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Health Promotion and Maintenance Questions are numbered by the order in which they appeared in the test.

* Represents the correct answer. Question 1 The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning?

A) Performance on written testsB) Responses to verbal questionsC) Completion of a mailed surveyD) Reported behavioral changes

Review Information: The correct answer is D: Reported behavioral changesIf the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.

Question 2 The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?

A) April 8B) January 15C) February 11D) December 23

Review Information: The correct answer is D: December 23Naegele''s rule states: Add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

Question 3 The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?

A) Focus on the child's needs and recoveryB) Explain the cause of the child's illness

C) Acknowledge that early care would have been better

D) Accept their feelings without judgment

Review Information: The correct answer is D: Accept their feelings without judgmentParents often blame themselves for their child''s illness. Feeling helpless and angry is normal and these feelings must be accepted.

Question 4 When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?

A) Competitive board games with older children

B) Playing with their own toys along side with other children

C) Playing alone with hand held computer games

D) Playing cooperatively with other preschoolers

Review Information: The correct answer is D: Playing cooperatively with other preschoolersCooperative play is typical of the late preschool period.

Question 5 A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?

A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room

B) Ask the client if there are second thoughts about having the procedure

C) Notify the anesthesia department and the surgeon of the client's refusal

D) Ask the client if the preference would be to remove the dentures in the operating room receiving area

Review Information: The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving areaClients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept.Question 6 When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?

A) Provide a verbal explanation just prior to the surgery

B) Provide the child with a booklet to read about the surgery

C) Introduce the child to another child who had heart surgery 3 days ago

D) Explain the surgery using a model of the heart

Review Information: The correct answer is D: Explain the surgery using a model of the heartAccording to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery.

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Question 7 When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?

A) Prenatally on ultrasoundB) In early infancyC) When the child begins to bear weightD) During the preadolescent growth spurt

Review Information: The correct answer is D: During the preadolescent growth spurtIdiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males.

Question 8 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?

A) "Good morning. Do you remember where you are?"

B) "Hello. My name is Elaine Jones and I am your nurse for today."

C) "How are you today? Remember, you're in the hospital."

D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones."

Review Information: The correct answer is D: "Good morning. You’re in the hospital. I am your nurse Elaine Jones."As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location and the caregiver’s name.

Question 9 The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?

A) Hold a rattleB) Bang two blocksC) Drink from a cupD) Wave "bye-bye"

Review Information: The correct answer is A: Hold a rattleThe age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.

Question 10 An appropriate treatment goal for a client with anxiety would be to

A) ventilate anxious feelings to the nurseB) establish contact with realityC) learn self-help techniquesD) become desensitized to past trauma

Review Information: The correct answer is C: learn self-help techniquesExploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn self-help techniques will assist in learning to cope with anxiety.

Question 11 The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children?

A) Growth problems will occur if the fracture involves the periosteum

B) Epiphyseal fractures often interrupt a child's normal growth pattern

C) Children usually heal very quickly, so growth problems are rare

D) Adequate blood supply to the bone prevents growth delay after fractures

Review Information: The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth patternThe epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it can interrupt and alter growth.

Question 12 While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform?

A) Measure the length of the massB) Auscultate the massC) Percuss the massD) Palpate the mass

Review Information: The correct answer is B: Auscultate the massAuscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture.

Question 13 While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following

3responses by the nurse would be best?

A) "That's OK, its all right to skip your medication now and then."

B) "I will have to call your doctor and report this."

C) "Is there a reason why you don't want to take your medicine?"

D) "Do you understand the consequences of refusing your prescribed treatment?"

Review Information: The correct answer is C: "Is there a reason why you don''t want to take your medicine?"When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Question 14 The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?

A) Formula or breast milkB) Dilute nonfat dry milkC) Warmed fruit juiceD) Fluoridated tap water

Review Information: The correct answer is A: Formula or breast milkFormula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.

Question 15 A client states, "People think I’m no good, you know what I mean?" Which of these responses

would be most therapeutic?

A) "Well people often take their own feelings of inadequacy out on others."

B) "I think you’re good. So you see, there’s one person who likes you."

C) "I’m not sure what you mean. Tell me a bit more about that."

D) "Let's discuss this to see the reasons you create this impression on people."

Review Information: The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that."This therapeutic communication technique elicits more information, especially when delivered in an open, non-judgmental fashion.

Question 16 When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?

A) BiofeedbackB) Deep breathingC) DistractionD) Imagery

Review Information: The correct answer is B: Deep breathingDeep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.

Question 17 The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?

A) Hold and cuddle the child frequently

B) Encourage the child to feed himself finger food

C) Allow the child to walk independently on the nursing unit

D) Engage the child in games with other children

Review Information: The correct answer is B: Encourage the child to feed himself finger foodAccording to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.

Question 18 A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis?

A) Noncompliance related to medication side effects

B) Knowledge deficit related to misunderstanding of disease state

C) Defensive coping related to chronic illness

D) Altered health maintenance related to occupation

Review Information: The correct answer is A: Noncompliance related to medication side effectsThe client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.

Question 19

4A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?

A) Discharge the client from home health care because of noncompliance

B) Notify the provider of the client's failure to follow prescribed diet

C) Discuss diet with the client to learn the reasons for not following the diet

D) Make a referral to Meals-on-Wheels

Review Information: The correct answer is C: Discuss diet with the client to learn the reasons for not following the dietWhen new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client''s behavior and feelings as a basis for future teaching and intervention.Question 20 A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that

A) such fantasies can gratify unconscious wishes or prepare for anticipated future events

B) detaching or dissociating in this way postpones painful feelings

C) converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership

D) isolating the feelings in this way reduces conflict within the client and with others

Review Information: The correct answer is A: such fantasies can gratify unconscious wishes or prepare for anticipated future eventsFantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.

Q&A-Delegation Questions are numbered by the order in which they appeared in the test.

* Represents the correct answer. Question 1 Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection?

A) "Have the client sit on the side of the bed before helping the client to walk."

B) "If the client is dizzy ask the client to take some slow, deep breaths."

C) "Help the client to walk in the room as often as the client wishes."

D) "When you help the client to walk, ask if any pain occurs."

Review Information: The correct answer is A: "Have the client sit on the side of the bed before helping the client to walk."This statement gives clear directions to the UAP about the task and is most closely associated with the information provided in the stem that this is the client''s first time out of bed after surgery.

Question 2 The home care nurse has been managing a client for 6 weeks. What is the best method to

determine the quality of care provided by a home health care aide assigned to assist with the care of this client?

A) Ask the client and family if they are satisfied with the care given

B) Determine if the home health aide's care is consistent with the plan of care

C) Investigate if the home health aide is prompt and stays an appropriate length of time for care

D) Check the documentation of the aide for appropriateness and comprehensiveness

Review Information: The correct answer is B: Determine if the home health aide''s care is consistent with the plan of careAlthough the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider''s orders, the initial nursing assessment, the client’s responses to the planned interventions, and the client''s and family''s feedback or inquires. The other possible answers represent aspects of accomplishing “B”.

Question 3 Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?

A) Assess and document skin turgor and color changes

B) Test stool for occult blood and urine for glucose and report results

C) Suggest foods high in iron and those easily consumed

D) Report mental status changes and the degree of mental clarity

Review Information: The correct answer is B: Test stool for occult blood and urine for glucose and report resultsThe UAP can do standard, unchanging procedures that require no decision making.

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Question 4 The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?

A) A client with peripheral vascular disease and an ulceration of the lower leg.

B) A pre-operative client awaiting adrenalectomy with a history of asthma

C) An elderly client with hypertension and self-reported non-compliance

D) A new admission with a history of transient ischemic attacks and dizziness

Review Information: The correct answer is A: A client with peripheral vascular disease and an ulceration of the lower leg.This client is stable with no risk of instability as compared to the other clients. And this client has a chronic condition, needs supportive care.

Question 5 A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate?

A) A client admitted with multiple trauma with a history of a newly implanted pacemaker

B) A new admission with left-sided weakness from a stroke and mild confusion

C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction

D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident

Review Information: The correct answer is D: A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accidentThis client is the most stable with a predictable outcome.

Question 6 The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most immediately accurate?

A) The RN has no accountability for this situation

B) The RN did not delegate appropriatelyC) The UAP is covered by the RN’s license

D) The UAP is responsible for following instructions

Review Information: The correct answer is D: The UAP is responsible for following instructionsThe UAP is responsible for carrying out the activity correctly once directions have been clearly communicated especially if given verbally and in writing.

Question 7 As the RN responsible for a client in isolation, which can be delegated to the practical nurse (PN)?

A) Reinforcement of isolation precautions

B) Assessment of the client's attitude about infection control

C) Evaluation of staffs' compliance with control measures

D) Observation of the client's total environment for risks

Review Information: The correct answer is A: Reinforcement of isolation precautionsPNs and UAPs can reinforce information that was originally given by the RN.

Question 8 A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?

A) Unlicensed assistive personnel (UAP)B) Senior nursing studentC) PND) RN

Review Information: The correct answer is D: RNThe RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to the others listed.

Question 9 The charge nurse on a cardiac step-down unit makes assignments for the team consisting of a registered nurse (RN), a practical nurse (PN), and an unlicensed assistive personnel (UAP). Which client should be assigned to the PN?

A) A 49 year-old with new onset atrial

6fibrillation with a rapid ventricular response

B) A 58 year-old hypertensive with possible angina

C) A 35 year-old scheduled for cardiac catheterization

D) A 65 year-old for discharge after angioplasty and stent placement

Review Information: The correct answer is B: A 58 year-old hypertensive with possible anginaThis is the most stable client. The clients in options C and D require initial teaching. The client in option A is considered unstable since the dysrhythmia is a new onset.

Question 10 The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to?

A) Practical nurse (PN)B) Registered Nurse (RN)C) Unlicensed assistive personnel (UAP)D) Volunteer

Review Information: The correct answer is C: Unlicensed assistive personnel (UAP)The measurement and recording of vital signs may be delegated to UAP. This falls under the umbrella of routine task with stable clients. Other considerations for delegation of care to UAP would be: Who is capable and is the least expensive worker to do each task?

Question 11 Which of these clients would be appropriate to assign to a practical nurse (PN)?

A) A trauma victim with multiple lacerations and requires complex dressings

B) An elderly client with cystitis and an indwelling urethral catheter

C) A confused client whose family complains about the nursing care 2 days after surgery

D) A client admitted for possible transient ischemic attack with unstable neurological signs

Review Information: The correct answer is B: An elderly client with cystitis and an indwelling urethral catheterThis is a stable client, with predictable outcome and care and minimal risk for complications.

Question 12 Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?

A) Assist with plans for any clients discharged

B) Provide basic hygiene care to all clients on the unit

C) Assess a client after an acute myocardial infarction

D) Gather the vital signs of all clients on the unit

Review Information: The correct answer is B: Provide basic hygiene care to all clients on the unitBasic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.

Question 13 A staff nurse complains to the nurse manager

that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?

A) "I will arrange for a conference with you and the UAP within the next week"

B) "I can assure you that I will look into the matter"

C) "I would like for you to approach the UAP about the problem the next time it occurs"

D) I will add this concern to the agenda for the next unit meeting

Review Information: The correct answer is C: "I would like for you to approach the UAP about the problem the next time it occurs"Helping staff manage conflict is part of the manager''s role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager''s intervention when possible.

Question 14 A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)?

A) Teach the client how to cough up secretions

B) Changes the tracheostomy trach tiesC) Monitor if client has shortness of breathD) Perform routine tracheostomy dressing

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Review Information: The correct answer is D: Perform routine tracheostomy dressing careUnlicensed assistive personnel should be able to perform routine tracheostomy care.

Question 15 An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse?

A) A newly diagnosed client with type 2 diabetes mellitus who is learning foot care

B) A client from a motor vehicle accident with an external fixation device on the leg

C) A client admitted for a barium swallow after a transient ischemic attack

D) A newly admitted client with a diagnosis of pancreatic cancer

Review Information: The correct answer is B: A client from a motor vehicle accident with an external fixation device on the legThis client is the most stable, requires basic safety measures and has a predictable outcome.

Question 16 The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate?

A) "Tell the family they can bring in a pizza if the patient would prefer that."

B) "Make sure the patient gets at least 2 cartons of milk."

C) "Stop the IV if the patient is able to eat solid

food."

D) "Encourage the patient to eat slowly to prevent gas."

Review Information: The correct answer is D: "Encourage the patient to eat slowly to prevent gas."The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the task and how to promote the best outcome.

Question 17 Which one of these tasks can be safely delegated to a practical nurse (PN)?

A) Assess the function of a newly created ileostomy

B) Care for a client with a recent complicated double barrel colostomy

C) Provide stoma care for a client with a well functioning ostomy

D) Teach ostomy care to a client and their family members

Review Information: The correct answer is C: Provide stoma care for a client with a well functioning ostomyThe care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. This client has minimal risk of instability of the situation.

Question 18 An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions?

A) "How long have you been a UAP?”B) "What type of care did you give in

pediatrics?”

C) "Do you have your competency checklist that we can review?”

D) "How comfortable are you to care for adult clients?”

Review Information: The correct answer is C: "Do you have your competency checklist that we can review?”The UAP must be competent to accept the delegated task. Further assessment of the qualifications of the UAP is important in order to assign the right task.

Question 19 During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?

A) "What degree of supervision for basic care do you think you need?"

B) "Let’s review your skills check-list for type and level of skill"

C) "Are you comfortable working independently?"

D) "What client care tasks or assignments do you prefer?"

Review Information: The correct answer is B: "Let’s review your skills check-list for type and level of skill"The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills.

Question 20 A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor?

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A) Provide decubitus ulcer care and apply a dry dressing

B) Bathe and feed a client on bed rest

C) Oral suctioning of an unresponsive elderly client

D) Teaching a family intermittent (bolus) feedings via G-tube before discharge

Review Information: The correct answer is D: Teaching a family intermittent (bolus) feedings via G-tube before dischargeInitial teaching can not be delegated to a UAP or a PN and must be done by RNs.

Question 21 Which of these clients would be most appropriate to assign to a practical nurse (PN)?

A) A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection

B) A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia

C) A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation

D) A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure

Review Information: The correct answer is C: A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitationThis client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability.

Question 22 The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a

musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?

A) Report signs of redness overlying a joint

B) Monitor the client's response to ambulatory activity

C) Encouragement for the independence in self-care

D) Assist the client to transfer from a bed to a chair

Review Information: The correct answer is B: Monitor the client''s response to ambulatory activityMonitoring the client’s response to interventions requires assessment, a task to be performed by an RN.

Question 23 When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?

A) "If we work together we can get all of the client care completed."

B) "Since I am late for lunch, would you do this one client's glucose test?"

C) "This client seems confused, we need to watch monitor closely."

D) "I’ll come back and make the bed after I go to the lab."

Review Information: The correct answer is B: "Since I am late for lunch, would you do this one client''s glucose test?"Only the RN and PN can delegate to UAPs. One UAP can not delegate a task to another UAP. The RN or PN is legally accountable for the nursing care.

Question 24 A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?

A) Ask the client the degree of relief and document the client’s response

B) Decrease the set rate on the pump by 2 ml/minute

C) Check the IV site for drainage and loose tape

D) Assist the client with ambulation and a gown change with supervision

Review Information: The correct answer is D: Assist the client with ambulation and a gown change with supervisionWhen directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be delegated since they do not require independent judgment.

Question 25 Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?

A) "The client has complaints of not sleeping well for the past week"

B) "The family wants to discontinue the home meal service, meals on wheels"

C) "The urine in the urinary catheter bag is of

9a deeper amber, almost brown color"

D) "The partner says the client has slower days every other day"

Review Information: The correct answer is C: "The urine in the urinary catheter bag is of a deeper amber, almost brown color"Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation.

Q&A-Priority Questions are numbered by the order in which they appeared in the test. * Represents the correct answer.

Question 1 The nurse must know that the most accurate oxygen delivery system available is

A) the Venturi maskB) nasal cannulaC) partial non-rebreather maskD) simple face mask

Review Information: The correct answer is A: the Venturi maskThe most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client’s respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%.

Question 2 A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to

A) begin decontamination procedures for the client

B) ensure physiologic stability of the client

C) wrap the client in blankets to minimize staff contamination

D) double bag the client’s contaminated clothing

Review Information: The correct answer is B: ensure physiologic stability of the clientThe nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination.

Question 3 The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?

A) Elevate the foot of the bedB) Apply knee high support stockingsC) Encourage passive exercisesD) Prevent pressure at back of knees

Review Information: The correct answer is D: Prevent pressure at back of kneesPreventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.

Question 4 If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?

A) Obtain emergency equipmentB) Assess heart rate, rhythm and all pulsesC) Apply pressure to the vessel insertion siteD) Use cold packs at the exit incision site

Review Information: The correct answer is C: Apply pressure to the vessel insertion siteIf a central venous catheter is accidentally removed, pressure should be applied to the vein entry site.

Question 5 The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?

A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery

B) 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning

C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days

D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery

Review Information: The correct answer is C: 3

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days post partum, temperature of 100.8 degrees Fahrenheit the past 2 daysA temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection.

Question 6 The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is

A) reconnect the tube

B) raise the collection chamber above the client's chest

C) call the health care providerD) clamp the chest tube

Review Information: The correct answer is D: clamp the chest tubeImmediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client’s chest is the first action to take, followed by health care provider notification.

Question 7 A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is appropriate reinforcement of information by the nurse?

A) "Drink at least 8 glasses of water a day."B) "Be sure to take the medication with food."C) "It is safe to take with oral contraceptives."D) "Stop the medication after 5 days."

Review Information: The correct answer is A: "Drink at least 8 glasses of water a day."

Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim.

Question 8 A client calls the evening health clinic to state “I know I have a severely low sugar since the Lantus insulin was given 3 hours ago and it peaks in 2 hours.” What should be the nurse’s initial response to the client?

A) What else do you know about this type of insulin?

B) What are you feeling at this moment?C) Have you eaten anything today?

D) Are you taking any other insulin or medication?

Review Information: The correct answer is B: What are you feeling at this moment?When a client has changed from stable to unstable, the nurse’s initial response should be to do further assessment of the client.

Question 9 The nurse is caring for a client who is receiving total parenteral nutrition (TPN) (hyperalimentation and lipids). What is the priority nursing action on every 8 hour shift?

A) Monitor blood pressure, temperature and weight

B) Change the tubing under sterile conditions

C) Check urine glucose, acetone and specific gravity

D) Adjust the infusion rate to provide for total volume

Review Information: The correct answer is C: Check urine glucose, acetone and specific gravityBecause of the high dextrose and protein content in parenteral nutrition, the nurse should assess the urine at least every 8 hours.

Question 10 The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman following the birth of an Rh positive baby. Which assessment is a priority before the nurse gives the injection?

A) Newborn's blood typeB) Coombs' test resultsC) Previous RhoGAM historyD) Gravida and parity

Review Information: The correct answer is B: Coombs'' test resultsRh (D) immune globulin (RhoGAM) is given only if antibody formation has not occurred. A negative Coombs'' test confirms this.

Question 11 A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?

A) foul smelling urineB) burning on urinationC) elevated temperatureD) nausea and anorexia

Review Information: The correct answer is C: elevated temperatureElevated temperature after 72 hours on an

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antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented. Options A and B are expected with cystitis. Option D may be related to the antibiotics as a side effect and should also be reported to the provider.

Question 12 The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism following treatment for chronic renal disease. Which of the following lab data should receive priority attention?

A) Calcium and phosphorus levelsB) Blood sugarC) Urine specific gravityD) Blood urea nitrogen

Review Information: The correct answer is A: Calcium and phosphorus levelsCalcium and phosphorous levels will be elevated until the client is stabilized.

Question 13 When caring for a client with urinary incontinence, which content should be reinforced by the nurse?

A) hold the urine to increase bladder capacityB) avoid eating foods high in sodium

C) restrict fluid to prevent elimination accidents

D) avoid taking antihistamines

Review Information: The correct answer is D: avoid taking antihistaminesAntihistamines can aggravate urinary

incontinence and should be avoided by these clients. Holding the urine, avoiding sodium, and restricting fluids have not been shown to reduce urinary incontinence.

Question 14 A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to

A) maintain fluid and electrolyte balanceB) manage post-operative painC) ambulate the client within 1 hour of surgeryD) control bladder spasms

Review Information: The correct answer is B: manage post-operative painDue to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.

Question 15 A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be

A) elevate the arm no higher than heart levelB) remove the cast

C) assess capillary refill of the exposed hand and fingers

D) apply a warm soak to the hand

Review Information: The correct answer is C: assess capillary refill of the exposed hand and fingersA deterioration in neurovascular status indicates

the development of compartment syndrome (elevated tissue pressure within a confined area) which requires immediate pressure-reducing interventions.

Question 16 A client is 2 days post operative. The vital signs are: BP - 120/70, HR -- 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?

A) Heart rateB) Respiratory rateC) Blood pressureD) Temperature

Review Information: The correct answer is B: Respiratory rateTachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.

Question 17 A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the nurse prior to the procedure is

A) time of the client's last mealB) client's allergy historyC) assessment of the peripheral pulsesD) results of the blood coagulation studies

Review Information: The correct answer is B: client''s allergy historyIntravenous Pyelogram is a dye study that uses an iodine-based contract. Therefore, the study is contraindicated in clients with allergy to iodine.

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Question 18 What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)?

A) Symptom relief occurs in a few daysB) Alcohol use is to be avoided

C) Medication must be stored in the refrigerator

D) Episodes of diarrhea can be expected

Review Information: The correct answer is B: Alcohol use is to be avoidedAlcohol potentiates the action of tricyclic antidepressants.

Question 19 Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?

A) Measure the vital signsB) Palpate the abdomenC) Assess for breath soundsD) Verify tube patency

Review Information: The correct answer is D: Verify tube patencyTube patency should be checked prior to all feedings. The feeding should not be attempted if the tube is not patent.

Question 20 The nurse is caring for a client with a vascular

access for hemodialysis. Which of these findings necessitates immediate action by the nurse?

A) pruritic rashB) dry, hacking coughC) chronic fatigueD) elevated temperature

Review Information: The correct answer is D: elevated temperatureIt is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature. The other findings should be reported to the provider as well.

Question 21 The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?

A) Gum bleedingB) Lung soundsC) Homan's signD) Generalized weakness

Review Information: The correct answer is A: Gum bleedingThe prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients.

Question 22

The registered nurse (RN) is making decisions regarding client room assignments on a pediatric unit. Which possible roommate would be most appropriate for a 3 year-old child with minimal change nephrotic syndrome?

A) 2 year-old with respiratory infection

B) 3 year-old fracture whose sibling has chickenpox

C) 4 year-old with bilateral inguinal hernia repair

D) 6 year-old with a sickle cell anemia crisis

Review Information: The correct answer is C: 4 year-old with bilateral inguinal hernia repairThe nurse must know that children with nephrotic syndrome are at high risk for development of infections as a result of the standard use of immunosuppressant therapy, as well as from the accumulation of fluid (edema). Therefore, these children must be protected from sources of possible infection. D is incorrect because the sickle cell crisis is potentially due to an infectious process.

Question 23 The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?

A) Administer calcium gluconateB) Call the provider immediatelyC) Discontinue the magnesium sulfateD) Perform additional assessments

Review Information: The correct answer is C: Discontinue the magnesium sulfateThe assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.

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Question 24 A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?

A) Repeat glycohemoglobin in 24 hours

B) Document Accu-checks, intake and output every 4 hours

C) Humulin N 20 units IV push

D) IV fluids of 0.9% normal saline at 125 ml per hour

Review Information: The correct answer is C: Humulin N 20 units IV pushRegular insulin is the only insulin that can be given by the intravenous route. This is the initial order to question. Option A should also be questioned, although it is not a priority since the client would not be harmed by this action. This lab test gives the average glucose on the hemoglobin molecule for the past 2 to 3 months. There would be no need to repeat it at this time. A fasting glucose in the morning would be a more appropriate assessment. The other orders are within expected actions in this situation.

Question 25 The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately?

A) slight pink-tinged drainageB) abdominal discomfortC) muscle weaknessD) cloudy drainage

Review Information: The correct answer is D: cloudy drainageCloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis.

Q&A-Pharmacology Questions are numbered by the order in which they appeared in the test.

* Represents the correct answer. Question 1 A post-operative client has a prescription for acetaminophen with codeine. What should the nurse recognizes as a primary effect of this combination?

A) Enhanced pain reliefB) Minimized side effectsC) Prevention of drug toleranceD) Increased onset of action

Review Information: The correct answer is A: Enhanced pain reliefCombination of analgesics with different mechanisms of action can afford greater pain relief.

Question 2 A nurse is caring for a client who is receiving methyldopa hydrochloride (Aldomet) intravenously. Which of the following assessment findings would indicate to the nurse that the client may be having an adverse reaction to the medication?

A) HeadacheB) Mood changesC) HyperkalemiaD) Palpitations

Review Information: The correct answer is B: Mood changesThe nurse should assess the client for alterations in mental status such as mood changes. These symptoms should be reported promptly.

Question 3 When providing discharge teaching to a client with asthma, the nurse will warn against the use of which of the following over-the-counter medications?

A) Cortisone ointments for skin rashesB) Aspirin products for pain reliefC) Cough medications containing guaifenesinD) Histamine blockers for gastric distress

Review Information: The correct answer is B: Aspirin products for pain reliefAspirin is known to induce asthma attacks. Aspirin can also cause nasal polyps and rhinitis. Warn individuals with asthma about signs and symptoms resulting from complications due to aspirin ingestion.Question 4 The nurse practicing in a long term care facility recognizes that elderly clients are at greater risk for drug toxicity than younger adults because of which of the following physiological changes of advancing age?

A) Drugs are absorbed more readily from the GI tract

B) Elders have less body water and more fat

C) The elderly have more rapid hepatic metabolism

D) Older people are often malnourished and anemic

Review Information: The correct answer is B: Elders have less body water and more fatBecause elderly persons have decreased lean body tissue/water in which to distribute medications, more drug remains in the circulatory system with potential for drug toxicity. Increased body fat results in greater amounts of fat-soluble drugs being absorbed, leaving less in circulation, thus increasing the duration of action of the drug.

Question 5 In providing care for a client with pain from a sickle cell crisis, which one of the following

14medication orders for pain control should be questioned by the nurse?

A) DemerolB) MorphineC) MethadoneD) Codeine

Review Information: The correct answer is A: DemerolMeperidine is not recommended in clients with sickle cell disease. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Clients with sickle cell disease are particularly at risk for normeperidine-induced seizures.

Question 6 The nurse is administering diltiazem (Cardizem) to a client. Prior to administration, it is important for the nurse to assess which parameter?

A) TemperatureB) Blood pressureC) VisionD) Bowel sounds

Review Information: The correct answer is B: Blood pressureDiltiazem (Cardizem) is a calcium channel blocker that causes systemic vasodilation resulting in decreased blood pressure.

Question 7 A client with an aplastic sickle cell crisis is receiving a blood transfusion and begins to complain of "feeling hot." Almost immediately, the client begins to wheeze. What is the nurse's first action?

A) Stop the blood infusionB) Notify the health care providerC) Take/record vital signsD) Send blood samples to lab

Review Information: The correct answer is A: Stop the blood infusionIf a reaction of any type is suspected during administration of blood products, stop the infusion immediately, keep the line open with saline, notify the health care provider, monitor vital signs and other changes, and then send a blood sample to the lab.Question 8 A client with atrial fibrillation is receiving digoxin (Lanoxin). Which of these assessments is most important for the nurse to perform?

A) Monitor blood pressure every 4 hours

B) Measure apical pulse prior to administration

C) Maintain accurate intake and output records

D) Record an EKG strip after administration

Review Information: The correct answer is B: Measure apical pulse prior to administrationDigitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is less than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is.

Question 9 The nurse is caring for a 10 year-old client who will be placed on heparin therapy. Which assessment is critical for the nurse to make before initiating therapy

A) Vital signsB) WeightC) Lung soundsD) Skin turgor

Review Information: The correct answer is B: WeightCheck the client''s weight because dosage is calculated on the basis of weight.

Question 10 The use of atropine for treatment of symptomatic bradycardia is contraindicated for a client with which of the following conditions?

A) Urinary incontinenceB) GlaucomaC) Increased intracranial pressureD) Right sided heart failure

Review Information: The correct answer is B: GlaucomaAtropine is contraindicated in clients with angle-closure glaucoma because it can cause pupillary dilation with an increase in aqueous humor, leading to a resultant increase in optic pressure.

Question 11 The health care provider orders an IV aminophylline infusion at 30 mg/hr. The pharmacy sends a 1,000 ml bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, the RN will set the

15infusion rate at:

A) 20 ml per hourB) 30 ml per hourC) 50 ml per hourD) 60 ml per hour

Review Information: The correct answer is D: 60 ml per hourUsing the ratio method to calculate infusion rate: mg to be given (30) : ml to be infused (X) :: mg available (500) : ml of solution (1,000). Solve for X by cross-multiplying: 30 x 1,000 = 500 x X (or cancel), 30,000 = 500 X, X = 30,000/500, X = 60 ml per hour.

Question 12 The nurse is applying silver sulfadiazine (Silvadene) to a child with severe burns to arms and legs. Which side effect should the nurse be monitoring for?

A) Skin discolorationB) Hardened escharC) Increased neutrophilsD) Urine sulfa crystals

Review Information: The correct answer is D: Urine sulfa crystalsSilver sulfadiazine is a broad spectrum anti-microbial, especially effective against pseudomonas. When applied to extensive areas, however, it may cause a transient neutropenia, as well as renal function changes with sulfa crystals production and kernicterus.

Question 13 The nurse is caring for a client who is receiving procainamide (Pronestyl) intravenously. It is important for the nurse to monitor which of the following parameters?

A) Hourly urinary outputB) Serum potassium levels

C) Continuous EKG readingsD) Neurological signs

Review Information: The correct answer is C: Continuous EKG readingsProcainamide (Pronestyl) is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring by ECG.

Question 14 The nurse is teaching a parent how to administer oral iron supplements to a 2 year-old child. Which of the following interventions should be included in the teaching?

A) Stop the medication if the stools become tarry green

B) Give the medicine with orange juice and through a straw

C) Add the medicine to a bottle of formulaD) Administer the iron with your child's meals

Review Information: The correct answer is B: Give the medicine with orange juice and through a strawAbsorption of iron is facilitated in an environment rich in Vitamin C. Since liquid iron preparation will stain teeth, a straw is preferred.

Question 15 A client with bi-polar disorder is taking lithium (Lithane). What should the nurse emphasize when teaching about this medication?

A) Take the medication before mealsB) Maintain adequate daily salt intakeC) Reduce fluid intake to minimize diuresis

D) Use antacids to prevent heartburn

Review Information: The correct answer is B: Maintain adequate daily salt intakeSalt intake affects fluid volume, which can affect lithium (Lithane) levels; therefore, maintaining adequate salt intake is advised. edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 16 The nurse is assessing a 7 year-old after several days of treatment for a documented strep throat. Which of the following statements suggests that further teaching is needed?

A) "Sometimes I take my medicine with fruit juice."

B) "My mother makes me take my medicine right after school."

C) "Sometimes I take the pills in the morning and other times at night."

D) "I am feeling much better than I did last week."

Review Information: The correct answer is C: "Sometimes I take the pills in the morning and other times at night."Inconsistency in taking the prescribed medication indicates more teaching is needed.

Question 17 An elderly client is on an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease. The nurse would suggest a spacer to

A) enhance the administration of the

16medication

B) increase client compliance

C) improve aerosol delivery in clients who are not able to coordinate the MDI

D) prevent exacerbation of COPD

Review Information: The correct answer is C: improve aerosol delivery in clients who are not able to coordinate the MDISpacers improve the medication delivery in clients who are unable to coordinate the movements of administering a dose with an MDI.

Question 18 The nurse is providing education for a client with newly diagnosed tuberculosis. Which statement should be included in the information that is given to the client?

A) "Isolate yourself from others until you are finished taking your medication."

B) "Follow up with your primary care provider in 3 months."

C) "Continue to take your medications even when you are feeling fine."

D) "Continue to get yearly tuberculin skin tests."

Review Information: The correct answer is C: "Continue to take your medications even when you are feeling fine."The most important piece of information the tuberculosis client needs is to understand the importance of medication compliance, even if no longer experiencing symptoms. Clients are most infectious early in the course of therapy. The numbers of acid-fast bacilli are greatly reduced as early as 2 weeks after therapy begins.

Question 19

The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse's immediate action?

A) Stomatitis lesion in the mouthB) Severe nausea and vomitingC) Complaints of pain at site of infusionD) A rash on the client's extremities

Review Information: The correct answer is C: Complaints of pain at site of infusionA vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants which cause pain along the vein wall, with or without inflammation.

Question 20 The nurse is instructing a client with moderate persistent asthma on the proper method for using MDIs (multi-dose inhalers). Which medication should be administered first?

A) SteroidB) AnticholinergicC) Mast cell stabilizerD) Beta agonist

Review Information: The correct answer is D: Beta agonistThe beta-agonist drugs help to relieve bronchospasm by relaxing the smooth muscle of the airway. These drugs should be taken first so that other medications can reach the lungs.

Question 21 The nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which of the following over-the-counter medications should the nurse recognize as having the most elemental calcium per tablet?

A) Calcium chlorideB) Calcium citrateC) Calcium gluconateD) Calcium carbonate

Review Information: The correct answer is D: Calcium carbonateCalcium carbonate contains 400mg of elemental calcium in 1 gram of calcium carbonate.

Question 22 The provider has ordered daily high doses of aspirin for a client with rheumatoid arthritis. The nurse instructs the client to discontinue the medication and contact the provider if which of the following symptoms occur?

A) Infection of the gumsB) Diarrhea for more than one dayC) Numbness in the lower extremitiesD) Ringing in the ears

Review Information: The correct answer is D: Ringing in the earsAspirin stimulates the central nervous system which may result in ringing in the ears.

Question 23 A 5 year-old has been rushed to the emergency room several hours after acetaminophen poisoning. Which laboratory result should receive attention by the nurse?

A) Sedimentation rateB) Profile 2C) BilirubinD) Neutrophils

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Review Information: The correct answer is C: BilirubinBilirubin, along with liver enzymes ALT and AST, may rise in the second stage (1-3 days) after a significant overdose, indicating cellular necrosis and liver dysfunction. A prolonged prothrombin time may also be found.. (2nd edition). Mosby: St. Louis, Missouri.

Question 24 The nurse is caring for a client with schizophrenia who has been treated with quetiapine (Seroquel) for 1 month. Today the client is increasingly agitated and complains of muscle stiffness. Which of these findings should be reported to the health care provider?

A) Elevated temperature and sweating.B) Decreased pulse and blood pressure.C) Mental confusion and general weakness.D) Muscle spasms and seizures.

Review Information: The correct answer is A: Elevated temperature and sweating.Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increase in CPK. This is a life-threatening complication.

Question 25 A client is receiving dexamethasone (Decadron) therapy. What should the nurse plan to monitor in this client?

A) Urine output every 4 hoursB) Blood glucose levels every 12 hoursC) Neurological signs every 2 hoursD) Oxygen saturation every 8 hours

Review Information: The correct answer is B: Blood glucose levels every 12 hoursThe drug Decadron increases glycogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and acetone production must be monitored.

Question 26 The nurse is teaching a child and the family about the medication phenytoin (Dilantin) prescribed for seizure control. Which of the following side effects is most likely to occur?

A) VertigoB) DrowsinessC) Gingival hyperplasiaD) Vomiting

Review Information: The correct answer is C: Gingival hyperplasiaSwollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.

Question 27 A newly admitted client has a diagnosis of depression. She complains of “twitching muscles” and a “racing heart”, and states she stopped taking Zoloft a few days ago because it was not helping her depression. Instead, she began to take her partner's Parnate. The nurse should immediately assess for which of these adverse reactions?

A) Pulmonary edemaB) Atrial fibrillationC) Mental status changesD) Muscle weakness

Review Information: The correct answer is C: Mental status changesUse of serotonergic agents may result in Serotonin Syndrome with confusion, nausea, palpitations, increased muscle tone with twitching muscles, and agitation. Serotonin syndrome is most often reported in patients taking 2 or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve the MAOIs, SSRIs, and the tricyclic antidepressants.). Philadelphia: Saunders.

Question 28 A client has been receiving dexamethasone (Decadron) for control of cerebral edema. Which of the following assessments would indicate that the treatment is effective?

A) A positive Babinski's reflexB) Increased response to motor stimuliC) A widening pulse pressureD) Temperature of 37 degrees Celsius

Review Information: The correct answer is B: Increased response to motor stimuliDecadron is a corticosteroid that acts on the cell membrane to decrease inflammatory responses as well as stabilize the blood-brain barrier. Once Decadron reaches a therapeutic level, there should be a decrease in symptomology with improvement in motor skills.

Question 29 The nurse is assessing a client who is on long term glucocorticoid therapy. Which of the

18following findings would the nurse expect?

A) Buffalo humpB) Increased muscle massC) Peripheral edemaD) Jaundice

Review Information: The correct answer is A: Buffalo humpWith high doses of glucocorticoid, iatrogenic Cushing''s syndrome develops. The exaggerated physiological action causes abnormal fat distribution which results in a moon-shaped face, a intrascapular pad on the neck (buffalo hump) and truncal obesity with slender limbs.

Question 30 A client is ordered atropine to be administered preoperatively. Which physiological effect should the nurse monitor for?

A) Elevate blood pressureB) Drying up of secretionsC) Reduce heart rateD) Enhance sedation

Review Information: The correct answer is B: Drying up of secretionsAtropine dries secretions which may get in the way during the operative procedure.

Question 31 A client confides in the RN that a friend has told her the medication she takes for depression, Wellbutrin, was taken off the market because it caused seizures. What is an appropriate response by the nurse?

A) "Ask your friend about the source of this information."

B) "Omit the next doses until you talk with the doctor."

C) "There were problems, but the recommended dose is changed."

D) "Your health care provider knows the best drug for your condition."

Review Information: The correct answer is C: "There were problems, but the recommended dose is changed."Wellbutrin was introduced in the U.S. in 1985 and then withdrawn because of the occurrence of seizures in some patients taking the drug. The drug was reintroduced in 1989 with specific recommendations regarding dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with dose.

Question 32 A child presents to the Emergency Department with documented acetaminophen poisoning. In order to provide counseling and education for the parents, which principle must the nurse understand?

A) The problem occurs in stages with recovery within 12-24 hours

B) Hepatic problems may occur and may be life-threatening

C) Full and rapid recovery can be expected in most children

D) This poisoning is usually fatal, as no antidote is available

Review Information: The correct answer is B: Hepatic problems may occur and may be life-threateningClinical manifestations associated with acetaminophen poisoning occurs in 4 stages. The third stage is hepatic involvement which may last up to 7 days and be permanent. Clients who do not die in the hepatic stage gradually recover.

Question 33 A client is receiving digitalis. The nurse should instruct the client to report which of the following side effects?

A) Nausea, vomiting, fatigueB) Rash, dyspnea, edemaC) Polyuria, thirst, dry skinD) Hunger, dizziness, diaphoresis

Review Information: The correct answer is A: Nausea, vomiting, fatigueSide effects of digitalis toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digitalis inhibits the sodium potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output.

Question 34 The provider has ordered transdermal nitroglycerin patches for a client. Which of these instructions should be included when teaching a client about how to use the patches?

A) Remove the patch when swimming or bathing

B) Apply the patch to any non-hairy area of the body

C) Apply a second patch with chest painD) Remove the patch if ankle edema occurs

Review Information: The correct answer is B: Apply the patch to any non-hairy area of the bodyThe patch application sites should be rotated.Question 35 A pregnant woman is hospitalized for treatment of pregnancy induced hypertension (PIH) in the third trimester. She is receiving magnesium sulfate intravenously. The nurse understands that this medication is used mainly for what purpose?

A) Maintain normal blood pressureB) Prevent convulsive seizuresC) Decrease the respiratory rate

19D) Increase uterine blood flow

Review Information: The correct answer is B: Prevent convulsive seizuresMagnesium sulfate is a central nervous system depressant. While it has many systemic effects, it is used in the client with pregnancy induced hypertension (PIH) to prevent seizures.

Question 36 A client with anemia has a new prescription for ferrous sulfate. In teaching the client about diet and iron supplements, the nurse should emphasize that absorption of iron is enhanced if taken with which substance?

A) AcetaminophenB) Orange juiceC) Low fat milkD) An antacid

Review Information: The correct answer is B: Orange juiceAscorbic acid enhances the absorption of iron.Question 37 The health care provider has written "Morphine sulfate 2 mgs IV every 3-4 hours prn for pain" on the chart of a child weighing 22 lb. (10 kg). What is the nurse's initial action?

A) Check with the pharmacist

B) Hold the medication and contact the provider

C) Administer the prescribed dose as orderedD) Give the dose every 6-8 hours

Review Information: The correct answer is B: Hold the medication and contact the providerThe usual pediatric dose of morphine is 0.1 mg/kg every 3 to 4 hours. At 10 kg, this child typically should receive 1.0 mg every 3 to 4 hours.

Question 38 The nurse is monitoring a client receiving a thrombolytic agent, alteplase (Activase tissue plasminogen activator), for treatment of a myocardial infarction. What outcome indicates the client is receiving adequate therapy within the first hours of treatment?

A) Absence of a dysrhythmia (or arrhythmia)B) Blood pressure reductionC) Cardiac enzymes are within normal limitsD) Return of ST segment to baseline on ECG

Review Information: The correct answer is D: Return of ST segment to baseline on ECGImproved perfusion should result from this medication, along with the reduction of ST segment elevation.Question 39 A nurse is assigned to perform well-child assessments at a day care center. A staff member interrupts the examinations to ask for assistance. They find a crying 3 year-old child on the floor with mouth wide open and gums bleeding. Two unlabeled open bottles lie nearby. The nurse's first action should be

A) call the poison control center, then 911

B) administer syrup of Ipecac to induce vomiting

C) give the child milk to coat her stomach

D) ask the staff about the contents of the bottles

Review Information: The correct answer is D: ask the staff about the contents of the bottlesThe nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called.

Question 40 A client is receiving erythromycin 500mg IV every 6 hours to treat a pneumonia. Which of the following is the most common side effect of

the medication?

A) Blurred visionB) Nausea and vomitingC) Severe headacheD) Insomnia

Review Information: The correct answer is B: Nausea and vomitingNausea is a common side-effect of erythromycin in both oral and intravenous forms.