PREDICTOR TEST 2
Legal Nursing: 5 items
Prioritization/Triage: 5 items
Delegation: 6 items
Fundamentals: 10 items
Pedia: 15 items
Pharmacology: 18 items
Musculo: 5 items
Cardio: 9 items
Respi: 6 items
Endo: 5 items
Diet: 5 items
Psych: 8 items
Isolation/CD: 6 items
GI: 5 items
Renal; 7 items
Neuro: 6 items
Onco: 5 items
MCN: 6 items
Total: 132 items
- Which of the following reflects a true statement regarding informed consent?
a. Withdrawal of the consent should be written and signed by the patient’s witness.
b. Implied consent can be considered during emergency situations and when there is no one to give the consent.
c. Emancipated minor can not legally sign consent until he reaches the age of 18.
d. Withdrawal of consent must be ahead of time and should be approved by the physician.
RATIONALE: B. Withdrawal of consent can be done at any time even against the medical advice. Informed consent can be waived for urgent medical or surgical intervention as
long as institutional policy permits. A client has the right to refuse consent and undergo treatment, but this decision must be documented in the medical record. Emancipated minor can be considered legally capable of signing consent. Consents are not needed for emergency care if all of the following criteria are met:
- There is an immediate threat to life
- Experts agree that it is an emergency
- Client is unable to consent
- A legally authorized person can not be reached
(Saunders Comprehensive © 2005, p. 55-56/ NSNA © 2005, p 187)
- Which of the following constitute a breach of confidentiality?
a. A nurse telling the other nurse that the patient who had a fight with her is
about to be discharged.
b. Nurses in the cafeteria talking about the increase in the number of admission
of abused patients.
c. Nurses talking about the health management of the patients in the hallway.
d. A nurse observing the patient while the patient reads her chart.
RATIONALE: A. This choice involves a publication of embarrassing facts and public disclosure of private information between the client and the nurse. Sharing information to a third party with no direct involvement in the care of the client constitute breach of confidentiality. (Saunders Comprehensive © 2005, p. 56-57)
- 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 health care provider decides the family has a right to know the
d) When a visitor insists that the visitor has been given permission by the client
RATIONALE: 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. (Saunders Comprehensive © 2005, p. 56-57)
- A client is being treated for paranoid schizophrenia. When the client
became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
a) May result in charges of unlawful seclusion and restraint
b) Leaves the nurse vulnerable for charges of assault and battery
c) Was appropriate in view of the client's history of violence
d) Was necessary to maintain the therapeutic milieu of the unit
RATIONALE: A. May result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior to the staff, the other clients, or the client upon himself. (Saunders Comprehensive © 2005, p. 53)
- Which of the following situation constitute a false imprisonment?
a) A nurse placing antiskid pads on an agitated patient on wheelchair
b) A nurse secluding a wandering patient in a room
c) A nurse performing a procedure without consent
d) A nurse threatening to give a medication to a client who continues to be
RATIONALE: B. Seclusion should only be used when there is an immediate threat of violence or threatening behavior to the staff, the other clients, or the client upon himself. In the absence of this situation, seclusion may constitute to false imprisonment. (Saunders Comprehensive © 2005, p. 53)
1. The nurse has been assigned to these clients in the emergency room. Which client would the nurse go 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
RATIONALE: C. Tension pneumothorax with slight tracheal deviation to the right 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.
(Med-Surg by Black © 2005, p. 1905)
2. The nurse is working in an acute pediatric unit. One of the LPN’s has assessments on four postoperative clients. Which client requires the nurse’s most immediate attention?
a) An 18-month-old one day postoperative for cleft palate repair with a pulse of 120 beats per minute.
b) Possible peripheral IV infiltration (rate 50cc/hr) on a 15-year-old herniorrhaphy.
c) An 8-year-old tonsillectomy just returned from recovery room, having frequent swallowing.
d) A 12-year-old appendectomy, two days postoperative and refusing to ambulate.
RATIONALE: C. The swallowing may be a sign of bleeding from the surgical site. This requires immediate investigation with a flashlight, and if there is fresh blood, the surgeon should be notified. Aspiration and/or excessive blood loss re potentially life-threatening. (Meds Complete Q&A for NCLEX-RN, p. 329)
3. A home care nurse is planning her visits for the day. Which of the following clients should the nurse visit first?
a) A 76-year-old man with chronic obstructive pulmonary disease (COPD).
b) A 50-year-old woman three days after a right mastectomy.
c) A 40-year-old woman with type 1 diabetes mellitus (IDDM) with a foot ulcer.
d) A 62-year-old man two days post-op after an inguinal hernia repair.
RATIONALE: B. The client who is 3 days post-op after mastectomy is the least stable and is potential for major complication. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 126- 128)
4. After receiving a report from the night nurse, which of the following clients would the nurse see first?
a) A 40-year-old man with left-sided weakness asking for assistance to the bedside commode.
b) A 31-year-old woman refusing Carafate before breakfast.
c) A 65-year-old man with nasogastric tube who had a bowel resection yesterday.
d) A 52-year-old woman complaining of chills who is scheduled for a cholecystectomy.
RATIONALE: D. This clients needs an immediate attention since this is an unstable situation since chills are indicative of an infectious process and the client is scheduled for surgery. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 126- 128)
5. The nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first?
a) A one-day-old infant who is crying and the anterior fontanel is bulging.
b) A two-day-old infant who is lying quietly alert with a heart rate of 185.
c) A five-hour-old infant who is sleeping and the hands and feet are bilaterally blue.
d) A 12-hour-old infant who is being held; the respirations are 45 breaths per minute and irregular.
RATIONALE: B. A two-day-old infant who is lying quietly alert with a heart rate of 185 shows a tachycardia and requires further investigation. Normal resting rate is 120-160. An infant who is crying normally causes fontanel to bulge due to increased intracranial pressure. Normal respiratory rate for infant is 30-60 per minute with apneic episodes. Acrocyanosis is normal for 2-6 hours post-delivery due to poor peripheral circulation. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 247)
1. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
a) Converse with the client to determine if the mucous membranes are impaired
b) Report hourly outputs of less than 30 ml/hr
c) Monitor client's ability for movement in the bed
d) Check skin turgor every 4 hours
RATIONALE: B. When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.
2. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?
a) Take a history on a newly admitted client
b) Adjust the rate of a gastric tube feeding
c) Check the blood pressure of a 2 hours post operative client
d) Check on a client receiving chemotherapy
RATIONALE: C. Check the blood pressure of a 2 hours post operative client .
UAPs must be assigned to tasks that require no nursing judgment or decision making situations. Vital signs on stable clients are commonly assigned to unlicensed staff.
3. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with
a) Difficulty swallowing after a mild stroke
b) An order of enemas until clear prior to colonoscopy
c) An order for a post-op abdominal dressing change
d) Transfer orders to a long term facility
RATIONALE: B. an order of enemas until clear prior to colonoscopy.
The UAP can be assigned routine tasks which have predictable outcomes.
4. A child with a compound fracture of the left femur is being admitted to the pediatric unit. Which of the following actions is best for the nurse to take?
a) Ask the nursing assistant to obtain equipment for the child’s care while the nurse talks with the child and his parents.
b) Ask the LPN/LVN to stay with the child and his parents while the nurse obtains the phone orders from the physician.
c) Ask the LPN/LVN to assess the peripheral pulses of the child’s left leg while the nurse completes the admission forms.
d) Ask the nursing assistant to obtain the child’s vital signs while the nurse obtains a history from the parents.
RATIONALE: A. Asking the nursing assistant to obtain equipment for the child’s care while the nurse talks with the child and his parents is the appropriate answer. Obtaining equipments do not require assessment, evaluation, or nursing judgment.
(NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 121-126)
5. Which of the following task is appropriate to delegate to an experienced nursing assistant?
a) Observe the amount and characteristic of the returns from a continuous bladder irrigation for a client after a transuretheral resection.
b) Obtain a 24-hour diet recall from a recently admitted client with anorexia nervosa.
c) Observe a client newly diagnosed with diabetes mellitus practice injection technique using an orange.
d) Obtain a clean catch urine specimen from a client suspected of having a urinary tract infection.
RATIONALE: D. This choice involve standard, unchanging activities that require no judgment. There is no indication that the client has a catheter so this is a routine procedure. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 121-126)
6. Which of the following clients should the nurse on pediatric units assign to an LPN/LVN?
a) A 10-year old admitted for observation after an acute asthmatic attack.
b) A 3-year old girl admitted yesterday with laryngotracheobronchitis who has tracheostomy.
c) A 6-year old boy admitted for a fracture of the femur in balanced suspension traction.
d) A 5-year old girl admitted after gastric lavage for Tylenol ingestion.
RATONALE: C. This child has a problem that has a predictable outcome. No information provided in the choice that leads you to believe that this child is unstable at this time. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 121-126)
1. Which of the following is true about Port-A-Cath device?
a. It is a centrally implanted device that is tunneled subcutaneously and inserted into a central vein and is used to deliver fluids to patient in long term care.
b. It is a peripherally inserted central catheter used to deliver fluids in patients in
acute and long-term care.
c. It is usually inserted in the basilic, brachial, and cephalic veins to deliver fluids
or draw blood.
d. It is usually connected to a subcutaneously implanted port in the forearm and
delivers fluid centrally into the superior vena cava.
RATIONALE: A. Port-A-Cath is a centrally implanted device. A subcutaneous pocket is formed and a reservoir is placed; a cath is attached into the reservoir and tunneled subcutaneously into a central vein (usually the cath tip is in the super vena cava). It is used in long term therapy, chemotherapy, medication, or blood product infusion, blood specimen collection, and IV fluids. (Lippincott Manual of Nursing Practice, 7th ed, p. 96)
2. Which of the following is an appropriate measure for patient’s with implanted port such as Port-A-Cath?
a. Don clean gloves and clean site with alcohol and 3 povidone iodine swabs
before infusing fluid into the central line.
b. If unable to aspirate blood, flush port with saline and look for possible site for
c. After aspirating blood, flush with 10 ml heparinized saline solution.
d. In the absence of blood after flushing, repeat port access before informing the
health care provider.
RATIONALE: D. In the absence of blood return, flush port with 10 ml NSS only. Sterile gloves must be used to prevent introduction of microorganisms to the central line. If unable to aspirate blood, the port must be flushed with saline and try to aspirate blood again, if still no blood is withdrawn repeat port access. Calling the health care provider is the last resort if the above measures fail. (Lippincott Manual of Nursing Practice, 7th ed, p. 96)
3. Which of the following is true about tracheostomy care?
a. Change tie tapes every 24 hours
b. Change tracheostomy tie tapes before suctioning secretions
c. Put on face shields and clean gloves when cleaning
d. Cleaning of the fresh stoma and suctioning should be performed every 4
RATIONALE: A. In performing tracheostomy care trachea and pharynx should be suctioned first before tracheostomy care. Sterile gloves are used to prevent contamination of the wound. Cleaning of the fresh stoma should be done every 8 hours and suctioning should be only as needed. Change tracheostomy ties at the end of the day only or more frequently if soiled or wet. (Lippincott Manual of Nursing Practice, 7th ed, p. 218-220)
4. 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
RATIONALE: 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. (Saunders Comprehensive © 2005, p. 853)
5. A low-pressure alarm sounds on a ventilator. The nurse assesses the client and determines which of the following probable cause of the alarm?
a) Pooling of secretions in the airway
b) A leak in the tube
c) A kink in the tubing
d) Client bites the oral endotracheal tube
RATIONALE: B. Causes of low pressure alarm in a ventilator are disconnection or leak in the ventilator or in the client’s airway cuff and a spontaneous cessation of breathing. Other choices are causes of high pressure alarm. (Saunders Comprehensive © 2005, p. 733)
- What is the appropriate position for conducting thoracentesis?
a) Lateral position
b) Lying on bed with the affected side and head elevated at 450
c) Sitting on the edge of bed and leaning forward
d) Semi-Fowlers position
RATIONALE: C. During the procedure, to facilitate the removal of fluid from the chest wall, position the client sitting on the edge of the bed and leaning over the bedside table, with the feet supported on a stool, or lying on bed on the unaffected side with the head of the bed elevated about 45 degrees (Fowler’s position). (Saunders Comprehensive © 2005, p. 227)
7. A nurse in the intensive care unit (ICU) observes a patient on mechanical ventilator is biting the endotracheal tube. The nurse would anticipate which alarm to sound?
a) Low pressure alarm
b) Moderate pressure alarm
c) High pressure alarm
d) No alarm
RATIONALE: C. Causes of high pressure alarm are increased secretions in the airway, wheezing or bronchospasm, a displaced endotracheal tube, obstruction as a result of water or kinks in the tubing, when the client coughs, gags, or bites on the endotracheal tube, and when the client is anxious or fights the ventilator. (Saunders Comprehensive © 2005, p. 733)
8. Which of the following nursing action during phototherapy needs an intervention?
a) Turning the infant every 2 hours
b) Undress the infant completely under the light
c) Shields the gonads and infant’s eye
d) Drawing blood while the infant is exposed to light
RATIONALE: D. When obtaining blood sample for bilirubin, the light should be turned off to eliminate false-low bilirubin levels. Bilirubin is destroyed when exposed to light. (Lippincott’s Manual of Nursing Practice © 2004, p. 1175)
9. The nurse delivers external cardiac compression to a client while performing cardiopulmonary resuscitation (CPR). Which of the following action by the nurse is best?
a) Check the return of the client’s pulse after every 8 breaths by the nurse.
b) Maintain a position close to the client’s side with the nurse’s knees apart.
c) Maintain vertical pressure on the client’s chest through the heel of the nurse’s hand.
d) Re-check the nurse’s hand position after every 10 chest compressions.
RATIONALE: C. The nurse’s elbow should be locked, arms straight, with shoulders directly over hands. Incorrect pressure or improperly placed hands could cause injury to the client. (Saunders Comprehensive © 2005, p. 210-202)
10. A client is receiving packed red blood cells. Several minutes after the infusion is started, the client complains of itching and develops hives on his chest and abdomen. Which of the following actions should the nurse take first?
a) Slow down the rate of infusion
b) Mix IV fluid with the blood to dilute it
c) Call the physician for an order of an antihistamine
d) Stop the infusion
RATIONALE: D. the client is having transfusion reaction and the best action is to stop the transfusion. This action must take first before calling the physician. (Saunders Comprehensive © 2005, p. 164-167)
1. A nurse in the ER is attending an infant who vomits after every feeding. What appropriate question will the nurse ask the mother to suspect intussusception?
a. “Is there a blood streak in the vomitus?”
b. “Is the infant manifesting projectile vomiting?”
c. “Is the vomitus dark or coffee ground in color?”
d. “Is there a fecal material in the vomitus?”
RATIONALE: D. A bile-stained fecal emesis is suggestive of intussusception. Projectile vomiting is usually seen in increased ICP. Coffee ground could be an internal bleeding. Blood streak is observed in PTB. (Saunders Comprehensive © 2005, p. 451).
2. A mother asks the nurse about the best way to give Nystatin (Mycostatin) suspension to her 6 month old infant with oral thrush. What will the nurse advice the mother?
a. Mix the suspension with the infant’s formula
b. Dissolve and cover nipple with solution and let baby suck.
c. Ask the physician for the medicine in a different form
d. Place medicine in a baby teaspoon and let the infant swallow together with water
RATIONALE: B. Nystatin (Mycostatin) is an antifungal drug given to treat fungal infections in the oral cavity (oral thrush). The “S&S” (swish and swallow) method for adults ensures contact of the medicine in the oral mucosa for as long as possible. Giving the suspension to infants in this manner (choice B) allows the drug to be in contact with the oral mucosa before swallowed. It should be administered after meals and the client should not be allowed to drink anything for 30 minutes. Mixing the medication in the formula is not the best method because if the infant can not finish the formula, the mother won’t be able to tell how much medicine the infant ingested. (Clinical Drug Therapy 7th ed., p. 612)
3. Which of the following statement is true about pain perceptions in children?
a. Children can better tolerate pain than adults do
b. Children may not admit that they are experiencing pain
c. A child can be easily diverted from pain
d. Children easily become accustomed to pain
RATIONALE: B. Children often denies the perception of pain due to their fear of medical procedures such as injection. (Straight A’s in Pediatric Nursing)
4. A 9-year-old girl asks a nurse what is the first sign of puberty. The nurse appropriately tells her that the first sign of puberty in female child is
b. Appearance of acne
c. Development of breast buds
d. Appearance of axillary hair
RATIONALE: C. The first noticeable change in puberty in females involves the breast. This change can precede menstruation by 2 years. Axillary hair appears near the time of menarche. Acne can occur during puberty but it isn’t the first sign. (Straight A’s in Pediatric Nursing)
5. A neonate has atopic dermatitis on his scalp. What is the appropriate teaching the nurse can give to neonate’s mother?
a. Applying warm wet compress to the skin for itching
b. Adding 2 cups of cornstarch to a tub of warm water as baths
c. Frequent bathing and using antiseptic soaps
d. Maintaining the skin dry and giving oral antihistamine.
RATIONALE: B. Colloid baths, such as the addition of 2 cups of cornstarch to warm water as bath can be used to temporarily relieve pruritus. The major goals of management for atopic dermatitis (eczema) is to relieve pruritus, hydrating the skin and maintaining skin moisture, reduce inflammation, and prevent or control secondary infection. Skin hydration can be done by applying preparations that occlude the skin to prevent evaporation and retain moisture in the upper skin layers. Glycerin lubricants are preferred. Cold wet compress are soothing to the skin and provides an antiseptic protection. When bathing no soap or a very mild, nonperfumed soap is advised. Moderate to severe pruritus is relieved by oral antihistamine, topical steroids, and mild sedatives as indicated. (Wong’s Essentials of Pediatric Nsg © 2004, p. 1179-1178)
6. A 15-year-old white male child with cystic fibrosis is experiencing increasing shortness of breath, cough and sputum production, fatigue, and weight loss. Which of the following actions is inappropriate for the child?
a. Allowing the child to set his own goals so that he can accomplish it all.
b. Performing CPT twice daily or more frequently if needed.
c. Administering pancreatic enzymes during meals or snacks.
d. Encouraging a high-protein, high-calorie diet
RATIONALE: A. Teens with a long-term fatal illness needs to be granted as much control as possible. Letting the child set goals completely on his own isn’t realistic because he may not fully comprehend all of the medical aspects of his condition. Other choices are appropriate. (Wong’s Essentials of Pediatric Nursing © 2004, p. 863-868)
7. An 8-year old child develops juvenile rheumatoid arthritis. Which of the following measures are not advisable to the child?
a. Administer aspirin initially to relieve pain
b. Encouraging exercise in a pool
c. Applying hot packs during passive exercises
d. Choosing a soft mattress and pillow to enhance comfort
RATIONALE: D. Positioning in a child with JRA is very important. The child must rest on a firm mattress with no pillow or a very low one and has no support under the knee. Exercising in a pool is excellent therapy since it allows freedom of movement with support and minimum gravitational pull. If there is pain in motion, a hot pack or warm bath before therapy may help. Aspirin is the initial drug of choice for JRA. (Wong’s Essentials of Pediatric Nsg. © 2004, p. 1238-1239)
8. 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
RATIONALE: C. The age at which the normal child develops the ability to sit
steadily without support is 8 months. (Saunders Comprehensive © 2005, p. 378)
9. 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
a) Cartoon stickers
b) Large wooden puzzle
c) Blunt scissors and paper
d) Beach ball
RATIONALE: B. 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. (Wong’s Essentials of Pediatric Nsg. © 2004, p. 342- 343 )
10. 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."
RATIONALE C: All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern in these clients. Other information of interest is that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of these parent’s pregnancies will result in a child with cystic fibrosis. (Wong’s Essentials of Pediatric Nsg. © 2004, p. 863-868 )
11. 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
RATIONALE C: 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’s Essentials of Pediatric Nsg. © 2004, p. 998 )
12. 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
RATIONALE: B. Twenty 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. . (Wong’s Essentials of Pediatric Nsg. © 2004, p. 427-435)
13. Which of these parents' comment for 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) Vomiting that increases in intensity and shooting across the room
d) Irritation and spitting up immediately after feedings.
RATIONALE: C. Mild regurgitation or emesis that progresses to projectile vomiting
is a pattern of vomiting associated with pyloric stenosis as an initial finding. The other findings are present, though not initial findings. (Lippincott’s Manual of Nursing Practice © 2004, p. 1458)
14. A child, three months of age, has been admitted with a tentative diagnosis of intussusception. The parent asks the nurse how the diagnosis is made. Based on an understanding of the diagnostic evaluation for intussusception, what should the nurse say to the parents?
a) “A small amount of tissue from the colon will be biopsied.”
b) “Genotyping can identify this condition.”
c) “A barium enema will be given to visualize the obstruction.”
d) “An upper GI series should identify the area involved.”
RATIONALE: C. A barium enema is given, which may also treat the condition by nonsurgical means. The telescoping of the bowel, which characterizes intussusception, may be reduced by hydrostatic pressure of the barium enema. (Saunders Comprehensive© p.454)
15. Your assessing an infant after repair of a myelomeningocele. What complication is most common after this surgery?
d) Central cyanosis
RATIONALE: B. The most common complication after repair of myelomeningocele (herniation of the spinal cord through a defect in the vertebral canal) is hydrocephalus, which occurs when cerebrospinal fluid (CSF) accumulates in dilated cerebral ventricles. This condition can occur post-operatively because of an imbalance in the production and absorption of CSF. Meningitis and sepsis are infections that can develop after surgical repair of myelomeningocele, but they aren’t common complications. Central cyanosis doesn’t typically occur after this surgery.
1. The physician has written an order of misoprostol (Cytotec) for the client with NSAID induced ulcers. The client asks the nurse about the action of the drug and on how does it help her condition. The nurses’ appropriate response would be
a. “Misoprostol (Cytotec) promotes secretion of bicarbonate and cytoprotective mucus.”
b. “Misoprostol (Cytotec) suppresses the secretion of gastric acid produced by the histamine receptors in the stomach.”
c. “Misoprostol (Cytotec) increase the rate of gastric emptying.”
d. “Misoprostol (Cytotec) neutralizes the acidity of the gastric tract.”
RATIONALE: A. Misoprostol (Cytotec) is a mucosal protective medication. It suppresses the action of gastric acid, promotes secretion of bicarbonate and cytoprotective mucus. It maintains submucosal blood flow by promoting vasodilation. (Saunders Comprehensive © 2005, p. 711)
2. A client is prescribed with cilostazol (Pletal) 100 mg
a. It increases the force of myocardial contraction and deceases the rate of
b. Blocks the vagal stimulation of the SA node in the heart thus increasing heart
c. Dissolves clots and other plasma protein causing emboli.
d. Decreases platelet aggregation and clotting time
RATIONALE: D. Cilostazol (Pletal) inhibits platelet aggregation and clotting time and causes vasodilation. It is indicated for clients with peripheral arterial disease. (Nsg Drug Handbook © 2005, p. 330)
3. In what client should the nurse question the doctor with regards to a beta-blocker prescription?
a. Client with PR of 66 bpm
b. Client with CHF
c. Cleint with angina pectoris
d. Client with acute MI
RATIONALE: B. Beta-adrenergic blockers causes a negative inotropic (force of contraction) and chronotropic (heart rate) effect. These drugs can be safely introduced for the management of hypertension, angina, acute MI, and supraventricular tachycardia. (Reviews and Rationale for Nsg. Pharmacology, p. 198)
4. A nurse administering kayexalate would follow-up which client?
a. Client saying, “I haven’t emptied my bowels for the last 48 hours.”
b. Client saying, “I have difficulty focusing on far object.”
c. Client saying, “I get thirsty often.”
d. Client saying, “I feel dizzy when standing.”
RATIONALE: A. Kayexalate is a potassium-removing resin that exchanges sodium ion for potassium ions in the intestine to treat hypekalemia. Client taking the medication shoudlk be watched for constipation and fecal impaction. Encouraging increase fluid intake or administering cleansing enema in elderly to prevent fecal impaction is advised. (Nsg Drug Handbook © 2005, p. 1238)
5. A nurse is caring for a patient with gastroesophageal reflux disease (GERD) who is taking metoclopramide (Reglan). The nurse asks about the purpose of the medication. The nurse understands the purpose of the medication when she verbalizes that the medication has which of the following actions?
a. Coats the stomach
b. Decreases the gastric motility
c. Enhances the gastric emptying
d. Neutralizes the gastric acidity
RATIONALE: C. Metoclopromide (Reglan) is a GI stimulant increasing the motility of the GI tract and shortening gastric emptying time. (Reviews and Rationale for Nsg. Pharmacology, p. 298)
6. A client is told to take vitamin B3 (niacin). Which of the following nursing action is appropriate to instruct to the client?
a. Report any signs of facial flushing after oral ingestion
b. Instruct to change positions slowly to avoid sudden BP drop
c. Take niacin with warm water
d. Encourage exposure to sunlight for better absorption
RATIONALE: B. Niacin (Vit B3) is indicated for clients with high cholesterol levels. It causes peripheral vasodilation and can be used to treat clients with peripheral vascular disease. Nursing instructions include taking the medication with meals to prevent GI upset and with cold water. Direct exposure to sunlight and sudden change in position is discouraged because this may potentiate vasodilation.
7. The client is taking lithium carbonate (Eskalith) at home. Which of the following client activities would require the nurse further teaching?
a. Drinking 2000 to 3000 ml of fluid each day
b. Avoiding tea and cola in the diet
c. Maintaining a low- calorie diet
d. Jogging in warm days
RATIONALE: D. Excessive fluid loss predisposes the client taking lithium to toxicity. Activities that predispose fluid loss should be discouraged such as jogging, taking diuretics and fluids with diuretic effect (tea, cola, coffee). The drug causes weight gain thus a low-calorie diet is applicable. (Reviews and Rationale for Nsg. Pharmacology, p. 427)
8. Which of the following side effects would the nurse anticipate in a client treated with theophylline (Theo-Dur)?
a. nasal stuffiness and tremors
b. cough and hoarseness
c. palpitations and insomnia
d. bronchospasm and anxiety
RATIONALE: C. Theophylline (Theo-Dur) is used as a bronchodilator in clients with COPD and other chronic respiratory disorder. This medication is also useful for symptom control of clients with asthma and reversible bronchospasm. S/E: seizure, anxiety, headache, insomnia, dysrhythmias, tachycardia, angina, palpitations, N&V, anorexia, cramps, and tremors. (Reviews and Rationale for Nsg. Pharmacology, p. 542)
9. A nurse about to give temazepam (Restoril)
RATIONALE: A. Temazepam (Restoril) is a benzodiazepine that probably acts on the limbic system, thalamus, and hypothalamus of the CNS to produce hypnotic effects. (Nsg Drug Handbook © 2005, p. 403)
10. Which of the following side effects is not expected in a client taking magnesium sulfate?
b. nausea and vomiting
c. flushed warm feeling, drowsiness
d. Decreased hand grasp strength
RATIONALE: A. MgSO4 causes hyponatremia not hypernatremia. (RRSN Pharmacology © 2003, p. 526-527)
11. 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
RATIONALE: 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 within days. (Reviews and Rationale for Nsg. Pharmacology, p. 427)
12. A victim of a stab wound develops a shock and a sudden drop in his blood pressure. Which of the following emergency drug is appropriate to give to the client?
a) dopamine (Intropin)
b) isoproterenol (Isuprel)
c. atropine sulfate
d. epinephrine (adrenaline)
RATIONALE: A. Dopamine hydrochloride (Intropin) is used to treat shock and correct hemodynamic imbalances, it helps improve perfusion to vital organs, increases cardiac output, and correct hypotension. (Nsg. Drug Handbook © 2005, p. 560)
13. The physician’s order reads “Add 250 mg of dobutamine (Dobutrex) to 250 ml of D5W to infuse at a rate of 2.5mcg/kg/min”. If the patient weighs 85 kg and the drop factor is 60 mcgtt = 1 ml, what will be the flow rate for this inotropic agent?
a) 15 mcgtts/min
b) 20 mcgtts/min
c) 13 mcggts/min
d) 12 mcgtts/min
Convert: 2.5 mcg to mg
1000 mcg: 1 mg:: 2.5 mcg: x mg
1,000x = 2.5
x = .0025 mg
85 kg= 12.75 or 13 mcgtts/min
14. The nurse prepares to administer the doctors order which read “Infuse 250 mg of dobutamine (Intropin) to 250 ml of 0.9% saline solution at a rate of 8 mcg/kg/min in a patient who is 168 lbs.” The drop factor is 15 gtts = 1 ml. what is the flow rate for this solution?
a) 13 gtts
b) 9 gtts/min
c) 12 gtts/min
d) 8 gtts/min
Convert: 168 lbs to kg
= 76.36 kg
Convert: 8 mcg to mg
1,000 mcg: 1 mg:: 8 mcg: x mg
1,000x = 8
x = .008 mg
76.36 kg= 9.16 gtts or 9 gtts/min
15. A client is admitted in hypertensive crisis due to pheochromocytoma. The physician orders nitroprusside (Nitropress) IV at 3mcg/kg/min. in addition to the routine assessments, which of the following interventions is most critical for the nurse to include in the plan of care?
a) Obtain an infusion pump for Nitropress.
b) Place the client in a modified Trendelenburg position.
c) Provide a darkened, quiet environment for the client.
d) Prepare the client for an arterial line (A-line) insertion.
RATIONALE: A. Because Nitropress is a potent vasodilator with immediate onset of action, it must be administered via infusion pump to ensure an accurate dosage rate. (Nsg. Drug Handbook © 2005, p. 298)
16. A woman with breast cancer is prescribed with tamoxifen (Nolvadex) 20 mg
a) It inhibits estrogen production
b) It suppresses progesterone production
c) It disrupts the normal DNA synthesis of cancer cells
d) It prevents the normal androgenic response
RATIONALE: A. Nolvadex is indicated for the treatment of breast cancer in women and men. It acts as an estrogen antagonist and inhibits the hormone dependent tumor growth. (Nsg. Drug Handbook © 2005, p. 960)
17. Which of the following response is appropriate for a client taking alendronate sodium (Fosamax)?
a) “I can take calcium supplements together with the drug.”
b) “I need to stay upright for 30 minutes after taking the drug.”
c) “It is best for the drug to be taken before sleeping.”
d) “I will drink it with a glass of milk for best absorption.”
RATIONALE: B. Client taking Fosamax should be instructed not to lie down for at least 30 minutes after taking the medication to facilitate delivery to the stomach and reduce risk of esophageal irritation. It should be taken also only with a glass of plain water at least 30 minutes before ingesting anything else including food, beverage, and other drugs. (Nsg. Drug Handbook © 2005, p. 1242)
18. A client suffering with Parkinsonism is taking levodopa (Sinemet) daily. Based on the knowledge about the side effect of the drug, which of the following nursing actions would be necessary to implement?
a) Change positions slowly
b) Avoid direct sunlight
c) Increase fluid intake
d) Monitor for bleeding tendencies
RATIONALE: A. Levodopa counteracts the depletion of dopamine in the extrapyramidal centers which are thought to produce Parkinsonism. Patient taking the drug should be warned about possible dizziness and orthostatic hypotension. Tell the client to change positions slowly and dangle legs before rising. (Nsg. Drug Handbook © 2005, p. 512)
1. Which of the following are true with crutches?
a. The client should stand erect with weight resting on the hand grip at the level of
the patient’s waist and the axilla 2 inches above the crutch.
b. The client should walk or move crutches with elbows slightly extended 200 to
c. The client’s body should be erected, weight supported by the hands and the
axilla is off the crutches.
d. The client should flex the knee of the affected leg to lower self into the chair
while placing the unaffected leg straight out in front.
RATIONALE: C. In using crutches, the client assumes an erect position, the top of the crutch is 2 inches below the axilla and the tip of the crutch is 6 inches in front and to the side of the feet. Client’s elbow should be slightly flexed 200 to 300 when hand is on the grip at the level of the greater trocanter. Weigth should not be borne by the axillae. (Saunders Comprehensive © 2005, p. 1005/ NSNA © 2005, p 367)
2. 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
a) Isometric exercises
b) Range of motion
c) Aerobic exercises
d) Isotonic exercises
RATIONALE: A. 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. (Med-Surg by Black © 2005, p. 631-636)
3. A nurse obtaining a health history of a client initially suspected with carpal tunnel syndrome would most likely expect the client to report which of the following?
a) “I feel numbness in my hands.”
b) “I feel tingling and burning sensation at the sole of my foot.”
c) “I feel a fluid filled sac in my wrist.’
d) “I am having difficulty moving my fourth and fifth fingers.”
RATIONALE: A. Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve is compressed as it passes through the wrist along a pathway to the hand. Initially, the client may be awakened at night by pain and paresthesia, progressive weakness, inability to perform fine motor activities, and burning or numbness of the thumb, index and middle finger. Tingling and burning sensation at the sole is a manifestation of tarsal tunnel syndrome. Contracture of the fourth and fifth finger is a characteristic of Dupuytren’s contracture. (Med-Surg by Black © 2005, p. 2155-2157)
4. An elderly woman with osteoporosis client suffers a fracture of the hip after slipping into the floor. The nurse would expect which of the following observation?
a) Lengthened affected leg and externally rotated hip.
b) Shortened affected leg and externally rotated hip
c) Lengthened affected leg and internally rotated hip
d) Shortened affected leg and internally rotated hip.
RATIONALE: B. Immediately after a hip fracture, the client is unable to bear weight on the affected leg. Objective findings include a shortened affected leg and an externally rotated hip. (Med-Surg by Black © 2005, p. 639)
5. A client received a large contusion on the head and a fracture of the neck of femur. Which of the following signs and symptoms related to fracture of the neck of femur would the nurse find?
a) Groin and hip pain that increases with hip movement.
b) Inability to extend the knee fully.
c) Severe pain over the greater trochanter of the femur.
d) Pain over the proximal thigh.
RATIONALE: A. A femoral neck fracture is characterized by groin and hip pain that increases with hip movement. Intertrochanteric fractures are accompanied by severe pain over the greater trochanter of the femur, whereas subtrochanteric fractures typically produce pain over the proximal thigh. Inability to extend fully the knee is a characteristic of a patellar fracture. (Med-Surg by Black © 2005, p. 639)
1. A nurse is conducting health history of a client with a diagnosis of congestive heart failure (CHF). Which of the following questions would best help the nurse support the diagnosis?
a. “Do you easily get tired after a mild exercise?”
b. “Do you experience leg cramps after walking a few blocks?”
c. “Does your sputum contain a streak of blood?”
d. “Where does the pain radiates?”
RATIONALE: A. CHF is characterized by fatigue and activity intolerance due to the inadequate supply of oxygen in the body caused by the pumping failure of the heart. (Saunders Comprehensive © 2005, p. 796)
2. A client with a history of heart failure would most likely exhibit which of the following symptoms?
- Crackles and wheezing upon auscultation of the lungs
- Paradoxical movement of the diaphragm
- Piercing chest pain and increasing dyspnea
- Presence of pulsus paradoxus.
RATIONALE: A. Refer for list of s/sx of CHF to (Saunders Comprehensive © 2005, p. 796)
3. 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
RATIONALE C: 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. (Saunders Comprehensive © 2005, p. 799-800)
4. An ambulatory client reports edema during the day in his feet and ankles that disappear 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?"
RATIONALE: B: "Do you become short of breath during your
normal daily activities?" These are the symptoms 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. (Saunders Comprehensive © 2005, p. 796)
5. 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
RATIONALE: 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.(Saunders Comprehensive © 2005, p. 805)
6. Which of the following laboratory finding(s) is/are used as an indicator of acute myocardial infarction (AMI)? Select all that apply:
a) (CK) - MB isoenzyme
d) Cardiac tropinin T
e) Erythrocyte sedimentation rate (ESR)
RATIONALE: ALL. Laboratory findings in acute myocardial infarction include elevated levels of serum creatine kinase (CK)-MB isoenzyme, myoglobin, cardiac troponin T, and cardiac
7. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which doctor’s order would the nurse give priority?
b) Morphine sulfate
RATIONALE: B. Pain is related to ischemia, and relief of pain will decrease
myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands.
8. A client with a history of heart failure visits the clinic. He states, “I have not been feeling like my old self for about two weeks.” It would be most important for the nurse to ask which of the following questions?
a) “Do you have chest pain when you inhale?”
b) “How do you feel after you eat dinner?”
c) “Where do you sleep at night?”
d) “Do you ankles swell at the end of the day?”
RATIONALE: C. Asking this question would identify if the client is sleeping in bed, his breathing is not compromised. If he has to sleep in a recliner, he is having orthopnea. Orthopnea is a symptom of left-sided failure, and this would be a priority. Swelling is a symptom of right-sided heart failure but left-sided failure is a priority. Bloating after meals is a symptom of right-sided heart failure. This is not as important as breathing. Pain on inspiration may indicate irritation of the parietal pleura of the lung, and is not associated with heart failure. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 64)
9. A nurse obtaining a health history of a client with Raynaud’s disease would probably obtain information about which of the following manifestations of the disease?
a) A pulsating mass over the umbilicus
b) Intermittent claudication
c) Blanching of the extremity during vasospasm
d) Diminished pulses of the distal extremity
RATIONALE: C. Raynaud’s disease is vasospasms of the arterioles and arteries of the upper and lower extremities. It primarily affects fingers, toes, ears, and cheeks. Symptoms are blanching of the extremity, followed by cyanosis during vasoconstriction. Reddened tissue when vasospasm is relieved, numbness, tingling, swelling, and a cold temperature of the affected body part. Choice A, is a sign of abdominal aneurys. Choice B& C are signs of Buerger’s disease. (Saunders Comprehensive © 2005, p. 806)
- Select all that apply to LUNG CANCER:
a. bloody sputum
c. dysphagia and hoarseness
d.wheezing in the lungs
e. edema of face and neck
g. chest pain
RATIONALE: ALL except B. (Diseases: A Nsg Process Approach to Excellent Care, p. 343)
- All of the following are appropriate instructions to a client with metered dose inhaler without spacer, except?
a. Ask the client to inhale and hold breath for 5-10 seconds before removing the
b.Hold the inhaler 2 inches away from the open mouth.
c. Instruct the client to place the mouth tightly around the mouthpiece.
d.Allow the client to wait 1-2 minutes before taking another dose.
RATIONALE: C. A metered dose inhaler should not be put in the mouth but held about two finger widths (1 ½ - 2 inches) away in front of the mouth. If a spacer is used the mouth piece of the inhaler must be placed in the mouth and close lips around it tightly. Incentive spirometer is the one in which the client needs to seal his mouth tightly around the mouth piece. (Saunders Comprehensive © 2005, p. 210, 762)
3. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
a) Eat foods high in sodium increases sputum liquefaction
b) Use oxygen during meals improves gas exchange
c) Perform exercise after respiratory therapy enhances appetite
d) Cleanse the mouth of dried secretions reduces risk of infection
RATIONALE: B. The use oxygen during meals improves gas
exchange. Clients with emphysema breathe easier when using oxygen while eating. (Med-Surg by Black © 2005, p. 1818)
4. 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) Hyperresonance of areas of consolidation
RATIONALE: A. Pneumonia causes a marked increase in interstitial and alveolar
fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields. (Med-Surg by Black © 2005, p. 1841)
5. A client had a right lobectomy yesterday and has a chest tube connected to a suction at 20 cm of water pressure. Upon assessment of the client this morning, the nurse notes that there is no fluctuation in the water-seal chamber. What would be the nurse’s immediate action?
a) Increase the suction until fluctuation return
b) Order for an immediate x-ray to determine if the lung has re-expanded
c) Check for presence of a dependent loop
d) Elevate the client’s bed to Fowler’s position
RATIONALE: C. Fluctuation of the water level in the tube shows that there is effective communication between the pleural cavity and the drainage bottle. A decrease of fluctuation in the first operative day most likely means that the tubing is obstructed by blood clots, there is a kinks or presence of a dependent loop. (Saunders Comprehensive © 2005, p. 242)
6. A client has just returned to the unit after a right pneumonectomy. The nurse’s action shows appropriate understanding about the surgical procedure when she position the client on his:
a) Left side or back
b) Right side or back
c) Flat on his back
d) Alternating right and left side positions
RATIONALE: B. After a pneumonectomy, the operative side should be dependent so that fluid in the pleural space remains below the level of the bronchial stump, and the inoperative side can fully expand. (NSNA by Stein © 2005, p. 301)
- Select all that apply to Cushing’s disease signs and symptoms:
b. amenorrhea and decrease libido
d. purplish striae
RATIONALE: ALL except E. Cushing’s causes hypocalcemia and hyperkalemia. (Saunders Comprehensive © 2005, p. 634)
- A nurse assigned to a post-thyroidectomy patient would prioritize which of the following observation?
a. Complains of fatigue after transferring self to chair
b. Presence of numbness and tingling sensation around the mouth
c. Hoarseness and sore throat
d. Voice weakness
RATIONALE: B. Post-op complication of thyroidectomy includes hypocalcemia secondary to accidental removal of the parathyroid gland during the surgery. S/sx are Chvostek’s and Trousseau’s sign, numbness and tingling around the mouth, toes and finger, muscle spasm or twitching. Hoarseness and voice weakness may be observed temporarily due to trauma to the laryngeal nerve. (Med-Surg by Black © 2005, p. 1205).
- A client contacts his home care nurse with complaints of nausea and abdominal pain. He has type 1 diabetes. How should the nurse advise the client?
a) “Increase your activity level.”
b) “Hold your regular dose of insulin.”
c) “Check your blood glucose level every 3-4 hours.”
d) “Increase your consumption of foods containing simple sugars.”
RATIONALE: C. This action is an assessment. Before you can advise the client, you must identify whether the client is hypoglycemia or hyperglycemic. Holding his regular dose of insulin will increase the blood glucose level. Increasing the consumption of foods containing simple sugars is an implementation and would increase the client’s blood glucose level. Increasing the activity may decrease the client’s glucose level. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 62)
- The mother of a boy with type 1 diabetes calls the physician’s office to discuss the child’s self-monitoring blood glucose (SBMG) home reading. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings his blood sugar readings were 220 mg/dl and 210 mg/dl. What should the nurse tell the boy’s mother?
a) Check his blood sugar during the night.
b) Continue with his medication regimen.
c) Serve his bedtime snack earlier in the evening.
d) Give his NPH insulin later in the evening.
RATIONALE: A. This situation is about Somogyi effect, which is rebound hyperglycemia that occurs in response to a rapid increase in blood glucose during the night. Treatment includes adjusting the evening diet, changing the insulin dose, and altering the amount of exercise to prevent nocturnal hypoglycemia. Before any intervention, the client should be assessed first. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 79)
- Select all that applies about proper foot care in a client with diabetes mellitus (DM)?
a) Apply moisturizing lotion on the feet and between toes.
b) Cut toe nails straight across
c) Treating ingrown toenails
d) Soaking feet with lukewarm water
e) Do not cross legs
f) Keep feet warm by wearing cotton socks
g) Wearing open-toed shoes to prevent moisture
h) Do not smoke
RATIONALE: BEFH. Preventive foot care instructions:
- Providing meticulous skin care and foot care by inspecting the feet daily and monitoring for any redness, swelling, or break in the skin integrity.
- Avoid thermal injuries from hot water, heating pads, and baths.
- Wash feet with warm (not hot) water and dry thoroughly (avoid foot soaks).
- Do not treat corn, blisters, or ingrown toenails.
- Do not cross legs and wear tight garments that may constrict blood flow.
- Apply moisturizing lotion to the feet but not between the toes.
- Wear socks to keep feet warm and change cotton socks daily.
- Do not wear open-toed shoes or shoes with strap that goes between the toes.
- Cut toe nails straight across and smooth nails with emery board.
- Do not smoke.
(Saunders Comprehensive © 2005, p. 644)
- Which food choices would you recommend to a client with iron deficiency anemia?
a. Pork liver and egg yolk
b. Tofu and green beans
c. Enriched milk and cereals
d. White tuna and whole grains
RATIONALE: A. Iron-rich foods are bread and cereals, dark green vegetables, egg yolk, liver, and meats. (Saunders Comprehensive © 2005, p. 129)
- A pregnant woman advised to increase her folic acid intake should eat what foods?
a. Enriched cereals and organ meats
b. Poultry products and green leafy vegetables
c. Legumes and eggs
d. Whole milk and fish liver oils
RATIONALE: B. Folic acid rich foods are organ meats, muscle meats, poultry, fish, eggs, green leafy vegetables. (NSNA by Stein © 2005, p. 153)
- Which of the following food preferences is a good source of calcium?
a. Fortified milk and whole grain cereals
b. Brocolli and yellow vegetables
c. Legumes and eggs
d. Tofu and yogurt
RATIONALE: D. Calcium-rich foods are milk, cheese, ice cream, broccoli, collard greens, kale, oysters, shrimp, salmon, clams, sardines, carrots, green beans, rhubarb, spinach, tofu, yogurt–low fat. (NSNA by Stein © 2005, p. 152/ Saunders Comprehensive © 2005, p. 129)
- Following gastric resection, a client is taught nutritional habits that will slow gastric emptying, helping to decrease the incidence of the “dumping syndrome.” Which foods selected by the client indicate to the nurse that he understands the instructions given?
b) Ice cream
d) Wheat bread
RATIONALE: B. Foods high in fat are recommended for clients with dumping syndrome, because fats tend to slow down the gastric emptying.
- A is client admitted with end stage cirrhosis of the liver. Which of the following dietary measures would the nurse institute?
a) High protein, high calorie diet
b) Low protein, high calorie diet
c) High fat, Low protein
d) Low fat, Low calorie diet
RATIONALE: B. Ammonia is one of the end products of protein metabolism. A low-protein, high-calorie diet will reduce the source of ammonia and promote adequate carbohydrates for energy requirements while “sparing” protein from breakdown of energy. Lippincott’s Manual of Nursing Practice © 2004, p. 640)
- A nurse is orienting a group of students about anorexia nervosa. Which statement by one of the students reveals an early sign of anorexia nervosa?
a. “I go out to eat with my friends at least 3 times a week.”
b. “My menstrual period sometimes doubles in a month.”
c. “I sometimes skip meals when I’m busy.”
d. “I jog three times a day for a total of 5 hours per day.”
RATIONALE: D. Excessive exercise, consumption of very small amounts of food, and food rituals are all signs of anorexia nervosa. Menstrual periods commonly cease, and the client’s weight is below normal. (Straight A’s in Pediatric Nursing)
2. An unemployed woman, age 24, seeks help because she feels depressed and abandoned and does not know what to do with her life. She says she has quit her last five jobs because her coworkers did not like her and did not train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The patient's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis?
a). Flat affect, social withdrawal, and unusual dress
b). Suspiciousness, hypervigilance, and emotional coldness
c). Lack of self-esteem, strong dependency needs, and impulsive behavior
d). Insensitivity to others, sexual acting out, and violence
RATIONALE: C. Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships, mood, and self-image also is common. Typically, the patient cannot tolerate being alone and expresses feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, patients usually are insensitive to others and act out sexually; they also may be violent.
3. 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
RATIONALE: B. Hostility and absence of involvement are data supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the
purpose of medication suggests altered thinking processes.
4. 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?
The correct answer is D: Ping-pong This provides an outlet for physical energy and requires limited attention.
5. A 30-year-old man was admitted one week ago with a diagnosis of schizophrenia, paranoid type. Since his admission, he has had several verbal outburst of anger but has not been violent. A staff member tells the nurse that the client is pacing up and down the hall very rapidly and muttering to himself in an angry manner. Which of the following is the best initial nursing action?
a) Gather several staff members and approach the client together.
b) Prepare intramuscular injection of haloperidol (Haldol) to give him prn.
c) Contact the client’s psychiatrist and request an order for restraint.
d) Observe the client’s behavior and approach him in a non-threatening manner.
RATIONALE: D. The nurse must first assess the client’s condition before deciding on an appropriate intervention. The best initial action is to approach him calmly, in a non-threatening manner, to ask him to verbalize his problem. (Meds Complete Q&A for NCLEX-RN, p. 349)
6. An agitated client throws a chair across the dayroom on the psychiatry floor and threatens the other clients with physical harm. What should the nurse do first?
a) Ask the client why he is so angry.
b) Assemble staff and put the client in preventive seclusion.
c) Remove the other clients in the dayroom
d) Tell the client that his wife will be called to the hospital.
RATIONALE: B. Seclusion may be used alone or in conjunction with medication to de-escalate a potentially dangerous situation; nurse can initiate and terminate client seclusion based on established protocols. Choice C, would allow client to determine disposition of other clients and gives the client control over staff and other clients.
7. A nurse would assess for which of the following characteristic in a client with passive-aggressive personality disorder?
a) Mistrust and suspiciousness
b) Procastination and low self-confidence
c) Lack of empathy and entitlement
d) Excessive emotionality and attention-seeking
RATIONALE: B. Passive-aggressive personality disorder is characterized by a negative attitude and pervasive patterns of passive resistance to demands for adequate social and occupational performance. These clients may appear cooperative, even ingratiating, or sullen, and withdrawn, depending on the circumstances. Their mood fluctuates rapidly and erratically, and they may be easily upset or offended. Self-confidence is low despite the bravo showdown. They express their resistance through procrastination, forgetfulness, stubbornness, and intentional inefficiency. (Psychiatric Mental Health Nursing by Videbeck © 2004, p. 399)
8. Which of the following underlying emotions is commonly seen in passive-aggressive personality disorder?
RATIONALE: C. Often, clients with passive-aggressive behavior do not recognize that they feel angry and may express anger indirectly. (Psychiatric Mental Health Nursing by Videbeck © 2004, p. 400)
Isolation Precaution/ Communicable Disease:
- Which of the following patient requires the nurse to use gloves and gown when taking blood pressure?
a. Patient with Hepatitis B infection
b. Patient diagnosed with AIDS
c. Patient with VRE
d. Patient with meningococcal infection
RATIONALE: C. Vancomycin-Resistant Enterococci (VRE) spreads easily from person to person by direct contact. Meningitis requires droplet precaution; Hep B requires only gloves since it is blood-borne disease. AIDS do not require gloves and gown except the patient is exhibiting signs and symptoms of Kaposis sarcoma which is highly contagious. (Diseases: A Nsg Process Approach to Excellent Care, p. 114)
2. A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
A. "A man should wear a latex condom during intimate sexual
B. "I've heard about people who got AIDS from blood transfusions.”
C. "I won't donate blood because I don't want to get AIDS."
D. "I.V. drug users can get HIV from sharing needles."
RATIONALE: C. HIV is transmitted through infected blood, semen, and certain other body fluids. Although a transfusion with infected blood may cause HIV infection in the recipient, a person cannot become infected by donating blood. The other options reflect accurate understanding of HIV transmission.
3. A three-month old client is in respiratory isolation. Which of the following nursing actions will most effectively prevent the spread of pathogens via droplet infection?
a) Provide enteric precautions when caring for the baby
b) Wearing gown and mask when feeding the infant
c) Having the baby wear mask when in the playroom
d) Using sterile gloves when changing her diapers.
RATIONALE: B. To prevent the spread of pathogens to other clients, the nurse must ensure that respiratory secretions are not transmitted. When feeding and burping the infant, the respiratory secretions will be mixed with the formula. When the baby burps, there is a risk of spreading the pathogens via droplet as well as by contact with the nurse’s uniform. Wearing gown and mask will decrease the probability of transmitting the organism. (Meds Complete Q&A for NCLEX-RN, p. 285)
4. Which of the following nursing actions would reflect a wrong statement about universal or standard precautions?
a) Wearing gloves while taking BP of an HIV patient.
b) Wearing gowns and gloves in providing care for a client with VRE.
c) Placing a newly admitted client with meningitis in a droplet precaution.
d) Placing a client with Clostridium difficile in a single room.
RATIONALE: A. A client with HIV without any symptoms of Kaposis sarcoma or any draining lesions does not necessarily require gloves when conducting direct contact such as obtaining BP. (Disease: A nursing Process Approach to Excellent Care: p. 474)
5. Which of the following are appropriate interventions for a client with Impetigo? Select all that apply.
a) Place in a private room
b) Limit visit for 30 min per day
c) Wear mask in giving care
d) Do not share towels and washcloths
e) Cut child’s finger nails short
RATIONALE: ADE. Impetigo is a serious, superficial skin infection that spreads most easily among infants, young children, and elderly. Contact isolation and the use of standard precautions are necessary to prevent the spread of infection. Wearing mask is not necessary when rendering nursing care. Parents should be instructed not to share towels, linens, washcloth, and dishes with the client. Emphasize the importance of meticulous handwashing technique. Advise parents to cut their child’s fingernails short and to have frequent bathing with an antibacterial soap. Placing the client in a private room prevents transmission of organism to other clients. Limiting visit for 30 minutes and wearing mask are not necessary. (Disease: A nursing Process Approach to Excellent Care: p. 1250)
- A construction worker is admitted to the hospital for treatment of active tuberculosis. The nurse teaches the client about tuberculosis. Which statement, if made by the client, would indicate to the nurse that further teaching is necessary?
b) “I will remain in isolation for at least 6 weeks.”
c) “I should cover my nose and mouth when coughing or sneezing.”
d) “I will have to take medication for six months.”
RATINALE: B. The client does not need to be isolated for six weeks. The client’s activities will be restricted about two to three weeks after medication therapy is initiated. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 53)
1. 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
d) Sedimentation rate
RATIONALE: C. In the laboratory data provided, the only elevated level expected is
bilirubin. Additional liver function tests will confirm the diagnosis. (Med-Surg by Black © 2005, p. 1329)
- The nurse knows that the discharge teaching is successful for a client with hepatitis A virus if the client indicates she will refrain from which of the following activities?
a) Eating fried foods
b) Donating blood
c) Ordering a salad in the restaurant
d) Vacationing in a foreign country
RATIONALE: B. Once a person is infected with hepatitis A virus, they can never donate blood. The client is able to tolerate fats within two months so dietary fat is not contraindicated.
3. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important?
a) I got back from
b) I had the best raw oysters last week.
c) I have many different sex partners.
d) I had a blood transfusion 15 years ago.
RATIONALE: D. I had a blood transfusion 15 years ago. The client who was transfused prior to blood screening for hepatitis C may show findings many years later. Options b and c are associated with risk of hepatitis B.
4. A nurse is caring a client with pancreatitis. On assessment the nurse notes that the client calcium level is declining. What would the nurse prepare at the client’s bedside in response to hypocalcemia?
b) Cardiac monitor
c) Tracheostomy set
d) Gastric lavage
RATIONALE: B. Client’s cardiovascular, respiratory, neuromuscular, and gastrointestinal status during hypocalcemia must be closely monitored. The client should be placed on cardiac monitor and a calcium supplements must be available at the bedside. (Saunders Comprehensive © 2005, p. 92-93)
5. A nurse is conducting health teaching in the prevention of the different types of hepatitis. Which of the following statement made by one of the students would indicate a correct understanding of the disease process?
a) “The use of condom during sex would prevent transmission of Hep.A.”
b) “Eating steamed shellfish would place the person at risk for Hep. C.”
c) “Tattooing and body piercing would contribute to Hep. B infection.”
d) “Recombinant HB vaccine will provide active immunity for Hep. D”
RATIONALE: D. Hepa D virus causes hepatitis only in association with hepatitis B virus and only in the presence of HBsAG. Prophylaxis for Hep D is also the same with Hep B such as HBIG (passive), recombinant hepatitis B vaccine (active), hepatitis B vaccine (passive). The use of condom is indicated for the prevention of Hep.B. Eating raw fish and shellfish would put a person at risk for Hep.A. Tattooing and body piercing contributes to the transmission of Hep.C. (Med-Surg by Black © 2005, p. 1323-1325).
1. In a pediatric patient, what is an early sign of acute renal failure?
b) Decreased urine output
RATIONALE: B. A decreased urine output (oliguria) is an early sign of acute renal failure (ARF). Hypertension and anemia occur later in ARF. Hematuria is rare. (Wong’s Essentials of Pediatric Nsg © 2004, p. 1050-1052)
2. 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.
RATIONALE: C. Parents often recognize the increasing abdominal girth first. This is
an early sign of Wilm''s tumor, a malignant tumor of the kidney. (Wong’s Essentials of Pediatric Nsg © 2004, p. 1048-1050)
3. 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
RATIONALE: D. Hypertension is a key assessment in the course of the disease. (Wong’s Essentials of Pediatric Nsg © 2004, p. 1046-1048)
4. 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
RATIONALE: 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. (Wong’s Essentials of Pediatric Nsg © 2004, p. 1043-1046)
5. 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
RATIONALE: A. 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, and anticipatory preparation such as seizure precautions are needed. (Wong’s Essentials of Pediatric Nsg © 2004, p. 1046-1048)
6. 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 mls of 0.9% Normal Saline
c) Palpate for a thrill over the fistula
d) Check color and warmth in the extremity
RATIONALE: C: To assess for patency in a fistula or graft, the nurse auscultates
for a bruit and palpates for a thrill. Other options are not related to evaluation for patency. (Med-Surg by Black © 2005, p. 958-961)
7. A client is admitted in acute renal failure and undergoes peritoneal dialysis. Immediately after infusing 2,000 cc of 2.5% dialysate, the nurse should do which of the following first?
a) Monitor the client’s vital signs
b) Weight the client
c) Assess the outflow of the fluid
d) Clamp the inflow tubing
RATIONALE: D. Shortly after the dialysate infusion, the tubing should be clamped so that air will not enter the peritoneal cavity and cause complications. Although careful monitoring is necessary to detect such complications as peritonitis, pneumonia, and fluid overload, it should be done after the inflow tubing has been clamped. Weighing the client immediately after dialysate infusion is not necessary; the client should be weight daily. ( Meds Complete Q&A Book for NCLEX-RN, p. 277)
1. 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
RATIONALE: B. 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. (Med-Surg by Black © 2005, p.2211-2234)
2. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
b) Loss of half of visual field
c) Shallow respirations
d) Tonic-clonic seizures
RATIONALE: C: A.L.S. 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. (Med-Surg by Black © 2005, p.2185-2186)
3. A client, age 31, is brought to the emergency room after an automobile accident. She is conscious upon admission. A physical examination and x-ray reveal a transaction of the spinal cord at T4. The nurse should give highest priority to which of the following?
a) The client has an allergy to iodine.
b) The client has a blood pressure of 110/80
c) The client last voided seven hours ago
d) The client smokes two packs of cigarettes per day
RATIONALE: C. A distended bladder is the most common cause of autonomic dysreflexia, an acute emergency that occurs as a result of exaggerated autonomic responses. It is characterized by severe, pounding headache with paroxysmal hypertension, profuse sweating, and bradycardia. Because it is an emergency situation, the objective is to remove the triggering stimulus as possible. (Saunders Comprehensive © 2005, p. 950)
4. A client asks a nurse about some of the causes of migraine headache. Which of the following nurse’s response would not constitute to the causes of migraines?
a) Changes in weather pattern
b) Sleep pattern changes
c) Menstrual cycle fluctuations
d) Exposure to infection
RATIONALE: D. Although the cause is unknown, migraine headaches are believed to be associated with constriction and dilation of intracranial and extracranial arteries. Changes in weather pattern, menstrual cycle fluctuations, sleep pattern changes, insufficient or excessive exercise, glaring light, and fatigue can trigger migraine. Foods associated with migraine headache include aged or processed cheese and meats, alcoholic beverage (particularly red wine), food additives (such as MSG), chocolate, and caffeine-containing foods, and nuts. (Diseases: A Nursing Process Approach to Excellent Care, p. 765)
5. Which of the following signs and symptoms are considered principal symptoms of Amyotrophic Lateral Sclerosis (AML)?
a) Drooping of the mouth, incomplete eye closure, and inability to puff out his cheek.
b) Muscle weakness, muscle atrophy of the feet and hands, and fasciculation.
c) Alteration in mental function, asymmetrical weakness of limb, and fasciculation.
d) Progressive weakness in the muscles of the arms, leg, and trunk and increased breath sounds upon auscultation.
RATIONALE: B. Signs and symptoms of ALS depends on the location of the affected neurons and the severity of the disease. Muscle weakness, atrophy, and fasciculation are the principal symptoms of the disorder. Unlike any degenerative disease, ALS doesn’t affect mental function. As the disease progresses, the patient may report progressive weakness in muscles of arms, legs, and trunk. Neurological examination reveals brisk and overactive stretch reflexes. When the disease progresses to the brain stem and cranial nerve, the patient has difficulty speaking, chewing, swallowing, and ultimately breathing. In these patients, auscultation may reveal decreased breath sounds. Choice A is s/sx of Bell’s palsy. (Diseases: A Nursing Process Approach to Excellent Care, p. 795)
6. A 35-year-old woman who just recently gave birth suffers from Bell’s palsy. A nurse who is in charge of providing discharge teaching would include which of the following instructions?
a) Chew on the unaffected side of the mouth and eat semisolid foods.
b) To reduce pain, apply moist cold packs to the affected side of the face.
c) Wear eye glasses when going outdoors to protect the eyes.
d) Avoid massaging the face
RATIONALE: A. Patient teaching for clients with Bell’s palsy includes protecting the eyes with an eye patch, especially when outdoors. Tell the client to keep warm and avoid exposure to dust and wind. When exposure is unavoidable, instruct him to cover his face. To help client cope with difficulty in eating and drinking, instruct him to chew on the unaffected side of his mouth and to eat semisolid foods. To reduce pain, moist heat compress can be applied to the affected side. To help maintain muscle tone, massage the client’s face with a gentle upward motion two to three times daily for 5 to 10 minutes. (Diseases: A Nursing Process Approach to Excellent Care, p. 805)
1. A client is diagnosed with 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
RATIONALE: C. Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, client's are at high risk for pathological fractures. (Med-Surg by Black © 2005, p.2302-2303)
2. The nurse is caring for a client with benign prostatic hypertrophy. 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
RATIONALE: C. Clients with Benign Prostatic Hypertrophy have overflow incontinence with frequent urination in small amounts day and night. (Med-Surg by Black © 2005, p.1016)
3. A client has just received the diagnosis of endometrial cancer in its early stage. In taking a nursing history, which of the following symptoms is most likely to be reported by this client?
a) Uterine enlargement
b) Post menopausal bleeding
c) An abnormal Papanicolaou (Pap) smear
d) Pelvic discomfort
RATIONALE: B. Most clients with endometrial cancer report having a postmenopausal bleeding 12 months or more months after menses had stopped. In more advance stage, palpation may disclose an enlarged uterus. An abnormal Pap smear test is found in clients with cervical cancer. Pelvic discomfort is observed in ovarian cancer. (Disease: A Nsg. Approach to Excellent Care, p.378)
4. A client is receiving combination of chemotherapy for breast cancer. Her most recent complete blood count (CBC) shows the following: Hgb 12.2, Hct 36%, WBC 2.3/cu mm, and platelets 150,000. Which of the following goals should be given priority by the nurse in planning care?
a) Maintenance of tissue integrity
b) Prevention of infection
c) Maintenance of tissue perfusion
d) Prevention of bleeding or injury
RATIONALE: B. The low white blood cell count (normal is 4.5-11/cu mm) puts the client at risk for infection. All other values are within normal limits. (Saunders Comprehensive © 2005, 118-119)
5. The nurse is caring for a client with cervical cancer. The nurse notes that the radium implant has become dislodged. Which of the following actions would the nurse take first?
a) Wrap the implant in a blanket and place it behind a lead shield.
b) Stay with the client and contact radiology
c) Obtain a dosimeter reading on the client and report it to the physician
d) Pick up the implant with long-handed forceps and place in a lead container.
RATIONALE: D. A dislodged implant should not be touched by bare hands, forceps and container should be in the client’s room. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 262)
1. Which of the following lab finding are consistent with a mother to whom the nurse will expect to administer RHoGAM following delivery?
a) Mother Rh negative with positive Coombs, father Rh negative, baby Rh negative.
b) Mother Rh negative with negative Coombs, father Rh positive, baby Rh positive.
c) Mother Rh negative with positive Rh antibody titer, father Rh positive, baby Rh positive.
d) Mother Rh negative with negative Coombs, father Rh positive, baby Rh negative.
RARIONALE: B. This mother should receive RHoGAM because her negative Coombs shows that she has no antibodies in her system (Rh or other). The infant is Rh positive; therefore, the risk of exposure to Rh positive blood cell is present. (Meds Complete Q&A for NCLEX-RN, p. 356)
2. A nurse in the labor room is preparing care for a woman who is diagnosed with a prolapsed cord. What are the appropriate measures for the nurse to take? Select all that apply
a) Prepare for emergency cesarean birth
b) Push the cord inwardly with fingers
c) Elevate fetal head from the cord
d) Provide oxygen to the mother
e) Elevate the mothers hips
f) Administer Rh immune globulin
RATIONALE: ACDE. In a prolapsed cord, the umbilical cord is displaced causing cord compression and compromising fetal circulation. Interventions include relieving cord compression immediately by repositioning the mother, turn her side to side or elevate hips to shift the fetal presenting part toward her diaphragm. Elevate fetal presenting part that is lying on the cord by applying finger pressure with a sterile gloved hand. The cord should not be attempted to be pushed inwardly towards the uterus. Monitor fetal heart rate and hypoxia. Administer oxygen and prepare the mother to emergency cesarean birth. (Saunders Comprehensive © 2005, p. 310)
3. A nurse in the maternity unit is caring for a client with placenta previa. The nurse formulates a plan of care and monitor the client for which of the following risks associated with placenta previa?
b) Disseminated intravascular coagulation
c) Rh incompatibility
d) Hemorrhage and shock
RATIONALE: D. Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. This site is not favorable for contracture because it does not contain the same intertwining musculature as the fundus of the uterus, thus this site is prone to bleeding. Infection, DIC, and Rh incompatibility are not risks that are specifically related to placenta previa. (Saunders Comprehensive © 2005, p. 311)
4. Immediately after administering a lumbar epidural anesthesia to a mother, the nurse would initially assess for
a) Fetal heart rate
b) Maternal BP
d) Intensity of contractions
RATIONALE: B. Epidural anesthesia causes maternal hypotension. To prevent hypotension the mother should be positioned side-lying to displace the uterus from the venacava. Intravenous fluids is increased if hypotension occurs. Fetal heart rate is also monitored but blood pressure is assessed initially to prevent further complication and compromise fetal oxygenation. The anesthetic do not cause headache because the dura matter is not penetrated. (Saunders Comprehensive © 2005, p. 301)
5. The mother who is in labor will experience a more intense back pain, in what fetal position?
a) Low occiput posterior
b) Transverse position
c) Breech Position
d) Low anteroposterior
RATIONALE: A. Because the fetal head rotates against the sacrum, the woman with this presenting part may experience pressure and pain from her lower back from sacral nerve compression during labor. This sensation may be so intense that she asks for medication for relief, not for her contractions but for the intense back pressure and pain she is feeling. (Maternal and Child Health Nursing by Pillitteri © 2004, p. 557)
6. A 21-year-old woman inactive labor is admitted to the labor suite. An hour later, the membranes rupture spontaneously. The nurse observes a glistening white cord protruding from the vagina. Which of the following actions should the nurse take first?
a) Place clean sterile gauze over the cord and wet it with sterile normal saline.
b) Return to the nurses’ station and place an emergency call to the physician.
c) Apply manual pressure to the presenting part and have the mother assume a knee-chest position.
d) Administer oxygen by mask at 10-12liter/minute and assess the mother’s vital signs.
RATIONALE: C. A prolapsed cord is an emergency situation. The nurse must relieve pressure on the cord to prevent fetal anoxia. (NCLEX-RN Strategies for the Registered Nursing Licensing Exam © 2007, p. 11)