin turgor

The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

16. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn findings suggests to the nurse that the infant has fetal alcohol syndrome?

A) Growth retardation is evident

B) Multiple anomalies are identified

C) Cranial facial abnormalities are noted

D) Prune belly syndrome is suspected

The correct answer is C: Cranial facial abnormalities are noted

Characteristic facial abnormalities are seen in the newborn with fetal alcohol syndrome.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

17. The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority?

A) Show her films on the physiology of lactation

B) Give the client several illustrated pamphlets

C) Assist her to position the newborn at the breast

D) Give her privacy for the initial feeding

The correct answer is C: Assist her to position the newborn at the breast

While all of the responses are helpful in teaching, the priority is placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

18. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention?

A) pulse oximetry of 85%

B) nocturia

C) crackles in lungs

D) diaphoresis

The correct answer is A: pulse oximetry of 85%

An oxygen saturation of 88% or less indicates hypoxemia and requires the nurse''s immediate attention.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

19. The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What action should the nurse do first?

A) Explain the stages of death and dying to the family

B) Recommend an easy-to-read book on grief

C) Assess the family's patterns for dealing with death

D) Ask about their religious affiliations

The correct answer is C: Assess the family''s patterns for dealing with death

When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that the client and their family''s needs are adequately identified in order to select the best nursing care approaches.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

20. Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?

A) A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement

B) A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement

C) A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement

D) A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement

The correct answer is B: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement

When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

21. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid

A) surfing

B) scuba diving

C) parasailing

D) swimming

The correct answer is B: scuba diving

The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

22. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?

A) Tuberculin skin testing

B) Sputum culture

C) White blood cell count

D) Chest x-ray

The correct answer is B: Sputum culture

The sputum culture is the most accurate method for determining the presence of active TB.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

23. The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is "Asthma causes

A) the airway to become narrow and obstructs airflow."

B) air to be trapped in the lungs because the airways are dilated."

C) the nerves that control respiration to become hyperactive."

D) a decrease in the stress hormones which prevents the airways from opening."

The correct answer is A: the airway to become narrow and obstructs airflow."

Asthma is defined as airway obstruction or a narrowing that is characterized by bronchial irritability after exposure to various stimuli.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

24. The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor?

A) The increased homeless population in major cities

B) The rise in reported cases of positive HIV infections

C) The migration patterns of people from foreign countries

D) The aging of the population located in group homes

The correct answer is B: The rise in reported cases of positive HIV infections

Between 1985 and 2002 there has been a significant increase in the reported cases of TB. The increase was most evident in cities with a high incidence of positive HIV infection. Positive HIV infection currently is the greatest known risk factor for reactivating latent TB infections.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

25. The nurse is attending a workshop about caring for persons infected with hepatitis. Which characteristic is most appropriate when defining the incidence rate of hepatitis?

A) The number of persons in a population who develop hepatitis B during a specific period of time

B) The total number of persons in a population who have hepatitis B at a particular time

C) The percentage of deaths resulting from hepatitis B during a specific time

D) The occurrence of hepatitis B in the population at a particular time

The correct answer is A: The number of persons in a population who develop hepatitis B during a specific period of time

This is the correct definition of incidence of the disease.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

26. Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?

A) Consider a liquid supplement to increase calories

B) Discuss consequences of an unbalanced diet with the child

C) Provide fruit, vegetable and protein snacks

D) Encourage the child to keep a daily log of foods eaten

The correct answer is B: Discuss consequences of an unbalanced diet with the child

It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

27. The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?

A) Complaints of numbness and tingling in feet

B) Wheezing noted when lung sound auscultated

C) Excessive perspiration

D) Difficulty sleeping

The correct answer is A: Complaints of numbness and tingling in feet

A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

28. The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is

A) "The top layer of the skin is destroyed."

B) "The skin layers are swollen and reddened."

C) "All layers of the skin were destroyed in the burn."

D) "Muscle, tissue and bone have been injured."

The correct answer is C: "All layers of the skin were destroyed in the burn."

A third degree burn is a full thickness injury to dermis, epidermis and subcutaneous tissue.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

29. The nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?

A) The mother feels calmer and talks to the baby while nursing

B) The mother awakens the newborn to feed whenever it falls asleep

C) The newborn falls asleep after 3 minutes at the breast

D) The newborn refuses the supplemental bottle of glucose water

The correct answer is A: The mother feels calmer and talks to the baby while nursing

Early evaluation of successful breastfeeding can be measured by the client''s voiced confidence and satisfaction with the infant.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

30. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that

A) The child is within the age group most susceptible to SIDS

B) The peak age for occurrence of SIDS is 8 to 12 months of age

C) The apnea monitor is not effective on a child in this age group

D) 95% of SIDS cases occur before 6 months of age

The correct answer is D: 95% of SIDS cases occur before 6 months of age

Peak age of SIDS occurrence is 2 to 4 months and 95% of cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

31. The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?

A) Fecal impaction

B) Infrequent voiding

C) Stress incontinence

D) Burning with urination

The correct answer is A: Fecal impaction

The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

32. An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements?

A) "Spiritual healing is emphasized and the mind contributes to the cure."

B) "The primary belief is that dietary practices result in health or illness."

C) "Fasting and prayer are initial actions to take in physical injury."

D) "Meditation is intensive in the initial 48 hours and daily thereafter."

The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the cure."

For the Christian Scientist, a mind cure uses spiritual healing methods. For the believer, medical treatments may interfere with drawing closer to God.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

33. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?

A) Capillary refill less than 3 seconds

B) Pale mucous membranes

C) Respirations 36 breaths per minute

D) Complaints of fatigue when ambulating

The correct answer is A: Capillary refill less than 3 seconds

Since the hemoglobin and hematocrit are normal for an adult female, addition assessments should be normal. This capillary refill time is normal.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

34. The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered

A) Expected

B) Rude

C) Professional

D) Enjoyable

The correct answer is B: Rude

Native Americans consider direct eye contact to be impolite or aggressive among strangers.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

35. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by

A) tachypnea

B) acidic byproducts

C) vomiting and dehydration

D) hyperpyrexia

The correct answer is A: tachypnea

Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

36. The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?

A) Impaired skin integrity related to dependent edema

B) Activity intolerance related to oxygen supply and demand imbalance

C) Constipation related to immobility

D) Risk for infection related to ineffective mobilization of secretions

The correct answer is B: Activity intolerance related to oxygen supply and demand imbalance

This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

37. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?

A) the skin

B) the lungs

C) the muscles

D) bowel and bladder

The correct answer is A: the skin

A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

38. An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?

A) lung sounds

B) urine output

C) level of alertness

D) appetite

The correct answer is C: level of alertness

Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

39. A nurse is teaching a class for new parents at a local community center. The nurse would stress that _______ is most hazardous for an 8 month-old child.

A) riding in a car

B) falling off a bed

C) an electrical outlet

D) eating peanuts

The correct answer is D: eating peanuts

Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

40. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill?

A) Stubborn behavior

B) Rejection of parents

C) Frustration with adults

D) Assertion of control

The correct answer is D: Assertion of control

Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child''s progress from dependency to autonomy and independence.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

NCLEX practice #13

noreply@blogger.com (RegisteredNurseTech) — Tue, 06 Nov 2007 08:48:00 +0000

1. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?

A) "I want to protect my child from any falls."

B) "I will set limits on exploring the house."

C) "I understand our child’s need to use those new skills."

D) "I intend to keep control over our child’s behavior."

The correct answer is C: "I understand our child’s need to use those new skills."

Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

2. The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?

A) Decrease in level of consciousness

B) Loss of bladder control

C) Altered sensation of stimuli

D) Emotional lability

The correct answer is A: Decrease in level of consciousness

A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

3. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?

A) "You need to regain your strength before attempting such exertion.

B) "When you can climb 2 flights of stairs without problems, it is generally safe."

C) "Have a glass of wine to relax you, then you can try to have sex."

D) "If you can maintain an active walking program, you will have less risk."

The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe."

There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

4. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?

A) Polyphagia

B) Dehydration

C) Bed wetting

D) Weight loss

The correct answer is C: Bed wetting

In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

5. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?

A) Raise the side rails on the bed

B) Place the call bell within reach

C) Instruct the client to remain in bed

D) Have the client empty bladder

The correct answer is D: Have the client empty bladder

The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A. Note: It is much easier to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can then be carried out more safely.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

6. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is to

A) verify correct placement of the tube

B) check that the feeding solution matches the dietary order

C) aspirate abdominal contents to determine the amount of last feeding remaining in stomach

D) ensure that feeding solution is at room temperature

The correct answer is A: verify correct placement of the tube

Proper placement of the tube prevents aspiration.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

7. A nurse is evaluating the quality of home care for a client with Alzheimer's disease. It would be a priority to reinforce which statement by a family member?

A) "At least 2 full meals a day should be eaten."

B) "We go to a group discussion every week at our community center."

C) "We have safety bars installed in the bathroom and have 24 hour alarms on the doors."

D) "Taking the medication 3 times a day is not a problem."

The correct answer is C: "We have safety bars installed in the bathroom and have 24 hour alarms on the doors."

Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are positive statements, however safety is most important to reinforce.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

8. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

A) increase fluids that are high in protein

B) restrict fluids

C) force fluids and reassess blood pressure

D) limit fluids to non-caffeine beverages

The correct answer is C: force fluids and reassess blood pressure

Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

9. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which

A) increase the heart rate

B) lead to dehydration

C) are considered aerobic

D) may be competitive

The correct answer is B: lead to dehydration

The client must take in adequate fluids before and during exercise periods.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

10. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

A) Gravida 4 para 2

B) Gravida 2 para 1

C) Gravida 3 para 1

D) Gravida 3 para 2

The correct answer is C: Gravida 3 para 1

Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

11. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention?

A) "I have bad muscle spasms in my lower leg of the affected extremity."

B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger."

C) "I have to use the bedpan to pass my water at least every 1 to 2 hours."

D) "It seems that the pain medication is not working as well today."

The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger."

The nurse would be concerned about all of these comments, however the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. Although option D requires further investigation, it is not life threatening.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

12. What would the nurse expect to see while assessing the growth of children during their school age years?

A) Decreasing amounts of body fat and muscle mass

B) Little change in body appearance from year to year

C) Progressive height increase of 4 inches each year

D) Yearly weight gain of about 5.5 pounds per year

The correct answer is D: Yearly weight gain of about 5.5 pounds per year

School age children gain about 5.5 pounds each year and increase about 2 inches in height.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

13. Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiograph test?

A) Client must be NPO before the examination

B) Enema to be administered prior to the examination

C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination

D) No special orders are necessary for this examination

The correct answer is D: No special orders are necessary for this examination

No special preparation is necessary for this examination.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

14. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease (PID). The nurse recognizes that this condition most frequently follows which type of infection?

A) Trichomoniasis

B) Chlamydia

C) Staphylococcus

D) Streptococcus

The correct answer is B: Chlamydia

Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

15. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to

A) go get a blood pressure check within the next 48 to 72 hours

B) check blood pressure again in 2 months

C) see the health care provider immediately

D) visit the health care provider within 1 week for a BP check

The correct answer is A: go get a blood pressure check within the next 48 to 72 hours

The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is ‘usually much lower,’ a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

16. Which of these statements best describes the characteristic of an effective reward-feedback system?

A) Specific feedback is given as close to the event as possible

B) Staff are given feedback in equal amounts over time

C) Positive statements precede a negative statement

D) Performance goals should be higher than what is attainable

The correct answer is A: Specific feedback is given as close to the event as possible

Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

17. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

A) Blood pressure 94/60

B) Heart rate 76 BPM

C) Urine output 50 ml/hour

D) Respiratory rate 16

The correct answer is A: Blood pressure 94/60

Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both medications.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

18. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize

A) eating 3 balanced meals a day

B) adding complex carbohydrates

C) avoiding very heavy meals

D) limiting sodium to 7 gms per day

The correct answer is C: avoiding very heavy meals

Eating large, heavy meals can pull blood away from the heart for digestion, which is dangerous for the client with coronary artery disease.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

19. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission?

A) A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago

B) A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24 hours ago

C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning

D) An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago

The correct answer is A: A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago

The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client in option A is most likely stable and could continue medication therapy at home.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

20. A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?

A) A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying

B) A teenager who got a singed beard while camping

C) An elderly client with complaints of frequent liquid brown colored stools

D) A middle aged client with intermittent pain behind the right scapula

The correct answer is B: A teenager who got a singed beard while camping

This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

21. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

A) the muscles

B) the cerebellum

C) the kidneys

D) the leg bones

The correct answer is A: the muscles

Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- “myo” --which typically means muscle.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

22. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is

A) Maintain fluid and electrolyte balance

B) Control nausea

C) Manage pain

D) Prevent urinary tract infection

The correct answer is C: Manage pain

The immediate goal of therapy is to alleviate the client’s pain, which can be quite severe with kidney stones.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

23. While assessing a 1 month-old infant, which finding should the nurse report immediately?

A) Abdominal respirations

B) Irregular breathing rate

C) Inspiratory grunt

D) Increased heart rate with crying

The correct answer is C: Inspiratory grunt

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

24. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest."

B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?"

C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10

D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

The correct answer is C: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10

Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

25. The nurse anticipates that for a family who practices Chinese medicine the priority therapeutic goal would be to

A) achieve harmony

B) maintain a balance of energy

C) respect life

D) restore yin and yang

The correct answer is D: restore yin and yang

For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

26. Which of these findings indicate that a pump set to deliver a basal rate of 10 ml per hour plus PRN morphine drip for breakthrough pain is not working?

A) The client complains of discomfort at the IV insertion site

B) The client states "I just can't get relief from my pain"

C) The level of the drug is 100 ml at 8 AM and is 80 ml at noon

D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon

The correct answer is C: The level of the drug is 100 ml at 8 AM and is 80 ml at noon

The minimal dose is 10 ml per hour, which would mean 40 mls are given in a 4 hour period. Only 60 mls should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

27. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

A) Narrowed QRS complex

B) Shortened "PR" interval

C) Tall peaked T waves

D) Prominent "U" waves

The correct answer is C: Tall peaked T waves

A tall peaked T wave is a sign of hyperkalemia. The provider should be notified regarding discontinuing the medication.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

28. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

A) Should be taken in the morning

B) May decrease the client's energy level

C) Must be stored in a dark container

D) Will decrease the client's heart rate

The correct answer is A: Should be taken in the morning

Thyroid supplement should be taken in the morning to minimize the side effect of insomnia.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

29. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should

A) place a call to the client's provider for instructions

B) send him to the emergency room for evaluation

C) reassure the client's partner that the symptoms are transient

D) instruct the client's partner to call the provider if his symptoms become worse

The correct answer is B: send him to the emergency room for evaluation

This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

30. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to

A) Excessive fetal weight

B) Low blood sugar levels

C) Depletion of subcutaneous fat

D) Progressive placental insufficiency

The correct answer is D: Progressive placental insufficiency

The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

31. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the registered nurse implement first?

A) Gastric lavage PRN

B) Antidote N-acetylcysteine (NAC) (Mucomyst) for age per pharmacy

C) Start a Dextrose 5% with 0.33% normal saline IV to keep vein open

D) Activated charcoal per pharmacy

The correct answer is A: Gastric lavage PRN

Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next actions to complete would be to administer activated charcoal, then Mucomyst and lastly the IV fluids.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

32. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure

A) right heart function

B) left heart function

C) renal tubule function

D) carotid artery function

The correct answer is B: left heart function

The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

33. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

A) Weight gain of 5 pounds

B) Edema of the ankles

C) Gastric irritability

D) Decreased appetite

The correct answer is D: Decreased appetite

Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

34.A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, skin hot to touch, sits leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

A) Prepare the child for x-ray of upper airways

B) Examine the child's throat

C) Collect a sputum specimen

D) Notify the healthcare provider of the child's status

The correct answer is D: Notify the healthcare provider of the child''s status

These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

35. Which individual is at greatest risk for developing hypertension?

A) 45 year-old African American attorney

B) 60 year-old Asian American shop owner

C) 40 year-old Caucasian nurse

D) 55 year-old Hispanic teacher

The correct answer is A: 45 year-old African American attorney

The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. (2004). Current medical Diagnosis and Treatment. (43rd edition). USA:McGraw-Hill.

36. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?

A) Electrical energy fields

B) Spinal column manipulation

C) Mind-body balance

D) Exercise of joints

The correct answer is B: Spinal column manipulation

The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

37. A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse. Which finding of this disease would the nurse not expect to see at this time?

A) Positive sweat test

B) Bulky greasy stools

C) Moist, productive cough

D) Meconium ileus

The correct answer is C: Moist, productive cough

Option C is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

38. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is

A) start a peripheral IV

B) initiate closed-chest massage

C) establish an airway

D) obtain the crash cart

The correct answer is C: establish an airway

Establishing an open airway is always the primary objective in a cardiopulmonary arrest.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

39. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

A) Apply dressing using sterile technique

B) Improve the client's nutrition status

C) Initiate limb compression therapy

D) Begin proteolytic debridement

The correct answer is B: Improve the client''s nutrition status

The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

40. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

A) Angina at rest

B) Thrombus formation

C) Dizziness

D) Falling blood pressure

The correct answer is B: Thrombus formation

Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is within the first 12 hours after the procedure.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

No work

noreply@blogger.com (RegisteredNurseTech) — Sun, 04 Nov 2007 04:17:00 +0000

I was done taking my exams and now is my time to practice my skills and find work. At first, I thought of teaching in care giving school or nursing school because they have a good salary but I really want to practice as a Nurse that’s why now I am between two opposing forces. If I want to earn, my choice is to teach in a care giving school because I don’t need any training and I prefer teaching in care giving school than teaching nursing student because I don’t need Masteral(requirement-post graduate course) which will be additional stress in my empty pocket. On the other hand, In hospital, In order to be employ I need to undergo training and what I don’t like is I need to pay the institution for my training which is supposed to be they are the one who needs to pay me because I’m going to work for them and they will benefit from me. It’s really a big problem for me because I want to work to earn money but it’s the opposite and they are the one who’s going to earn from me if I will apply in hospital. Also, I called almost all hospital in Manila (Philippines) and unfortunately most of them were no vacancy and some stop hiring perhaps because of their long waiting list of employee waiting to be train and employ. October 31, I passed my resume to a care giving school and hopefully they would call me back as soon as possible. I do have good rating in my local board exam and grades when I was in college and that’s one of the reasons I am qualified in their criteria. On the same day, my plan was to apply for work in either care giving school or hospital so, I do have choices to choose from. After passing my credentials to a care giving school, I went to orthopedic hospital to pass my credential but when I checked their requirements, they have additional requirements which I don’t have. I thought I brought all the necessary requirements I needed in applying but I was wrong and it cause me delay. I was supposed to go to the other hospitals to apply but instead I went home and called them to ask their requirements so, I would not waste my time and fair. Each hospital has different requirements and I made a correct choice when I went home. Now, I am waiting for Monday because that’s the time that offices and classes will resume after holiday. I am hoping that I can find work as soon as possible because I want to be productive.

Im back from ielts

noreply@blogger.com (RegisteredNurseTech) — Sat, 27 Oct 2007 14:27:00 +0000

I need IELT's to be combined with my CGFNS for my papers to be processed going to US. I am bound for US and the passing rate is a total band score of 6.5 but in speaking the standard passing score is 7. It doesnt matter what is your score in reading, listening and writing as long as you can achieve a total score of 6.5(including speaking).
I took my IELTS exam 2 days ago in Baguio City. 2 days prior to my exam I asked my friends in Baguio about hotel where I can stay for 1 day and I also checked the internet to look for hotel so I have many choices to choose. I list down all the hotels I found and called each of them to asked for details like accommodation fee, available rooms, availability of television, hot shower, and blah blah blah. Im planning to stay for 1 day only but all of them have a cut off time of 1200 pm. Since my speaking exam was 1830 I have no choice but to extend my time. If I will extend my time I will be charge for P100 per hour and my plan was to leave Baguio by 2200 because that is the only time closest to 1900 where my exam will be done. All in all I need to pay additional fee which is kinda expensive, I paid 2 days accommodation instead because It was cheaper than paying additional P1000 for 10 hours extension. I packed all the necessary things I need, Im wearing eye glass now because this past few months my eyes were frequently irritated so I brought my contact lenses because the owner of the review center where I reviewed told me not to wear my eye glass in my interview(I dont know and I didnt even ask), my alarm clock that is irritating because it is very loud to make sure that I will wake up in the morning, wax for my hair and blah blah blah. I left Manila 0730 oct24 and arrived 1400 in Baguio. I left earlier so I have plenty of time to relax from my tiring trip and also I hate rushing. I went directly in my hotel and I liked it because it is located in the center of Baguio. I was sleepy but i didnt sleep because I want to have a good sleep at night. I went to MRLRC (marlon labagnoy review center) and gave my sister's gift to her friend there and visited my dorm in San Roque to checked my friends I met when I stayed there 4 months ago. I ate my dinner in KFC facing the transparent glass outside looking for people walking. I smoke after(i know, im not suppose to smoke) and went to the opposite side and bought water and bread as my breakfast tomorrow. I was looking for cinnamon bread but I cant find one and instead bought brownies slice and creamy peanut butter roller. I dropped by in Cathedral but it was already close and walked into my hotel which is 2 blocks from the Cathedral. I red until 2400 to lessen my anxiety and tried to sleep but I didnt had a good sleep. My eyes were close but I was not, I listened to music but still ineffective.
I heard a loud alarm and thought of a fire but I realized that it was the alarm clock I brought. I prepared and went to my testing center. I was in the entrance of the building, I checked my pocket to make sure I have my pencil, eraser, and sharpener. It was gone, I gasped and checked it again in my pocket for several times. I didnt found it and I thought of only one possible place where I left it and it was the cab. I looked for the cab I rode and I saw it not so far away. I didnt know what to do, I stand and think for 5 seconds if I will chase it or I will chase it because If I will buy another pencil, eraser, and sharpener I will surely be late. Buying another materials was not an option because according to IELT's "late comers will not be accepted in the testing center". The cab was moving while I was standing and the distance was becoming huge. There were two pathway for the cab. If the cab turned right I dont have any chance of getting my belongings but if it turned left I do have chance because the front of the building is oval and the entrance gate is in the middle part at the side. It turned left , I didnt waste my time and dashed into the otherside so I can intercept the cab. I was able to intercept the cab and checked the seat but it was not there. I felt week, I searched again and luckily it was there and found it in the floor. I was drenching into sweat because of the adrenaline in dashing and the feeling when I found it. We started taking the listening first, followed by reading and writing. In listening, the audio encountered some technical problems and cause some delay. By 1200, we finished the exam and I immediately went to session road to eat my lunch. My mind changed and went to SM(shopping mall) instead where I have variety of fast food to choose, also, to visit my friend working in one of the botique in SM. I again end up into KFC, I visited my friend but he was not there so I just went to church then went home after. I rested for a bit and read again. By 1700, I was already prepared but I was still reading since my speaking was 1825. When I looked into my cellphone, one of the staff in IELT's texted me and told me to go in testing center immediately because my turn for interview was near. I didnt heard my cellphone because it was in the silent mode, I turned it to silent mode because I didnt want to be distracted in my reading. Instead of helping me to concentrate
, it was the opposite. I was again end up dashing and when I arrived I rested for 5 minutes then, I had my speaking. I practiced for my introduction a lot but the interviewer didnt ask me much about that part. When I was done, I stayed for 5 minutes then left. I left together with 3 other examinee who also took their speaking exams because of the scarcity in cab that time. We were dropped into session road and went to our separate ways. I bought water and immediately went to hotel to contact my friend named "M"to invite him to go out. I ate my dinner before heading back to my friend. I went there and my friend "M" was not there. His place is a boarding house and my friend "P" who is the owner's grandson of the boarding house and our friends entertained me. I joined their boarders who were really cool and funny. I stayed there until morning watching them in their gambling game. I was supposed to go home by 2200 of oct25 but I stayed because I also missed Baguio and my friends there. I went to my hotel by 0700 and left Baguio. I was sleepy and seems unconscious in the bus because I was up the whole night and morning. I was home and still continued sleeping. The result will be out within 13 days, hopefully I will pass it also as I passed my other exams. Next step is working, earning money and supporting myself in NCLEX.

Nurse strike in Cali

noreply@blogger.com (RegisteredNurseTech) — Sun, 21 Oct 2007 16:11:00 +0000

RN's in Cali are striking because of patient ratio and quality care, they are striking because of nurse patient 1:8 ratio and benefits . . . . If they will only know the situation in Philippines. Worst possible cases and worst environment plus a salary of 5000 below in most public (especially to provinces) and some in private hospitals. If they will know that nurse patient ratio are 1:25 up in most public hospitals and 1:10 to private hospitals. Perhaps we can do what they did because we have rights, am i right?

Hundreds of picketing nurses greeted patients today at 15 Northern California hospitals.

Nearly 5,000 registered nurses walked off the job at 7 a.m. to begin a two-day strike.

At Eden Hospital in Castro Valley, some 75 nurses were outside the building in the early morning chanting "Beat back the Sutter attack," and "Patients first, not profits."

Inside, replacement nurses carried on, though one grandmother leaving after the morning birth of a granddaughter said she could tell they were not used to the routines.

A hospital spokeswoman said it was "business as usual" there.

On the picket line, Tina Simon, a nurse at Eden since 1980, said nurses on some floors routinely go without lunch and other breaks because the hospital has no one to relieve them.

"This is a very stressful job. I don't think a patient should have a tired nurse with low blood sugar taking care of them."

The state has a law mandating a nurse-patient ratio, but the striking nurses say it is not enough.

"Obviously, there is a safe staffing law but the hospital industry is finding ways to bypass that," said Bob Auen, an ICU nurse.

The nurses also want a dedicated team to help lift and move patients. Simon said she had back surgery for a disc that ruptured when she tried to move a patient bed....

Complete article can be view here- http://www.contracostatimes.com/ci_7136262

NCLEX practice #14

noreply@blogger.com (RegisteredNurseTech) — Wed, 17 Oct 2007 06:44:00 +0000

1. Which contraindication should the nurse assess for prior to giving a child immunizations?

A) Mild cold symptoms

B) Chronic asthma

C) Depressed immune system

D) Allergy to eggs

The correct answer is C: Depressed immune system

Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

2. Which of the following situations is most likely to produce sepsis in the neonate?

A) Maternal diabetes

B) Prolonged rupture of membranes

C) Cesarean delivery

D) Precipitous vaginal birth

The correct answer is B: Prolonged rupture of membranes

Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

3.A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering

A) pulmonary embolectomy

B) vena caval interruption

C) increasing the Coumadin therapy to an INR of 3-4

D) thrombolytic therapy

The correct answer is B: vena caval interruption

Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

4. A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies

A) destroy organisms causing disease

B) maintain fluid balance

C) boost the immune system

D) increase bodily energy

The correct answer is C: boost the immune system

The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body''s own defenses.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

5. The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?

A) bounding pulse

B) rapid respirations

C) oliguria

D) neck veins are distended

The correct answer is C: oliguria

Kidneys maintain fluid volume through adjustments in urine volume.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

6. The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information?

A) "I usually avoid driving at night since lights sometimes seem to make things blur."

B) "I take half of the usual dose for my sinuses to maintain my blood pressure."

C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."

D) "I take extra fiber and drink lots of water to avoid getting constipated."

The correct answer is D: "I take extra fiber and drink lots of water to avoid getting constipated."

Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

7. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?

A) Capillary refill of fingers on right hand is 3 seconds

B) Skin warm to touch and normally colored

C) Client reports prickling sensation in the right hand

D) Slight swelling of fingers of right hand

The correct answer is C: Client reports prickling sensation in the right hand

A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

8. The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?

A) "Your child must use a care seat until he weighs at least 40 pounds."

B) "The child must be 5 years of age to use a regular seat belt."

C) "Your child must reach a height of 50 inches to sit in a seat belt."

D) "The child can use a regular seat belt when he can sit still."

The correct answer is A: "Your child must use a care seat until he weighs at least 40 pounds."

Children should use car seats until they weigh 40 pounds.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

9. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are

A) sedation as needed to prevent exhaustion

B) antibiotic therapy for 10 to 14 days

C) humidified air and increased oral fluids

D) antihistamines to decrease allergic response

The correct answer is C: humidified air and increased oral fluids

The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids is mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

10. A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?

A) Conduct guided imagery or distraction

B) Ensure that the stump is elevated the first day post-op

C) Wrap the stump snugly in an elastic bandage

D) Administer opioid narcotics as ordered

The correct answer is B: Ensure that the stump is elevated the first day post-op

This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

11. A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 degrees Fahrenheit (35 degrees Celsius) axillary. The nurse recognizes that cold stress may lead to what complication?

A) Lowered BMR

B) Reduced PaO2

C) Lethargy

D) Metabolic alkalosis

The correct answer is B: Reduced PaO2

Cold stress causes increased risk for respiratory distress. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 degrees Fahrenheit (36 degrees Celsius).

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

12. A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?

A) Regulate the neonate’s temperature using a radiant heater

B) Withhold feedings while under the phototherapy

C) Provide water feedings at least every 2 hours

D) Protect the eyes of neonate from the phototherapy lights

The correct answer is C: Provide water feedings at least every 2 hours

Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate’s skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

13. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?

A) Disruption of fetal glucose supply

B) Pancreatic insufficiency

C) Maternal insulin dependency

D) Reduced glycogen reserves

The correct answer is A: Disruption of fetal glucose supply

After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

14. A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?

A) Check the skin on the sacrum for breakdown

B) Inspect the pin site for signs of infection

C) Auscultate the lungs for atelectasis

D) Perform a neurovascular check for circulation

The correct answer is D: Perform a neurovascular check for circulation

While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell’s traction is Buck’s traction with a sling under the knee.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

15. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct?

A) Days 7-10

B) Days 10-13

C) Days 14-16

D) Days 17-19

The correct answer is D: Days 17-19

Ovulation occurs 14 days prior to menses. Considering that the woman''s cycle is 32 days, subtracting 14 from 32 suggests ovulation is at about the 18th day.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

16. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

A) Neurotoxicity

B) Hepatomegaly

C) Nephrotoxicity

D) Ototoxicity

The correct answer is C: Nephrotoxicity

Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

17.The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?

A) "I'm going to try feeding my baby some rice cereal."

B) "When he wakes at night for a bottle, I feed him."

C) "I dip his pacifier in honey so he'll take it."

D) "I keep formula in the refrigerator for 24 hours."

The correct answer is C: "I dip his pacifier in honey so he''ll take it."

Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

18. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in an incubator. Which action is a nursing priority?

A) Protect the eyes of the neonate from the heat lamp

B) Monitor the neonate’s temperature

C) Warm all medications and liquids before giving

D) Avoid touching the neonate with cold hands

The correct answer is B: Monitor the neonate’s temperature

When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

19. A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes

A) amputation just above the tumor

B) surgical excision of the mass

C) bone marrow graft in the affected leg

D) radiation and chemotherapy

The correct answer is D: radiation and chemotherapy

The initial treatment of choice for Ewing''s sarcoma is a combination of radiation and chemotherapy.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

20. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

A) Place the child in the nearest bed

B) Administer IV medication to slow down the seizure

C) Place a padded tongue blade in the child's mouth

D) Remove the child's toys from the immediate area

The correct answer is D: Remove the child''s toys from the immediate area

Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child''s mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

21. A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?

A) Call the health care provider

B) Access the site by cutting a window in the cast

C) Simply record the findings in the nurse's notes only

D) Outline the spot with a pencil and note the time and date on the cast

The correct answer is D: Outline the spot with a pencil and note the time and date on the cast

This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse’s notes.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

22.The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?

A) Irritability

B) Slight edema at site

C) Local tenderness

D) Seizure activity

The correct answer is D: Seizure activity

Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

23. When suctioning a client's tracheostomy, the nurse should instill saline in order to

A) decrease the client's discomfort

B) reduce viscosity of secretions

C) prevent client aspiration

D) remove a mucus plug

The correct answer is D: remove a mucus plug

While no longer recommended for routine suctioning, saline may thin and loosen viscous secretions that are very difficult to move, perhaps making them easier to suction.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

24. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?

A) Venturi mask

B) Partial rebreather mask

C) Non-rebreather mask

D) Simple face mask

The correct answer is C: Non-rebreather mask

The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

25. At a senior citizens meeting a nurse talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?

A) "I give my insulin to myself in my thighs."

B) "Sometimes when I put my shoes on I don't know where my toes are."

C) "Here are my up and down glucose readings that I wrote on my calendar."

D) "If I bathe more than once a week my skin feels too dry."

The correct answer is B: "Sometimes when I put my shoes on I don''t know where my toes are."

Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients who do not feel pressure and/or pain are at high risk for skin impairment.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

26 A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?

A) Suction the client frequently while restrained

B) Secure all 4 restraints to 1 side of bed

C) Obtain a sitter for the client while restrained

D) Request an order for a cough suppressant

The correct answer is C: Obtain a sitter for the client while restrained

The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

27. Which client is at highest risk for developing a pressure ulcer?

A) 23 year-old in traction for fractured femur

B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance

C) 75 year-old with left sided paresthesia who is incontinent of urine and stool

D) 30 year-old who is comatose following a ruptured aneurysm

The correct answer is C: 75 year-old with left sided paresthesia who is incontinent of urine and stool

Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

28. The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?

A) Birth weight

B) Racial differences

C) Fetal distress in labor

D) Birth trauma

The correct answer is C: Fetal distress in labor

The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

29. The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?

A) Periorbital edema

B) Dizzy spells

C) Lethargy

D) Shortness of breath

The correct answer is B: Dizzy spells

Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Near syncope refers to lightheartedness, dizziness, temporary confusion. Such "spells" may indicate runs of ventricular tachycardia or periods of asystole and should be reported immediately.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

30. A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?

A) Vary the interview style for each candidate to learn different techniques

B) Use simple questions requiring "yes" and "no" answers to gain definitive information

C) Obtain an interview guide from human resources for consistency in interviewing each candidate

D) Ask personal information of each applicant to assure he/she can meet job demands

The correct answer is C: Obtain an interview guide from human resources for consistency in interviewing each candidate

An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse should use resources available in the agency before attempts to develop one from scratch. Certain personal questions are prohibited, and HR can identify these for novice managers.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

31. Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it:

A) considers client and staff needs

B) conserves time spent on planning

C) frees the nurse manager to handle other priorities

D) allows requests for special privileges

The correct answer is A: considers client and staff needs

Decentralized staffing takes into consideration specific client needs and staff interests and abilities.

Marriner-Tomey, A. (2000). Guide to Nursing Management and Leadership. . St. Louis: Mosby.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

32. The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?

A) Using a moist soft brush or cloth to clean teeth and gums

B) Swabbing teeth and gums with flavored mouthwash

C) Offering a bottle of water for the child to drink

D) Brushing with toothpaste and flossing each tooth

The correct answer is A: Using a moist soft brush or cloth to clean teeth and gums

The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

33. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?

A) Drink small amounts of liquids frequently

B) Eat the evening meal just before retiring

C) Take sodium bicarbonate after each meal

D) Sleep with head propped on several pillows

The correct answer is D: Sleep with head propped on several pillows

Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

34. Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

A) Liver function

B) Kidney function

C) Blood sugar

D) Cardiac enzymes

The correct answer is A: Liver function

INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

35. In addition to standard precautions, a nurse should implement contact precautions for which client?

A) 60 year-old with herpes simplex

B) 6 year-old with mononucleosis

C) 45 year-old with pneumonia

D) 3 year-old with scarlet fever

The correct answer is A: 60 year-old with herpes simplex

Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

36. What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?

A) Set good examples themselves

B) Protect their child from outside influences

C) Make sure their child understands all the safety rules

D) Discuss the consequences of not wearing protective devices

The correct answer is A: Set good examples themselves

The preschool years are the time for parents to begin emphasizing safety principles as well as providing protection. Setting a good example themselves is crucial because of the imitative behaviors of pre-schoolers; they are quick to notice discrepancies between what they see and what they are told.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

37. A client who is 12 hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client's behavior?

A) Cardiac rhythm strip

B) Pupillary response

C) Pulse oximetry

D) Peripheral glucose stick

The correct answer is C: Pulse oximetry

A sudden change in mental status in any post-op client should trigger a nursing intervention directed toward respiratory evaluation. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these finding which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the client''s behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out then significant changes in glucose would be evaluated.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

38. A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis?

A) History of menopause at age 50

B) Taking high doses of steroids for arthritis for many years

C) Maintaining an inactive lifestyle for the past 10 years

D) Drinking 2 glasses of red wine each day for the past 30 years

The correct answer is B: Taking high doses of steroids for arthritis for many years

The use of steroids, especially at high doses over time, increases the risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor calcium absorption and moderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk factor, however.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

39. The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to

A) restrict visitors to immediate family

B) avoid arousal of the client except for family visits

C) keep client's hips flexed at no less than 90 degrees

D) apply a warming blanket for temperatures of 98 degrees Fahrenheit or less

The correct answer is A: restrict visitors to immediate family

Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

40. A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have avoided by

A) placing an obturator at the client’s bedside

B) having another nurse assist with the procedure

C) fastening clean tracheostomy ties before removing old ties

D) placing the client in a flat, supine position

The correct answer is C: fastening clean tracheostomy ties before removing old ties

Fastening clean tracheostomy ties before removing old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not prevent a dislodged tracheostomy.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

NCLEX practice #15

noreply@blogger.com (RegisteredNurseTech) — Wed, 17 Oct 2007 06:16:00 +0000

1. After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states “I am so confused. I lose my money. I just can’t remember telephone numbers.” The most therapeutic response for the nurse to make is

A) "You were seriously ill and needed the treatments."

B) "Don't get upset. The confusion will clear up in a day or two."

C) "It is to be expected since most clients have the same results."

D) "I can hear your concern and that your confusion is upsetting to you."

The correct answer is D: "I can hear your concern and that your confusion is upsetting to you."

Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short term effects would be discussed.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

2. The visiting nurse makes a postpartum visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The initial nursing intervention would be to

A) call the police to report indications of domestic violence

B) confront the husband about abusing his wife

C) leave the home because of the unsafe environment

D) interview the client alone to determine the origin of the injuries

The correct answer is D: interview the client alone to determine the origin of the injuries

It would be wrong to assume domestic violence without further assessment. Separate the suspected victim from the partner until battering has been ruled out.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

3. A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?

A) Fresh juice, carrots, vanilla pudding

B) Apple juice, ham salad, fresh pineapple

C) Hamburger, fries, strawberry shake

D) Red wine, fava beans, aged cheese

The correct answer is D: Red wine, fava beans, aged cheese

Red wine and cheese contain tyramine (as do chicken liver and ripe bananas) and so are contraindicated when taking MAOIs. Fava beans contain other vasopressors that can interact with MAOIs also causing malignant hypertension.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

4. The client asks the nurse how the health care provider could tell she was pregnant “just by looking inside.” What is the best explanation by the nurse?

A) Bluish coloration of the cervix and vaginal walls

B) Pronounced softening of the cervix

C) Clot of very thick mucous that obstructs the cervical canal

D) Slight rotation of the uterus to the right

The correct answer is A: Bluish coloration of the cervix and vaginal walls

Chadwick''s sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

5.A client is discharged on warfarin sulfate (Coumadin). Which statement by the client indicated a need for further teaching?

A) "I know I must avoid crowds."

B) "I will keep all laboratory appointments."

C) "I plan to use an electric razor for shaving."

D) "I will report any bruises for bleeding."

The correct answer is A: "I know I must avoid crowds."

There are no specific reasons for the client on Coumadin to avoid crowds. General instructions for any cardiac surgical client include limiting exposure to infection.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

6. A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response?

A) Give him written material from the American Heart Association about sexual activity with heart disease

B) Answer his questions accurately in a private environment

C) Schedule a private, uninterrupted teaching session with both the client and his wife

D) Assess the client's knowledge about his health problems

The correct answer is D: Assess the client''s knowledge about his health problems

The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

7. The nurse is assessing a client with chronic obstructive pulmonary disease receiving oxygen for low PaO2 levels. Which assessment is a nursing priority?

A) Evaluating SaO2 levels frequently

B) Observing skin color changes

C) Assessing for clubbing fingers

D) Identifying tactile fremitus

The correct answer is A: Evaluating SaO2 levels frequently

The best method to evaluate a client''s oxygenation is to evaluate the SaO2. This is just as effective as an arterial blood gas reading to evaluate oxygenation status, and is less traumatic and expensive.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

8. The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?

A) "The first of every month, because it is easiest to remember"

B) "Right after the period, when your breasts are less tender"

C) "Do the exam at the same time every month"

D) "Ovulation, or mid-cycle is the best time to detect changes"

The correct answer is B: "Right after the period, when your breasts are less tender"

The best time for a breast self exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

9. The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regards to tardive dyskinesia?

A) TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30

B) It can occur in clients taking antipsychotic drugs longer than 2 years

C) Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible

D) TD can easily be treated with anticholinergic drugs

The correct answer is B: It can occur in clients taking antipsychotic drugs longer than 2 years

Tardive dyskinesia is a extrapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Early symptoms of tardive dyskinesia are fasciculations of the tongue or constant smacking of the lips.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. (2004). Current medical Diagnosis and Treatment. (43rd edition). USA:McGraw-Hill.

10. A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?

A) Ataxia and course hand tremors

B) Vomiting, diarrhea and lethargy

C) Pruritus, rash and photosensitivity

D) Electrolyte imbalance and cardiac arrhythmias

The correct answer is B: Vomiting, diarrhea and lethargy

These are early signs of lithium toxicity.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

11. A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse knows that fetal monitoring must now assess for what complication?

A) Early decelerations

B) Late accelerations

C) Variable decelerations

D) Periodic accelerations

The correct answer is C: Variable decelerations

When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

12. Initial postoperative nursing care for an infant who has had a pyloromyotomy would initially include

A) bland diet appropriate for age

B) intravenous fluids for 3-4 days

C) NPO then glucose and electrolyte solutions

D) formula or breast milk as tolerated

The correct answer is C: NPO then glucose and electrolyte solutions

Post-operatively, the initial feedings are clear liquids in small quantities to provide calories and electrolytes.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

13. Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements?

A) Potassium

B) Sodium

C) Chloride

D) Calcium

The correct answer is B: Sodium

Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

14. The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?

A) Link the caregiver with a support group

B) Ask friends to visit regularly

C) Schedule a home visit each week

D) Request anti-anxiety prescriptions

The correct answer is A: Link the caregiver with a support group

Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer''s chapters.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

15. A nurse is caring for a client who has just been admitted with an overdose of aspirin. The following lab data is available: PaO2 95, PaCO2 30, pH 7.5, K 3.2 mEq/l. Which should be the nurse's first action?

A) Monitor respiratory rate

B) Monitor intake and output every hour

C) Assist the client to breathe into a paper bag

D) Prepare to administer oxygen by mask

The correct answer is C: Assist the client to breathe into a paper bag

Side effects of aspirin toxicity include hyperventilation, which can result in respiratory alkalosis in the initial stages. Breathing into a paper bag will prevent further reduction in PaCO2.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

16. When teaching a client with a new prescription for lithium (Lithane) for treatment of a bi-polar disorder which of these should the nurse emphasize?

A) Maintaining a salt restricted diet

B) Reporting vomiting or diarrhea

C) Taking other medication as usual

D) Substituting generic form if desired

The correct answer is B: Reporting vomiting or diarrhea

If dehydration results from vomiting, diarrhea or excessive perspiration, tolerance to the drug may be altered and symptoms may return.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

17. What must be the priority consideration for nurses when communicating with children?

A) Present environment

B) Physical condition

C) Nonverbal cues

D) Developmental level

The correct answer is D: Developmental level

While each of the factors affect communication, the nurse recognizes that developmental differences have implications for processing and understanding information. Consequently, a child’s developmental level must be considered when selecting communication approaches.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

18. Which clinical finding would the nurse expect to assess first in a newborn with spastic cerebral palsy?

A) cognitive impairment

B) hypotonic muscular activity

C) seizures

D) criss-crossing leg movement

The correct answer is D: criss-crossing leg movement

Cerebral palsy is a neuromuscular impairment resulting in muscular and reflexive hypertonicity and the criss-crossing, or scissoring leg movements.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

19. The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?

A) Provide small feedings every 3 hours

B) Maintain intravenous fluids

C) Add strained cereal to the diet

D) Change to reduced calorie formula

The correct answer is A: Provide small feedings every 3 hours

Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

20. The nurse is assessing a woman in early labor. While positioning for a vaginal exam, she complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What should be the initial nursing action?

A) Call the health care provider

B) Encourage deep breathing

C) Elevate the foot of the bed

D) Turn her to her left side

The correct answer is D: Turn her to her left side

The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her back causing supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the woman to the side reduces this pressure and relieves postural hypotension.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

21. A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant?

A) Estrogen

B) HCG

C) Alpha-fetoprotein

D) Progesterone

The correct answer is B: HCG

Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

22. As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?

A) What and how much the client drinks, according to family and friends

B) The blood alcohol level of the client

C) The blood pressure level of the client

D) The blood glucose level of the client

The correct answer is B: The blood alcohol level of the client

Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

23. A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest

A) during the night shift when staffing is limited

B) when the client’s mood improves with an increase in energy level

C) at the time of the client's greatest despair

D) after a visit from the client's estranged partner

The correct answer is B: when the client’s mood improves with an increase in energy level

Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

24. In response to a call for assistance by a client in labor, the nurse notes that a loop on the umbilical cord protrudes from the vagina. What is the priority nursing action?

A) call the health care provider

B) check fetal heart beat

C) put the client in knee-chest position

D) turn the client to the side

The correct answer is C: put the client in knee-chest position

Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The Trendelenburg position accomplishes this. The exposed cord is covered with saline soaked gauze, not reinserted. The fetal heart rate also should be checked, and the provider called. A prolapsed umbilical cord is a medical emergency.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

25. A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?

A) "When I take in a deep breath, it stabs like a knife."

B) "The pain came on after dinner. That soup seemed very spicy."

C) "When I turn in bed to reach the remote for the TV, my chest hurts."

D) "I feel pressure in the middle of my chest, like an elephant is sitting on my chest."

The correct answer is D: "I feel pressure in the middle of my chest, like an elephant is sitting on my chest."

This is a classic description of chest pain in men caused by myocardial ischemia. Women experience vague feelings of fatigue and back and jaw pain.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

26. Which medication is more helpful in treating bulimia than anorexia?

A) Amphetamines

B) Sedatives

C) Anticholinergics

D) Narcotics

The correct answer is C: Anticholinergics

In contrast to anorexics, individuals with bulimia are troubled by their behavioral characteristics and become depressed. The person feels compelled to binge, purge and fast. Feeling helpless to stop the behavior, feelings of self-disgust occur.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

27. A client is treated in the emergency room for diabetic ketoacidosis and a glucose level of 650mg.D/L. In assessing the client, the nurse's review of which of the following tests suggests an understanding of this health problem?

A) Serum calcium

B) Serum magnesium

C) Serum creatinine

D) Serum potassium

The correct answer is D: Serum potassium

Potassium is lost in diabetic ketoacidosis during rehydration and insulin administration. Review of this lab finding suggests the nurse has knowledge of this problem.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

28. A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is

A) bowel sounds

B) heart rate

C) peripheral pulses

D) lung sounds

The correct answer is D: lung sounds

Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

29. A client has been started on a long term corticosteroid therapy. Which of the following comments by the client indicate the need for further teaching?

A) "I will keep a weekly weight record."

B) "I will take medication with food."

C) "I will stop taking the medication for 1 week every month."

D) "I will eat foods high in potassium."

The correct answer is C: "I will stop taking the medication for 1 week every month."

Emphatically warn against discontinuing steroid dosage abruptly because that may produce a fatal adrenal crisis.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

30. The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?

A) Repeatedly remind the client of the time and location

B) Explain the risks of walking with no purpose

C) Use protective devices to keep the client in the bed or chair in the room

D) Attach a wander-guard sensor band to the client's wrist

The correct answer is D: Attach a wander-guard sensor band to the client''s wrist

This type of identification band easily tracks the client''s movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

31. The nurse is assessing a client's home in preparation for discharge. Which of the following should be given priority consideration?

A) Family understanding of client needs

B) Financial status

C) Location of bathrooms

D) Proximity to emergency services

The correct answer is A: Family understanding of client needs

Functional communication patterns between family members are fundamental to meeting the needs of the client and family.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

32. When teaching a client about an oral hypoglycemic medication, the nurse should place primary emphasis on

A) recognizing findings of toxicity

B) taking the medication at specified times

C) increasing the dosage based on blood glucose

D) distinguishing hypoglycemia from hyperglycemia

The correct answer is B: taking the medication at specified times

A regular interval between doses should be maintained since oral hypoglycemics stimulate the islets of Langerhans to produce insulin.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

33. A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to

A) begin intravenous therapy

B) initiate continuous blood pressure monitoring

C) administer oxygen therapy

D) institute cardiac monitoring

The correct answer is C: administer oxygen therapy

Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

34. The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be to

A) medicate the client for pain

B) call the provider

C) cover the wound with sterile saline dressing

D) place the bed in a flat position

The correct answer is C: cover the wound with sterile saline dressing

When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

35. The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?

A) Heart rate

B) Neurologic status

C) Urine output

D) Blood pressure

The correct answer is D: Blood pressure

The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client''s blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

36. The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's

A) poor nutritional status

B) decreased gastrointestinal motility

C) increased splanchnic blood flow

D) altered peripheral resistance

The correct answer is B: decreased gastrointestinal motility

Together with shrinkage of the gastric mucosa, and changes in the levels of hydrochloric acid, this will decrease absorption of medications and interfere with their actions.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

37. The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?

A) Central venous pressure reading of 11

B) Respiratory rate of 22

C) Pulse rate of 48 BPM

D) Blood pressure of 144/92

The correct answer is C: Pulse rate of 48 BPM

One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

38. A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?

A) Wine, beer, cheese, liver and chocolate

B) Wine, citrus fruits, yogurt and broccoli

C) Beer, cheese, beef and carrots

D) Wine, apples, sour cream and beef steak

The correct answer is A: Wine, beer, cheese, liver and chocolate

These foods are tyramine rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

39. The nurse is working in a high risk antepartum clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which information should receive priority attention by the nurse?

A) Her father and brother are insulin dependent diabetics

B) She has taken 800 mcg of folic acid daily for the past year

C) Her husband was treated for tuberculosis as a child

D) She reports recent use of over-the counter sinus remedies

The correct answer is D: She reports recent use of over-the counter sinus remedies

Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications should be followed up immediately.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

40. After assessing a 70 year-old male client's laboratory results during a routine clinic visit, which one of the following findings would indicate an area in which teaching is needed:

A) Serum albumin 2.5 g/dl

B) LDL Cholesterol 140 mg/dl

C) Serum glucose 90 mg/dl

D) RBC 5.0 million/mm3

The correct answer is A: Serum albumin 2.5 g/dl

Serum albumin level is low (normal 3.0 – 5.0 g/dl in elders), indicating nutritional counseling to increase dietary protein is needed. Socioeconomic factors may need to be addressed to help the client comply with the recommendation.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

NCLEX practice #16

noreply@blogger.com (RegisteredNurseTech) — Wed, 17 Oct 2007 05:11:00 +0000

1. Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?

A) Hemoglobin 15 gm/dl

B) Chloride 100 mEq/L

C) Sodium 130 mEq/L

D) Carbon dioxide 20 mEq/L

The correct answer is D: Carbon dioxide 20 mEq/L

Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Pagana, K.D. and Pagana, T.J. (2002). Mosby''s Manual of Diagnostic and Laboratory Tests. (2nd ed.). Philadelphia: Lippincott.

2. The nurse is caring for a client with asthma who has developed gastroesophageal reflux disease (GERD). Which of the following medications prescribed for the client may aggravate GERD?

A) Anticholinergics

B) Corticosteroids

C)Histamine blocker

D)Antibiotics

The correct answer is A: Anticholinergics

An anticholinergic medication will decrease gastric emptying and the pressure on the lower esophageal sphincter.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

3. A client is receiving and IV antibiotic infusion and is scheduled to have blood drawn at 1:00 pm for a "peak" antibiotic level measurement. The nurse notes that the IV infusion is running behind schedule and will not be competed by 1:00. The nurse should:

A) Notify the client's health care provider

B) Stop the infusion at 1:00 pm

C) Reschedule the laboratory test

D) Increase the infusion rate

The correct answer is C: Reschedule the laboratory test

If the antibiotic infusion will not be completed at the time the peak blood level is due to be drawn, the nurse should ask that the blood sampling time be adjusted

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

4. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?

A) Change in body image

B) An unfamiliar environment

C) Perceived loss of control

D) Guilt over being hospitalized

The correct answer is C: Perceived loss of control

For school age children, major fears are loss of control and separation from friends/peers.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

5. Which of the following assessments by the nurse would indicate that the client is having a possible adverse response to the isoniazid (INH)?

A)Severe headache

B)Appearance of jaundice

C) Tachycardia

D) Decreased hearing

The correct answer is B: Appearance of jaundice

Clients receiving INH therapy are at risk for developing drug induced hepatitis. The appearance of jaundice may indicate that the client has liver damage.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

6. A client with tuberculosis is started on Rifampin. Which one of the following statements by the nurse would be appropriate to include in teaching? "You may notice:

A)an orange-red color to your urine."

B)your appetite may increase for the first week.”

C)t is common to experience occasional sleep disturbances."

D) if you take the medication with food, you may have nausea."

The correct answer is A: an orange-red color to your urine."

Discoloration of the urine and other body fluids may occur. It is a harmless response to the drug, but the patient needs to be aware it may happen.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

7. The clinic nurse is discussing health promotion with a group of parents. A mother is concerned about Reye's Syndrome, and asks about prevention. Which of these demonstrates appropriate teaching?

A)"Immunize your child against this disease."

B)"Seek medical attention for serious injuries."

C) "Report exposure to this illness."

D) "Avoid use of aspirin for viral infections."

The correct answer is D: "Avoid use of aspirin for viral infections."

The link between aspirin use and Reye''s Syndrome has not been confirmed, but evidence suggests that the risk is sufficiently grave to include the warning on aspirin products.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

8. The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse?

A)"You should be emptying the pouch yourself."

B)"Let me demonstrate to you how to empty the pouch."

C) "What have you learned about emptying your pouch?"

D) "Show me what you have learned about emptying your pouch.

The correct answer is D: "Show me what you have learned about emptying your pouch."

Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

9. A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is

A)"Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK."

B) "The food has been prepared in our kitchen and is not poisoned."

C) "Let's see if your partner could bring food from home."

D) "If you don't eat, I will have to suggest for you to be tube fed."

The correct answer is C: "Let''s see if your partner could bring food from home."

Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise. Option D offers a logical response to a primarily affective concern. When the client’s condition has improved, gentle negation of the delusional premise can be employed.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

10. A client has had a positive reaction to purified protein derivative (PPD). The client asks the nurse what this means. The nurse should indicate that the client has

A)active tuberculosis

B)been exposed to mycobacterium tuberculosis

C) never had tuberculosis

D) never been infected with mycobacterium tuberculosis

The correct answer is B: been exposed to mycobacterium tuberculosis

The PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests are needed to determine if active tuberculosis is present.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

11. A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to

A) add dietary fiber

B) reduce ammonia levels

C)stimulate peristalsis

D) control portal hypertension

The correct answer is B: reduce ammonia levels

Lactulose blocks the absorption of ammonia from the GI tract and secondarily stimulates bowel elimination.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

12. The nurse is teaching a client about the toxicity of digoxin. Which one of the following statements made by the client to the nurse indicates more teaching is needed?

A) "I may experience a loss of appetite."

B) "I can expect occasional double vision."

C) "Nausea and vomiting may last a few days."

D) "I must report a bounding pulse of 62 immediately."

The correct answer is D: "I must report a bounding pulse of 62 immediately."

Slow heart rate is related to increased cardiac output and an intended effect of digoxin. The ideal heart rate is above 60 BPM with digoxin. The client needs further teaching.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

13. A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?

A) Blood pressure

B) Cardiac enzymes

C) ECG analysis

D) Respiratory rate

The correct answer is A: Blood pressure

Since an effect of this drug is vasodilation, the client must be monitored for hypotension.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

14. In discharge teaching, the nurse should emphasize that which of these is a common side effect of clozapine (Clozaril) therapy?

A) Dry mouth

B) Rhinitis

C) Dry skin

D) Extreme salivation

The correct answer is D: Extreme salivation

A significant number of clients receiving Clozapine (Clozaril) therapy experience extreme salivation.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

15. A client is admitted to the hospital with findings of liver failure with ascites. The health care provider orders spironolactone (Aldactone). What is the pharmacological effect of this medication?

A)Promotes sodium and chloride excretion

B) Increases aldosterone levels

C)Depletes potassium reserves

D) Combines safely with antihypertensives

The correct answer is A: Promotes sodium and chloride excretion

Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. It had no effect on ammonia levels.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

16. A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if he can swim in the family pool. The best response from the nurse is

A)"Your child should not swim at all while the tubes are in place."

B)"Your child may swim in your own pool but not in a lake or ocean."

C)"Your child may swim if he wears ear plugs."

D) "Your child may swim anywhere."

The correct answer is C: "Your child may swim if he wears ear plugs."

Water should not enter the ears. Children should use ear plugs when bathing or swimming and should not put their heads under the water.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

17. A client has just been diagnosed with breast cancer. The nurse enters the room and the client tells the nurse that she is stupid. What is the most therapeutic response by the nurse?

A) Explore what is going on with the client

B) Accept the client’s statement without comment

C) Tell the client that the comment is inappropriate

D) Leave the client's room

The correct answer is A: Explore what is going on with the client

Exploring feelings with the verbally aggressive client helps to put angry feelings into words and then to engage in problem solving.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

18. The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the beach. Which of the following is the best advice about sun protection for this child?

A) "Use a sunscreen with a minimum sun protective factor of 15."

B) "Applications of sunscreen should be repeated every few hours."

C)"An infant should be protected by the maximum strength sunscreen."

D) "Sunscreens are not recommended in children younger than 6 months."

The correct answer is D: "Sunscreens are not recommended in children younger than 6 months."

Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned while near water. A hat and light protective clothing should be worn

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

19. The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?

A) Alteration in body image

B) High risk for infection

C) Altered growth and development

D) Impaired physical mobility

The correct answer is B: High risk for infection

Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

20. A post-operative client is admitted to the post-anesthesia recovery room (PACU). The anesthetist reports that malignant hyperthermia occurred during surgery. The nurse recognizes that this complication is related to what factor?

A) Allergy to general anesthesia

B) Pre-existing bacterial infection

C) A genetic predisposition

D) Selected surgical procedures

The correct answer is C: A genetic predisposition

Malignant hyperthermia is a rare, potentially fatal adverse reaction to inhaled anesthetics. There is a genetic predisposition to this disorder.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

21. The nurse is caring for a client with a new order for bupropion (Wellbutrin) for treatment of depression. The order reads “Wellbutrin 175 mg. BID x 4 days.” What is the appropriate action?

A)Give the medication as ordered

B)Question this medication dose

C)Observe the client for mood swings

D) Monitor neuro signs frequently

The correct answer is B: Question this medication dose

Bupropion (Wellbutrin) should be started at 100mg BID for three days then increased to 150mg BID. When used for depression, it may take up to four weeks for results. Common side effects are dry mouth, headache, and agitation. Doses should be administered in equally spaced time increments throughout the day to minimize the risk of seizures.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

22. A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. What is the nurse's best response?

A)"Your doctor will advise you about your risks."

B)"Unless you had previous problems, every 2 years is best."

C) "Once a woman reaches 50, she should have a mammogram yearly."

D) "Yearly mammograms are advised for all women over 35."

The correct answer is C: "Once a woman reaches 50, she should have a mammogram yearly."

The American Cancer Society recommends a screening mammogram by age 40, every 1 - 2 years for women 40-49, and every year from age 50. If there are family or personal health risks, other assessments may be recommended.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

23. The nurse is providing care to a newly a hospitalized adolescent. What is the major threat experienced by the hospitalized adolescent?

A) Pain management

B) Restricted physical activity

C) Altered body image

D) Separation from family

The correct answer is C: Altered body image

The hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance during this developmental stage.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

24. A client has many delusions. As the nurse helps the client prepare for breakfast the client comments "Don’t waste good food on me. I’m dying from this disease I have." The appropriate response would be

A) "You need some nutritious food to help you regain your weight."

B) "None of the laboratory reports show that you have any physical disease."

C) "Try to eat a little bit, breakfast is the most important meal of the day."

D) "I know you believe that you have an incurable disease."

The correct answer is D: "I know you believe that you have an incurable disease."

This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

25. An older adult client is to receive and antibiotic, gentamicin. What diagnostic finding indicates the client may have difficult excreting the medication?

A) High gastric pH

B) High serum creatinine

C) Low serum albumin

D) Low serum blood urea nitrogen

The correct answer is B: High serum creatinine

An elevated serum creatinine indicates reduced renal function. Reduced renal function will delay the excretion of many mediations.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

26. The feeling of trust can best be established by the nurse during the process of the development of a nurse-client relationship by which of these characteristics?

A)Reliability and kindness

B)Demeanor and sincerity

C)Honesty and consistency

D) Sympathy and appreciativeness

The correct answer is C: Honesty and consistency

Characteristics of a trusting relationship include respect, honesty, consistency, faith and caring.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

27. The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?

A)Teach her how to meet the needs of self and her family

B)Explain the changes in diet necessary for pregnant women

C) Question her understanding and use of the food pyramid

D) Conduct a diet history to determine her normal eating routines

The correct answer is D: Conduct a diet history to determine her normal eating routines

Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

28. A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from the other clients. Which of these statements by the nurse would be the most appropriate to promote interaction with other clients?

A)"Your team here thinks it's good for you to spend time with others."

B) "It is important for you to participate in group activities."

C)"Come with me so you can paint a picture to help you feel better."

D) "Come play Chinese Checkers with Gloria and me."

The correct answer is D: "Come play Chinese Checkers with Gloria and me."

This gradually engages the client in interactions with others in small groups rather than large groups. In addition, focusing on an activity is less anxiety-provoking than unstructured discussion. The statement is an example of a positive behavioral expectation.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

29. The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching?

A) Cocaine use can cause fetal growth retardation

B) The drug has been linked to neural tube defects

C) Newborn withdrawal generally occurs immediately after birth

D) Breast feeding promotes positive parenting behaviors

The correct answer is A: Cocaine use can cause fetal growth retardation

Cocaine is vasoconstrictive, and this effect in the placental vessels causes fetal hypoxia and diminished growth. Other risks of continued cocaine use during pregnancy include preterm labor, congenital abnormalities, altered brain development and subsequent behavioral problems in the infant.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

30. A client tells the RN she has decided to stop taking sertraline (Zoloft) because she doesn’t like the nightmares, sex dreams, and obsessions she’s experiencing since starting on the medication. What is an appropriate response by the nurse?

A)"It is unsafe to abruptly stop taking any prescribed medication."

B)"Side effects and benefits should be discussed with your health care provider."

C)"This medication should be continued despite unpleasant symptoms."

D) "Many medications have potential side effects."

The correct answer is A: "It is unsafe to abruptly stop taking any prescribed medication."

Abrupt withdrawal may occasionally cause serotonin syndrome, consisting of lethargy, nausea, headache, fever, sweating and chills. A slow withdrawal may be prescribed with sertraline to avoid dizziness, nausea, vomiting, and diarrhea.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

31. A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?

A)Hemoglobin

B)Red Blood Cell Indices

C)Platelet count

D) Neutrophil percent

The correct answer is A: Hemoglobin

Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100gL). "This level is low enough to foster the patient''s own erythropoiesis without enlarging the spleen." (Lewis, p. 744)

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

32. A 12 year-old child is admitted with a broken arm and is told surgery is required. The nurse finds him crying and unwilling to talk. What is the most appropriate response by the nurse?

A)Give him privacy

B)Tell him he will get through the surgery with no problem

C) Try to distract him

D) Make arrangements for his friends to visit

The correct answer is A: Give him privacy

A 12 year-old child needs the opportunity to express his emotions privately.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

33. A client on telemetry begins having premature ventricular beats (PVBs) at 12 per minute. In reviewing the most recent laboratory results, which would require immediate action by the nurse?

A)Calcium 9 mg/dl

B)Magnesium 2.5 mg/dl

C)Potassium 2.5 mEq/L

D) PTT 70 seconds

The correct answer is C: Potassium 2.5 mEq/L

The patient is at risk for ventricular dysrhythmias when the potassium level is low.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

34. The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed?

A)Ambivalence, dependence, demanding

B)Denial, projection, regression

C) Intellectualization, rationalization, repression

D) Identification, assimilation, withdrawal

The correct answer is B: Denial, projection, regression

Helplessness and hopelessness may contribute to regressive, dependent behavior which often occurs at any age with hospitalization. Denying or minimizing the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

35. The nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments?

A) Rely on child's self-report

B) Use a peak-flow meter

C)Note skin color changes

D) Monitor pulse rate

The correct answer is B: Use a peak-flow meter

The peak flowmeter, if used correctly, shows effectiveness of inhalants.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

36. The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. A What is priority in teaching the child and family about this drug?

A)The child should carry a nasal spray for emergency use

B)The family must observe the child for dehydration

C)Parents should administer the daily intramuscular injections

D) The client needs to take daily injections in the short-term

The correct answer is A: The child should carry a nasal spray for emergency use

Diabetes insipidus results from reduced secretion of the antidiuretic hormone, vasopressin. The child will need to administer daily injections of vasopressin, and should have the nasal spray form of the medication readily available. A medical alert tag should be worn.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

37. The nurse administers cimetidine (Tagamet) to a 79 year-old male with a gastric ulcer. Which parameter may be affected by this drug, and should be closely monitored by the nurse?

A)Blood pressure

B)Liver function

C) Mental status

D) Hemoglobin

The correct answer is C: Mental status

The elderly are at risk for developing confusion when taking cimetidine, a drug that interacts with many other medications.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

38. The nurse has just received report on a group of clients and plans to delegate care of several of the clients to a practical nurse (PN). The first thing the RN should do before the delegation of care is

A)Provide a time-frame for the completion of the client care

B)Assure the PN that the RN will be available for assistance

C)Ask about prior experience with similar clients

D) Review the specific procedures unique to the assignment

The correct answer is C: Ask about prior experience with similar clients

The first step in delegation is to determine the qualifications of the person to whom one is delegating. By asking about the PN''s prior experience with similar clients/tasks, the RN can determine whether the PN has the requisite experience to care for the assigned clients

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

39. A nurse is assigned to care for a comatose diabetic on IV insulin therapy. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?

A) Check the client's level of consciousness

B Obtain the regular blood glucose readings

C) Determine if special skin care is needed

D) Answer questions from the client's spouse about the plan of care

The correct answer is B: Obtain the regular blood glucose readings

The UAP can safely obtain blood glucose readings, which are routine tasks.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

40. A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? "Take Fosamax

A) on an empty stomach."

B) after meals."

C) with calcium."

D) with milk 2 hours after meals."

The correct answer is A: on an empty stomach."

Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must also be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

October is Breast Awareness Month

noreply@blogger.com (RegisteredNurseTech) — Mon, 15 Oct 2007 14:20:00 +0000

Mammograms are the best method to detect breast cancer early. If you are age 40 years or older, get a mammogram every one to two years.

Breast cancer is the most common cause of death from cancer among Hispanic women and the second most common cause of death from cancer among white, black, Asian/Pacific Islander, and American Indian/Alaska Native women.

Ways You Can Help Lower Your Risk of Breast Cancer

• Control your weight and exercise. Make healthy choices in the foods you eat and the kinds of drinks you have each day. Stay active.

• Know your family history of breast cancer. If you have a mother, sister, or daughter with breast cancer, ask your doctor what is your risk of getting breast cancer and how you can lower your risk.

• Find out the risks and benefits of hormone replacement therapy on developing breast cancer. Some women use hormone replacement therapy (HRT) to treat the symptoms of menopause. Ask your doctor about the risks and benefits of HRT and find out if hormone replacement therapy is right for you.

• Limit the amount of alcohol you drink.

Screening and Early Detection

Breast cancer screening means checking a woman’s breast for cancer before there are signs or symptoms of the disease. Three main tests are used to screen the breast for cancer. Talk to your doctor about which tests are right for you, and when you should have them.

Mammogram. A mammogram is an X-ray of the breast. Mammograms are the best method to detect breast cancer early when it is easier to treat and before it is big enough to feel or cause symptoms. Having regular mammograms can lower the risk of dying from breast cancer. If you are age 40 years or older, be sure to have a screening mammogram every one to two years.

Clinical breast exam. A clinical breast exam is an examination by a doctor or nurse, who uses his or her hands to feel for lumps or other changes.

Breast self-exam. A breast self-exam is when you check your own breasts for lumps, changes in size or shape of the breast, or any other changes in the breasts or underarm (armpit).

Which tests to choose: Having a clinical breast exam or a breast self-exam has not been found to decrease risk of dying from breast cancer. Keep in mind that, at this time, the best way to find breast cancer is with a mammogram. If you choose to have clinical breast exams and to perform breast self-exams, be sure you also get regular mammograms.

October 19, 2007 Is National Mammography Day

As part of National Breast Cancer Awareness Month, the third Friday in October each year is designated as National Mammography Day, to remind women to get a mammogram every one to two years.

On National Mammography Day and throughout National Breast Cancer Awareness Month, women are encouraged to make an appointment to get a mammogram if they have not had one. In honor of National Mammography Day, many accredited mammography facilities will offer free or low -cost mammograms.

Community Health Nursing

noreply@blogger.com (RegisteredNurseTech) — Sun, 14 Oct 2007 21:26:00 +0000

Before, I was helping my sister in her community health nursing; she wants detailed information about the phases of Community health nursing. I tried searching the internet but I can’t find them. So, I just told her about what I know about that. I t is not detailed but It helped her.

Goal: the community will be self reliant regarding health needs

The Community has 5 phases include:

1. Pre- entry

- Investigation of peace and order of the place

- Community must composed of poor family

- Courtesy call to Mayor and Local Unit(Barangay)

- Only one organization per local unit to avoid conflict between the 2 organizations

2. Entry/Integration

- Students live in their respective foster parent

- Live the lifestyle of your foster family

- Help your family in their work like farming, student is supposed to do what the family are doing

- Attend occasions in the community like wedding, feast, birthday, and other

-Home visit (student can standby in community’s small store because that’s the place where one can mostly find the community people)

3. Core Group formation

- List of responsible people in the community

- Voting of candidates for Group formation who will take over the community’s needs when the student nurse leave the community

- Formation of second group so, second group can take over the community’s need when the first group is not available

4. Strengthening and Maintenance

-Leadership training for the 2 groups

5. Phase out

- Student nurses leave the community because they are already self reliant

- It usually takes from 2 to 3 years

Life is short

noreply@blogger.com (RegisteredNurseTech) — Sun, 14 Oct 2007 21:16:00 +0000

I was studying when my friend in MRLRC texted me and told me that one of our friends died because of leptospirosis, according to her it happened so fast that he went into coma then died. I was shocked and felt week when I received her text message because my friend was healthy, he doesn’t smoke and he has a monstrous stamina in playing basketball. I don’t know what happened to him, perhaps because of the continuous rain and typhoon; he was infected through exposure into rat’s urine and feces. That time, I can’t really believe that his life ended that way. I realized that life is really unpredictable and felt scared because I thought what if it happened to me. I don’t want to think that way but It captured my imagination, I lied down and think of many things. Personally, Im not yet ready because I still have mouths to feed and I also want to help many people especially my family and relatives.

Umbilical Cord Blood Banking

noreply@blogger.com (RegisteredNurseTech) — Fri, 12 Oct 2007 14:48:00 +0000

Have you heard of umbilical cord blood banking?
I heard these from a discussion in a television and research it in the internet for clarification

Before birth, cord is the lifeline of the child inside the womb, it provides nutrient and transports oxygen.After delivery, the cord and placenta are no use and often discarded but recent research found out that the blood remaining in the cord and placenta are rich with blood forming cells (stem cells). These healthy cells can be collected and stored so they can be used in treatment of patient with serious illness like leukemia, lymphoma and other inherited diseases.They are encouraging cord donation from different races and ethnic backgrounds so every race can find their match and also because of numerous medical benefits.
They can be obtained from self and donor either within your family or other family as long as one found their match.Umbilical cord blood banking provides one an insurance because one have a piece of mind because of the availability of valuable resources when one needs it. Ethical dilemma is one of the problem because couples tend to bear another child for the access to blood forming cells. This is stored in a specialized equipment,the initial fee range from $900 to $1200, and annual storage fee is approximately $100. If one doesnt want to preserve their child's cord blood they can donate it to foundations, non profit organizations, and medical institutions to help other people and there are no cost to you.

CGFNS review

noreply@blogger.com (RegisteredNurseTech) — Fri, 12 Oct 2007 13:55:00 +0000

I had my review for CGFNS in Marlon Ray Labagnoy Review Center in Baguio, I met so many friends from review center and my dorm. Baguio is a good place for me because of the low temperature which is conducive for studying. When I arrived in my dorm in Baguio, my dorm was so quiet that I can hear ringing sound in my ear and my dormmate's were not yet there. I texted my friend from Manila who know some place in Baguio where I can hang out, that time I went to Nevada square and grab some drinks alone then immediately went home after 12 am. In my dorm I saw my dormmate and he was not a guy who am i expecting to be a dormmate because he is gay, I didnt encounter any problem with him because he is a nice guy. When sleeping, I always wear pajama, socks, and cap because I has a little intolerance to cold temp. My place in baguio is 5 minutes walk from review center, I think my calves increased in size when I was there because of many upward slopes. After a month, I transferred into a single room to enjoy my privacy, Im not saying that I didnt enjoy my privacy with my roommate what Im saying is that having my own room is much better.I had two relationship, they were my review mate in baguio.Unfortunately, none of them last. In my first month, I already gain many friends, they are mostly from the Northern part of Luzon like Pangansinan, Ilocos Norte and etc. Every week I played basketball with my friends versus MRLRC staff and I also hang out with them partying and drinking. My time there was balance I study and hang out if Im knowledge overload. In my second month, I was more serious and focus in studying compared to my first month. My first month was more on exploration of Baguio. I also had friends who were in high school level, when I was with them Im always the oldest. My friends from manila mark and jeff also visited me, how thoughtful. We drink alcohol named LETHAL INJECTION in Nevada square and meet some friends, I only remember DESZAH because she is the kindest among the other, then they left after 1 day.In MRLRC, I also met 5 schoolmates. I never met them in FEU and only some of them are familiar, I know them more in the review. What interesting is Mr Labagnoy give prizes whoever top his exams every last day of review program(intensive, course, final coaching, crash review). I sometimes top his exam but unfortunately it was not in the last day of his program.

In Ambassador hotel in Manila,In our CRASH REVIEW I received what Im waiting for. In our pre examination for CGFNS I top his exam and its not just top. Im their top 1 and I received 5000 pesos. That time I was really anxious because tomorrow is my examination, When Im taking exams I always prepare myself for whatever happens and plan ahead of time. I already have plans if I fail and if I passed. I was anxious because I cant fail my exam because of my expenses in CGFNS application, in review center and my cost of living in baguio. Being top 1 in sir Labagnoy's pre examination somehow gave me some relief.

When I took my CGFNS, I passed it with a score of close to 495. The score doesnt matter, what important is I passed it.